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[ { "category": "Nursing/other", "chartdate": "2116-04-29 00:00:00.000", "description": "Report", "row_id": 1577971, "text": "Neuro: alert and orianted x3, mae, following commands correctly, diladid and torodol for pain with good response.\n\nCardiac: nsr to st with no ectopy did start on po lopressor and stil tachy does need to have dose increased, sbps wnls, palpible pedial pulses, +2 edema in extremities, skin warm dry and intact, low grade temp in of 100.\n\nResp: lungs dim in bases on 3 liters nc satting around 94-95%, ct system to sxn draining small amount of serosang with no air leak, is using i/s and is coughing and deep breathing but needs encouragement.\n\nSkin: Chest with dsd that is cdi, ct dsd is cdi.\n\nGi/Gu: tolerating po's, poor appetite needs encouragment to eat, abd is soft round and nontender with good bowel sounds, on riss, making 30 or >/hr of u/o.\n\nPlan: deline and f2 later today, encourage to cough and deep and to use i/s. encourage to eat, continue with pain meds as needed.\n" }, { "category": "Nursing/other", "chartdate": "2116-04-27 00:00:00.000", "description": "Report", "row_id": 1577967, "text": "post-op\nD: PT ADM TO CSRU FROM OR INTUBATED, CCO/ALINE, 2 MED CT, ON NEO AND PROPOFOL- LOW CVP TO 4- PAD 16- SBP 70-140/--TX WITH TOTAL OF 2 LITER LR IN ADDITION TO WHAT WAS INFUSING WHEN HE CAME- CVP EVENTAULLY LEVELED OUT AT 13 PT APPEARS TO LIKE CVP B/W 13-16- HR DOWN INTO 90'S SBP >100/ ON NO PRESSORES. WEANED TO CPAP WITH 5 PEEP AND 5 IPS ON 40%, TV .500CC, SAT 100%, -EXTUBATED BY RESP WITH MIN DIFFICULTY.\nPT C/O PAIN CONSISTENTLY- PEROCET HAD BEEN PUT FDOWN HIS OGT, MSO4 GIVEN IVP WITH MIN RELIEF, OBTAINED AN ORDER FOR TORADOL WITH GOOD RELIEF. PT NAUSEA X 1 APPEARED TO RAISE MUCOUS--? WHAT WAS LEFT IN THE BACK OF HIS THROAT--MED WITH REGLAN--NO FURTHER NAUSEA NOTED. PLAN: CONTINUE FLUID RESUSITATION AS NEEDED-(PT AN ).\nNEURO; PT AWAKE YET FALLS ASLEEP EASILY, ALERT ORIENTED X 3, MAE, PUPILS EQUAL AND RX TO LIGHT.\nCARDIAC: PT IN SR WITH RATE UP TO 130'S AT TIMES- RESPONDED TO FLUID--EVENTUALLY DOWN TO 90-100- SBP AS NOTED 70-140/- AGAIN RESPONDED TO LFUID, CVP UP TO 11 WITH PAD 20, CO 7 WITH SVO2 70--PT EXTREMITIES WARM AND DRY.\nRESP: PT BS CLEAR, AS NOTED PT WEANED AND EXTUBATED, PRIOR TO EXTUBATION SX THIN YELLOW SPUTUM. ON 4L NP SAT 97%.\nGI: ABD SOFT, BS ABSENT, OGT PRIOR TO REMOVAL DRAINING BILIOUS MATERIAL IN SM AMT. H2 BLOCKER. PT DID EXPERIENCE ? VOMITED--MED WITH REGLAN- NO FURTHER EPISODE NOTED.\nGU: FOLEY DRAINING CL YELLOW URINE IN >60CC/HR AMTS, CREAT .9\nSKIN: NO OBVIOUS SKIN BREAKDOWN NOTED, ORIGINAL POST OF DRSG D&I-\nPAIN; PT WITH MOD AMT OF PAIN DESPITE PEROICET/MSO4 REGIEME- ADDED TORADOL WITH EXCELLENT RELIEF.\n\nPLAN; CONT TO MONITOR- RESUSITATE WITH FLUID AS PT AN APPEARS TO LIKE CVP 13-16--AT WHICH POINT HIS HR IS DOWN AND SBP >100/\n\n" }, { "category": "Nursing/other", "chartdate": "2116-04-28 00:00:00.000", "description": "Report", "row_id": 1577968, "text": "Neuro: A&O X3, C/O pain several times, medicated with toradol, MSO4 and percocet with good results, MAE's well\n\nCardiac: ST to SR this AM, rare PVC, one 4 beat run of AF noted, repleated K+ with 20 meq KCL IVPB\n\nResp: lungs clear, O2 at 2 LPM via NC, good cough\n\nGI: tolerating liquids well, + BS, no BM\n\nGU: foley to gravity drainage draining clear yellow urine, huo dropping off\n\nsocial: pt's wife called , visited X1\n\nPlan: 500 cc fluid challange, attempt to wean off neo, get OOB, ? change pain medications, follow labs and treat as indicated and as ordered, ? deline and transfer to 2 when appropriate, increase diet and activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2116-04-28 00:00:00.000", "description": "Report", "row_id": 1577969, "text": "NEURO: PT IS A&OX3, MAES, LIFTS & HOLDS W/EQUAL STRENGTH & FOLLOWS COMMANDS. +PERRL. PO DILAUDED, IV TORADOL GIVEN FOR C/O INCISIONAL PAIN W/GOOD EFFECT.\n\nCV: SR 90S-ST TO LOW 100s, NO ECTOPY, PACER SET FOR ADEMAND 60. BP 90s-100s AT REST TO 110s-130s W/STIMULATION. NEO TITRATED TO KEEP SYSTOLIC >90. SWAN DC'D, TRAUMA LINE IN. CT DRAINING MIN SEROSANG DRNG QH. PPPs. PT AFEBRILE.\n\nRESP: BILATERAL UPPER LS CLR, BASES DIM. O2SATS >97% ON 3L NC. PT TO CDB AND USE I.S. USES IS UP TO 1000. RR 20s. C/O SLIGHT SOB DURING ACTIVITY.\n\nGI/GU: PT C/O NAUSEA-POORLY TOL CLR LIQs IN AM~IMPROVED AFTER IV REGLAN. BS HYPOACTIVE AT START OF SHIFT, NOW PRESENT. TOL SOUP FOR LUNCH-NO C/O NAUSEA. HUO IN AM MARGINAL, DIURESED OKAY AFTER20MG IVP LASIX GIVEN THIS AFTERNOON.\n\nENDO: BS MONITORED PER CSRU SS PROTOCOL.\n\nPLAN: CONTINUE MONITORING CARDIORESPIRATORY STATUS. MONITOR BP, WEAN NEO AS TOL TO KEEP SBP >90. . CDB, I.S. WEAN 02 AS TOL. INCREASE ACT & PO INTAKE AS TOL. TRANSFER TO FLR IN AM IF APPROPRIATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-04-28 00:00:00.000", "description": "Report", "row_id": 1577970, "text": "ADDENDUM\n\nK, CALCIUM REPLETED. ST 100s-110s~>2.5 IV LOPRESSOR ORDERED ON ROUNDS; HUO TAPERING TO < 30CC/HR~GAVE IVP LASIX EARLY PER .\n" }, { "category": "Echo", "chartdate": "2116-04-27 00:00:00.000", "description": "Report", "row_id": 79988, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Mitral valve disease. Shortness of breath. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 12:50\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\nLA. No spontaneous echo contrast or thrombus in the body of the LAA. No\nLA mass/thrombus (best excluded by TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. A catheter or pacing wire is seen in the RA and extending into\nthe RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Severe symmetric LVH. No asymmetric LVH. Normal LV cavity\nsize. No LV aneurysm. Normal regional LV systolic function. Overall normal\nLVEF (>55%). No resting LVOT gradient. No LV mass/thrombus.\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. Normal RV wall\nthickness. Normal RV systolic function.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Mildly dilated aortic root. Normal ascending aorta\ndiameter. Focal calcifications in ascending aorta. Normal aortic arch\ndiameter. Simple atheroma in aortic arch. Focal calcifications in aortic arch.\nMildly dilated descending aorta. Simple atheroma in descending aorta. Focal\ncalcifications in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. No masses or vegetations on aortic valve. Severe AS. Mild (1+) AR.\nEccentric AR jet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient received antibiotic prophylaxis. The TEE probe was\npassed with assistance from the anesthesioology staff using a laryngoscope.\nThe patient was under general anesthesia throughout the procedure. The patient\nappears to be in sinus rhythm.\n\nConclusions:\nPRE-CPB: The left atrium is normal in size. No spontaneous echo contrast is\nseen in the body of the left atrium. No spontaneous echo contrast or thrombus\nis seen in the body of the left atrium or left atrial appendage. No left\natrial mass/thrombus seen (best excluded by transesophageal echocardiography).\nNo atrial septal defect is seen by 2D or color Doppler. There is severe\nsymmetric left ventricular hypertrophy. There is no asymmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. No left\nventricular aneurysm is seen. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). No masses or\nthrombi are seen in the left ventricle. Right ventricular chamber size and\nfree wall motion are normal. Right ventricular systolic function is normal.\nThe ascending, transverse and descending thoracic aorta are normal in diameter\nand free of atherosclerotic plaque. The aortic root is mildly dilated. There\nare simple atheroma in the aortic arch. There are focal calcifications in the\naortic arch. The descending thoracic aorta is mildly dilated. There are simple\natheroma in the descending thoracic aorta. The aortic valve is bicuspid. The\naortic valve leaflets are severely thickened/deformed. No masses or\nvegetations are seen on the aortic valve. There is severe aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet\nis eccentric. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is a trivial/physiologic pericardial effusion.\nPRE-CPB: Well-seated mechanical valve in the aortic position with small\nparavalvular leak at the side of the intraatrial septum (NCC location).\nResidual gradient is 8 mmHg peak and 5 mean. Trivial AI. LV systolic finction\nis preserved.\n\n\n" }, { "category": "ECG", "chartdate": "2116-04-27 00:00:00.000", "description": "Report", "row_id": 209768, "text": "Sinus rhythm. Prior inferior wall myocardial infarction. Prior anterior wall\nmyocardial infarction. Left ventricular hypertrophy. Compared to the previous\ntracing of the rate has increased. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "Radiology", "chartdate": "2116-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906329, "text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural effusion, tamponade, pulmonary edema, pneumothorax.\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTIC ANEURYSM REPAIR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, tamponade, pulmonary edema, pneumothorax. Please page \n or call with issues.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable.\n\n INDICATION: Status post aortic valve replacement, check for chest\n abnormalities.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. There is now status post sternotomy and the metallic ring-\n shaped component of an aortic valve prosthesis is identified in place. The\n patient is intubated. The ETT terminates in the trachea some 6 cm above the\n level of the carina. An NG tube reaches far below the diaphragm entering the\n fundus of the stomach. A right internal jugular vein sheath carries a Swan-\n Ganz catheter, the tip of which terminates overlying the outflow tract of the\n right ventricle. There is no evidence of pneumothorax. In comparison with\n the preoperative examination of considerable postoperative\n mediastinal hematoma is noted. There is, however, no evidence of significant\n pulmonary vascular congestion and no acute infiltrates are seen. The lateral\n pleural sinuses remain free. A single left-sided chest tube is noted\n apparently advanced from below.\n\n IMPRESSION: Status post aortic valve replacement without evidence of\n pneumothorax or significant vascular congestion. Position of Swan-Ganz\n catheter in outflow tract of right ventricle could be corrected by further\n advancement into the pulmonary artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 906982, "text": " 5:24 PM\n CHEST (PA & LAT) Clip # \n Reason: assess atelectasis\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTIC ANEURYSM REPAIR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p AVR with h/o Left atelectasis\n REASON FOR THIS EXAMINATION:\n assess atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old status post AVR with left-sided atelectasis, please\n reassess.\n\n PA AND LATERAL CHEST: Compared to AP upright chest of . Median\n sternotomy wire status post valve replacement. Prosthetic AVR again\n identified. Mild linear right basilar atelectasis. The atelectatic opacity\n at the left lung base has improved and somewhat cleared compared to the prior\n study. The heart remains moderately enlarged but there is no evidence of\n congestive heart failure. The mid and upper lung zones are clear. The\n visualized osseous structures are unremarkable.\n\n IMPRESSION: Bibasilar atelectasis, with improved aeration at the left base.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906633, "text": " 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTIC ANEURYSM REPAIR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p AVR\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male status post aortic valve repair.\n\n COMPARISON: .\n\n FINDINGS: There has been interval removal of an endotracheal tube,\n nasogastric tube, Swan-Ganz catheter, pleural drains, and left basilar chest\n tube. There is stable widening of the cardiac and mediastinal contours. The\n patient is status post median sternotomy. No pneumothorax is identified.\n There is worsening left retrocardiac opacity. The right lung is grossly\n clear.\n\n IMPRESSION:\n 1. Interval removal of various lines and tubes without evidence of\n pneumothorax.\n 2. Worsening left basilar atelectasis.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945440, "text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old renal transplant with type I diabetes, with sob, elevated trop,\n hyperglycemia.\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE AP CHEST RADIOGRAPH\n\n INDICATION: 51-year-old with type 1 diabetes and shortness of breath.\n\n COMPARISON: PA and lateral chest radiographs, .\n\n FINDINGS: Lungs demonstrate low lung volumes when compared to previous\n radiographs. Increased prominence of vascular markings noted with\n cephalization. Cardiomediastinal silhouette is unchanged with stable\n moderate cardiomegaly. Median sternotomy wires and mediastinal clips signify\n previous coronary artery bypass grafting. No pleural effusions or\n pneumothoraces identified. No definite consolidation identified.\n\n IMPRESSION: Vascular redistribution and cephalization consistent with mild\n CHF.\n\n" }, { "category": "Radiology", "chartdate": "2200-01-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 945027, "text": " 5:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with headache.\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn MON 6:14 AM\n No ICH or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old female with headache.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift\n of normally midline structures. Low attenuation in the periventricular white\n matter is likely related to chronic microvascular infarction in this patient\n with diabetes. There are two small left basal ganglia lacunar infarcts. The\n -white matter differentiation appears preserved. There is no\n hydrocephalus. The surrounding soft tissue and osseous structures are\n unremarkable. The visualized paranasal sinuses and mastoid air cells are\n clear.\n\n IMPRESSION:\n 1. No intracranial hemorrhage or mass effect.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-01-26 00:00:00.000", "description": "Report", "row_id": 1323490, "text": "Condition Update\nAssessment:\n Please see carevue for details\n\n Neuro: Pt A&Ox3, follows all commands, MAE, PERL, full strength in all extremities. Denies pain. Independent with ADLs\n\n Resp: LS clear bilat throughout. Denies SOB.\n\n CV: Remains NSR, no ectopy noted. Denies CP. VSS. +2 generalized edema noted.\n\n GI: ABD obeses, pos bs. Denies n/v. No BM this shift. po's\n\n GU: Voiding adequate amounts of clear yellow urine\n\n Endo: Pt on and off insulin gtt, recieving 18units glargine and reg insulin by counting carbs. While off gtt, pt treating hyperglycemia with reg insulin per protocol discussed with . following pt closely.\n\nPlan:\n Monitor for CP, consult, better glucose control, provide pt with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-27 00:00:00.000", "description": "Report", "row_id": 1323491, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains awake, alert and oriented. MAEW = & strong. Up to BR independently well. Denies discomfort this pm.\n BS clear t/o, NS w/o ecxtopy, VSS. No CP, Sob for short period when up to BR this pm, O2 on at 2l, sats stable t/o. O2 remains on w/no further episodes noted. Voiding clear yellow urine.\n Off insulin gtt at beginning of shift, Sc insuling according to pt per . BS slowly normalizing from >200 range. Insulin gtt restarted at 2 units at 0100 per MICU team , BS continue to normalize to 110-120 range this am. Pt verbalizing concern that Insulin gtt is not consistent w/stabilizing patient and working to goal of returning home. Pt. verbalized concerns to MICU team, will discuss in am on rounds.\n PLAN: monitor HD status r/t MI, optimise blood glucose levels, provide emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-27 00:00:00.000", "description": "Report", "row_id": 1323492, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile, HR stable BP 140-150's, this afternoon BP climbing up to 170's. O2 on 2L nc with O2 sats 96-100% pt seen by PT ambulated with oxygen and then sat in chair with oxygen off and Sats in low 90's. Pt assisted back to bed with supervision and sat down to 79% and pt then stated she didn't feel well, denied any chest pain, c/o SOB. O2 applied BP down from 150 to 108, EKG done(resident reviewed and noted no changes). Sats up to 100% and pt reported feeling much better with O2. Within a couple minutes BP back up to baseline. PT recommending home O2. Case manager called referral in for home services and O2 tank delivered this afternoon. Pt plans to be discharged at noon tomorrow. MICU resident aware.\n Blood sugars checked hourly. Gtt off for a couple of hours in this afternoon to see patient and would like SC regular insulin given prior to meals along with dose of lantus. Patient becoming very frustrated with poor communication btwn teams and plan for insulin.\nPLAN:\n Follow rec for blood sugar control\n O2\n D/c home with services tomorrow\n Notify H.O. with any changes\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": "2200-01-24 00:00:00.000", "description": "Report", "row_id": 1323486, "text": "nuero: alert and oriented x3, pleasant. pt follows commands.\n\npain: pt c/o right shoulder pain received tylenol with good effect. please see cardiac for chest pain\n\npulm: lung clear, o2 sat 93-96%. pt went down for lung scan this morning.\n\ncards: pt with 2 eposides of chest pressure, 1st eposide resolved on own, dr. called and into assess patient. pt second of chest pressure, ekg done pt recieved 1sl nitrogylcerin with good effect, dr. into assess patient. pt has denied any further c/o chest pressure/pain. pt recieved lasix 40mg po today per dr. .\n\ngi: pt tolerating regular diet\n\ngu: pt viods on commode.\n\nf/e blood sugar 72 insulin gtt shut off, pt callled and stated \"my blood sugar feels low, blood sugar 62, pt recieved juice, crackers repeat blood sugar 267 tx'd with 6 units of regular insulin per sliding scale, blood sugar 475 dr. aware, pt recieved insulin 14u sc x1 per dr. , pt restarted back on insulin gtt please see flow sheet for titration of insulin gtt.\n\nactivity: pt oob to chair .\n\nplan: continue to monitor, check blood sugar every hour, pt to recieve glargine scheduled does of glargine. monitor cardiac status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-01-25 00:00:00.000", "description": "Report", "row_id": 1323487, "text": "7pm-7am Nursing Note\nSee CarVue for objective data and trends\n\nNEURO: Pt. alert and oriented X 3, MAE. No neuro deficits noted.\nCV: BP ranging 130s-150s. HR 70s-80s in NSR. SBP elevated to 170 briefly but back to baseline after scheduled isordil given. Pt denies CP this shift. Had one episode of \"dizziness\" after ambulating to commode which resolved without intervention ? r/t BP drop to 120 with position change. Pt tolerated subsequent ambulations better without complaints.\nRESP: LS CLear, Pox 96-98%. RR even and non-labored. Pt on 3liters NC at present.\nGI/GU: ABdomen large but soft to palpation. Pt c/o constipation and started on colace this shift. positive BS, flatus. Pt voiding in commode in adequate amounts.\nENDO: Pt remains on insulin gtt with improved control(see carevue for data)\nPLAN: Monitor BS closely. Assess VS and pt. for CP.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-25 00:00:00.000", "description": "Report", "row_id": 1323488, "text": "npn\n Pt is a+o, mae- ambulate to toliet with 1 assist.\n\nResp- 2 liters nasal with sao2 95-100- lungs clear bilat.\n\nGI_ diet\n\nHemodynmics- nsr- sbp 120-160's, lopressor , isordil tid.\n\n\nEndocrine- cont insulin gtt- units/hr- glargine increased to 18 units .\n" }, { "category": "Nursing/other", "chartdate": "2200-01-26 00:00:00.000", "description": "Report", "row_id": 1323489, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains awake, alert and oriented, amb to toilet w/1 assist. Voiding clear yellow urine. Lungs clear, sats 96-98% on O2 2l NC.\n Remains on lopressor and isordil w/SBP better controlled to 120's later in shift. Insulin gtt cont 1-4 units/hr to maint BS 100-140 range. Glargine dose due 6am.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-22 00:00:00.000", "description": "Report", "row_id": 1323482, "text": "Nursing note:\n 51 year old diabetic woman w/mult. medical problems admitted to SICU from 3 @ 1700 w/elevated glucose levels for glucose control. Pt. admitted to w/SOB, HA.\n A/Ox3, no neuro deficits. Lung sounds clear, sats 91% on RA, 99% on 2L NC. Afebrile. SR in 60-s70s, no ectopy. SBP 150s-160s. Full set labs sent, 1 set blood cultures sent. UA done on floor prior to arrival. +BS, abdomen obese. Tolerating diabetic /renal diet. No N/V. Dopplerable pulses, mild pedal edema. Begun on insulin gtt for glucose 321, to be checked hourly, following CSRU protocol for now. Pt. does void but has yet to do so since admit.\nA/P: Stable w/? unclear source of elevated WBCs and elevated glucose levels despite mult. doses of own insulin on 3 today. Monitor sugars closely.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-23 00:00:00.000", "description": "Report", "row_id": 1323483, "text": "NPN (NOC):\n\nPT REMAINED ON INSULIN DRIP PER CSRU PROTOCOL UNTIL 4AM WHEN FSBS DROPPED TO 60. PT WAS GIVEN OJ AND CRACKERS. ONE HR LATER, FSBS WAS 123. 12U GLARGINE GIVEN AND NO SSI PER SCALE (TEAM WANTED TO BEGIN SSI THIS AM.) AT 6AM, FSBS 273, SO 6 U SSI GIVEN. AM LABS PND. PT HAS SENT OWN INSULIN HOME W/ HUSBAND.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-23 00:00:00.000", "description": "Report", "row_id": 1323484, "text": " 0830\n NEURO WNL MAE STANDS WITH MILD WEAKNESS IN FAIR SPIRITS SLEEPS IN SHORT NAPS\n HEART S1S2 NSR TO ST M PULSES POS 3 THRU OUT VSS NO TEMP NOTED\n RESP CLEAR DIM AT BASES SAO2 ON ROOM AIR 90 ON /2L NP PRODUCTIVE COUGH\n ABD NO STOOL U/O FAIR SOFT NON TENDOR PO WELL OCC PERIODS NAUSEA NO VOMIT NOTED\n DM CONTROL BLOOD SURGARS REMAIN CONTROL MD AWARE SEE FLOW SHEETS UNDER CAREVIEW FOR DETAILS\n PLAN CLOSE MONITOR B/S PO INTAKE AND CARDIAC STATUS\n" }, { "category": "Nursing/other", "chartdate": "2200-01-24 00:00:00.000", "description": "Report", "row_id": 1323485, "text": "NPN (NOC):\n\nBS'S HAVE BEEN VERY LABILE AGAIN TONIGHT. INSULIN DRIP CONTINUED AT 7 UNITS UNTIL 10 PM WHEN FSBS WAS 132. RATE CUT IN HALF TO 3.5. AT 11 PM DRIP OFF FOR FSBS OF 80. BY 2AM FSBS WAS 225 SO 4 UNITS REGULAR GIVEN. W/IN AN HOUR HOWEVER, FSBS WAS 338. DRIP RESTARTED AND TITRATED PER FLOW SHEET. AM LABS PND. STILL NEEDS CLOSE MONITORING.\n" }, { "category": "Nursing/other", "chartdate": "2200-01-28 00:00:00.000", "description": "Report", "row_id": 1323493, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT, ORIENTED X3, PLEASANT AND COOPERATIVE\nCV: AFEBRILE. VSS. LE PINK AND WARM\nRESP: INTERMITTENTLY USING O2 AT 3-4 LITERS WITH SATS >97%. BS CLEAR\nGI: DIET WELL. ABD SOFT\nGU: VOIDING QS\nENDO: INSULIN GTT OFF AT 2200. BS AT 2400 = 224, COVERED WITH 2 UNITS APIDRA, 0400 BS 237= COVERED WITH 4 UNITS APIDRA. CONT TO FOLLOW WITH CLINIC\nA/P: PT TO BE DISCHARGED HOME TODAY PER HER REQUEST AT NOON, CHECK BS Q4HRS TIL DISCHARGE AND TX ACCORDING TO NOTES.\n" }, { "category": "Echo", "chartdate": "2200-01-23 00:00:00.000", "description": "Report", "row_id": 65043, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 62\nWeight (lb): 180\nBSA (m2): 1.83 m2\nBP (mm Hg): 133/30\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 15:09\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: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Small LV cavity. Mild global LV\nhypokinesis. No LV mass/thrombus. TDI E/e' >15, suggesting PCWP>18mmHg.\nTransmitral Doppler and TVI c/w Grade II (moderate) LV diastolic dysfunction.\nNo resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function depressed.\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. No MVP. Normal mitral valve\nsupporting structures. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Moderate [2+] TR. Severe PA systolic hypertension.\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 moderately dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is small. There is mild\nglobal left ventricular hypokinesis (ejection fraction 40-50 percent). No\nmasses or thrombi are seen in the left ventricle. Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg).\nTransmitral Doppler and tissue velocity imaging are consistent with Grade II\n(moderate) LV diastolic dysfunction. There is no ventricular septal defect.\nThe right ventricular free wall is hypertrophied. The right ventricular cavity\nis dilated. Right ventricular systolic function appears depressed. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild to moderate (+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nsevere pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (images reviewed) of , the pulmonary hypertension is worse (now severe), with a dilated and\nhypokinetic right ventricle and a reduced left ventricular ejection fraction\nand significant diastolic dysfunction with evidence of increased left\nventricular end-diastolic pressure.\n\n\n" }, { "category": "ECG", "chartdate": "2200-01-27 00:00:00.000", "description": "Report", "row_id": 128413, "text": "Sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof the previously described multiple abnormalities persist without\ndiagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2200-01-24 00:00:00.000", "description": "Report", "row_id": 128414, "text": "Sinus rhythm. Left atrial abnormality. Incomplete right bundle-branch block.\nAnterolateral myocardial infarction, age indeterminate. Possible acute/recent,\nin evolution. Diffuse ST-T wave abnormalities suggest ischemia. Compared to the\nprevious tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2200-01-23 00:00:00.000", "description": "Report", "row_id": 128415, "text": "Sinus rhythm\nLeft atrial abnormality\nIncomplete right bundle branch block\nAnterolateral myocardial infarct, age indeterminate - possible acute/recent/in\nevolution\nDiffuse ST-T wave abnormalities - suggest ischemia\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2200-01-22 00:00:00.000", "description": "Report", "row_id": 128416, "text": "Sinus rhythm\nLeft atrial abnormality\nIncomplete right bundle branch block\nAnterolateral myocardial infarct, age indeterminate - possible acute/recent/in\nevolution\nDiffuse ST-T wave abnormalities - suggest ischemia\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2200-01-20 00:00:00.000", "description": "Report", "row_id": 128417, "text": "Sinus bradycardia. Right bundle-branch block. Recent or ongoing inferolateral\nand apical myocardial infarction. Compared to the previous tracing of \nno diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2200-01-20 00:00:00.000", "description": "Report", "row_id": 128418, "text": "Sinus rhythm. Left atrial abnormality. Incomplete right bundle-branch block\nwith probable anterolateral myocardial infarction of indeterminate age. Diffuse\nST-T wave abnormalities, cannot exclude ischemia. These findings also suggest\nright ventricular hypertrophy/overload. Compared to the previous tracing\nof bradycardia is absent and the QRS complexs and T wave changes in\nlead V4 are probably positional.\n\n" }, { "category": "ECG", "chartdate": "2200-01-29 00:00:00.000", "description": "Report", "row_id": 129186, "text": "Sinus rhythm. Probable left atrial abnormality. Mmodest right ventricular\nconduction delay pattern. Probable anterolateral myocardial infarction, age\nindeterminate. Consider right ventricular overload/hypertrophy. Diffuse\nST-T wave abnormalities. Cannot exclude ischemia. Clinical correlation is\nsuggested. Since the previous tracing of probably no significant\nchange.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2200-01-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 945575, "text": " 3:32 PM\n CHEST (PA & LAT) Clip # \n Reason: to correlate with AP, per attending\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with NSTEMI, DKA\n REASON FOR THIS EXAMINATION:\n to correlate with AP, per attending\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 15:32 HOURS.\n\n HISTORY: Non-ST elevation myocardial infarction.\n\n COMPARISON: .\n\n FINDINGS: There is evidence of prior median sternotomy and CABG. Numerous of\n the more upper sternal wires are fractured as previously noted. The lungs are\n clear. No focal consolidation is evident. The heart is enlarged but stable.\n No pleural effusion or pneumothorax is evident. The visualized osseous\n structures are otherwise unremarkable.\n\n IMPRESSION: No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-01-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 945090, "text": " 12:13 PM\n CHEST (PA & LAT) Clip # \n Reason: consolidation, infiltrate\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old renal transplant with type I diabetes, with sob, elevated trop,\n hyperglycemia.\n REASON FOR THIS EXAMINATION:\n consolidation, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: PA and lateral chest.\n\n INDICATION: Shortness of breath.\n\n PA and lateral views of the chest are obtained and compared with the\n prior radiograph of . There is evidence of prior cardiac surgery. The\n heart size is mildly enlarged. There is no evidence of acute infiltrate,\n pleural effusion, or pneumothorax on the current images. The bony structures\n are unremarkable for the patient's age.\n\n IMPRESSION:\n\n Stable radiograph with no convincing radiographic evidence of acute\n superimposed disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-01-24 00:00:00.000", "description": "LUNG SCAN", "row_id": 945658, "text": "LUNG SCAN Clip # \n Reason: T1DM, SEVERE PUL HTN, CAD S/P CABG, RENAL FAILURE, S/P TRANS STE W L MAIN DZ, CP, RT HEART STRAIN ? PE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 5.0 mCi Tc-m MAA ();\n 40.0 mCi Tc-99m DTPA Aerosol ();\n HISTORY: 51 year old woman with severe pulmonary hypertension\n\n INTERPRETATION:\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate no\n ventilatory defects.\n\n Perfusion images in the same 8 views show normal perfusion.\n\n Chest x-ray shows no airspace disease but some cardiac enlargement.\n\n IMPRESSION: Normal lung scan. No evidence of pulmonary embolus.\n\n\n , M.D.\n , M.D. Approved: 4:50 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2200-01-20 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 945024, "text": " 5:02 AM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: r/o DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with CP/SOB, LLE swelling\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: MMBn MON 5:41 AM\n Negative.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old female with chest pain and shortness of breath, now\n with left lower extremity swelling.\n\n LEFT LOWER EXTREMITY ULTRASOUND WITH DOPPLER EXAMINATION: scale, color\n flow, and Doppler ultrasound of the left common femoral, superficial femoral,\n popliteal veins were performed. Normal flow, augmentation, compressibility,\n and waveforms were demonstrated. No intraluminal thrombus was seen.\n\n IMPRESSION: Negative left lower extremity DVT study.\n\n" }, { "category": "Radiology", "chartdate": "2200-01-20 00:00:00.000", "description": "REST MIBI", "row_id": 945057, "text": "REST MIBI Clip # \n Reason: T1DM, CAD S/P CABG, RENAL FAILURE S/P TRANSPLANT, STE C/W LEFT MAIN DISEASE, POSITIVE TROPONINS, NO CP\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 10.1 mCi Tc-m Sestamibi ();\n HISTORY: 51 year old female with IDDM, CAD s/p CABG, renal failure p/w positive\n troponins, left main disease, no chest pain.\n\n INTERPRETATION:\n\n Following injection of MIBI while patient was at rest and experiencing chest\n pain, static and gated SPECT images were obtained and analyzed. A bull's-eye\n display of tracer distribution throughout the myocardium was also obtained.\n\n Imaging Protocol:\n\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n The image quality is severely limited by soft tissue attenuation.\n\n Rest images show some irregular tracer uptake in the ventricular walls.\n However, due to severe attenuation artifacts, images are diagnostically\n uninterpretable.\n\n IMPRESSION:\n\n Diagnostically uninterpretable study due to artifacts from significant soft\n tissue attenuation.\n\n\n , M.D.\n , M.D. Approved: WED 4:07 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" } ]

[ { "category": "ECG", "chartdate": "2174-11-10 00:00:00.000", "description": "Report", "row_id": 307614, "text": "Normal sinus rhythm. Borderline A-V conduction delay. Left atrial\nabnormality. Q waves in leads V1-V2 suggestive of possible prior anteroseptal\nmyocardial infarction. Q-T interval prolongation. Compared to the previous\ntracing of no diagnostic interval change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2153-12-24 00:00:00.000", "description": "Report", "row_id": 1892867, "text": "Neonatology Attending\n\n1485 gram 30 week male admitted for management of prematurity\n\n1485 gram 30 week (EDC ) male born to a 41 yo G7 P2->3 SAb2 TAB2 Hispanic female\nPNS: O+/Ab-/SNR/RI/HBsAg-/GBS unknown\nPregnancy c/b multiple evaluations for ? ROM over last 2 weeks-->negative testing. Presented today with SROM (+ fern) and preterm labor with q 5 min contractions. Normal USs during pregnancy. Antibiotics given ~1/2 hr ptd. Delivered by R C/S under spinal anesthesia. Apgars .\n\nPast Maternal Ob history remarkable for 38 week female C/S and 29 week female C/S (this was hospitalized at NICU and is currently doing well).\n\nSH: Married. 2 sisters at home. This is father's first premature . 15 yo sister was in DR. named .\nFH: noncontributory\n\nExam Vigorous premature male, pink and comfortable in RA\nT 98 P 180 R 44 BP 52/31 mean 38 O2 sat 94% in RA\nWt 1485 grams (50-75%) Lt 38 cm (25-50%) HC 28 cm (50%)\nAF soft, flat, nondysmorphic, intact palate, normal RR OU, adequate aeration, clear bs, no murmur, normal pulses, soft abd, 3 vessel cord, no hsm, normal male genitalia, testes in canal, no hip click, patent anus, no sacral dimple, + Mongolian spot on buttocks, pink and well perfused, MAE, active with normal tone for age\n\nPKU sent\nDS 33\n\nA: 30 week male delivered secondary to PROM (?duration) and active labor. No respiratory distress at present. Hemodynamically stable. At risk for sepsis. Hypoglycemic requiring treatment.\n\nP: Monitor\n NPO\n UV for access\n Babygram for line placement\n D10W bolus\n IV fluids (Hold starter PN since he is being transferred)\n Usual attention to lytes and DS\n CBC, BC\n A/G for R/O sepsis with course dependent on labs and clinical status\n Follow bili\n HUS at 1 week\n Eye exam at 4 weeks\n Support family. I had brief meeting with the family before delivery. Mother familiar with course at this GA. Parents saw in L&D.\n Pediatrician is \n Due to high census at NICU plan transfer to NICU for further care. Parents aware and consent to transfer. Potential for retrotransfer when our census is lower.\n I called transport team () and arranged transfer. NICU is full therefore he is being transferred to .\n I called Dr. (fellow) at and gave sign out.\n\n" }, { "category": "Nursing/other", "chartdate": "2153-12-24 00:00:00.000", "description": "Report", "row_id": 1892868, "text": "Admission Note\nNICU Nursing Admission Note\n\n admitted to NICU to eval for prematurity. Apgras . Please see Attending MD note for maternal history and 's physical exam. VSS. See flowsheet for vital signs. BW 1485g.\n\n\n placed upon radiant warmer. Baby meds given. DLUVC placed by and palcement confirmed by Xray. CBC and blood cultures sent. Results pending. D/S 33. D10W bolus given at 0230 and D10W with 1/2 unit hep/cc to infuse at 80cc/k/d. Ampi and Gent given.\n\nTransport to via transport team.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-12-24 00:00:00.000", "description": "Report", "row_id": 1892869, "text": "Xray demonstrates UVC tip at T9.\n" }, { "category": "Nursing/other", "chartdate": "2153-12-24 00:00:00.000", "description": "Report", "row_id": 1892870, "text": "Neonatal NP-Procedure Note\n\nprocedure: UVC placement\nindication: IV access\n\n\n positioned for procedure. #5 fr double lumen UVC placed without difficulty to premeasured distance of 8cm and secured. Awaiting Xray confirmation of tip position.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-12-24 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 935581, "text": " 2:30 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: line position\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with newly placed lines\n REASON FOR THIS EXAMINATION:\n line position\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST AND ABDOMEN, , 0228 HOURS\n\n HISTORY: Infant with newly placed lines. Line position.\n\n FINDINGS: The umbilical venous catheter tip projects over the expected\n position of the distal right atrium. This location was discussed with the ICU\n team at morning rounds. The lungs are well expanded and clear. The heart and\n mediastinal contours are normal. A pleural effusion is not seen. The bowel\n gas pattern is nonobstructive.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2153-09-25 00:00:00.000", "description": "Report", "row_id": 1507072, "text": "NPN 7p-7a\nNeuro: alert and oriented, answers questions appropriately. Slept most of the evening.\n\nResp: Comfortable on vent settings. Minimal secretions. Breath sounds clear with occasional wheeze.\n\nCV: HR 70-80's A fib with rare PVC. BP 88-110/60's. 2 am Dilt. held due to BP 88.\n\nGI: Tolerating diet well. No stool\n\nGU: Foley d/c'd this am\n\nID: afebrile\n\nSocial: family in to visit this evening. Ready to have pt. come home.\n\nImp/Plan\n-d/c to home.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-25 00:00:00.000", "description": "Report", "row_id": 1507073, "text": "Respiratory Care Note\nPt remains on AC as noted. BS clear bilaterally. MDI given a/o. Pt's home ventilator checked and set up for return home. Home teaching about ventilator and suctioning done. Pt taken by ambulance home.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-25 00:00:00.000", "description": "Report", "row_id": 1507074, "text": "D/C note\nPt D/C'd to home via ACL's with daughter. D/C Plan and meds explained to pt's daughter. 1&2 referrals done and sent with pt. Pt stable for transfer home.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-24 00:00:00.000", "description": "Report", "row_id": 1507068, "text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTED X 3. VERY DEPRESSED ABOUT CT SCAN RESULTS. RESIDENT IN TO CLARIFY ANY MISUNDERSTANDINGS ABOUT PT'S PROGNOSIS AND PLAN OF CARE. PT CONT TO BE ABLE TO HELP WITH TURNING, MOVING ALL EXTREMETIES. NO C/O PAIN.\n\nRESP: PT REMAINS ON VENT NO CHANGES OVERNIGHT, NO PROBLEMS. SX'ING FOR MOD AMT'S OF THICK YELLOW SPUTUM. LUNG SOUNDS COARSE AT TIMES. CLEAR WITH SX'ING. O2 SAT'S HIGH 90'S. TRACH SITE CLEAN, NO DRAINAGE NOTED.\n\nCV: PT REMAINS IN AFIB WITH CONTROLLED RATES IN THE 50'S-80'S WITH OCC TO FREQ PVC'S. TAKING PO CARDIZEM WITH APPLESAUCE. AFEBRILE.\nBP DROPS BRIEFLY AFTER DOSE.\n\nGI: PT TAKING . PT ATE FAIRLY WELL DURING THE DAY AND WAS ABLE TO TAKE IN GOOD AMT OF APPLESAUCE AND SIPS OF CRANBERRY JUICE. ABD SOFT/DISTENDED, PASSING FLATUS AND SM AMT;S OF COLORED STOOL.\n\nGU: FOLEY CATH PATENT DRAINING SMALL AMTS OF CLEAR YELLOW URINE. RECEIVE 250CC NS FLUID BOLUS.\n\nENDO: NO INSULIN COVERAGE OVERNIGHT.\n\nSKIN: NO ISSUES AT THIS TIME.\n\nACCESS: 1PERIPH IV.\n\nSOCIAL: PT WANTS TO GO HOME. DAUGHTER NOT HAPPY THAT PT HAS TO WAIT FOR LAB RESULTS AND FOR THE TEAM TO ROUND ON HER MOTHER. IS AWARE THAT PT'S INR IS ELEVATED AND IS UNABLE TO RECEIVE COUMADIN. DONOT WANT TO TREAT WITH VIT K FOR FEAR THAT PT COULD CLOT BECAUSE OF HER A FIB. PT IS FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-24 00:00:00.000", "description": "Report", "row_id": 1507069, "text": "Respiratory Care Note\nPt received on AC as noted. BS coarse with expiratory wheezes bilaterally. Pt suctioned for small to moderate amts. BS improved after rx, but slightly coarse on R. Passy-muir valve used today with Speech therapy. Pt placed on PSV with first attempt, but pt felt it was harder to breath and became SOB. Pt placed on AC and was able to speak more easily. Plan to remain on current settings at this time - Pt planning on going home at 10am on .\n" }, { "category": "Nursing/other", "chartdate": "2153-09-24 00:00:00.000", "description": "Report", "row_id": 1507070, "text": "NPN MICU-B 7AM-7PM\nS/O: NEURO: Alert and interactive, MAE. Appears a little depressed about dx and prognosis. Will be going home tomorrow if INR levels are within range.\n\nC/V: BP-97-120/45-56, HR 90-110 A-fib with occ PVC's. AM K+-3.2 rec'd 80mEq PO and 2amps Mag IV. No c/o's CP. INR still elevated but are decreasing to 6.8 from 10, evening PTT PND.\n\nRespir: Remains on A/C 30%/400/12, Peep-5. Suctioning occ for small amts thick yellow secretions. Attempted Passe-Muir valve with Speech and Swallowing RN, did not tolerate the valve on while on PS, requirred A/C mode and then did not tolerate it well for long only for a few minutes. See S&S note. L/S ex wheezes, @ bases.\n\nGI: Taking solid food well, needs assist with feeding. Has +BS, no BM today.\n\nGU: Has foley in place with adequate amt u/o.\n\nDispo: Plan to be d/c home with daugther in the AM if INR levels are within goal range. Daughter stated that she does not need VNA referrals. The respir Co. that maintains her home has been notified and a RT will be @ pt's home tomorrow when she is d/c'd. Page 1 needs to be completed by MD.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-25 00:00:00.000", "description": "Report", "row_id": 1507071, "text": "RESP CARE: Pt remains /on vent/on AC 12/400/.30/5 PEEP. Lungs slightly coarse. Sxd small amt thick yellow sputum. ALB MDI given Q4. NO RSBI done as pt will be going home today on her own LP-6 ventilator.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-23 00:00:00.000", "description": "Report", "row_id": 1507064, "text": "MICU NPN 7AM-3PM:\nNeuro: Pt in slightly better mood today. Alert and oriented times three, follows commands. MAE Does not like to turn but will accept the turn when encouraged to do so.\n\nCV: Dilt drip stopped and pt switched to QID PO dose. Crush pils and mix in custard or applesauce. BP 90-120/50. HR 70-90 sinus rhythm with rare PVC noted. Coumadin will be held again tonight for supertherapeutic INR level 10.8 today. Will need labs repeated in AM or sooner if she developes signs of bleeding.\n\nResp: Pt switched to PSV during the day. Sats are good. RR 20's. Suctioned for thick pale yellow secretions.\n\nGI: Pt taking better PO's today. Swollows well with the trach in place if things are soft and chewed well. No choking noted. Took entire bowl of oatmeal and a cup of tea this AM for breakfast. She then had glass of cranberry juice and peaches and soup for lunch. Needs to be encourage to eat and does well when fed.\n\nGU: UO dropped to 15cc's for two hours and pt given 250cc's NS bolus with good effect. After encouraging PO's more her UO has improved. Adequate UO via foley at this time.\n\nID: Afebrile on no antibiotics.\n\nIV Access: Pt has only one peripheral IV in place and can be a challenge to draw blood from.\n\nSocial: Planned family meeting this evening with Dr. at 5PM. Daughter is present and anxious for results of CT.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-23 00:00:00.000", "description": "Report", "row_id": 1507065, "text": "Pt has had an uneventful shift. Bs are equal with a light wheeze noted though out. she has denied needing sx most of the shift. She tolerates both A/C & PSV equaly well. Resp status seems stable and unchanged @ this time.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-23 00:00:00.000", "description": "Report", "row_id": 1507066, "text": "Brief Update tp NPN:\nPt and daughter met with Dr. who told them that there was nothing more that we could offer in terms of treatment options. Family and pt are appropriately upset and would like to plan to have pt go home tomorrow on the vent. This will need further discussion since pt's latest INR was up to 10.8. She will need to have this rechecked in AM along with a hct to make sure she is stable to go home. Pt crying for a while afte the meeting. I supported her in her grief as much as possible and plans will need to go ahead tomorrow for support at home with the vent, labs, foley etc.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-24 00:00:00.000", "description": "Report", "row_id": 1507067, "text": ",rrt\npt. rested t/o shift no c/o sxing for moderate #'s tan thick sputum, b/l b.s. mostly clear & coarse.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-22 00:00:00.000", "description": "Report", "row_id": 1507060, "text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-vs have been stable. continues in afib.dilt drip infusing at 5 mgs/hr.\n\nRESP-has been on CPAP 12/5 x 30% for several hours now and feels comfortable.lungs sound improved from yesterday.sx for scant amt secretions-trach site looks good.o2 sats have been >95%. prefers HOB elevated.\n\nID-has been flushed all day in the face but was afebrile. denies any chills.wbc=6.0. is not on antibx.? allergic reaction\n\nF/E-has had marginal urinary output.team aware. no peripheral edema noted. ivf at kvo. please see labs as listed in carevue.\n\nGI-has been taking custard and applesauce without signs aspiration.had a large amt liquid stool. on ppi.\n\nNEURO-a+o x 3. no sedatives given today.has seemed downhearted and is worried about CT results.\n\nSKIN-grossly intact\n\nIV ACCESS-has peripheral heplock.\n\nSOCIAL-daughter in this afternoon.plan to meet with Dr ~5pm to discuss CT results and make a plan.\n\na-uneventful day.\n\nP-will rest overnight on vent prn.encourage po's.need to address long term nutrition plan. offer emotional support.,\n" }, { "category": "Nursing/other", "chartdate": "2153-09-22 00:00:00.000", "description": "Report", "row_id": 1507061, "text": "Pt BS equal with light wheezes noted. She is in good spirites. Awake and alert. She tolerates both A/C & PSV well. No changes requested for her vent. support @ this time. Her resp. status seems unchanged\n" }, { "category": "Nursing/other", "chartdate": "2153-09-23 00:00:00.000", "description": "Report", "row_id": 1507062, "text": ",rrt\npt. placed to rest mode a/c ,400 12 +5 .30 @~ per her request,\"tired\" sx moderate # white/tan sputum mdi's done Q4 with vent checks, no changes made.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-23 00:00:00.000", "description": "Report", "row_id": 1507063, "text": "NURSING PROGRESS NOTES:\nNEURO: PT ALERT AND ORIENTED X 3. SEEMS VERY DEPRESSED. MOST LIKELY NERVOUS ABOUT CT RESULTS. ABLE TO ASSISST WITH TURNING IN THE BED. MAE EASILY. PEARL. NO C/O PAIN.\n\nRESP: NO VENT CHANGES OVERNIGHT, SEE FLOWSHEET FOR DATA. SX FOR SM AMT'S OF THICK WHITE SECRETIONS. LUNG SOUNDS SLIGHTLY COARSE AT TIMES. O2 SAT'S HIGH 90'S TO 100%. PT HAS STRONG COUGH. TRACH SITE CLEAN NO DRAINAGE.\n\nCV: HR REMAINS IN AFIB WITH OCC TO FREQ PVC'S. REMAINS ON DILT DRIP. BP LOW DOWN TO THE 80'S LAST EVENING AND WAS GIVEN A 250CC NS BOLUS.\nNO FURTHER PROB FOR REST OF THE NIGHT.\n\nGI: PT TAKING IN SMALL AMT'S BUT NOT ENOUGH TO GIVE NOURISHMENT. TOLERATES CUSTARD WITHOUT ANY DIFF SWALLOWING. PT SMALL AMT OF FOUL COLORED STOOL.\n\nGU: FOLEY CATH PATENT DRAINING SM TO MOD AMT'S OF CLEAR YELLOW URINE.\n\nSKIN: NO ISSUES.\n\nENDO: NO SSRI OVERNIGHT.\n\nSOCIAL: DAUGHTER VISITED EARLIER IN NIGHT. SEEMS VERY DEPRESSED ABOUT MOTHER'S CONDITION AS WELL. PT REMAINS FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-21 00:00:00.000", "description": "Report", "row_id": 1507058, "text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-has been in afib all day, with hr elevated to ~100 (did not receive po dilt due to bronch first thing this am).was started on a dilt drip at 5 mgs/hr.her bp has been stable. cardiac echo was done this am\n\nRESP-was bronched at 8:30 am-revealed patent airways and edema. has required infreq sx for scant amts sputum.lungs are coarse throughout anteriorally.was briefly trialed on PSV but returned to simv for her chest CTA-remains on this.feeling comfortable. inhalers as per RT.also, her trach was replaced by RT with a #7.was able to take crushed pills with applesauce without signs aspiration but we trimmed down her po meds considerably.\n\nID-afebrile.wbc=3.5.no antibx\n\nGI-npo except meds with applesauce.abd soft with positive bowel sounds.no stool today.\n\nF/E-has been voiding in diaper-unable to measure,placed a foley catheter and pt drained 450 ccs clear yellow urine. no peripheral edema noted.please see labs as listed in carevue.\n\nNEURO-was premedicated with 1 mg versed and 25 fent for bronch-woke up quickly.has been a+o x 3, cooperative.asks many questions.was medicated for CT with benadryl, iv prednisone and famotidine for questionable reaction 30 years ago during a venogram.\n\nIV ACCESS-has 1 heplock\n\nSOCIAL-has a devoted daughter who accompanied us to CT scan.\n\na-busy day with multiple procedures.pt anxious about CT results\n\nP-will rest overnight on her home vent settings.watch i's and o's. will have a repeat speech and swallow study.need to address long term nutrition.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-22 00:00:00.000", "description": "Report", "row_id": 1507059, "text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTED X 3. PT ABLE TO MAKE NEEDS WELL KNOWN BY MOUTHING WORDS. PT ABLE TO MAE AND MOVES FAIRLY WELL IN BED. NO C/O DISCOMFORT OVERNIGHT.\n\nCV: PT REMAINS IN AFIB WITH OCC PVC'S. PT CONT ON DILT DRIP AT 5MG. BP WITHIN NORMAL LIMITS. O2 SAT'S 96-100%. LUNG SOUNDS COARSE AT TIMES BUT WILL CLEAR WITH SUCTIONING. PT REMAINED ON VENT OVERNIGHT, WILL ATTEMPT PSV AND TRACH COLLAR AGAIN TODAY IF TOLERATING.\n\nRESP: SEE FLOWSHEET FOR VENT DATA.\n\nGI: PT NPO OVERNIGHT. TAKING ICE CHIPS AND TOLERATING WELL. NEEDS SPEECH AND SWALLOW STUDY.\n\nGU: FOLEY CATH LEAKING AT BEGINING OF SHIFT. 5CC MORE ADDED TO BALLOON. NO FURTHER LEAKING NOTED. URINE CLEAR YELLOW BUT VERY FOUL SMELLING.\n\nSKIN: INTACT.\n\nENDO: NO INSULIN GIVEN OVERNIGHT. REMAINS ON SSRI, AND Q 6/HR FINGERSTICKS.\n\nACCESS: STILL ONLY HAS ONE PERIPH IV.\n\nSOCIAL: DAUGHTER VISITED AND THEN WENT HOME. NEED TO SPEAK WITH DAUGHTER TODAY ABOUT PT'S POOR CAT SCAN RESULTS, WHICH CAME BACK AS SEVERE METASTISIS TO THE LUNGS. PT IS FULL CODE AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-20 00:00:00.000", "description": "Report", "row_id": 1507054, "text": "MICU NPN Admit to MICU\n 83y.o. female admitted today from Interventional Pulmonology lab. PMH includes thyroid CA with mets, s/p trach and s/p photodynamic therapy to trachea for tumor obstruction which was done . Pt was doing well on home vent at night and nasal canula during the day until two weeks ago she began to increasing c/o daytime SOB requiring daytime vent also. Seen in IP today for trach change in hopes this would help the symptome. On admit to unit her sat was 78%. She was distressed and improved once put on the vent. Her trach was changed without difficulty. She is admitted this eve to MICU due to her chronic vent issues and will have work-up for increased SOB. Plan is of CT angio/bronch.\n\nPHM: Met CA to lungs, thyroid CA s/p thyroidectomy, cataracts, a-fib on coumadin, MR, DVT s/p filter, HTN, occular migrains, asthma, home vent\n\nAllergies: PCN, Buspar, iodine, haldol, levoquin, sulfa, percocet, trazadone, bactrim\n\nNeuro: Pt arrived alert andorieted times three. Follows commands. Moves well in bed but c/o pain with any touch to her legs and arms which her daughter says is a result of neuropathy from GBS years ago.\n\nCV: BP 110/50 on admission, remains in a-fib with HR 70-90. No ectopy noted. Dropped BP to 80's when asleeep and since pt had not had anything to eat all day we gave her fluid bolus 500cc's times one. Hct stable as well as INR 2.4. Given her HS coumadin as ordered.\n\nResp: Came up on her home vent with sats 80%. Pt with large amts thick pale yellow secretions suctioned with 10F catheter due to small diameter of trach. Sats improved after suctioning and have been running 92% on our vent on AC 15, TV 400, FIO2 25% with 5cm peep. Lungs coarse, deminished. Getting albuterol MDI Q4hr. Requires suctioning Q4hrs or so at home.\n\nGI: NPO after MN for bronch tomorrow. ?scheduled for 8AM. Takes her pills mixed in applesauce and swallows this without difficulty.\n\nGU: Does not have foley. Was incontinent of large amt urine on admission to unit. Was incontinent at that time due to coughing and agitation and asked for diaper to be applied after this happened. Will leave catheter out for now(None ordered) but will need to reassess this tomorrow.\n\nEndo: Ordered for sliding scale coverage QID.\n\nID: Afebrile with normal WBC\n\nSocial: Pt's daughter is spokesperson and proxy. Aware of plan and updated by the team.\n\n" }, { "category": "Nursing/other", "chartdate": "2153-09-21 00:00:00.000", "description": "Report", "row_id": 1507055, "text": "1900-0700 rn notes micu\n\nneuro: alert/awake, follows commands, opens eyes spont, commuunication via mouth words. MAE.\n\nresp:pt received on vent 30%/400/RR15/pee5, decreased RR 12. sx moderated yellow secretion, sx done per pt request. SAt 96-98%, LS coarse.\n\ncv: HR 90's, Afib, PVC's rare. SBP 110-120, no fluid boluses requerid. morning labs pending. given Prednison PO, please give Benadryl/ Famotidine/Prednison before CT scan, pt allergic to Iodine.\n\ngu/gi:pt voides in diapers large amount urine. BAD soft/dis, BS +, no BM this shift. pt NPO( exept meds, takes meds with applesause, tollerates good) for bronch/CT angio.\n\nid: afebrile, Tmax 98.4.\n\naccess: 1piv.\n\nskin: intact.\n\nplan: bronch/CT angio in the morning.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-21 00:00:00.000", "description": "Report", "row_id": 1507056, "text": "resp care\nPt originally on a/c 500x15 25% 5peep according to home vent settings. Vt to 400cc because at home her cuff is deflated and she has a large cuff leak.Abg drawn on a/c 400x15 25%. Fio2 inc to 30% and rr to 12 to correct abg. BS coarse. Suct for thick creamy secretions. Alb mdi given q4 as ordered. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2153-09-21 00:00:00.000", "description": "Report", "row_id": 1507057, "text": "Pt BS are equal with light wheezes noted. Pt placed on PSV when awake and is to go back on A/C when sleeping. Trach tube changed to #7 to allow better sx. pt sxed for small amounts of thick yellow sputum.\npt went to ct today for a chest ct with contrast. She also received a bronch this morning.\n" }, { "category": "Echo", "chartdate": "2153-09-21 00:00:00.000", "description": "Report", "row_id": 77451, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nWeight (lb): 150\nBP (mm Hg): 104/52\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Low normal\nLVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets are moderately\nthickened. There is mild aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2153-09-21 00:00:00.000", "description": "Report", "row_id": 183163, "text": "Atrial fibrillation\nPremature ventricular contraction\nAnterolateral ST-T changes\nConsider left ventricular hypertrophy\nSince previous tracing, single ventricular premature complex new\n\n" }, { "category": "ECG", "chartdate": "2153-09-20 00:00:00.000", "description": "Report", "row_id": 183164, "text": "Atrial fibrillation with a moderate ventricular response. New biphasic\nT waves in leads V2-V5 compared to the previous tracing of . Rule out\nrecent anterolateral myocardial injury. Followup and clinical correlation are\nsuggested.\n\n" }, { "category": "Radiology", "chartdate": "2153-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883251, "text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute chest process\n Admitting Diagnosis: PROGRESSIVE RESPIRATORY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent increase DOE, O2 requirements, now on vent. On\n vent at home at night.\n REASON FOR THIS EXAMINATION:\n ? acute chest process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:22 A.M.:\n\n HISTORY: Increasing dyspnea.\n\n IMPRESSION: AP chest compared to and :\n\n Moderate pulmonary edema is more severe than it was on . Moderate\n to severe cardiomegaly with particular left atrial enlargement is stable.\n Large lung masses may be more numerous, but have not grown particularly in\n size. Tracheostomy tube in standard placement. Small bilateral pleural\n effusions are presumed. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-09-21 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 883324, "text": " 2:25 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate for pulmonary embolism, please get airway reconstru\n Admitting Diagnosis: PROGRESSIVE RESPIRATORY DISEASE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with , now more dyspneic / hypoxemic\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary embolism, please get airway reconstructions as well\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 4:00 PM\n no evidence of PE; lung metastases as before; full report to follow once\n airway reconstructions will be performed in the imaging lab during business\n hours\n WET READ VERSION #1 DFDkq SUN 3:58 PM\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest CT angiogram.\n\n HISTORY: 84-year-old woman with history of thyroid cancer and -,\n rule out pulmonary embolism\n\n TECHNIQUE: Thorax CT angiogram. Non-contrast images were also obtained.\n Coronal and sagittal reformations are also provided.\n\n Comparison is made with prior study dated .\n\n FINDINGS: Moderate cardiomegaly. There are calcifications within the\n coronary arteries. There is no evidence of pericardial effusion. The aorta is\n normal in caliber. There are no filling defects in the branches of the\n pulmonary artery suggesting pulmonary embolism. There is a filling defect in\n the left atrium at the level of the entrance of the inferior right pulmonary\n vein that might be related with turbulent flow versus direct tumor invasion\n of the left atrium. Bilateral pleural effusions. Multiple pulmonary soft\n tissue masses scattered throughout both lung parenchyma with more compromise\n of the lower lobes. The left branches of the airways are patent. There is\n compression of the distal branches of the midle lobe and basal segments of the\n lower right lobe by the hiliar and lung masses.\n\n The descending aorta is partially thrombosed and calcified.\n\n Tracheal tube in place.\n\n BONE WINDOWS: Important degenerative changes are seen throughout the thoracic\n spine\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Multiple metastatic pulmonary masses as described compressing the bronchus\n intermedius and the right lower lobe bronchi.\n 3. Turbulent flow versus direct invasion by tumor of the left atrium at the\n (Over)\n\n 2:25 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: evaluate for pulmonary embolism, please get airway reconstru\n Admitting Diagnosis: PROGRESSIVE RESPIRATORY DISEASE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n entrance of the right inferior pulmonary vein.\n\n" }, { "category": "Radiology", "chartdate": "2153-09-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883369, "text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: PROGRESSIVE RESPIRATORY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent increase DOE, O2 requirements, now on vent. On\n vent at home at night.\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Metastatic disease. Increased dyspnea.\n\n FINDINGS: The tracheostomy tube in situ.\n\n There are multifocal rounded soft tissue masses in the right and left lung,\n the largest at the right upper zone measures up to 5 cm, multiple others\n measuring over 3 cm in size.\n Increased opacification of the right lower zone and to a lesser extent left\n lower zone which previous CT has shown due to gross consolidation and multiple\n masses. Small to moderate size effusion at the right base.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2195-07-20 00:00:00.000", "description": "Report", "row_id": 1373116, "text": "T/SICU Nursing Admission Note\nThis is a 69 year old male admitted to the T/SICU s/p fasciotomy of the right lower arm for rhabdomyolysis after being found down for an extended period of time, presumably after a seizure. He has no drug allergies, and his past medical history and medications are listed in the FHP. Current ROS as follows:\n\nNeuro: Alert and oriented x3. MAE purposefully, follows commands. Mild mental retardation.\n\nPain: Non-descript when describing pain at surgical site, states \"it's okay\", refuses any pain medications.\n\nResp: Lung sounds clear, equal, diminished bibasilar. SPO2 high 90's on 2L NC. Coughing and deep breathing encouraged. Too drowsy for IS teaching.\n\nCV: Sinus rhythm rate 70-86. BP 128-148/60-75. Palpable pulses in all extremities, RUE warm to touch with cap refill <2 sec.\n\nGI: NPO. Bowel sounds hypoactive.\n\nGU: Foley to gravity, adequate amount of amber/yellow urine with some sediment. On D5W with sodium bicarb with goal U/O >100cc/hr; currently receiving NS bolus as urine output the prior hour to this note was 40cc.\n\nLabs/Lytes: Hemolyzed Mg level 1.9, no orders to replete. CK \n\nSocial: No family contact. Pt states siblings are aware of his hospitalization, and brought him into the ER.\n\nPlan:\nMaintain safety\nPain management\nGoal urine output >100cc/hr\nFrequent circulatory checks RUE\nNotify team of acute changes\n" }, { "category": "ECG", "chartdate": "2195-07-19 00:00:00.000", "description": "Report", "row_id": 264875, "text": "Sinus rhythm\nPossible inferior infarct - age undetermined\nNo change from previous\n\n" }, { "category": "Nursing/other", "chartdate": "2195-07-20 00:00:00.000", "description": "Report", "row_id": 1373117, "text": "NPN: \nROS: see carevue for details\n\nNEURO: patient alert & oriented x2-3, baseline MR. . +CSM to all extremities. c/o small amount of pain to right arm. PERLA , briskly reactive.\n\nCV: HR 70-80s, SR. BP stable. +pp. weak pulse to right radial, ulnar pulse strong. +pp. hemodynamically stable. CKs trending down.\n\nRESP: 02 sat on room air 95-97%. LS clear, diminished.\n\nGI: tolerating house diet without difficulty. abd s/nt/nd. +bs.\n\nGU: foley catheter with good urine output. clearing and becoming lighter t/o day. remains on D5W with bicarb at 250cc/hr with goal to maintain u/o better than 100 cc.\n\nENDO: bs WNL\n\nSKIN: multiple abrasion to right side, telfa dressing and bacitracin applied. right lower arm fasciotomy site with w>d dressing changed 2x today.\n\nSOCIAL: sister into visit today. patient lives in some sort of group home/ community, case manager called today for update, I refered her to patient's sister for info.\n\nID: no issues. afebrile\n\nPLAN: cont to flush kidneys, watch CD trends. encourage oob activity. monitor & support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2195-07-21 00:00:00.000", "description": "Report", "row_id": 1373118, "text": "neuro: pt alert obeys commands.oriented.\n\ngi: pos bowel sounds.taking liquids and small amounts po. difficulty swallowing pills so crushed and given with custard.. toleerated well.\n\ngu: foley draining clear yellow urine ~ 200 cc/hr.\n\niv: 2 iv's left arm. d5w with bicarb at 250 cc/hr.\n\nskin: r shoulder abrasion .cleansed with saline and covered with xeroform and dsd.abrasion under r arm cleansed with saline and covered with telfa. r hip large red abrasion cleansed with saline and covered with dsd. r anterior rib abrasion cleansed with ns and covered with dsd. r arm dressing changed for mod seosanguinous. covered with wet to dry ns gauze and covered with dsd and kling. fasciotomy site is clean and pink and open with stay sutures intact.\n\nPain: pt c/o pain in r arm only when turning and refuses pain med.\n" }, { "category": "Radiology", "chartdate": "2195-07-19 00:00:00.000", "description": "R HAND (AP, LAT & OBLIQUE) RIGHT", "row_id": 923911, "text": " 9:29 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGHTClip # \n HAND (AP, LAT & OBLIQUE) RIGHT\n Reason: eval fx, disloctn\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with R shoulder pain\n REASON FOR THIS EXAMINATION:\n eval fx, disloctn\n ______________________________________________________________________________\n FINAL REPORT\n 69-year-old male after fall with right shoulder, arm and wrist pain.\n\n THREE VIEWS OF THE RIGHT SHOULDER: There is no evidence of fracture or\n dislocation. There is normal bone mineralization. The acromioclavicular and\n glenohumeral articulations are preserved. There is no demonstrable\n degenerative change. Regional soft tissues are unremarkable.\n\n RIGHT ELBOW, THREE VIEWS: There is no evidence of fracture or dislocation.\n There is normal bone mineralization. There is no elbow effusion. Regional\n soft tissues are unremarkable.\n\n RIGHT HAND, THREE VIEWS: There is no evidence of fracture or dislocation.\n There is normal bone mineralization. There are no periarticular erosions.\n There is no significant degenerative change. The regional soft tissues are\n unremarkable.\n\n IMPRESSION: No fracture or dislocation of the right shoulder, right elbow, or\n right hand.\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2105-11-19 00:00:00.000", "description": "Report", "row_id": 229173, "text": "Artifact is present. Sinus tachycardia. Otherwise, normal tracing.\nCompared to the previous tracing of the rate is faster.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1030388, "text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, interval CXR\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n intubated, interval CXR\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 12:52 PM\n Two nodular opacities projecting over the left upper lung, more medial one was\n probably present on the initial chest radiograph, but is more conspicuous\n today. More lateral one is a newly apparent, and although it can represent\n summation shadows or artifact, further evaluation with chest CT when patient\n is extubated, breathing spontaneously and is able to follow breathing\n instructions is recommended.\n\n 2. No radiographic evidence of pneumonia or pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old female with status post colectomy for GI bleeding.\n\n COMPARISON: Several prior studies, most recent dated .\n\n FINDINGS: The support lines and tubes are in unchanged position. There are\n two small nodular opacities, projecting in the left upper lobe. 7-mm more\n medial one is slightly heterogeneous and has ill-defined borders, was present\n on several prior studies, but it is more conspicuous today. Another bilobed\n nodular density projects more laterally in the left upper lobe, measured\n approximately 13 x 7 mm in overall dimensions. There is no pneumothorax. A\n small left effusion may be present. No radiographic evidence of pneumonia.\n\n IMPRESSION:\n 1. Two nodular opacities are evident in the left upper hemithorax, further\n evaluation with dedicated chest CT is recommended, when patient is extubated,\n spontaneously breathing and is able to follow breathing instructions.\n\n 2. No radiographic evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1030389, "text": ", T. SICU-A 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, interval CXR\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n intubated, interval CXR\n ______________________________________________________________________________\n PFI REPORT\n Two nodular opacities projecting over the left upper lung, more medial one was\n probably present on the initial chest radiograph, but is more conspicuous\n today. More lateral one is a newly apparent, and although it can represent\n summation shadows or artifact, further evaluation with chest CT when patient\n is extubated, breathing spontaneously and is able to follow breathing\n instructions is recommended.\n\n 2. No radiographic evidence of pneumonia or pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-27 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1030103, "text": " 8:11 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? stroke\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman ? stroke\n REASON FOR THIS EXAMINATION:\n ? stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DFDkq TUE 2:33 PM\n Multiple small early subacute infarctions in both cerebral hemispheres,\n suggestive of embolic etiology. Diffuse irregularity in the anterior, middle\n and posterior cerebral arteries, most likely related to atherosclerosis in a\n patient of this age, and much less likely related to vasculitis. Bilateral\n mastoid air cell opacification.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Stroke.\n\n COMPARISON: Noncontrast head CT dated one day earlier is available for\n correlation.\n\n TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR, gradient echo,\n and diffusion-weighted images of the brain were obtained. Three-dimensional\n time-of-flight MRA of the head was obtained, and maximal intensity projections\n were generated.\n\n HEAD MRI WITHOUT CONTRAST: There are multiple small cortical infarctions in\n both cerebral hemispheres, involving the frontal, parietal, and occipital\n lobes. They demonstrate high signal on the diffusion-weighted and FLAIR\n images, which indicates that they are early subacute, less than 10 days old.\n There is no significant associated mass effect.\n\n There are multiple foci of high signal on T2-weighted and FLAIR images in the\n subcortical, deep, and periventricular white matter of the cerebral\n hemispheres, consistent with chronic small vessel ischemic disease. There is\n mild-to-moderate cerebral atrophy with associated prominence of the sulci and\n ventricles. Calcifications are noted in the globus pallidus bilaterally. A\n focus of increased susceptibility artifact in the left putamen may also\n represent a calcification or sequela of a remote hemorrhage.\n\n The mastoid air cells are opacified bilaterally. There is mild-to-moderate\n mucosal thickening in the left maxillary sinus. There is mild mucosal\n thickening in the right middle and posterior ethmoid air cells, and in the\n right sphenoid sinus.\n\n There is a grade I anterolisthesis in the cervical spine at C2/3, incompletely\n assessed.\n\n HEAD MRA: Flow is visualized in the intracranial internal carotid and\n vertebral arteries, and their major branches. There is diffuse irregularity\n (Over)\n\n 8:11 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? stroke\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in the anterior, middle and posterior cerebral arteries bilaterally, most\n likely related to atherosclerosis in a patient of this age. While there is a\n suggestion of mild beading, particularly in the posterior cerebral arteries,\n vasculitis is less likely. There is no evidence of an aneurysm.\n\n IMPRESSION:\n 1. Multiple small cortical infarctions in both cerebral hemispheres, in the\n distribution of the anterior and posterior circulation, suggestive of embolic\n etiology.\n\n 2. Chronic small vessel ischemic disease.\n\n 3. Bilateral mastoid air cell opacification.\n\n 4. Diffuse irregularity in the anterior, middle and posterior cerebral\n arteries bilaterally, most likely related to atherosclerosis in a patient of\n this age. Vasculitis is less likely.\n\n Findings were reported to Dr. at approximately 12 p.m. on\n .\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2150-07-27 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1030104, "text": ", T. SICU-A 8:11 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? stroke\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman ? stroke\n REASON FOR THIS EXAMINATION:\n ? stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Multiple small early subacute infarctions in both cerebral hemispheres,\n suggestive of embolic etiology. Diffuse irregularity in the anterior, middle\n and posterior cerebral arteries, most likely related to atherosclerosis in a\n patient of this age, and much less likely related to vasculitis. Bilateral\n mastoid air cell opacification.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2150-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031259, "text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval exam\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n interval exam\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SUN 9:28 AM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Interval followup tracheostomy tube.\n\n One portable supine view. Comparison with . The lungs are partially\n obscured by plastic tubing and monitor leads. There is streaky density at the\n bases consistent with subsegmental atelectasis and/or scarring. Mediastinal\n structures are stable. The left hemidiaphragm is mildly elevated. A\n tracheostomy tube and nasogastric tube remain in place. Allowing for\n technical differences there is no significant change.\n\n IMPRESSION: No significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1031467, "text": " 11:36 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed,42cm and needs tip con\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with recent CVA who needs picc line for access.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,42cm and needs tip confirmation please\n page Cardmel at with wet read,thanks.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX MON 1:24 PM\n PICC line terminates in superior vena cava.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: PICC line placement.\n\n One portable view. Comparison with . The lungs remain essentially\n clear. The heart and mediastinal structures are unchanged. A nasogastric\n tube and tracheostomy tube remain in place. A PICC line has been inserted on\n the right and terminates in the region of the mid superior vena cava. There\n is no other significant change.\n\n IMPRESSION: PICC line terminates in region of superior vena cava.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1031468, "text": ", T. SICU-A 11:36 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed,42cm and needs tip con\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with recent CVA who needs picc line for access.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,42cm and needs tip confirmation please\n page Cardmel at with wet read,thanks.\n ______________________________________________________________________________\n PFI REPORT\n PICC line terminates in superior vena cava.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031981, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with intubated\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, to evaluate for pneumonia.\n\n FINDINGS: There is probably little change in the appearance of the heart and\n lungs. What appeared to be multiple skin folds are simulating pleural lines\n on the right. No evidence of acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-27 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 1029989, "text": " 9:30 AM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: h/o CVA with new left upper extremity weakness, eval for ste\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n h/o CVA with new left upper extremity weakness, eval for stenosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRc TUE 1:17 PM\n Less than 40% stenosis of the internal carotid arteries bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old woman with history of CVA with new left upper\n extremity weakness.\n\n FINDINGS:\n\n RIGHT SIDE: There is atherosclerotic plaque at the carotid bifurcation and\n proximal internal and external carotid arteries. The peak systolic velocity\n in the common carotid artery 76 cm/sec, proximal ICA 49 cm/sec, mid ICA 64\n cm/sec, distal ICA 64 cm/sec and external carotid artery 91 cm/sec. ICA/CCA\n ratio 0.84. The flow in the vertebral artery is in antegrade direction.\n\n LEFT SIDE: There are atherosclerotic changes in the distal common carotid\n artery, carotid bifurcation and proximal internal carotid artery. The peak\n systolic velocity in the common carotid artery 113 cm/sec, proximal ICA 68\n cm/sec, mid ICA 66 cm/sec, distal ICA 45 cm/sec, and external carotid artery\n 85 cm/sec. ICA/CCA ratio 0.60. The flow in the vertebral artery is in\n antegrade direction.\n\n IMPRESSION: Mild atherosclerotic changes with less than 40% stenosis of the\n internal carotid arteries bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-27 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 1029990, "text": ", T. SICU-A 9:30 AM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: h/o CVA with new left upper extremity weakness, eval for ste\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n h/o CVA with new left upper extremity weakness, eval for stenosis\n ______________________________________________________________________________\n PFI REPORT\n Less than 40% stenosis of the internal carotid arteries bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029734, "text": ", T. SICU-A 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman intubated, ? fluid overload\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n Worsening atelectasis of the left lower lobe, no evidence of fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1030200, "text": " 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inteval exam\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n inteval exam\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 85-year-old woman, intubated.\n\n Since , bibasilar atelectasis decreased. If any, bilateral\n pleural effusion remain very tiny. Right subclavian vein catheter is in\n unchanged position. ETT tip is 5.3 cm above the carina. Nasogastric tube\n ends at least in the stomach. No other change.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031212, "text": " 8:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out infiltrate\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with increased sputum production, increased work of\n breathing, fever\n REASON FOR THIS EXAMINATION:\n rule out infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SUN 9:30 AM\n No acute infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Increased sputum production, rule out infiltrate.\n\n One view. Comparison with . Endotracheal tube has been removed and a\n tracheostomy tube has been inserted. Previously demonstrated nodular\n densities in the left lung are no longer apparent but they may be obscured by\n overlying tubes and a monitor lead. The cardiac silhouette is prominent but\n may be exaggerated by portable technique. The aorta is tortuous and\n calcified. Mediastinal structures are unchanged. A nasogastric tube remains\n in place. The bony thorax is grossly intact.\n\n IMPRESSION: Limited study demonstrating no active pulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029733, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman intubated, ? fluid overload\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 10:17 AM\n Worsening atelectasis of the left lower lobe, no evidence of fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Intubated patient, assess for fluid overload.\n\n Comparison is made with prior study . Left lower lobe\n atelectasis has worsened. If any, there are small bilateral pleural\n effusions. Right lower opacity has slightly increased likely due to\n atelectasis. Right subclavian catheter tip is in the SVC. ET tube is in\n standard position. NG tube tip is out of view below the diaphragm. No\n evidence of pneumothorax.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2150-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032195, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for atelectasis, infiltrates\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman intubated\n REASON FOR THIS EXAMINATION:\n evaluate for atelectasis, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, to evaluate for atelectasis or infiltrate.\n\n FINDINGS: In comparison with study of , there is little change.\n Hyperexpansion of the lungs persist without evidence of acute pneumonia or\n substantial atelectasis. Tubes remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031260, "text": ", T. SICU-A 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval exam\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n interval exam\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1029875, "text": " 4:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: new left upper extremity weakness, h/o CVA\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p subtotal colectomy. h/o cva with permanent speech deficit\n and resolved facial droop (unknown side)\n REASON FOR THIS EXAMINATION:\n new left upper extremity weakness, h/o CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female status post subtotal colectomy. History of\n CVA with permanent speech deficit and resolve facial droop, with new left\n upper extremity weakness.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass, mass\n effect, edema, or evidence of acute vascular territorial infarction.\n Ventricles and sulci are mildly prominent, most consistent with age-related\n atrophy. There is also mild-to-moderate periventricular and subcortical white\n matter hypodensity, most consistent with chronic small vessel ischemic change.\n Note is made of prominent calcifications in the bilateral carotid siphons.\n\n There is near-complete opacification of the left maxillary sinus, with\n adjacent bony sclerosis. There is also partial opacification of the bilateral\n mastoid air cells, left greater than right.\n\n IMPRESSION:\n 1. No acute intracranial process. Please note that MRI with diffusion-\n weighted imaging is more sensitive for the detection of acute brain ischemia.\n\n 2. Left maxillary sinus opacification, with adjacent bony remodeling, and\n bilateral mastoid air cell opacification.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1031213, "text": ", T. SICU-A 8:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out infiltrate\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with increased sputum production, increased work of\n breathing, fever\n REASON FOR THIS EXAMINATION:\n rule out infiltrate\n ______________________________________________________________________________\n PFI REPORT\n No acute infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032740, "text": " 11:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, also eval free air from yesterday xray\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with failure to wean, increasing wbc\n REASON FOR THIS EXAMINATION:\n eval for PNA, also eval free air from yesterday xray\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure with increasing white cell count and to evaluate\n for free air.\n\n FINDINGS: In comparison with study of , there is little change.\n Specifically, no evidence of acute pneumonia. The degree of intraperitoneal\n gas cannot be evaluated because the upper abdomen has been excluded from the\n image.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-11 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1033007, "text": ", T. SICU-A 3:15 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: r/o dvts\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CVA\n REASON FOR THIS EXAMINATION:\n r/o dvts\n ______________________________________________________________________________\n PFI REPORT\n No DVT in either leg.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-08 00:00:00.000", "description": "LP UNILAT UP EXT VEINS US LEFT PORT", "row_id": 1032426, "text": " 9:48 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: LT FOREARM SWELLING ,EVAL FOR DVT\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with swelling and warmth of left forearm\n REASON FOR THIS EXAMINATION:\n rule out DVT of the left upper extremity\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb SAT 11:37 AM\n No left upper extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old woman with swelling and warmth of left forearm.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler imaging of the left internal jugular,\n subclavian, axillary, brachial, basilic, and cephalic veins are performed.\n Normal compressibility, waveform, flow, and augmentation is demonstrated. No\n intraluminal thrombus is identified. Atherosclerotic plaque within the left\n common carotid artery is partially imaged.\n\n IMPRESSION: No left upper extremity DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033112, "text": ", T. SICU-A 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval xray\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p total abdominal colectomy with continued fevers after\n peg placement and free air noted\n REASON FOR THIS EXAMINATION:\n interval xray\n ______________________________________________________________________________\n PFI REPORT\n Normal heart and lungs. Persistent pneumoperitoneum. Trach okay.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-08 00:00:00.000", "description": "LP UNILAT UP EXT VEINS US LEFT PORT", "row_id": 1032427, "text": ", T. SICU-A 9:48 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: LT FOREARM SWELLING ,EVAL FOR DVT\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with swelling and warmth of left forearm\n REASON FOR THIS EXAMINATION:\n rule out DVT of the left upper extremity\n ______________________________________________________________________________\n PFI REPORT\n No left upper extremity DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034250, "text": " 3:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent CVA, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there is little change.\n Opacification persists in the retrocardiac area on the left, most likely\n related to atelectasis. Remainder of the lungs is clear. No vascular\n congestion. Tracheostomy tube remains in place.\n\n IMPRESSION: Little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033928, "text": " 1:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85F w hx of recent CVA on coumadin, present w/ nausea and largepainless bloody\n bowel movements at home x2 starting today. -F/C/S, more large bloody BMs\n in ED. HCT decreased from 32.9to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L\n IVF, Levo/Flagyl, 4units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued\n BRBPR. Brought to SICU for continued management8/19: admitted to SICU, s/p 7U\n PRBC by 0700 am(1U by OSH), s/p 6U FFP, East Surgical Service (),\n Cipro/Flagyl, Reverse coagulopathy c FFP, Serial Hct, transfuse pRBC as\n necessary, OR S/P subtotal colectomy8/20: extubated, then reintubated for resp\n distress8/21:CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr, tube feeds\n started :wean dilt, Wean PS, lasix 10 : vent wean, TFs increased :\n vent wean, TTE ordered, CT head given new LUE weakness and h/o CVA (CVA /\n with permanent speech deficit improved with rehab. also transient facial\n droop - unknown side), neurology consult (recc ASA/coumadin when permissible,\n carotid U/S, TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness,\n obtain hospital med records from / CVA tx), start\n statin/asa, start heparin qtt8/25: MRI head neck changed, TF to nutren25 :\n trying to wean patient on vent : family meeting, transfuse 2 PRBC, wean\n vent, d/c heparin qtt per neurology 8/28:2PRBC Hct 23-288/30: febrile, cx sent,\n persistent leukocytosis, vanc/zosyn started empirically, wean propofol --\n intermittent versed, afib8/31:Afib settled with lopressor 1 dose9/1: sent off\n triglycerides for continued propofol requirement, attempted to wean vent to \n but became tachycardic and had increased work of breathing9/2: increased \n ouput, started psyillium, TFs @ 20kcal/kg, PS trial9/5/08: PEG performed at\n bedside - ready for discharge to LTAC asap9/6: cont PS wean, awaiting vent\n rehab bed9/9: spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still high,\n started DTO, PICC removed PIV placed9/10: lasix gtt, albumin started (possibly\n volume overload causing tachypnea and inability to wean): stopped lasix\n gtt, started zosyn for Pseudomonas sputum. Low urine output overnight, multiple\n fluid boluses. Pt with episode of emesis during the day when given NS bolus. NS\n boluses d/c, writen for salt tabs\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Bloody stool.\n\n FINDINGS:\n\n Comparison is made to the prior study from . Tracheostomy is in the\n midline. Patient is somewhat rotated. There is no change in the appearance\n of the chest. There is mild atelectasis at the left lung base. The remainder\n of the lungs are otherwise clear. Heart and mediastinum are stable.\n\n (Over)\n\n 1:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "L ABDOMEN (LAT DECUB ONLY) LEFT", "row_id": 1033620, "text": " 7:19 AM\n ABDOMEN (LAT DECUB ONLY) LEFT Clip # \n Reason: Lateral Decubitus Film Please\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with abdominal distension\n REASON FOR THIS EXAMINATION:\n Lateral Decubitus Film Please\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND DECUBITUS ABDOMINAL RADIOGRAPH\n\n INDICATION: Abdominal distention.\n\n The stomach is markedly distended with a G-tube in place. There is persistent\n free air, likely due to gastrostomy tube. There is no evidence of ileus or\n obstruction.\n\n IMPRESSION: Distended stomach. Persistent intra-abdominal free air.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033820, "text": ", T. SICU-A 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inteval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and largepainless\n bloody bowel movements at home x2 starting today. -F/C/S, more large\n bloody BMs in ED. HCT decreased from 32.9to 29.4 in 1hr, INR 3.2, WBC 18.5\n received 2L IVF, Levo/Flagyl, 4units FFP, vit K 5units, 3 unit PRBC (1 in OSH).\n Continued BRBPR. Brought to SICU for continued management\n REASON FOR THIS EXAMINATION:\n inteval\n ______________________________________________________________________________\n PFI REPORT\n No change.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033111, "text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval xray\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p total abdominal colectomy with continued fevers after\n peg placement and free air noted\n REASON FOR THIS EXAMINATION:\n interval xray\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:24 PM\n Normal heart and lungs. Persistent pneumoperitoneum. Trach okay.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:22 A.M., \n\n HISTORY: Colectomy. Fevers. After PEG placement.\n\n IMPRESSION: AP chest compared to and 9:\n\n Lungs are fully expanded and are clear. No pneumothorax or pleural effusion.\n Pneumoperitoneum still present. Heart size normal. Tracheostomy tube in\n standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033561, "text": " 7:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o new infiltrate\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 11:00 P.M., \n\n HISTORY: Fever. Rule out pneumonia.\n\n IMPRESSION: AP chest compared to and , 5:36 a.m.:\n\n Lungs clear. No pleural effusion. Because of overlying tubing and\n connectors, a small left apical pneumothorax could be present but obscured.\n Followup advised. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033621, "text": " 7:19 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with ?sepsis\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 12:16 PM\n No significant change compared to the study done two hours previously.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n HISTORY: 85-year-old woman with sepsis.\n\n COMPARISON: Comparison is made to multiple past chest radiographs since early\n .\n\n FINDINGS: Compared to the study done approximately two hours earlier on\n , there is no significant change. The tip of the tracheostomy\n tube is angled towards the left wall of the trachea. The lungs are clear with\n no consolidation. There are no pleural effusions. The cardiomediastinal\n contour is unremarkable.\n\n IMPRESSION:\n No significant change compared to the study done two hours previously.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033622, "text": ", T. SICU-A 7:19 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with ?sepsis\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n No significant change compared to the study done two hours previously.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-17 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1034070, "text": " 8:00 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Eval gallbladder\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n Eval gallbladder\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 11:19 AM\n Partially contracted gallbladder with no stones and no signs of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with abdominal pain. Evaluate gallbladder.\n\n COMPARISON: No previous exams for comparison.\n\n FINDINGS: Note is made that this portable exam is limited due to the\n patient's body habitus. The liver shows no focal or textural abnormality.\n There is no biliary dilatation and the common duct measures 0.4 cm. The\n portal vein is patent with hepatopetal flow. The gallbladder is partially\n contracted as the patient is on tube feedings. No gallstones are identified\n and there are no signs of cholecystitis. The spleen is unremarkable and\n measures 10.7 cm. Both right and left kidneys show no hydronephrosis. The\n right kidney measures 11.0 cm and the left kidney measures 11.7 cm. A simple\n cyst is seen in the posterior aspect of the lower pole of the left kidney\n measuring 2.7 x 2.6 x 2.0 cm. A left pleural effusion is seen. A moderate\n amount of complex ascites fluid is seen in the right flank.\n\n IMPRESSION:\n 1. No gallstones and no signs of cholecystitis. Partially contracted\n gallbladder.\n 2. Left pleural effusion and complex ascites in the right flank.\n 3. 2.7 cm simple left renal cyst.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-17 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1034071, "text": ", T. SICU-A 8:00 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Eval gallbladder\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n Eval gallbladder\n ______________________________________________________________________________\n PFI REPORT\n Partially contracted gallbladder with no stones and no signs of cholecystitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033595, "text": ", T. SICU-A 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n PFI REPORT\n Interval worsening of left lower lobe linear atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1034303, "text": " 10:08 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please check placement l ceph picc(45 cm) call beeper \n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n please check placement l ceph picc(45 cm) call beeper with read asap\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a left subclavian PICC line that extends to about the cavoatrial\n junction. Otherwise, little change. This information was telephoned to the\n venous access nurse.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-10 00:00:00.000", "description": "G/GJ/GI TUBE CHECK", "row_id": 1032741, "text": " 11:36 AM\n G/GJ/GI TUBE CHECK Clip # \n Reason: evaluate for evidence of leak from PEG tube\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with failure to wean, increasing wbc, free air on yesterdays\n CXR\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of leak from PEG tube\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JLLW WED 3:46 AM\n no contrast extravasation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with failure to wean, elevated white blood\n cell count and free air on chest x-ray. Evaluate for leak from PEG placement.\n\n FINDINGS: Two frontal views of the abdomen pre- and post-injection of oral\n contrast through a gastric tube demonstrate free intraperitoneal air, notably\n in the left upper quadrant, as demonstrated on prior chest radiograph. Oral\n contrast remains within the stomach with no evidence of extravasation.\n\n IMPRESSION:\n 1. Again seen, free intraperitoneal air.\n 2. No evidence of extravasation of oral contrast.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-10 00:00:00.000", "description": "G/GJ/GI TUBE CHECK", "row_id": 1032742, "text": ", T. SICU-A 11:36 AM\n G/GJ/GI TUBE CHECK Clip # \n Reason: evaluate for evidence of leak from PEG tube\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with failure to wean, increasing wbc, free air on yesterdays\n CXR\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of leak from PEG tube\n ______________________________________________________________________________\n PFI REPORT\n no contrast extravasation\n\n" }, { "category": "Radiology", "chartdate": "2150-08-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032884, "text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA and free air in abdomen\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with failure to wean, increasing wbc, free air on yesterdays\n CXR\n REASON FOR THIS EXAMINATION:\n eval for PNA and free air in abdomen\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Failure to wean with increasing white count and free air.\n\n FINDINGS: In comparison with study of , there is little change. The\n cardiac silhouette is essentially within normal limits in this patient with a\n tracheostomy tube in place. No acute focal pneumonia. The degree of free\n intraperitoneal gas may be slightly less than on the study of , but is\n still significant.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 1033616, "text": " 5:54 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE ABDOMINAL RADIOGRAPH\n\n INDICATION: Abdominal pain.\n\n COMPARISON: .\n\n FINDINGS: There is persistent free air, due to gastrostomy tube. The stomach\n is markedly distended. There is no ileus or obstruction. There is marked\n degenerative change in the thoracic spine.\n\n IMPRESSION: Persistent free air likely due to gastrostomy. Gastric\n distension.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033366, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with trach, resp distress, failure to wean.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:10 PM\n 1) Status post recent PEG with persistent pneumoperitoneum. 2) Satisfactory\n appearance to tracheostomy, with hyperinflated but essentially clear lungs.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED :\n\n HISTORY: 85-year-old woman with tracheostomy, respiratory distress and\n inability to wean; evaluate for pulmonary edema.\n\n FINDINGS: Single bedside AP examination labeled \"supine\" is compared with\n studies dated and , with patient rotated to the right. Allowing\n for change in patient positioning, no acute process is seen. The tracheostomy\n is overall unchanged and a balloon-tipped gastrostomy tube is noted in the\n left upper abdomen, with persistent pneumoperitoneum, likely related to its\n placement. The lungs remain hyperinflated, but other than minimal left\n basilar linear scarring or atelectasis, clear. There is no evidence of CHF.\n Atherosclerosis of the thoracic aorta is re-demonstrated.\n\n IMPRESSION:\n 1) Status post PEG with persistent pneumoperitoneum.\n 2) Tracheostomy, unchanged with essentially clear lungs.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033819, "text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inteval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and largepainless\n bloody bowel movements at home x2 starting today. -F/C/S, more large\n bloody BMs in ED. HCT decreased from 32.9to 29.4 in 1hr, INR 3.2, WBC 18.5\n received 2L IVF, Levo/Flagyl, 4units FFP, vit K 5units, 3 unit PRBC (1 in OSH).\n Continued BRBPR. Brought to SICU for continued management\n REASON FOR THIS EXAMINATION:\n inteval\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc SAT 10:48 AM\n No change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: Recent CVA, on Coumadin with bloody bowel movements.\n\n Since yesterday, the tracheostomy tip is more central. Left basal atelectasis\n is unchanged. Lungs are otherwise clear. There is no pleural effusion. The\n cardiomediastinal silhouette and hilar contours are normal except to note\n tortuosity and calcifications of the aorta.\n\n\n" }, { "category": "Echo", "chartdate": "2150-07-27 00:00:00.000", "description": "Report", "row_id": 83432, "text": "PATIENT/TEST INFORMATION:\nIndication: Source of embolism.\nWeight (lb): 161\nBP (mm Hg): 132/80\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 15:33\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 and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Transmitral Doppler and TVI c/w Grade I (mild)\nLV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. Aortic valve not well seen. No masses\nor vegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nMild mitral annular calcification. Mild thickening of mitral valve chordae.\nCalcified tips of papillary muscles. Trivial MR. LV inflow pattern c/w\nimpaired relaxation.\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\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). Transmitral Doppler and tissue\nvelocity imaging are consistent with Grade I (mild) LV diastolic dysfunction.\nRight ventricular chamber size and free wall motion are normal. The number of\naortic valve leaflets cannot be determined. The aortic valve is not well seen.\nNo masses or vegetations are seen on the aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. Mild (1+) aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. No masses or vegetations\nare seen on the mitral valve, but cannot be fully excluded due to suboptimal\nimage quality. Trivial mitral regurgitation is seen. The left ventricular\ninflow pattern suggests impaired relaxation. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: No cardiac source of embolism identified. Preserved global and\nregional biventricular systolic function. Diastolic dysfunction. Mild aortic\nregurgitation.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033367, "text": ", T. SICU-A 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with trach, resp distress, failure to wean.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n PFI REPORT\n 1) Status post recent PEG with persistent pneumoperitoneum. 2) Satisfactory\n appearance to tracheostomy, with hyperinflated but essentially clear lungs.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034460, "text": ", T. SICU-A 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n PFI REPORT\n Persistent small bilateral pleural effusions and left lower lobe atelectasis\n or less likely pneumonia. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033594, "text": " 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc FRI 3:05 PM\n Interval worsening of left lower lobe linear atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure.\n\n Portable AP chest radiograph was compared to prior study dated at 8:18 p.m.\n\n The tracheostomy is at the midline with its tip 4.5 cm above the carina. The\n cardiomediastinal silhouette is stable. Interval worsening of the left linear\n opacities is demonstrated consistent with atelectasis. The upper lungs are\n unremarkable and continue to be hyperinflated. No evidence of pneumothorax or\n increased pleural effusion is present.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1034459, "text": " 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 11:03 AM\n Persistent small bilateral pleural effusions and left lower lobe atelectasis\n or less likely pneumonia. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, , 4:39 A.M.\n\n HISTORY: Respiratory failure.\n\n IMPRESSION: AP chest compared to :\n\n Small bilateral pleural effusion and left lower lobe consolidation, either\n atelectasis or pneumonia, unchanged since . Upper lungs clear.\n Heart size top normal. No pneumothorax. Tracheostomy tube in standard\n placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032553, "text": " 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess anatomical reason for resp failure.\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with trach, vent dependent\n REASON FOR THIS EXAMINATION:\n assess anatomical reason for resp failure.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n FINDINGS: In comparison with the study of , there is extensive gas within\n the peritoneal cavity, presumably related to the PEG tube insertion. Little\n change in the appearance of the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-08-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1033651, "text": " 9:09 AM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: interval distention and vomiting in a patient with gtube\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85F w hx of recent CVA on coumadin, present w/ nausea and largepainless bloody\n bowel movements at home x2 starting today. -F/C/S, more large bloody BMs\n in ED. HCT decreased from 32.9to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L\n IVF, Levo/Flagyl, 4units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued\n BRBPR. Brought to SICU for continued managementnow s/p total colectomy, trach\n and peg\n REASON FOR THIS EXAMINATION:\n interval distention and vomiting in a patient with gtube\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: Interval abdominal distension and nausea in patient with G-tube.\n\n COMPARISON: at 7:58.\n\n FINDINGS: There is trace free air layering along the pericolic gutter, likely\n due to patient's gastrostomy tube. The stomach remains dilated. There is no\n evidence of ileus or obstruction. There is marked degenerative change in the\n lumbar spine.\n\n IMPRESSION: Persistent free air likely due to gastrostomy tube. Gastric\n distention.\n\n" }, { "category": "Radiology", "chartdate": "2150-08-11 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1033006, "text": " 3:15 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: r/o dvts\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CVA\n REASON FOR THIS EXAMINATION:\n r/o dvts\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TUE 5:03 PM\n No DVT in either leg.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with CVA, rule out DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of bilateral common femoral,\n superficial femoral, popliteal and tibial veins were performed. There is\n normal flow, compression and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028554, "text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: short of breath, increased oxygen demands\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with GI bleed\n REASON FOR THIS EXAMINATION:\n short of breath, increased oxygen demands\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:23 AM\n PFI: No prior exam for comparison.\n\n Slight tortuosity and calcifications of the aorta. Hyperinflation and _____\n lucency of both upper lobes suggest emphysema. Small amount of air is in the\n esophagus. Left lower lobe atelectasis is tiny. Lungs are otherwise clear.\n There is no pleural effusion. Note that left costodiaphragmatic angle was\n excluded. Hilar contours are normal.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 85-year-old woman with gastrointestinal bleed. Shortness of\n breath.\n\n No prior exam for comparison.\n\n Slight tortuosity of the aorta is associated with calcifications of the aortic\n knob. The cardiomediastinal silhouette and hilar contours are otherwise\n normal. Left lower lobe atelectasis is tiny. There is no pleural effusion.\n Note that the left costodiaphragmatic angle was excluded. Hyperinflation and\n marked lucency of both upper lobes suggest emphysema. Lungs are otherwise\n clear.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028555, "text": ", T. SICU-A 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: short of breath, increased oxygen demands\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with GI bleed\n REASON FOR THIS EXAMINATION:\n short of breath, increased oxygen demands\n ______________________________________________________________________________\n PFI REPORT\n PFI: No prior exam for comparison.\n\n Slight tortuosity and calcifications of the aorta. Hyperinflation and _____\n lucency of both upper lobes suggest emphysema. Small amount of air is in the\n esophagus. Left lower lobe atelectasis is tiny. Lungs are otherwise clear.\n There is no pleural effusion. Note that left costodiaphragmatic angle was\n excluded. Hilar contours are normal.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028883, "text": " 12:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: resp distress\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n resp distress\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 4:48 PM\n Findings suggestive of overhydration, improved compared to prior study,\n atelectasis and aspiration are on the differential diagnosis, but less likely.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old woman with respiratory distress.\n\n COMPARISON: , 4:25 a.m.\n\n FINDINGS: The patient remains intubated, the endotracheal tube ends 4.4 cm\n above the carina. The nasogastric tube reaches the stomach. The cardiac\n silhouette is slightly decreased in size, compared to the prior study. There\n are persistent bibasal opacities as well of Kerley B lines, probably\n reflecting presence of mild improved interstitial edema. There is a small\n right pleural effusion. The left costophrenic angle is sharp.\n\n IMPRESSION: Bibasal opacities, in conjunction with Kerley B lines are\n suggestive of overhydration, improved compared to the prior study.\n Differential diagnosis includes aspiration and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028884, "text": ", T. SICU-A 12:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: resp distress\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with\n REASON FOR THIS EXAMINATION:\n resp distress\n ______________________________________________________________________________\n PFI REPORT\n Findings suggestive of overhydration, improved compared to prior study,\n atelectasis and aspiration are on the differential diagnosis, but less likely.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028794, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post op fluid status\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sub total colectomy\n REASON FOR THIS EXAMINATION:\n post op fluid status\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:18 AM\n Interval development of bibasal opacities consistent with atelectasis as well\n as a contribution of newly developed vascular engorgement, most likely due to\n volume overload.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after subtotal colectomy.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The ET tube tip is 5.6 cm above the carina. The NG tube tip is in the\n stomach. The left heart is mildly enlarged. The mediastinal contour is\n otherwise unremarkable. Interval increase in bibasal opacities as well as\n vascular enlargement in the perihilar area is demonstrated consistent with a\n combination of volume overload and potential bibasal areas of aspiration. The\n right subclavian line tip is in distal SVC. No evidence of pneumothorax is\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028795, "text": ", T. SICU-A 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post op fluid status\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sub total colectomy\n REASON FOR THIS EXAMINATION:\n post op fluid status\n ______________________________________________________________________________\n PFI REPORT\n Interval development of bibasal opacities consistent with atelectasis as well\n as a contribution of newly developed vascular engorgement, most likely due to\n volume overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029366, "text": ", T. SICU-A 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, chf\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with COPD, s/p ex lap, difficult to wean from vent\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, chf\n ______________________________________________________________________________\n PFI REPORT\n Retrocardiac opacity likely represents atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028594, "text": " 7:55 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval. line placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with LGIB\n REASON FOR THIS EXAMINATION:\n Eval. line placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:24 AM\n Since earlier today, the patient was intubated with ETT tip 5.3 cm above the\n carina. Nasogastric tube is installed with its distal tip in the fundus.\n Right subclavian vein catheter ends in low SVC. There is no pneumothorax.\n Calcifications of the left carotid artery are imaged. Hyperinflation and\n lucency of both upper lobes suggest emphysema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 85-year-old woman status post LGIB, evaluate line placement.\n\n Since earlier today, the patient was intubated with ETT tip 5.3 cm above the\n carina. Nasogastric tube was installed and has its tip in the fundus. Right\n subclavian vein catheter ends in low SVC. There is no pneumothorax.\n\n Calcifications of the left carotid artery are now imaged. Calcifications of\n the aortic knob are unchanged. Hyperinflation and lucency of both upper lobes\n suggest emphysema. Lungs are otherwise clear. There is no pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028595, "text": ", T. SICU-A 7:55 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval. line placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with LGIB\n REASON FOR THIS EXAMINATION:\n Eval. line placement\n ______________________________________________________________________________\n PFI REPORT\n Since earlier today, the patient was intubated with ETT tip 5.3 cm above the\n carina. Nasogastric tube is installed with its distal tip in the fundus.\n Right subclavian vein catheter ends in low SVC. There is no pneumothorax.\n Calcifications of the left carotid artery are imaged. Hyperinflation and\n lucency of both upper lobes suggest emphysema.\n\n" }, { "category": "Radiology", "chartdate": "2150-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029365, "text": " 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, chf\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with COPD, s/p ex lap, difficult to wean from vent\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, chf\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa FRI 10:21 AM\n Retrocardiac opacity likely represents atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: COPD, on ventilator, status post ex-lap with difficulty weaning.\n\n FINDINGS: An ET tube is seen approximately 5.0 cm above the carina. An NG\n tube is in a subdiaphragmatic location. Slight increased retrocardiac opacity\n with elevation of the left hemidiaphragm likely represents atelectasis. There\n are no definite pleural effusions. Linear opacity over the right apical lung\n field likely represents a skinfold.\n\n IMPRESSION: Retrocardiac opacity likely represents atelectasis. ET tube\n approximately 5 cm above the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029081, "text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Extubation failure\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with Subtotal colectomy\n REASON FOR THIS EXAMINATION:\n Extubation failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:45 AM\n PFI: No relevant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the right lung base has increased in\n transparency. Otherwise, the radiograph is unchanged. The size of the\n cardiac silhouette is unmodified, there is no evidence of newly appeared focal\n parenchymal opacities suggestive of pneumonia. The monitoring and support\n devices are in unchanged position.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1029082, "text": ", T. SICU-A 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Extubation failure\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with Subtotal colectomy\n REASON FOR THIS EXAMINATION:\n Extubation failure\n ______________________________________________________________________________\n PFI REPORT\n PFI: No relevant change.\n\n\n" }, { "category": "ECG", "chartdate": "2150-07-23 00:00:00.000", "description": "Report", "row_id": 225335, "text": "Atrial fibrillation with rapid ventricular response\nModest nonspecific ST-T wave changes\nSince previous tracing of , atrial fibrillation now present\n\n" }, { "category": "ECG", "chartdate": "2150-07-21 00:00:00.000", "description": "Report", "row_id": 225336, "text": "Sinus rhythm with slowing of the rate as compared with prior tracing\nof . The tracing is of improved technical quality. There is\nleft atrial abnormality. Probable prior inferior myocardial infarction.\nDelayed precordial R wave transition. No diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2150-07-21 00:00:00.000", "description": "Report", "row_id": 225337, "text": "Sinus tachycardia and occasional atrial ectopy. Delayed precordial R wave\ntransition. Baseline artifact precludes adequate interpretation. Diffuse\nnon-specific ST-T wave changes. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Respiratory ", "chartdate": "2150-08-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413987, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL / Air\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 Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Plan\n Pt received on PSV 10/5 as noted. Pt placed on trach mask trial at\n 9:10am and is tolerating very well. 300mg Tobramycin via neb\n suctioned for small amt thick, yellow secretions after neb. Plan to\n continue on trach mask trial as tolerated and place on PSV as needed.\n" }, { "category": "Nursing", "chartdate": "2150-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413587, "text": "Alteration in Nutrition\n Assessment:\n No TF last 2 days reportedl;y due to poor absorption.\n Action:\n PEG clamped to assess tolerance of gastric fluid.\n Response:\n 125ml bilious gastric fluid residual obtained.\n Plan:\n Will restart TF @ 1700 per orders. Advance slowly and cont to assess\n absorption.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Lg amts liquid stool via ileostomy. Minimal uo last 2 hrs. Current I&O\n -622ml. No TF last few days. HR 60\ns, controlled w/ iv lopressor.\n Action:\n Cont iv hydration @ 125ml/hr.\n Response:\n Plan:\n Restart TF this eve. Notify MD of low UO.\n" }, { "category": "Nursing", "chartdate": "2150-08-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413816, "text": "Ventilation, Impaired\n Assessment:\n Pt trached and vented, LS coarse\n Action:\n Pt put on trache collar, multiple nebs, frequent turning, HOB >30\n degrees\n Response:\n Initially did well but work of breathing became increased after about\n 1-2 hours so she was put back on the vent\n Plan:\n Continue trials on trache collar as tolerated, increase activity,\n frequent turns/movement.\n Muscle Performace, Impaired\n Assessment:\n Pt weak MAE, with deficit on left, followed all commands to best of\n ability.\n Action:\n PT consult, dangled pt on edge of bed.\n Response:\n Tolerated well.\n Plan:\n Continue to increase activity as tolerated.\n" }, { "category": "Nursing", "chartdate": "2150-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414108, "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": "2150-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414109, "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": "2150-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414110, "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 ------ Protected Section------\n Note started on wrong patient.\n ------ Protected Section Error Entered By: , RN\n on: 06:29 ------\n" }, { "category": "Nursing", "chartdate": "2150-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414046, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on trach collar 50%. Resp rate 20\ns, breathing appears\n comfortable. Lung sounds occasionally rhonchorous, suctioned every \n hours.\n Action:\n Cont\nd on trach collar overnight. Pulmonary hygiene.\n Response:\n Patient comfortable, tolerating trach collar.\n Plan:\n Continue with pulmonary hygiene/increasing activity. Rehab screening.\n" }, { "category": "Nursing", "chartdate": "2150-08-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414106, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on trach collar 50%. Resp rate 20\ns, breathing appears\n comfortable. Lung sounds occasionally rhonchorous, suctioned every \n hours. @ approx 2am, patient\ns breathing appeared labored..\n Action:\n Placed back on CPAP +10 press support and 8 peep. Pulmonary hygiene.\n Response:\n Patient tolerating trach collar approx 14 hours. Resp status stable.\n Plan:\n Continue with pulmonary hygiene/increasing activity. Trach collar\n again as tolerates. Rehab screening.\n" }, { "category": "Physician ", "chartdate": "2150-08-15 00:00:00.000", "description": "Intensivist Note", "row_id": 413377, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n : spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still\n high, started DTO, PICC removed PIV placed\n : lasix gtt, albumin started (possibly volume overload causing\n tachypnea and inability to wean)\n : stopped lasix gtt, started zosyn for Pseudomonas sputum. Low\n urine output overnight, multiple fluid boluses. Pt with episode of\n emesis during the day when given NS bolus. NS boluses d/c, writen for\n salt tabs\n Chief complaint:\n LGIB s/p total colectomy and failure to wean from vent\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 1000 mL LR 2. 150 mEq Sodium Bicarbonate/ 1000 mL D5W 3. 500 mL NS\n 4. Acetaminophen (Liquid)\n 5. Acetaminophen 6. Albuterol MDI 7. Aspirin 8. Calcium Gluconate 9.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 10. Diltiazem 11. Erythromycin 12. Famotidine 13. Fentanyl Citrate 14.\n Heparin Flush (10 units/ml)\n 15. HydrALAzine 16. 17. 18. 19. Insulin 20. Ipratropium Bromide MDI 21.\n Lorazepam 22. Magnesium Sulfate\n 23. Metoprolol Tartrate 24. Metoclopramide 25. MetRONIDAZOLE (FLagyl)\n 26. Metoprolol Tartrate 27. Metoprolol Tartrate\n 28. Midazolam 29. Miconazole Powder 2% 30. Nystatin Oral Suspension 31.\n Ondansetron 32. Piperacillin-Tazobactam Na\n 33. Potassium Chloride 34. Psyllium 35. Qvar 36. Sertraline 37.\n Simvastatin 38. Sodium Chloride\n 39. Sodium Chloride 0.9% Flush 40. Vancomycin 41. Warfarin\n 24 Hour Events:\n 24 hr events: meeting w/palliative care will decide whether cmo or not\n on . u/o steady at 20. pt in afib--IV lopressor given for rate\n control. PO lopressor d/c'd, probably not absorbing secondary to\n g-tube drainage. TF d/c...abdomen tender. maintinence fluids cont.\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:52 AM\n Metronidazole - 06:15 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 02:08 AM\n Metoprolol - 06:16 AM\n Other medications:\n Flowsheet Data as of 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.3\n HR: 99 (75 - 136) bpm\n BP: 117/46(64) {92/35(53) - 137/61(77)} mmHg\n RR: 14 (13 - 37) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 4,335 mL\n 869 mL\n PO:\n Tube feeding:\n 145 mL\n IV Fluid:\n 3,910 mL\n 869 mL\n Blood products:\n Total out:\n 1,179 mL\n 1,408 mL\n Urine:\n 524 mL\n 608 mL\n NG:\n 600 mL\n 500 mL\n Stool:\n Drains:\n Balance:\n 3,156 mL\n -539 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 538 (347 - 538) mL\n PS : 12 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 144\n PIP: 17 cmH2O\n SPO2: 98%\n ABG: ///30/\n Ve: 8.1 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Distended\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present), (Pulse -\n Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities\n Labs / Radiology\n 416 K/uL\n 8.0 g/dL\n 147 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 32 mg/dL\n 98 mEq/L\n 135 mEq/L\n 23.7 %\n 27.9 K/uL\n [image002.jpg]\n 03:09 AM\n 04:00 AM\n 05:20 PM\n 02:36 AM\n 02:31 AM\n 02:34 AM\n 06:15 AM\n 04:36 PM\n 01:33 AM\n 07:14 AM\n WBC\n 20.9\n 22.3\n 19.7\n 20.8\n 36.7\n 27.9\n Hct\n 29.2\n 27.9\n 28.2\n 26.8\n 28.8\n 24.1\n 23.7\n Plt\n 582\n 578\n 441\n \n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 1.1\n 1.2\n Glucose\n 170\n 191\n 139\n 126\n 160\n 138\n 140\n 147\n Other labs: PT / PTT / INR:22.9/34.8/2.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Differential-Neuts:92.7 %,\n Lymph:3.8 %, Mono:2.6 %, Eos:0.8 %, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.0 mg/dL, Mg:2.2 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: stabvle unchanged mental status, somewhat more awake and\n follows simple command, fentanyl versed prn\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, coumadin\n 2.2, afib rate controlled with beta blockade\n Pulmonary: Trach\n Gastrointestinal / Abdomen: possible RUQ pain will check lft's and\n follow with RUQ ultrasound\n Nutrition: Tube feeding, 1/2 ns cc/cc for replacement at a daily basis\n to reflect g tube output\n resume feeidng tomorrow\n Renal: Foley, Adequate UO, increased BUN/Cr below her dry weight, inc\n MF to 100/hr x 24 hr and re-assess\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Check cultures, concern for leukocytosis, suspect\n CDiff - add flagyl, D/C Vanc because tip grew nothing and 1/2 blood\n culture bottles grew gpc's - most likely contaminant\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today, KUB today\n Fluids: D5 1/2 NS\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:36 AM\n 20 Gauge - 10:37 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2150-08-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413583, "text": "Demographics\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Assisted spontaneous breathing.\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: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2150-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413505, "text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Pt in a fib, rate up to 130\n Action:\n Lopressor 10 mg iv x1 at 2100, followed by regular lopressor dose 10 mg\n iv at 2200\n Response:\n Converted to NSR\n Plan:\n Continue lopressor, monitor hr and monitor pattern with further\n treatment with lopressor as needed for RAF.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413764, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\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: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation, breath sounds bilaterally\n diminished, suctioned intermittently for moderate to small amounts of\n thick white to tan secretions, treated with Albuterol , atrovent, Q-var\n inhalers, and Vancomycin neb, SPO2 remains upper 90s, started trach\n mask trila at 0928, stopped at 1609, will continues to be followed.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413348, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\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 Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 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 Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Patient remains on CPAP/PSV ventilatory support with no\n parameter changes made throughout the night. No morning abg results at\n this time.\n RSBI = 144 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-16 00:00:00.000", "description": "Generic Note", "row_id": 413499, "text": "TITLE:\n Respiratory Care: Rec\nd pt on psv 12/5/40%. Pt has #7 portex trach.\n BS are mostly clear with occasional rhonchi which clear following\n suctioning. MDI\ns alb/atr/qvar as ordered with no adverse reactions.\n Nebs of tobramyacin initiated tonight. Some periods noted of\n tachycardia noc. AM ABG 7.49/43/95/ RSBI=145 No further changes noc.\n" }, { "category": "Physician ", "chartdate": "2150-08-19 00:00:00.000", "description": "Intensivist Note", "row_id": 414189, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n : spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still\n high, started DTO, PICC removed PIV placed\n : lasix gtt, albumin started (possibly volume overload causing\n tachypnea and inability to wean)\n : stopped lasix gtt, started zosyn for Pseudomonas sputum. Low\n urine output overnight, multiple fluid boluses. Pt with episode of\n emesis during the day when given NS bolus. NS boluses d/c, writen for\n salt tabs\n : urine output low but responsive to repletion of intravascular\n volume, CDiff sent and IV flagyl started for concern of CDiff, LFTs nl\n so RUQ U/S abdomen, continued abdominal pain and min distention\n prevented feeding today, weaned vent\n : RUQ U/S normal, held coumadin\n Chief complaint:\n Respiratory Failiure\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 2. 1000 mL LR 3. 1000 mL NS 4. Acetaminophen (Liquid) 5.\n Acetaminophen 6. Albuterol MDI 7. Aspirin\n 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10.\n Diltiazem 11. Erythromycin 12. Famotidine\n 13. Fentanyl Citrate 14. Heparin Flush (10 units/ml) 15. Heparin Flush\n (10 units/ml) 16. HydrALAzine\n 17. 18. 19. 20. 21. Insulin 22. Ipratropium Bromide MDI 23. Lorazepam\n 24. Magnesium Sulfate\n 25. Metoprolol Tartrate 26. Metoclopramide 27. MetRONIDAZOLE (FLagyl)\n 28. Metoprolol Tartrate 29. Miconazole Powder 2%\n 30. Nystatin Oral Suspension 31. Ondansetron 32.\n Piperacillin-Tazobactam Na 33. Potassium Chloride\n 34. Psyllium 35. Qvar 36. Sertraline 37. Simvastatin 38. Sodium\n Chloride 39. Sodium Chloride 0.9% Flush\n 40. Tobramycin Inhalation Soln 41. Warfarin\n 24 Hour Events:\n PICC LINE - START 10:00 AM\n INVASIVE VENTILATION - STOP 10:11 AM\n vented since admission, see chart.\n CALLED OUT\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 06:15 AM\n Piperacillin/Tazobactam (Zosyn) - 12:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 12:45 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.7\nC (98\n HR: 77 (67 - 88) bpm\n BP: 152/61(84) {109/27(49) - 168/67(88)} mmHg\n RR: 20 (20 - 32) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,444 mL\n 1,998 mL\n PO:\n Tube feeding:\n 974 mL\n 569 mL\n IV Fluid:\n 2,200 mL\n 1,229 mL\n Blood products:\n Total out:\n 1,760 mL\n 670 mL\n Urine:\n 1,110 mL\n 370 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 1,684 mL\n 1,328 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 372 (294 - 372) mL\n PS : 15 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 16 cmH2O\n SPO2: 97%\n ABG: ///28/\n Ve: 12.9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : , Diminished: @ bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 465 K/uL\n 8.4 g/dL\n 124 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 23 mg/dL\n 105 mEq/L\n 139 mEq/L\n 27.1 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 AM\n 04:36 PM\n 01:33 AM\n 07:14 AM\n 09:06 PM\n 04:28 AM\n 05:34 AM\n 06:01 AM\n 02:42 AM\n 03:11 AM\n WBC\n 36.7\n 27.9\n 23.8\n 15.9\n 20.8\n Hct\n 28.8\n 24.1\n 23.7\n 24.0\n 23.9\n 27.1\n Plt\n 461\n 416\n 456\n 434\n 465\n Creatinine\n 1.1\n 1.2\n 1.2\n 1.2\n 1.0\n 1.0\n 0.8\n TCO2\n 34\n Glucose\n 138\n 140\n 147\n 160\n 158\n 126\n 164\n 124\n Other labs: PT / PTT / INR:23.5/31.6/2.3, ALT / AST:17/18, Alk-Phos / T\n bili:123/0.3, Amylase / Lipase:, Differential-Neuts:90.8 %,\n Lymph:4.7 %, Mono:2.6 %, Eos:1.7 %, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:195 IU/L, Ca:8.6 mg/dL, Mg:2.0\n mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan: 85 year old female with respiratory failure\n Neurologic: Pain controlled, Awake, alert, siting in chair\n Cardiovascular: Aspirin, Full anticoagulation\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Alternate between TC\n and PS as needed\n Gastrointestinal / Abdomen: PEG\n Nutrition: Tube feeding, @ goal\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, Stable\n Endocrine: RISS, Well controlled\n Infectious Disease: Check cultures, D/C to Rehab with Course of\n Zosyn,Flagyl, inhaled tobra as per primary team\n Lines / Tubes / Drains: G-tube, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n complication, Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:47 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:00 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Transfer to rehab / long term facility\n Total time spent: 10 minutes\n" }, { "category": "Nursing", "chartdate": "2150-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413502, "text": "Alteration in Nutrition\n Assessment:\n Remains NPO . tube feeds on hold due to high residuals\n Action:\n G tube to gravity, draining large amts green liquid. Raglan,\n erythromycin given via g tube as ordered.\n Response:\n No bm, no Nausea or vomiting.\n Plan:\n Check with HO re: restarting tube feeds\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Tube feedings on hold\n Action:\n IVF increased to 125/hr after fluid bolus this afternoon\n Response:\n u/o borderline, but qs.\n Plan:\n Monitor I+O\n" }, { "category": "Nursing", "chartdate": "2150-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 414016, "text": "Muscle Performance, Impaired\n Assessment:\n Pt is extremely de-conditioned after prolonged ICU stay.\n Action:\n PT worked with patient then hoyered her into a chair\n Response:\n She remained in the chair very comfortable for a few hours\n Plan:\n Continue to perform ROM and continue PT consults, OOB to chair QD\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Placed on trach mask this AM; slightly tachypneic at times but overall\n tolerant of TM\n Action:\n Sxn\ned PRN for thick tan secretions\n Response:\n Patient tolerated TM from 0930 to present\n Plan:\n Keep her on TM as long as she will tolerate per SICU team\n Problem - Description In Comments\n Assessment:\n After being returned to bed, patient c/o nausea.\n Action:\n Zofran 4 mg administered; TF on hold X 90 minutes; cool compress\n applied\n Response:\n Patient did not vomit, was still nauseous but she nodded that she felt\n better\n Plan:\n Continue to monitor, administer zofran PRN\n" }, { "category": "Rehab Services", "chartdate": "2150-08-17 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 413743, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 436 /\n Reason of referral: RE-EVAL\n History of Present Illness / Subjective Complaint: 85 yo f c hx of CVA\n in on coumadin, now admitted c acute diverticulitis and GIB\n s/p subtotal colectomy c end ileiostomy and \ns pouch 8.19 c post\n op c/b a-fib and noted to have L UE weakness when weaned of sedation.\n Pt found to have multiple BG cortical infarcts likely embolic on MRI,\n she was unable to wean from vent and underwent trach/peg . PT has\n been following since \n Past Medical / Surgical History: see initial eval\n Medications: aspirin, metoprolol, lasix, diltiazem, ativan\n Radiology: cxr : mild atelectasis at the left lung base\n Labs:\n 23.9\n 7.8\n 434\n 15.9\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt following 80% of\n one step commands, slightly lethargic, attention and arousal improve in\n sitting at \n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 70\n 136/57\n 28\n 98% CPAP\n Rest\n /\n Sit\n 78\n 137/62\n 33\n 97% CPAP\n Activity\n /\n Stand\n /\n Recovery\n 71\n /\n 25\n 99% CPAP\n Total distance walked:\n Minutes:\n Pulmonary Status: CPAP PEEP 5, Psupport 10. LS diminished, pt suctioned\n for minimal thin white sputum via trach. Breathing pattern coordinated\n Integumentary / Vascular: trach, PIV in R foot, peg, RRR\n Sensory Integrity: withdraws to pain all 4 extremities.\n Pain / Limiting Symptoms: Pt grimacing with L elbow and shldr ROM\n Posture: increased kyphosis\n Range of Motion\n Muscle Performance\n R DF -10\n L DF -8\n Pt moving L fingers, wrist flex/ext\n R shldr flexion 2+/5 R elb flexion 3-/5\n 2/5 L quad 2-/5\n R LE grossly 2+/5 t/o\n Motor Function: LUE with increased extensor tone 2+, L LE with\n increased extension tone 3+\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Deferred transfer and OOB due to PIV in R foot\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt tolerated sitting at for approx 10 mins c Min A to CG.\n Pt with posterior, L lateral bias at , pt attempting to use R UE to\n maintain balance and midline\n Education / Communication: Pt status discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Muscle Performance, Impaired\n 5.\n Ventilation, Impaired\n Clinical impression / Prognosis: 85 yo f s/p subtotal colectomy c end\n ileostomy c post op c/b Afib and multiple B cortical infarcts c/b\n inability to wean from vent presents with above impairments c/w\n nonprogressive CNS dysfunction. Since initial evaluation on pt has\n shown improved cognition and mobility. Her balance has improved, and\n she is now demonstrating some active movement of L UE and LE. Pt\n remains well below baseline and will require skilled PT/OT in rehab\n setting upon d/c.\n Goals\n Time frame: 1 wk\n 1.\n sup to sit c mod A\n 2.\n RR less than 28 c activity\n 3.\n maintain balance at c S for 5 min\n 4.\n increase MMT t/o\n 5.\n maintain SaO2 > 95% on TM\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n F/u balance, mobility strength training, pulm hygiene. Cont d/c\n planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413428, "text": "Demographics\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Assisted spontaneous breathing.\n Visual assessment of breathing pattern: Pt has episodes of tachypnea.\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": "Respiratory ", "chartdate": "2150-08-17 00:00:00.000", "description": "Generic Note", "row_id": 413634, "text": "TITLE:\n Respiratory Care. Rec\nd pt on psv 5/5/40%. Pt has #8 portex trach. BS\n are coarse to clear and suctioning for small amounts of white/tan thick\n secretions. MDI\ns administered alb/atr/qvar as ordered with no adverse\n reactions. Nebs of tobramyacin x1. No abg\ns. RSBI= Plan to\n continue t/c trials as tolerates.\n" }, { "category": "Social Work", "chartdate": "2150-08-17 00:00:00.000", "description": "Inital", "row_id": 413724, "text": "TITLE:\n Referral received on from nursing on behalf of pt\ns family.\n Family meeting was held prior to this referral; in the meeting family\n was made aware that pt\ns overall medical condition was more complex\n than originally expected. Pt now less likely to be independent from\n the ventilator. Family expressing concerns that pt never wanted to\n live on life supports.\n Pt\ns daughter is her health care proxy, pt\ns son and daughter in law\n present for t he meeting. Daughter explains that prior to admission pt\n was a vibrant woman wh9o had many hobbies and many friends. Pt was\n living in an complex. Daughter and son feeling that\n they should be thinking about changing goals of care. Suggested that\n we speak with pt about her wishes as pt had been and able to\n communicate with family however upon approach pt was not able to be\n awakened.\n Dr. met with family and encouraged them to speak with the\n palliative care team coordinated that meeting. Today pt is awake and\n , outreach to family and discuss pt\ns status with the team\n" }, { "category": "Respiratory ", "chartdate": "2150-08-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413855, "text": "Demographics\n Day of intubation: 14\n Day of mechanical ventilation: 14\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL / Air\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 / Thin\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 Comments: Continues on CPAP/PS settings.\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: Plan to wean on trach mask as tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2150-08-16 00:00:00.000", "description": "Intensivist Note", "row_id": 413541, "text": "SICU\n HPI:\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n : spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still\n high, started DTO, PICC removed PIV placed\n : lasix gtt, albumin started (possibly volume overload causing\n tachypnea and inability to wean)\n : stopped lasix gtt, started zosyn for Pseudomonas sputum. Low\n urine output overnight, multiple fluid boluses. Pt with episode of\n emesis during the day when given NS bolus. NS boluses d/c, writen for\n salt tabs\n : urine output low but responsive to repletion of intravascular\n volume, CDiff sent and IV flagyl started for concern of CDiff, LFTs nl\n so RUQ U/S abdomen, continued abdominal pain and min distention\n prevented feeding today, weaned vent\n .\n Chief complaint:\n respiratory failuire, sepsis\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 1000 mL LR 2. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 3. 500\n mL NS 4. Acetaminophen (Liquid)\n 5. Acetaminophen 6. Albuterol MDI 7. Aspirin 8. Calcium Gluconate 9.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 10. Diltiazem 11. Erythromycin 12. Famotidine 13. Fentanyl Citrate 14.\n Heparin Flush (10 units/ml)\n 15. HydrALAzine 16. 17. 18. 19. Insulin 20. Ipratropium Bromide MDI 21.\n Lorazepam 22. Magnesium Sulfate\n 23. Metoprolol Tartrate 24. Metoclopramide 25. MetRONIDAZOLE (FLagyl)\n 26. Metoprolol Tartrate 27. Midazolam\n 28. Miconazole Powder 2% 29. Nystatin Oral Suspension 30. Ondansetron\n 31. Piperacillin-Tazobactam Na\n 32. Potassium Chloride 33. Psyllium 34. Qvar 35. Sertraline 36.\n Simvastatin 37. Sodium Chloride\n 38. Sodium Chloride 0.9% Flush 39. Tobramycin Inhalation Soln 40.\n Warfarin\n 24 Hour Events:\n meeting w/palliative care will decide whether cmo or not on .\n u/o steady at 20. pt in afib--IV lopressor given for rate control. PO\n lopressor d/c'd, probably not absorbing secondary to g-tube drainage.\n TF d/c...abdomen tender. maintinence fluids cont.\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Metronidazole - 05:40 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:57 PM\n Coumadin (Warfarin) - 09:00 PM\n Metoprolol - 05:41 AM\n Other medications:\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.4\n HR: 78 (73 - 159) bpm\n BP: 126/48(66) {98/29(46) - 142/61(80)} mmHg\n RR: 30 (15 - 35) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,378 mL\n 1,352 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,258 mL\n 1,292 mL\n Blood products:\n Total out:\n 2,705 mL\n 1,255 mL\n Urine:\n 1,055 mL\n 305 mL\n NG:\n 1,150 mL\n 950 mL\n Stool:\n 50 mL\n Drains:\n Balance:\n 673 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 402 (322 - 504) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 145\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.49/43/95./31/8\n Ve: 11.5 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Rhonchorous : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands\n Labs / Radiology\n 456 K/uL\n 7.9 g/dL\n 158 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 98 mEq/L\n 137 mEq/L\n 24.0 %\n 23.8 K/uL\n [image002.jpg]\n 02:36 AM\n 02:31 AM\n 02:34 AM\n 06:15 AM\n 04:36 PM\n 01:33 AM\n 07:14 AM\n 09:06 PM\n 04:28 AM\n 05:34 AM\n WBC\n 22.3\n 19.7\n 20.8\n 36.7\n 27.9\n 23.8\n Hct\n 27.9\n 28.2\n 26.8\n 28.8\n 24.1\n 23.7\n 24.0\n Plt\n 578\n 441\n 478\n 461\n 416\n 456\n Creatinine\n 0.4\n 0.4\n 0.4\n 1.1\n 1.2\n 1.2\n 1.2\n TCO2\n 34\n Glucose\n 139\n 126\n 160\n 138\n 140\n 147\n 160\n 158\n Other labs: PT / PTT / INR:27.0/43.1/2.7, ALT / AST:17/18, Alk-Phos / T\n bili:123/0.3, Amylase / Lipase:, Differential-Neuts:90.8 %,\n Lymph:4.7 %, Mono:2.6 %, Eos:1.7 %, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:195 IU/L, Ca:8.7 mg/dL, Mg:2.2\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan: 85 year old female s/p LGIB with colectomy, CVA,\n now currently with ? sepsis\n Neurologic: Neurologically stable, exam unchanged. Countinue Warafin.\n ativan/midaz prn\n Cardiovascular: Full anticoagulation, Hemodynamically Stable, in and\n out afib,\n Pulmonary: Trach, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: Pt with abdominal pain, LFTs checked\n yesterday- WNL. Exam benign. Will clamp peg and re-asses\n Nutrition: NPO, secondary to abdominal, on\n Renal: Foley, Adequate UO, Currently adequate with higher maintenance\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Check cultures, Pseudomonas pneumonia,\n Zosyn,inhaled Tobra, Flagyl, Tmax improving, decreasing WBC\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:36 AM\n 20 Gauge - 10:37 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Respiratory ", "chartdate": "2150-08-16 00:00:00.000", "description": "Generic Note", "row_id": 413469, "text": "TITLE:\n Respiratory Care: Rec\nd pt on psv 12/5/40%. Pt has #7 portex trach.\n BS are mostly clear with occasional rhonchi which clear following\n suctioning. MDI\ns alb/atr/qvar as ordered with no adverse reactions.\n Nebs of tobramyacin initiated tonight. Some periods noted of\n tachycardia noc. No further changes noc.\n" }, { "category": "Nursing", "chartdate": "2150-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413607, "text": "Alteration in Nutrition\n Assessment:\n No TF last 2 days reportedl;y due to poor absorption.\n Action:\n PEG clamped to assess tolerance of gastric fluid.\n Response:\n 125ml bilious gastric fluid residual obtained.\n Plan:\n Will restart TF @ 1700 per orders. Advance slowly and cont to assess\n absorption.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Lg amts liquid stool via ileostomy. Minimal uo last 2 hrs. Current I&O\n -622ml. No TF last few days. HR 60\ns, controlled w/ iv lopressor.\n Action:\n Foley cath irrigated. Dr notified of UO. TF restarted.\n Response:\n Foley patent.\n Plan:\n Monitor UO for next 2 hrs. If no improvement, M.D. Cont IV\n hydration @ 125ml/hr for now.\n" }, { "category": "Nursing", "chartdate": "2150-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413609, "text": "Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt sleeping much of time when unattended. Still weak on L side.\n Action:\n Assisted OOB to chair w./ lift. No vent changes made today.\n Response:\n Tolerated OOB x 3 hrs well. Able to stay awake and visit w/ daughter.\n :\n Cont PROM and OOB daily. Cont slow vent wean as tol.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-17 00:00:00.000", "description": "Generic Note", "row_id": 413677, "text": "TITLE:\n Respiratory Care. Rec\nd pt on psv 5/5/40%. Pt has #8 portex trach. BS\n are coarse to clear and suctioning for small amounts of white/tan thick\n secretions. MDI\ns administered alb/atr/qvar as ordered with no adverse\n reactions. Nebs of tobramyacin x1. No abg\ns. RSBI= 112 Plan to\n continue t/c trials as tolerates.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 414065, "text": "Demographics\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 Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL / Air\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 / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use,\n Tachypneic (RR> 35 b/min); Comments: Placed back on CPAP/PS d/t\n tachypnea, ^^wob at 0230. TM lasted 14 hours.\n Assessment of breathing comfort: Pt acknowledges dyspnea; Comments:\n Reports being SOB 0230--Placed back on vent.\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 Increase ventilatory support at night; Comments: Plan to keep on trach\n mask as tolerates.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n \\\n" }, { "category": "Nursing", "chartdate": "2150-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413984, "text": "Muscle Performance, Impaired\n Assessment:\n Pt is extremely de-conditioned after prolonged ICU stay.\n Action:\n PT worked with patient then hoyered her into a chair\n Response:\n She remained in the chair very comfortable for a few hours\n Plan:\n Continue to perform ROM and continue PT consults, OOB to chair QD\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2150-08-18 00:00:00.000", "description": "Intensivist Note", "row_id": 413909, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n Respiratory Failure,\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n . 1000 mL LR\n Continuous at 60 ml/hr Order date: @ 0433 21. Lorazepam 0.5-1 mg\n IV Q4H:PRN Order date: @ 1349\n 2. 1000 mL NS\n Continuous at 75 ml/hr Order date: @ 1804 22. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1142\n 3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Order date: @ 1819\n 23. Metoprolol Tartrate 5-10 mg IV Q2H:PRN\n hold for SBP<120 or HR<60 Order date: @ 1000\n 4. Acetaminophen 650 mg PR Q6H:PRN Fever Order date: @ 1327 24.\n Metoclopramide 10 mg PO Q6H Order date: @ 0840\n 5. Albuterol MDI 6 PUFF IH Q4H Order date: @ 1142 25.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0858\n 6. Aspirin 325 mg PO DAILY Order date: @ 2337 26. Metoprolol\n Tartrate 25 mg PO BID Order date: @ 0935\n 7. Calcium Gluconate IV Sliding Scale Order date: @ 1142 27.\n Miconazole Powder 2% 1 Appl TP :PRN Order date: @ 1523\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1142 28. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @\n 0451\n 9. Diltiazem 30 mg PO TID Order date: @ 1525 29. Ondansetron 4\n mg IV Q8H:PRN Order date: @ 1142\n 10. Erythromycin 250 mg PO Q6H Order date: @ 0840 30.\n Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 0654\n 11. Famotidine 20 mg PO DAILY Order date: @ 0756 31. Potassium\n Chloride IV Sliding Scale Order date: @ 0458\n 12. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain Order date: @\n 1142 32. Psyllium PKT PO BID Order date: @ 1228\n 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1119 33.\n Qvar *NF* 1 INH IH Start: Order date: @ 2125\n 14. HydrALAzine 10 mg IV Q6H prn htn Order date: @ 2305 34.\n Sertraline 50 mg PO DAILY Order date: @ 0754\n 15. IV access request: CVL D/C and culture tip Urgency: Routine Order\n date: @ 1002 35. Simvastatin 40 mg PO QHS Order date: @\n 2308\n 16. IV access request: PICC Leave port accessed Indication: Antibiotics\n Urgency: Urgent Order date: @ 36. Sodium Chloride 1 gm PO\n DAILY hyponatremia Start: Order date: @ 1508\n 17. IV access request: PICC D/C and culture tip Urgency: Routine Order\n date: @ 1238 37. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1142\n 18. IV access request: PICC Place Indication: Antibiotics Urgency: STAT\n Order date: @ 1648 38. Tobramycin Inhalation Soln 300 mg IH \n Order date: @ 0928\n 19. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1524 39. Warfarin 1 mg PO QHS\n Order date: @ 0833\n 20. Ipratropium Bromide MDI 2 PUFF IH Q4-6H:PRN SOB, wheeze Order\n date: @ 1142\n 24 Hour Events:\n ULTRASOUND - At 08:00 AM\n liver, gallbaldder\n no issues\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 09:34 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.2\nC (99\n HR: 72 (69 - 94) bpm\n BP: 143/48(71) {116/35(57) - 155/79(90)} mmHg\n RR: 23 (18 - 39) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,526 mL\n 1,207 mL\n PO:\n Tube feeding:\n 949 mL\n 343 mL\n IV Fluid:\n 2,401 mL\n 744 mL\n Blood products:\n Total out:\n 2,355 mL\n 670 mL\n Urine:\n 1,085 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,171 mL\n 537 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 302 (281 - 510) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 150\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///28/\n Ve: 5.8 L/min\n Physical Examination\n Labs / Radiology\n 434 K/uL\n 7.8 g/dL\n 164 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 104 mEq/L\n 139 mEq/L\n 23.9 %\n 15.9 K/uL\n [image002.jpg]\n 02:34 AM\n 06:15 AM\n 04:36 PM\n 01:33 AM\n 07:14 AM\n 09:06 PM\n 04:28 AM\n 05:34 AM\n 06:01 AM\n 02:42 AM\n WBC\n 20.8\n 36.7\n 27.9\n 23.8\n 15.9\n Hct\n 26.8\n 28.8\n 24.1\n 23.7\n 24.0\n 23.9\n Plt\n 56\n 434\n Creatinine\n 0.4\n 1.1\n 1.2\n 1.2\n 1.2\n 1.0\n 1.0\n TCO2\n 34\n Glucose\n 160\n 138\n 140\n 147\n 160\n 158\n 126\n 164\n Other labs: PT / PTT / INR:26.1/37.2/2.6, ALT / AST:17/18, Alk-Phos / T\n bili:123/0.3, Amylase / Lipase:, Differential-Neuts:90.8 %,\n Lymph:4.7 %, Mono:2.6 %, Eos:1.7 %, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:195 IU/L, Ca:8.6 mg/dL, Mg:2.1\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, stable, aao 3, pain\n controlled\n Cardiovascular: Beta-blocker, stable hemodynamically, po beta blocker\n Pulmonary: Trach, attempt to wean to trach collar, out of bed\n Gastrointestinal / Abdomen: stable\n Nutrition: replete with fiber full strength at goal\n Renal: Foley, Adequate UO, stable\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: zosyn, flagyl\n Lines / Tubes / Drains: Foley, NGT, Trach, foot IV 18G, d/c after PICC\n placed\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: CVA, (Respiratory distress: Failure), Post-op\n complication, Other: Lower GI bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:02 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:36 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2150-08-18 00:00:00.000", "description": "Intensivist Note", "row_id": 413910, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n Respiratory Failure,\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n . 1000 mL LR\n Continuous at 60 ml/hr Order date: @ 0433 21. Lorazepam 0.5-1 mg\n IV Q4H:PRN Order date: @ 1349\n 2. 1000 mL NS\n Continuous at 75 ml/hr Order date: @ 1804 22. Magnesium Sulfate\n IV Sliding Scale Order date: @ 1142\n 3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Order date: @ 1819\n 23. Metoprolol Tartrate 5-10 mg IV Q2H:PRN\n hold for SBP<120 or HR<60 Order date: @ 1000\n 4. Acetaminophen 650 mg PR Q6H:PRN Fever Order date: @ 1327 24.\n Metoclopramide 10 mg PO Q6H Order date: @ 0840\n 5. Albuterol MDI 6 PUFF IH Q4H Order date: @ 1142 25.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0858\n 6. Aspirin 325 mg PO DAILY Order date: @ 2337 26. Metoprolol\n Tartrate 25 mg PO BID Order date: @ 0935\n 7. Calcium Gluconate IV Sliding Scale Order date: @ 1142 27.\n Miconazole Powder 2% 1 Appl TP :PRN Order date: @ 1523\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1142 28. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @\n 0451\n 9. Diltiazem 30 mg PO TID Order date: @ 1525 29. Ondansetron 4\n mg IV Q8H:PRN Order date: @ 1142\n 10. Erythromycin 250 mg PO Q6H Order date: @ 0840 30.\n Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 0654\n 11. Famotidine 20 mg PO DAILY Order date: @ 0756 31. Potassium\n Chloride IV Sliding Scale Order date: @ 0458\n 12. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain Order date: @\n 1142 32. Psyllium PKT PO BID Order date: @ 1228\n 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1119 33.\n Qvar *NF* 1 INH IH Start: Order date: @ 2125\n 14. HydrALAzine 10 mg IV Q6H prn htn Order date: @ 2305 34.\n Sertraline 50 mg PO DAILY Order date: @ 0754\n 15. IV access request: CVL D/C and culture tip Urgency: Routine Order\n date: @ 1002 35. Simvastatin 40 mg PO QHS Order date: @\n 2308\n 16. IV access request: PICC Leave port accessed Indication: Antibiotics\n Urgency: Urgent Order date: @ 36. Sodium Chloride 1 gm PO\n DAILY hyponatremia Start: Order date: @ 1508\n 17. IV access request: PICC D/C and culture tip Urgency: Routine Order\n date: @ 1238 37. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1142\n 18. IV access request: PICC Place Indication: Antibiotics Urgency: STAT\n Order date: @ 1648 38. Tobramycin Inhalation Soln 300 mg IH \n Order date: @ 0928\n 19. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1524 39. Warfarin 1 mg PO QHS\n Order date: @ 0833\n 20. Ipratropium Bromide MDI 2 PUFF IH Q4-6H:PRN SOB, wheeze Order\n date: @ 1142\n 24 Hour Events:\n ULTRASOUND - At 08:00 AM\n liver, gallbaldder\n no issues\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 09:34 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.2\nC (99\n HR: 72 (69 - 94) bpm\n BP: 143/48(71) {116/35(57) - 155/79(90)} mmHg\n RR: 23 (18 - 39) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,526 mL\n 1,207 mL\n PO:\n Tube feeding:\n 949 mL\n 343 mL\n IV Fluid:\n 2,401 mL\n 744 mL\n Blood products:\n Total out:\n 2,355 mL\n 670 mL\n Urine:\n 1,085 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,171 mL\n 537 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 302 (281 - 510) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 150\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///28/\n Ve: 5.8 L/min\n Physical Examination\n Labs / Radiology\n 434 K/uL\n 7.8 g/dL\n 164 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 22 mg/dL\n 104 mEq/L\n 139 mEq/L\n 23.9 %\n 15.9 K/uL\n [image002.jpg]\n 02:34 AM\n 06:15 AM\n 04:36 PM\n 01:33 AM\n 07:14 AM\n 09:06 PM\n 04:28 AM\n 05:34 AM\n 06:01 AM\n 02:42 AM\n WBC\n 20.8\n 36.7\n 27.9\n 23.8\n 15.9\n Hct\n 26.8\n 28.8\n 24.1\n 23.7\n 24.0\n 23.9\n Plt\n 56\n 434\n Creatinine\n 0.4\n 1.1\n 1.2\n 1.2\n 1.2\n 1.0\n 1.0\n TCO2\n 34\n Glucose\n 160\n 138\n 140\n 147\n 160\n 158\n 126\n 164\n Other labs: PT / PTT / INR:26.1/37.2/2.6, ALT / AST:17/18, Alk-Phos / T\n bili:123/0.3, Amylase / Lipase:, Differential-Neuts:90.8 %,\n Lymph:4.7 %, Mono:2.6 %, Eos:1.7 %, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:195 IU/L, Ca:8.6 mg/dL, Mg:2.1\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, stable, aao 3, pain\n controlled\n Cardiovascular: Beta-blocker, stable hemodynamically, po beta blocker\n Pulmonary: Trach, attempt to wean to trach collar, out of bed\n Gastrointestinal / Abdomen: stable\n Nutrition: replete with fiber full strength at goal\n Renal: Foley, Adequate UO, stable\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: zosyn, flagyl\n Lines / Tubes / Drains: Foley, NGT, Trach, foot IV 18G, d/c after PICC\n placed\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: CVA, (Respiratory distress: Failure), Post-op\n complication, Other: Lower GI bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:02 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:36 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2150-08-18 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 413915, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise (ROM, strength)\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 70\n 151/53\n 22\n 99% CPAP\n Activity\n 78\n /\n 33\n 99% CPAP\n Recovery\n /\n 25\n 99% CPAP\n Total distance walked:\n Minutes:\n Gait: Deferred functional transfer due to the fact pts only IV access\n is in her R foot\n Balance: Pt tolerated sitting at EOB for 10mins requiring CG to S to\n maintain. Actively using B UE for support R > L\n Education / Communication: Pt status discussed with RN\n Other: L Knee with increased flexor tone, pain with PROM\n Active and purposeful movement x 4\n Assessment: Pt continues to make gains with balance and strength, feel\n once IV is removed from foot pt will also make progress towards\n functional transfers. Pt will do well in rehab upon d/c\n Anticipated Discharge: Rehab\n Plan: f/u ROM, strength, balances training.\n Pg \n Time: 8:40-910\n" }, { "category": "Respiratory ", "chartdate": "2150-08-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412700, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 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 / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\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 Alb and Atr given as ordered.\n" }, { "category": "Nursing", "chartdate": "2150-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412796, "text": "Pt is a 85F c hx of CVA in , on coumadin, adm with acute\n diverticulitis and GIB s/p subtotal colectomy c end ileostomy and\n pouch post op c/b Afib and noted to have LUE weakness when\n weaned off of propofol and with + multiple B coritical infarts,\n likley embolic, on MRI. Pt currently unable to wean from mechanical\n ventilation and now s/p trach/PEG.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Comfortable on PS 10/5 Free air noted on CXR, 40 cc gastrograffin and\n scout film done\n Action:\n PS . from 12 to 10\n Response:\n Became dyspneic with discordant resp pattern rate up to 30s after\n vigorous PT at side of bed, ROM to all 4s) Med with 1.0 midaz\n with excellent effect. RR down to 25 with good Vt\n Plan:\n Cont screen for rehab. Check results of scout film, cont to exercise\n with PT , advance activity level as tol. Benzos prn anxiety. Slow PS\n wean. TF on hold til results of scout film back\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Left side remains weaker than Right. Full list toward left when dangled\n at edge of bed\n Action:\n PT for ROM, activity progression\n Response:\n Exhausted after PT, dyspneic with minimal reserve\n Plan:\n Cont PT, allow rest periods. Possible tran to tomarrow if scout\n series negative.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412993, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: unknown.\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / 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 Increased IPS from 10 to 14 cm H20 for RR ~40bpm.\n Assessment of breathing comfort: Pt acknowledges dyspnea; Comments: c/o\n frqequently of abd pain.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Comments:\n Plan\n Next 24-48 hours: Continue present ICU monitoring/ rehab\n placement.\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: No RSBi as Pt willl be going to vent rehab.\n Respiratory Care Shift Procedures\n" }, { "category": "Respiratory ", "chartdate": "2150-08-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412808, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\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: Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Management:\n Vol/Press:\n pressure: 22 cmH2O\n volume: 8 mL /\n Airway problems: / valve leak\n Comments: Added 12cc air. Large leak.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\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": "Nursing", "chartdate": "2150-08-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412694, "text": "Impaired Skin Integrity\n Assessment:\n Peri area reddened and tender.\n Action:\n Area cleansed and dried. Team notified. Nystatin powder ordered.\n Pillow placed between knees.\n Response:\n Waiting for powder to apply.\n Plan:\n Keep area clean and dry. Apply powder as needed. Assess q shift\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-08-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412696, "text": "Impaired Skin Integrity\n Assessment:\n Peri area reddened and tender.\n Action:\n Area cleansed and dried. Team notified. Nystatin powder ordered.\n Pillow placed between knees.\n Response:\n Waiting for powder to apply.\n Plan:\n Keep area clean and dry. Apply powder as needed. Assess q shift\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Mod amt thick yellow sputum. +gag reflex\n Action:\n Suctioned freq. Trach and mouth care provided.\n Response:\n Airway patent . Less congested\n Plan:\n Continue pulm toileting\n" }, { "category": "Physician ", "chartdate": "2150-08-10 00:00:00.000", "description": "Intensivist Note", "row_id": 412779, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR\n Chief complaint:\n respiratory failure\n PMHx:\n CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n .\n Current medications:\n 24 Hour Events:\n BLOOD CULTURED - At 04:49 AM\n PICC line\n SPUTUM CULTURE - At 04:49 AM\n URINE CULTURE - At 04:50 AM\n FEVER - 101.6\nF - 04:00 AM\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 AM\n Other medications:\n Flowsheet Data as of 11:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 37.3\nC (99.2\n HR: 68 (68 - 87) bpm\n BP: 163/68(88) {119/47(65) - 163/78(101)} mmHg\n RR: 11 (11 - 36) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 2,121 mL\n 838 mL\n PO:\n Tube feeding:\n 916 mL\n 508 mL\n IV Fluid:\n 1,025 mL\n Blood products:\n Total out:\n 1,224 mL\n 1,289 mL\n Urine:\n 974 mL\n 489 mL\n NG:\n 50 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 897 mL\n -451 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 454 (107 - 507) mL\n PS : 12 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 15 cmH2O\n SPO2: 96%\n ABG: ///28/\n Ve: 8.1 L/min\n Physical Examination\n Labs / Radiology\n 560 K/uL\n 9.5 g/dL\n 191\n 0.4 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 15 mg/dL\n 100 mEq/L\n 135 mEq/L\n 28.2 %\n 18.8 K/uL\n [image002.jpg]\n 01:55 AM\n 03:14 AM\n 06:43 AM\n 06:56 AM\n 03:41 AM\n 03:20 AM\n 10:00 AM\n 04:00 PM\n 03:09 AM\n 04:00 AM\n WBC\n 14.9\n 14.0\n 12.5\n 15.8\n 18.8\n Hct\n 28.9\n 28.7\n 25.7\n 29.9\n 28.2\n Plt\n 490\n 489\n 487\n 607\n 560\n Creatinine\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n 0.4\n TCO2\n 29\n Glucose\n 161\n 140\n 102\n 112\n 158\n 160\n 149\n 170\n 191\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.3 mg/dL, Mg:1.8 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: stable\n Cardiovascular: stable\n Pulmonary: stable/try and wean vent\n Gastrointestinal / Abdomen: cont tf per peg tube...PEG study contrast\n Nutrition: at goal\n Renal: Foley, stable\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: spiked to 101.6...d/c fluconazole and pancx\n Lines / Tubes / Drains: right PICC\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:31 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Rehab Services", "chartdate": "2150-08-10 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 412787, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 436 /\n Reason of referral: Eval/Tx\n History of Present Illness / Subjective Complaint: Pt is a 85F c hx of\n CVA in , on coumadin, now adm with acute diverticulitis and\n GIB s/p subtotal colectomy c end ileostomy and pouch post\n op c/b Afib and noted to have LUE weakness when weaned off of propofol\n and with + multiple B coritical infarts, likley embolic, on MRI.\n Pt unable to wean from mechanical ventilation and now s/p trach/PEG.\n Past Medical / Surgical History: CVA c dysarthria , hyperlipidemia,\n COPD on homeO2,\n Medications: diltiazam, metoprolol, hydralazine\n Radiology: Head MRI Multiple B cortical infarcts.\n Labs:\n 28.2\n 9.5\n 560\n 18.8\n [image002.jpg]\n Activity Orders: OOB c A\n Social / Occupational History: Lives in retirement community.\n Supportive Dgt\n Living Environment: No stairs\n Prior Functional Status / Activity Level: Amb c RW.\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert. Able to follow\n about 20% simple commands. Orientated to person only.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 78\n 151/58\n 22\n Rest\n /\n Sit\n 82\n 188/92\n 32\n Activity\n 84\n 194/82\n 36\n 94\n Stand\n /\n Recovery\n 85\n 188/76\n 32\n 95\n Total distance walked:\n Minutes:\n Pulmonary Status: Discoordinate pattern. +DOE. CPAP 40%FiO2, 5 PEEP,\n 10Psupp, .300 TV. Wheezes t/o. Suctioned via trach for min thin white\n secrections.\n Integumentary / Vascular: Trach. PEG. Pouch. Foley. No edema.\n Sensory Integrity: Grimace to painful stim t/o extremities and\n withdrawl x LUE\n Pain / Limiting Symptoms: Grimace with PROM LUE\n Posture: WNL\n Range of Motion\n Muscle Performance\n R Df -15\n L Df -5\n Min spontaneous LUE movment\n R Shd 2+/5, Elbow \n RLE >2-/5. No active LLE movement noted.\n Motor Function: LUE extensor spasticiy .\n LLE flexor spasticity .\n No clonus.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Transfer deferred hypertension and DOE.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: ModA at EOB lean post-lat L.\n Education / Communication: c RN RE DOE/BP\n Pt RE Role of PT\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Ventilation, Impaired\n Clinical impression / Prognosis: Pt is a 85F who p/w above impairments\n c/w soft tissue surgery and nonprogressive neuro d/o. Pt is funtioning\n well below baseline limited by L sided weakness and spasticity \n embolic CVA. Pt will require STR at D/C and would benifit from >3hrs\n PT/OT/Speech daily. Pt has good rehab potential to make functional\n gains give high baseline level of function.\n Goals\n Time frame: 1 Week\n 1.\n Sup to Sit c ModA\n 2.\n Maintain balance at EOB c RUE support and x3min.\n 3.\n RR Less than 32 c above.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n Functional Mobility/Balance Training\n Breathing Exercises.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n 12-12:30\n" }, { "category": "Rehab Services", "chartdate": "2150-08-12 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 413023, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: wbc 19.7\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n Squat pivot\n\n\n\n\n\n T\n Sit to Stand:\n\n\n\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 70\n 157/64\n 34-40\n 98% CPAP\n Activity\n Sit\n 80\n 139/59\n 40-45\n 99% CPAP\n Recovery\n Sit\n 76\n 141/47\n 35-40\n 99% CPAP\n Total distance walked:\n Minutes:\n Gait:\n Balance: Pt tol sitting at EOB for approx 10min with min to mod A to\n maintain upright and midline. Pt with Posterior and left LOB without\n assistance. Pt unable to achieve full standing, was max A for squat\n pivot\n Education / Communication:\n Other: Pulm: rapid uncoordinated breathing pattern. Pt was suctioned\n via trach for scant amount of white sputum. CPAP peep 5 psup 14. Tvol\n .250-.400 t/o treatment.\n Cognition: pt followed 100% of 1 step commands\n Assessment: Pt is making gains with balance and mobility. Today she\n showed improved balance at EOB, and was able to assist with transfer.\n Pts respiratory status remains well below baseline, however her wbc is\n improving, and her secretions are minimal. Pt will greatly benefit from\n increased time OOB, and skilled PT/OT upon d/c in rehab.\n Anticipated Discharge: Rehab\n Plan: f/u balance training. transfer training. pulm hygiene\n" }, { "category": "Respiratory ", "chartdate": "2150-08-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413158, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\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: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use,\n Tachypneic (RR> 35 b/min), Gasping efforts\n Assessment of breathing comfort: Pt acknowledges dyspnea\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 Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt failed PSV wean, has weak cough, becomes tachypnic after any\n intervention such as turning. Sxn,\n" }, { "category": "Social Work", "chartdate": "2150-08-14 00:00:00.000", "description": "Progress Note", "row_id": 413241, "text": "TITLE:\n Family referred to this worker by nursing. Family just met with the\n surgeon and learned that the patient may not be weanable from the\n ventilator. Pt\ns son and daughter expressing their concerns re: pt\n stated wishes not to live on life supports.\n Children explain that prior to admission pt was a vibrant woman who had\n many interests and friends, lived an active life. Children want to\n have a conversation with pt re: her wishes in terms of continuing with\n aggressive medical intervention if there is little hope of the pt\n living independent ly. Children expressing their difficulty in having\n this conversation with their mother and are requesting that I help\n facilitate the conversation.\n Spoke with nursing, pt not on any sedation, last received pain meds 5\n hours ago. Pt not arousable at this time, family aware of this workers\n availability. Will attempt communication when patient is more able to\n participate.\n" }, { "category": "Nursing", "chartdate": "2150-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412431, "text": "** pt has remained npo during day for r/t scheduled with peg placemnt,\n , LR cont infusing at 60cc/hr. if peg being held tf need to be\n restarted\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Ls rhoncherous thru out, sats 97-98%s while pt remains on vent cpap at\n 40% 5/10, rr mainly teens with increase to 30\ns with pt needing\n suctioning.,\n Action:\n Pt suctioned q 2 to 3 hours for thick white secretions, ps to 10 by\n RT in early am, pt enc to c&db\n Response:\n Pt cough remains weak with little secretions cleared on her on, ps\n changed to 10 early am by RT,\n Plan:\n Cont with aggressive pulmonary toilet, wean vent as tolerated,\n Ineffective Coping\n Assessment:\n Pt had several episodes during shift where she seemed teary eyed,\n wanting staff to stay with her and hold her hand, no c/o pain or\n discomfort,\n Action:\n Verbal encouragement and words of support given, poc reviewed with pt,\n pt received Zoloft dosing in am\n Response:\n Pt nodding head indicating understanding of poc, receptive to support\n given, seems to be less stressed after with short naps taken\n Plan:\n Continue with verbal support and encouragement, update pt on poc as\n needed\n" }, { "category": "Rehab Services", "chartdate": "2150-08-13 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 413145, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: .\n Updated medical status: WBC 20.8\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n T\n Sit to Stand:\n\n\n\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 88\n 136/53\n 38\n 99% CPAP\n Activity\n /\n 48\n Recovery\n /\n 27-38\n Total distance walked:\n Minutes:\n Gait:\n Balance: Pt tolerated sitting at EOB for approx 10 mins with min A to\n maintain upright, pt actively using R UE to assist with balance. Unable\n to achieve standing with max A x 2.\n Education / Communication: Pt status discussed with RN, rec using \n or stretcher and slide for transfers\n Other: Pulm: PEEP 5 Psupport 14, Suctioned for scant thin white sputum.\n LS CTAB, rapid paradoxical breathing pattern t/o treatment.\n Tone: Increase in B LE extensor tone, and ADD tone, performed PROM for\n B LE.\n Assessment: 85 yo f s/p colectomy with post-op likley embolic CVA today\n continues to be functioning below baseline. She was alert and following\n 1 step commands, her balance is slightly improved at EOB. Pt will\n require rehab upon d/c.\n Anticipated Discharge: Rehab\n Plan: f/u balance, strength, transfer training, ROM with co-op.\n" }, { "category": "Physician ", "chartdate": "2150-08-14 00:00:00.000", "description": "Intensivist Note", "row_id": 413216, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n Respiratory Failure,\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1000 mL LR\n Continuous at 60 ml/hr Order date: @ 0433 21. Ipratropium Bromide\n MDI 2 PUFF IH Q4-6H:PRN SOB, wheeze Order date: @ 1142\n 2. 250 mL NS\n Continuous at 999 ml/hr for 250 ml Order date: @ 0411 22.\n Lorazepam 0.5-1 mg IV Q4H:PRN Order date: @ 1349\n 3. 500 mL NS\n Continuous at 999 ml/hr for 500 ml Order date: @ 0021 23.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1142\n 4. 500 mL NS\n Continuous at 999 ml/hr for 500 ml Order date: @ 0056 24.\n Metoprolol Tartrate 5-10 mg IV Q2H:PRN\n hold for SBP<120 or HR<60 Order date: @ 1000\n 5. 500 mL NS\n Continuous at 999 ml/hr for 500 ml Order date: @ 0412 25.\n Metoprolol Tartrate 100 mg PO TID htn\n hold SBP<100 or HR<60 Order date: @ 0920\n 6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Order date: @ 1819\n 26. Midazolam 0.5-2 mg IV Q4H:PRN Order date: @ 0748\n 7. Acetaminophen 650 mg PR Q6H:PRN Fever Order date: @ 1327 27.\n Miconazole Powder 2% 1 Appl TP :PRN Order date: @ 1523\n 8. Albuterol MDI 6 PUFF IH Q4H Order date: @ 1142 28. Nystatin\n Oral Suspension 5 mL PO QID:PRN Order date: @ 0451\n 9. Aspirin 325 mg PO DAILY Order date: @ 2337 29. Ondansetron 4\n mg IV Q8H:PRN Order date: @ 1142\n 10. Calcium Gluconate IV Sliding Scale Order date: @ 1142 30.\n Piperacillin-Tazobactam Na 4.5 g IV Q8H Order date: @ 0654\n 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1142 31. Potassium Chloride IV Sliding Scale Order date: @ 0458\n 12. Diltiazem 30 mg PO TID Order date: @ 1525 32. Psyllium \n PKT PO BID Order date: @ 1228\n 13. Famotidine 20 mg PO DAILY Order date: @ 0756 33. Qvar *NF* 1\n INH IH Start: Order date: @ 2125\n 14. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain Order date: @\n 1142 34. Sertraline 50 mg PO DAILY Order date: @ 0754\n 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1119 35.\n Simvastatin 40 mg PO QHS Order date: @ 2308\n 16. HydrALAzine 10 mg IV Q6H prn htn Order date: @ 2305 36.\n Sodium Chloride 1 gm PO DAILY hyponatremia Start: Order date:\n @ 1508\n 17. IV access request: CVL D/C and culture tip Urgency: Routine Order\n date: @ 1002 37. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1142\n 18. IV access request: PICC Leave port accessed Indication: Antibiotics\n Urgency: Urgent Order date: @ 38. Vancomycin 1000 mg IV Q\n 12H Order date: @ 1257\n 19. IV access request: PICC D/C and culture tip Urgency: Routine Order\n date: @ 1238 39. Warfarin 2 mg PO QHS Order date: @ 1027\n 20. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1524\n 24 Hour Events:\n FEVER - 102.5\nF - 01:00 PM\n flush via g-tube--acutely vomited, very low U/O; WBC count up to 37,\n fever persists\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 10:18 AM\n Other medications:\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.5\n T current: 37.2\nC (99\n HR: 88 (81 - 118) bpm\n BP: 115/59(70) {88/42(53) - 183/69(99)} mmHg\n RR: 28 (15 - 41) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.8 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 2,709 mL\n 1,828 mL\n PO:\n Tube feeding:\n 731 mL\n 145 mL\n IV Fluid:\n 1,499 mL\n 1,643 mL\n Blood products:\n 9 mL\n Total out:\n 2,725 mL\n 107 mL\n Urine:\n 1,555 mL\n 82 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -16 mL\n 1,721 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 416 (281 - 520) mL\n PS : 12 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 148\n PIP: 18 cmH2O\n SPO2: 98%\n ABG: ///28/\n Ve: 9.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Edema: No(t) Absent, Trace)\n Right Extremities: (Edema: Trace)\n Labs / Radiology\n 461 K/uL\n 9.1 g/dL\n 138 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 30 mg/dL\n 99 mEq/L\n 135 mEq/L\n 28.8 %\n 36.7 K/uL\n [image002.jpg]\n 03:20 AM\n 10:00 AM\n 04:00 PM\n 03:09 AM\n 04:00 AM\n 05:20 PM\n 02:36 AM\n 02:31 AM\n 02:34 AM\n 06:15 AM\n WBC\n 18.8\n 20.9\n 22.3\n 19.7\n 20.8\n 36.7\n Hct\n 28.2\n 29.2\n 27.9\n 28.2\n 26.8\n 28.8\n Plt\n 560\n 582\n 578\n \n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 1.1\n Glucose\n 158\n 160\n 149\n 170\n 191\n 139\n 126\n 160\n 138\n Other labs: PT / PTT / INR:18.9/24.3/1.7, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.1 mg/dL, Mg:1.7 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: arousable; follows commands, fentanyl/midaz prn\n Cardiovascular: Beta-blocker, maintains good BP\n Pulmonary: Trach\n Gastrointestinal / Abdomen: palce on eyrthro and reglan\n Nutrition: hold feeds, pnd abd ct\n Renal: Foley, maintinence fluids while npo\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: vanco-line gpc in blood; zosyn--pseudomonas in\n sputum (evidence for pneumonia equivocal)\n get chest/abd ct\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds:\n Imaging: CXR today, CT scan abd today, CT scan chest today\n Fluids: LR, LR bolus followed by bicarb drip prior to CT scan\n Consults: General surgery\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Respiratory ", "chartdate": "2150-08-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412520, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: Pt acknowledges dyspnea\n :\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": "2150-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412838, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic 30s all night, into 40s x 1 and difficulty catching breath.\n Action:\n Suctioned for little thin white secretions, rested on AC only very\n briefly by RT and medicated with 1 mg versed.\n Response:\n RR to upper 20s to low 30s with good tidal volumes. Pt appears to be\n resting comfortably.\n Plan:\n Cont to wean vent as able. Pulmonary toileting. rehab. Please see\n metavision flowsheets for details.\n *Continues with low urine output 10-20cc/hr and MD has been\n notified.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-11 00:00:00.000", "description": "Generic Note", "row_id": 412839, "text": "TITLE:\n RESPIRATORY CARE:\n Pt remains trached, vent supported. Minimal change overnight. Episodes\n of tachypnea persist, RR to 50 at times. Pt sx\nd for small amts\n thick white. Administering MDI\ns as ordered. See flowsheet for further\n pt data. Will follow.\n 04:05\n" }, { "category": "Respiratory ", "chartdate": "2150-08-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412933, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\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: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\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": "Nursing", "chartdate": "2150-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412938, "text": "Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Pt remains hypovolemic, ? r/t sepsis d/t gram + cocci in blood\n cultures.\n Action:\n Fluid boluses x2 this shift for low u/o. NS boluses through PEG tube\n started d/t hyponatremia. Hemodynamically stable. PICC discontinued\n and tip sent for culture. PIV established. Tmax 101- no further\n cultures sent.\n Response:\n U/o improved slightly. Ostomy output remains adequate. Remains\n hemodynamically stable.\n Plan:\n Will add colloids (albumin most likely) to\n OOB to chair. Tolerated well. Rehab in to eval. Will f/u in a few days.\n" }, { "category": "Physician ", "chartdate": "2150-08-12 00:00:00.000", "description": "Intensivist Note", "row_id": 413015, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n : spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still\n high, started DTO, PICC removed PIV placed\n Chief complaint:\n respiratory failure\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 1000 mL LR 2. 1000 mL NS 3. 500 mL NS 4. Acetaminophen (Liquid) 5.\n Albumin 25% (12.5g / 50mL)\n 6. Albuterol MDI 7. Aspirin 8. Calcium Gluconate 9. Chlorhexidine\n Gluconate 0.12% Oral Rinse 10. Diltiazem\n 11. Famotidine 12. Fentanyl Citrate 13. Heparin Flush (10 units/ml) 14.\n HydrALAzine 15. 16. 17.\n 18. Insulin 19. Ipratropium Bromide MDI 20. Lorazepam 21. Magnesium\n Sulfate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Midazolam 25. Miconazole Powder 2% 26.\n Nystatin Oral Suspension 27. Ondansetron\n 28. Opium Tincture 29. Potassium Chloride 30. Psyllium 31. Qvar 32.\n Sertraline 33. Simvastatin\n 34. Sodium Chloride 0.9% Flush 35. Vancomycin 36. Warfarin\n 24 Hour Events:\n PICC LINE - STOP 12:02 PM\n ULTRASOUND - At 03:00 PM\n Fluid bolus for low U/o,responded appropriately\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Vancomycin - 09:05 AM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 04:00 PM\n Fentanyl - 08:25 PM\n Other medications:\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 38.3\nC (100.9\n HR: 79 (64 - 87) bpm\n BP: 151/68(86) {109/34(52) - 162/140(144)} mmHg\n RR: 29 (15 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,931 mL\n 1,002 mL\n PO:\n Tube feeding:\n 1,081 mL\n 461 mL\n IV Fluid:\n 1,950 mL\n 251 mL\n Blood products:\n 50 mL\n Total out:\n 1,397 mL\n 1,095 mL\n Urine:\n 467 mL\n 295 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n 2,534 mL\n -93 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 577 (190 - 577) mL\n PS : 14 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Vent Dependant\n PIP: 19 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands\n Labs / Radiology\n 441 K/uL\n 9.0 g/dL\n 126 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 22 mg/dL\n 101 mEq/L\n 133 mEq/L\n 28.2 %\n 19.7 K/uL\n [image002.jpg]\n 06:56 AM\n 03:41 AM\n 03:20 AM\n 10:00 AM\n 04:00 PM\n 03:09 AM\n 04:00 AM\n 05:20 PM\n 02:36 AM\n 02:31 AM\n WBC\n 15.8\n 18.8\n 20.9\n 22.3\n 19.7\n Hct\n 29.9\n 28.2\n 29.2\n 27.9\n 28.2\n Plt\n 78\n 441\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 29\n Glucose\n 112\n 158\n 160\n 149\n 170\n 191\n 139\n 126\n Other labs: PT / PTT / INR:13.8/24.3/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.6 mg/dL, Mg:1.9 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan: 85 yera old female with Resp Failure\n Neurologic: Stable. Started on coumadin. US for DVT negative\n Cardiovascular: Stable. On Coumadin\n Pulmonary: (Ventilator mode: CPAP + PS), Cont to wean as tolerated.\n Gastrointestinal / Abdomen: Given DTO to slow ostomy output.\n Nutrition: Tube feeding\n Renal: Foley, had marginal UO yesterday, responded to fluids. Will\n increase daily inputs to compensate for GI outputs. Will check serum\n and urine osms.\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Check cultures, on IV vanco. PICC line d/c, tip\n sent for CX as pt with BCX + for staph\n Lines / Tubes / Drains: Foley, G-tube\n Wounds:\n Imaging: chest xray today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:34 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2150-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412363, "text": "Adm with BRBPR; +diverticulitus per OSH; OR for exp lap, total abd\n colectomy with end ileostomy. Course complicated by failure to wean-\n insertion of trach; left sided weakness\nCt showed cortical infarct,\n ?age; in/out a-fib\nrate control issues.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n LUE/LLE remain weakened; pt moving digits/toes sl on command; following\n some simple commands\n Action:\n Cont to monitor movement/sensation;\n Response:\n No change in current neuro status\n Plan:\n Cont to monitor. Will need rehab stay to maximize functional\n potential; daughter visiting ; social service and case management\n involved\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n TF infusing at goal rate; trach site unremarkable-slow to wean off vent\n Action:\n NPO after MN for scheduled PEG placement; suctioned Q3-4 hrs\n Response:\n No s/s aspiration; min secretions\n Plan:\n PEG placement. Cont VAP regimen.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n NPO 12Mn; u/o decreasing thru course of shift\n Action:\n LR started\n Response:\n Increase in hourly u/o evident\n Plan:\n i/o\ns; Keep u/o >30cc/hr; restart TF per surgical\ns recommendations via\n PEG\n" }, { "category": "Nursing", "chartdate": "2150-08-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412665, "text": "85F w/ hx recent CVA on coumadin, presented w/ nausea and large\n painless bloody bowel movements at home and more in ER; hct decreased\n from 32.9 to 29.4 in 1 hr; INR 3.2, WBC 18.5, received IVF\n resuscitation, abxs, FFP, vit K, PRBCs; found to have perfed bowel;\n Now with resection and ileostomy, c/b by post-op embolic stroke;\n Hx CVA, DM, htn, sever COPD, previously on home O2;\n Now also w/ trach and PEG, ready to be evaluated for rehab;\n **please also see metavision flownotes for objective data**\n Alteration in Nutrition\n Assessment:\n Pt s/p large tube feed residuals yesterday\n Action:\n Now on IV raglan q 6 hrs; restarted on tube feeds approx 12a;\n Response:\n Blood sugars trending up, suggesting some absorption of feeds;\n Plan:\n Cont to check residuals, advance rate as ordered\n Electrolyte & fluid disorder, other\n Assessment:\n This a.m.\ns serum K+ and Mg lower than desired\n Action:\n Received repletion of both\n Response:\n tbd\n Plan:\n Continue to follow daily levels as ordered, repletions as ordered per\n ss ordered\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt post-op for trach, pt nods\n to pain; resp rate and b/p up when\n in pain\n Action:\n Received conservative small doses fentanyl, 12.5 mcgs, approx q 4-5 hrs\n Response:\n Pt appeared comfortable following\n Plan:\n Continue conservative pain administration prn\n Impaired Skin Integrity\n Assessment:\n Peri-area w/ redness as already described, not new tonight; also left\n arm w/ bruising and swelling;\n Action:\n Receives rtn hygiene care; b/p left off left arm, did only intermittent\n manual initiated b/p cuff pressures approx q3 hrs, since b/p\n essentially stable\n Response:\n Lower left arm swelling much less today than yesterday; bruising\n likely d/t phlebotomy in light of coagulapathy at admission\n Plan:\n Continue cares per plan\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt now s/p trach; on PS/Peep at FIO2 0.40\n Action:\n Suctioned approx q 3 hrs overnoc for small amts white return overnoc\n Response:\n O2 sats high, at 98%\n Plan:\n Trach cares; wean on settings per team\n Further plans per a.m. rounds.\n" }, { "category": "Physician ", "chartdate": "2150-08-09 00:00:00.000", "description": "Intensivist Note", "row_id": 412668, "text": "SICU\n HPI:\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n Chief complaint:\n respiratory failure\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 2. 1000 mL LR 3. 1000 mL LR 4. 1000 mL LR 5. 20 mEq Potassium\n Chloride / 1000 mL D5 1/2 NS 6. Acetaminophen (Liquid)\n 7. Albuterol MDI 8. Aspirin 9. Calcium Gluconate 10. Chlorhexidine\n Gluconate 0.12% Oral Rinse 11. Diltiazem\n 12. Famotidine 13. Fentanyl Citrate 14. Fluconazole 15. Heparin 16.\n Heparin Flush (10 units/ml)\n 17. HydrALAzine 18. 19. 20. Insulin 21. Ipratropium Bromide MDI 22.\n Lorazepam 23. Magnesium Sulfate\n 24. Metoprolol Tartrate 25. Metoprolol Tartrate 26. Metoclopramide 27.\n Midazolam 28. Nystatin Oral Suspension\n 29. Ondansetron 30. Potassium Chloride 31. Psyllium 32. Qvar 33.\n Sertraline 34. Simvastatin 35. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Negative US to r/o DVT\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 06:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 03:45 AM\n Lorazepam (Ativan) - 03:45 AM\n Other medications:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.7\nC (99.8\n HR: 78 (61 - 82) bpm\n BP: 178/60(91) {124/50(68) - 178/80(100)} mmHg\n RR: 28 (21 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,023 mL\n 1,055 mL\n PO:\n Tube feeding:\n 466 mL\n 239 mL\n IV Fluid:\n 2,217 mL\n 816 mL\n Blood products:\n Total out:\n 1,424 mL\n 285 mL\n Urine:\n 814 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 770 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 388 (340 - 388) mL\n PS : 8 cmH2O\n RR (Set): 50\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 84\n PIP: 13 cmH2O\n SPO2: 98%\n ABG: ///27/\n Ve: 7.9 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, Pleasant, cooperative\n Labs / Radiology\n 560 K/uL\n 9.5 g/dL\n 158 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 136 mEq/L\n 28.2 %\n 18.8 K/uL\n [image002.jpg]\n 02:11 AM\n 03:11 AM\n 11:54 AM\n 12:05 AM\n 01:55 AM\n 03:14 AM\n 06:43 AM\n 06:56 AM\n 03:41 AM\n 03:20 AM\n WBC\n 21.9\n 12.8\n 14.9\n 14.0\n 12.5\n 15.8\n 18.8\n Hct\n 28.7\n 27.4\n 32\n 28.9\n 28.7\n 25.7\n 29.9\n 28.2\n Plt\n 89\n 487\n 607\n 560\n Creatinine\n 0.5\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 28\n 27\n 29\n Glucose\n 169\n 131\n 161\n 140\n 102\n 112\n 158\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.2 mg/dL, Mg:1.9 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan: 85 year old female with respiratory failure, s/p\n CVA and LGIB\n Neurologic: Stable, unchanged. PT with h/o multiple CVAs,bubble study\n for PFO positive @ osh, will plan to get lower extremity and consider\n IVC filter in future.\n Cardiovascular: Lopressor increased yesterday. US done to r/o DVT in\n upper extremity\n Pulmonary: (Ventilator mode: CPAP + PS), Continue with ARDS net\n ventilation. Wean PS as tolerated, Check Cxray\n Gastrointestinal / Abdomen: restarted feeds, tolerating\n Nutrition: Tube feeding, advance to goal\n Renal: Foley, patient had decreasing urine output overnight, responded\n fluids. D/C IVF at this time.\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: UA, Afebrile, currently on Fluconazle for yeast in\n urine. Will send UA\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:19 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2150-08-11 00:00:00.000", "description": "Intensivist Note", "row_id": 412908, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n Chief complaint:\n Respiratory Failure,\n PMHx:\n CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen (Liquid) 4. Albuterol MDI 5. Aspirin\n 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Diltiazem 9. Famotidine 10. Fentanyl Citrate 11. Heparin Flush (10\n units/ml) 12. Heparin 13. HydrALAzine\n 14. 15. 16. Insulin 17. Ipratropium Bromide MDI 18. Lorazepam 19.\n Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Metoprolol Tartrate 22. Midazolam 23. Miconazole Powder 2% 24.\n Nystatin Oral Suspension 25. Ondansetron\n 26. Potassium Chloride 27. Psyllium 28. Qvar 29. Sertraline 30.\n Simvastatin 31. Sodium Chloride 0.9% Flush\n 32. Warfarin\n 24 Hour Events:\n pt u/o decrased--10cc/hr. per primary team--d/c foley--maybe the\n source of fever. rehab service onboard\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 11:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 38.1\nC (100.6\n HR: 70 (66 - 91) bpm\n BP: 122/44(62) {114/44(62) - 167/73(94)} mmHg\n RR: 30 (21 - 36) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 1,456 mL\n 741 mL\n PO:\n Tube feeding:\n 856 mL\n 501 mL\n IV Fluid:\n Blood products:\n Total out:\n 2,561 mL\n 722 mL\n Urine:\n 721 mL\n 192 mL\n NG:\n 100 mL\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,105 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 247 (247 - 456) mL\n PS : 10 cmH2O\n RR (Spontaneous): 34\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 238\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ///27/\n Ve: 10.3 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands\n Labs / Radiology\n 578 K/uL\n 9.3 g/dL\n 139 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 20 mg/dL\n 101 mEq/L\n 134 mEq/L\n 27.9 %\n 22.3 K/uL\n [image002.jpg]\n 06:43 AM\n 06:56 AM\n 03:41 AM\n 03:20 AM\n 10:00 AM\n 04:00 PM\n 03:09 AM\n 04:00 AM\n 05:20 PM\n 02:36 AM\n WBC\n 12.5\n 15.8\n 18.8\n 20.9\n 22.3\n Hct\n 25.7\n 29.9\n 28.2\n 29.2\n 27.9\n Plt\n 487\n 607\n 560\n 582\n 578\n Creatinine\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 29\n Glucose\n 102\n 112\n 158\n 160\n 149\n 170\n 191\n 139\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.5 mg/dL, Mg:1.9 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: Stable\n Cardiovascular: Stable, to begin anticoagulation for stroke\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), weaning as tolerated\n Gastrointestinal / Abdomen: PEG\n Nutrition: add NS flushes as decreased urine output likely due to\n dehydration\n Renal: Foley, decreased urine output\n Hematology: Serial Hct, Stable\n Endocrine: RISS\n Infectious Disease: Check cultures, remove PICC line, Vanco for\n persumed staff, f/u final CX\n Lines / Tubes / Drains: G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:00 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 26 minutes\n" }, { "category": "Rehab Services", "chartdate": "2150-08-11 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 412915, "text": "Subjective:\n Trach'd\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n T\n Sit to Stand:\n Pt unable to stand c maxA\n\n\n\n\n\n\n\n\n\n\n\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 72\n 122/44\n 36\n 98\n Activity\n Sit\n 78\n 139/61\n 38\n 96\n Recovery\n Sit\n 70\n 122/46\n 29\n Total distance walked:\n Minutes:\n Transfer: Pt able to squat pivot to chair c MaxA\n Balance: ModA @ EOB post LOB. Unable to WB LUE\n Education / Communication: c RN RE Pt Status\n Pt RE Importance of OOB\n Other: Pt denied Pain\n Pulm: Dyscoordinate pattern c decreased BS at bases. Weak cough.\n Suctioned by RN via trach for min thin white secretions. +DOE.\n MS: Pt able to follow simple commands 50%\n Assessment: Pt is an 85F s/p colectomy c/b embolic CVA p/w improved\n activity tolerance today. Pt demonstrated increased strength t/o\n extremities compared to but continues to have significant weakness\n through out L>R. Pt will require STR at D/C and would benifit from\n >3hrs PT/OT.\n Anticipated Discharge: Rehab\n Plan: Cont c POC.\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413140, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Increased RR, Pt c/o feeling SOB, HR elevated\n Action:\n PS increased from 12 to 14, suctioned every hour, turned q two hours\n and OOB for 4 hrs today.\n Response:\n RR 18-25 now,\n Plan:\n Continue to monitor pt pulmonary status. Wean pt 2 if tolerated.\n Suction q 1-2hr as needed. Pulmonary toilet as tolerated. Versed/Ativan\n for anxiety as needed. Continue with plan of care.\n Motor Function, Impaired\n Assessment:\n Pt side weak post old CVA, Pt x3 assist OOB with PT. Pt unable to\n move Left arm and leg. Right side weak but pt able to move on bed.\n Extreme contractures in BLE.\n Action:\n Turn pt q two hours and PRN. OOB to chair for 4 hrs. ROM to\n extremities, Assess skin for signs of breakdown.\n Response:\n Pt stiff in extremities. Skin intact.\n Plan:\n Continue to turn pt , ROM, OOB as tolerated. Assess skin for breakdown.\n Pt in to work with the pt. Plan for rehab when pt discharged from\n .\n Alteration in Nutrition\n Assessment:\n Weight down 6 kg from admit. Copious amounts of emesis post NS fluid\n bolus per PEG. Large residual in PEG when placed to gravity >600 cc of\n undigested tube feed.\n Action:\n Tube feeds held, PEG placed to gravity bag, Pt given zofran for N/V.\n Placed back to bed. MD informed about pt N/V.\n Response:\n NS fluid bolus held. Salt tabs ordered to replace NS fluid bolus. Pt\n resting.\n Plan:\n Will restart tube feeds at 5pm MD orders. Will monitor residual\n with TF. Will provide zofran if needed for N/V. Monitor lytes and wt.\n Replace as needed. Will continue with the plan of care.\n" }, { "category": "Nursing", "chartdate": "2150-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413204, "text": "Alteration in Nutrition\n Assessment:\n Vomited during afternoon\n Action:\n Tube feed continued at 20cc/h\n Response:\n No further vomiting, glucose controlled.\n Plan:\n Advance tube feeds to goal, slowly, as tolerated.\n Ventilation, Impaired\n Assessment:\n Non compliant with vent early noc, high resp rate and low tidal\n volumes.\n Action:\n Sedated and pain controlled with ativan and fentanyl as ordered.\n Response:\n Pt visibly more comfortable, allowing for optimal ventilation.\n Plan:\n Maintain comfortable status for adequate ventilation.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Anuric. Pt probably dehydrated per report dr .\n Action:\n Foley cath changed and irrigated. Multiple fluid boluses as ordered for\n total of 2250cc.\n Response:\n Huo slowly returned and increased to >30cc by 0600.\n Plan:\n Monitor u/o hourly, intervening with fluids as ordered.\n Problem - Description In Comments\n Assessment:\n Day nurse reported that conversation was had between pts daughter and\n primary team re: pt being made dnr.\n Action:\n Dr notified who communicated with primary team.\n Response:\n Dnr/dni ordered.\n Plan:\n Dnr/dni (though pt already trach\n" }, { "category": "Respiratory ", "chartdate": "2150-08-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412429, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Respiratory Care Shift Procedures\n Comments:\n Pt received on PSV 15/5 as noted. PS weaned to 10cm\n pt tolerating\n fairly well with a RR 23-34. BS coarse throughout which clears with\n suctioning. Plan to continue to wean PS as tolerated to keep RR in\n 20\n" }, { "category": "Nursing", "chartdate": "2150-08-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412680, "text": "Alteration in Nutrition\n Assessment:\n TF increased to 45ml\n Action:\n Residuals checked Q4, reglan given\n Response:\n Residuals 120 team ok w/ <250\n Plan:\n Continue to increase TF to goal of 60. Monitor residuals. Notify team\n and hold TF if >250\n" }, { "category": "Nursing", "chartdate": "2150-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413352, "text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Pt went into rapid afib rate of 120\ns -140\ns. sbp stable at 120/60. Dr.\n aware and pt treated with 10mg of iv lopressor. Hr down to . sbp remains stable 103-120/40-60. pt treated with\n additional 5mg of iv lopressor x 2 with good response.\n Action:\n Lopressor changed to iv 5\n 10 mg q4 and lopressor prn ordered.\n Lopressor po discontinued.\n Response:\n Hr down to 88-100 still in afib at the current time. Sbp remains\n stable.\n Plan:\n Continue on iv lopressor at this time.\n Alteration in Nutrition\n Assessment:\n Pt with abd distention and wbc up to 36. tube feeds stopped and g\ntube\n to gravity. G-tube draining large amts of bilious drainage.\n Action:\n g-tube to remain at gravity. Tube feeds off a this time. Iv fluid\n started till this am.\n Response:\n Abd still distended and pt continues to have abd pain.\n Plan:\n Pt remains npo at this time. ? abd ct today if family wants.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain. Left lower quadrent tender to palpation. Abd remains\n slightly distended. G tube with large amts of bilious drainage.\n Action:\n Tube feeds on hold. Pt remains npo. Fentanyl for pain as needed.\n Response:\n Fentanyl effective in relieving pain.\n Plan:\n Fentanyl as needed. Npo at this timel\n" }, { "category": "Respiratory ", "chartdate": "2150-08-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413200, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: Tachypnea resolved with medication for pain.\n Assessment of breathing comfort: Improved with medication.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Comments: No abg results at this time. RSBI = 148 on 0-PEEP and 5 cm\n PSV.\n" }, { "category": "Nursing", "chartdate": "2150-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412356, "text": "Adm with BRBPR; +diverticulitus per OSH; OR for exp lap, total abd\n colectomy with end ileostomy. Course complicated by failure to wean-\n insertion of trach; left sided weakness\nCt showed cortical infarct,\n ?age; in/out a-fib\nrate control issues.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n LUE/LLE remain weakened; pt moving digits/toes sl on command; following\n some simple commands\n Action:\n Cont to monitor movement/sensation;\n Response:\n No change in current neuro status\n Plan:\n Cont to monitor. Will need rehab stay to maximize functional\n potential; daughter visiting ; social service and case management\n involved\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n TF infusing at goal rate; trach site unremarkable-slow to wean off vent\n Action:\n NPO after MN for scheduled PEG placement; suctioned Q3-4 hrs\n Response:\n No s/s aspiration; min secretions\n Plan:\n PEG placement. Cont VAP regimen.\n" }, { "category": "Nursing", "chartdate": "2150-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412357, "text": "Adm with BRBPR; +diverticulitus per OSH; OR for exp lap, total abd\n colectomy with end ileostomy. Course complicated by failure to wean-\n insertion of trach; left sided weakness\nCt showed cortical infarct,\n ?age; in/out a-fib\nrate control issues.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n LUE/LLE remain weakened; pt moving digits/toes sl on command; following\n some simple commands\n Action:\n Cont to monitor movement/sensation;\n Response:\n No change in current neuro status\n Plan:\n Cont to monitor. Will need rehab stay to maximize functional\n potential; daughter visiting ; social service and case management\n involved\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n TF infusing at goal rate; trach site unremarkable-slow to wean off vent\n Action:\n NPO after MN for scheduled PEG placement; suctioned Q3-4 hrs\n Response:\n No s/s aspiration; min secretions\n Plan:\n PEG placement. Cont VAP regimen.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n NPO 12Mn; u/o decreasing thru course of shift\n Action:\n LR started\n Response:\n Awaiting response as of this writing\n Plan:\n i/o\ns; Keep u/o >30cc/hr; restart TF per surgical\ns recommendations via\n PEG\n" }, { "category": "Respiratory ", "chartdate": "2150-08-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412587, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\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: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 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:\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min); Comments: Episodes of tachypnea.\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: 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": "2150-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412827, "text": "Pt is a 85F c hx of CVA in , on coumadin, adm with acute\n diverticulitis and GIB s/p subtotal colectomy c end ileostomy and\n pouch post op c/b Afib and noted to have LUE weakness when\n weaned off of propofol and with + multiple B coritical infarts,\n likley embolic, on MRI. Pt currently unable to wean from mechanical\n ventilation and now s/p trach/PEG.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Comfortable on PS 10/5 Free air noted on CXR, 40 cc gastrograffin and\n scout film done\n Action:\n PS . from 12 to 10\n Response:\n Became dyspneic with discordant resp pattern rate up to 30s after\n vigorous PT at side of bed, ROM to all 4s) Med with 1.0 midaz\n with excellent effect. RR down to 25 with good Vt\n Plan:\n Cont screen for rehab. Check results of scout film, cont to exercise\n with PT , advance activity level as tol. Benzos prn anxiety. Slow PS\n wean. TF on hold til results of scout film back\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Left side remains weaker than Right. Full list toward left when dangled\n at edge of bed\n Action:\n PT for ROM, activity progression\n Response:\n Exhausted after PT, dyspneic with minimal reserve\n Plan:\n Cont PT, allow rest periods. Possible tran to tomarrow if scout\n series negative.\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413136, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Increased RR, Pt c/o feeling SOB, HR elevated\n Action:\n PS increased from 12 to 14, suctioned every hour, turned q two hours\n and OOB for 4 hrs today.\n Response:\n RR 18-25 now,\n Plan:\n Continue to monitor pt pulmonary status. Wean pt 2 if tolerated.\n Suction q 1-2hr as needed. Pulmonary toilet as tolerated. Versed/Ativan\n for anxiety as needed. Continue with plan of care.\n Motor Function, Impaired\n Assessment:\n Pt side weak post old CVA, Pt x3 assist OOB with PT. Pt unable to\n move Left arm and leg. Right side weak but pt able to move on bed.\n Extreme contractures in BLE.\n Action:\n Turn pt q two hours and PRN. OOB to chair for 4 hrs. ROM to\n extremities, Assess skin for signs of breakdown.\n Response:\n Pt stiff in extremities. Skin intact.\n Plan:\n Continue to turn pt , ROM, OOB as tolerated. Assess skin for breakdown.\n Pt in to work with the pt. Plan for rehab when pt discharged from\n .\n Alteration in Nutrition\n Assessment:\n Weight down 6 kg from admit. Copious amounts of emesis post NS fluid\n bolus per PEG. Large residual in PEG when placed to gravity >600 cc of\n undigested tube feed.\n Action:\n Tube feeds held, PEG placed to gravity bag, Pt given zofran for N/V.\n Placed back to bed. MD informed about pt N/V.\n Response:\n NS fluid bolus held. Salt tabs ordered to replace NS fluid bolus. Pt\n resting.\n Plan:\n Will restart tube feeds at 5pm MD orders. Will monitor residual\n with TF. Will provide zofran if needed for N/V. Monitor lytes and wt.\n Replace as needed. Will continue with the plan of care.\n" }, { "category": "Nursing", "chartdate": "2150-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413273, "text": ".H/O fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Wbc 36.7,\n Action:\n Blood cultures drawn\n Response:\n Await results, pt presently t max 100.3\n Plan:\n Continue to monitor wbc, continue with antibiotics, monitor temp. await\n results from blood cultures\n Ineffective Coping\n Assessment:\n pt family unsure about how aggressive they want to be about of plan of\n care( i.e ct scan)\n Action:\n Meet with dr. , social work and palliative care\n Response:\n Family received information need to assist in making a decision. Ct\n scan on hold\n Plan:\n Continue to emotional support with family, provide with information as\n needed. Family to reassess wishes in am\n" }, { "category": "Nursing", "chartdate": "2150-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413443, "text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Pt went into Rapid afib rate as high 160, pt was not hypotensive\n during this eposide, dr. \n Action:\n Pt received at total of 15mg of iv Lopressor, pt continues on cardizem\n po\n Response:\n Hr decreased to 90-100,continues in afib\n Plan:\n Continue to monitor, pt respond well to iv Lopressor,\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Urine output dropped to 15cc, gastric tube draining 500cc ,dr . \n aware\n Action:\n Pt received 500 cc lr bolus x1, ivf increased to 125cc/hr\n Response:\n Urine output increased to 30cc/hr\n Plan:\n Continue to monitor,\n" }, { "category": "Nursing", "chartdate": "2150-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412352, "text": "Adm with BRBPR; +diverticulitus per OSH; OR for exp lap, total abd\n colectomy with end ileostomy. Course complicated by failure to wean-\n insertion of trach; left sided weakness\nCt showed cortical infarct,\n ?age; in/out a-fib\nrate control issues.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n LUE/LLE remain weakened; pt moving digits/toes sl on command; following\n some simple commands\n Action:\n Cont to monitor movement/sensation;\n Response:\n No change in current neuro status\n Plan:\n Cont to monitor. Will need rehab stay to achieve prior level of\n functioning\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n TF infusing at goal rate; trach site unremarkable-slow to wean off vent\n Action:\n NPO after MN for scheduled PEG placement\n Response:\n No s/s aspiration\n Plan:\n PEG placement. Cont VAP regimen\n" }, { "category": "Physician ", "chartdate": "2150-08-06 00:00:00.000", "description": "Intensivist Note", "row_id": 412353, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n Lower GIB c/b post-op embolic stroke\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen (Liquid) 4. Albuterol MDI 5. Aspirin\n 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Diltiazem 9. Famotidine 10. Fentanyl Citrate 11. Fluconazole 12.\n Heparin 13. Heparin Flush (10 units/ml)\n 14. 15. 16. Insulin 17. Ipratropium Bromide MDI 18. Magnesium Sulfate\n 19. Metoprolol Tartrate\n 20. Metoprolol Tartrate 21. Midazolam 22. Nystatin Oral Suspension 23.\n Ondansetron 24. Potassium Chloride\n 25. Psyllium 26. Qvar 27. Sertraline 28. Simvastatin 29. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n NPO for peg today, started on LR while NPO\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.4\n HR: 81 (68 - 89) bpm\n BP: 140/74(90) {133/58(83) - 188/80(109)} mmHg\n RR: 12 (12 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,056 mL\n 107 mL\n PO:\n Tube feeding:\n 888 mL\n 33 mL\n IV Fluid:\n 518 mL\n 44 mL\n Blood products:\n Total out:\n 1,449 mL\n 370 mL\n Urine:\n 999 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 607 mL\n -263 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): 425 (425 - 425) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: ///27/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Ostomy begin\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands\n Labs / Radiology\n 489 K/uL\n 9.3 g/dL\n 140 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 25 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.7 %\n 14.0 K/uL\n [image002.jpg]\n 05:20 AM\n 09:51 AM\n 03:30 AM\n 05:17 AM\n 02:11 AM\n 03:11 AM\n 11:54 AM\n 12:05 AM\n 01:55 AM\n 03:14 AM\n WBC\n 23.0\n 21.9\n 12.8\n 14.9\n 14.0\n Hct\n 28.2\n 28.7\n 27.4\n 32\n 28.9\n 28.7\n Plt\n 362\n 424\n 398\n 490\n 489\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 22\n 28\n 27\n Glucose\n 148\n 164\n 169\n 131\n 161\n 140\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC ,LGIB\n Assessment and Plan: 85 year old s/p TAC for perf divertic: massive\n LGIB c/b post op embolic stroke. Pt currently awaiting PEg today and\n placement in Vent facility\n Neurologic: fentanyl prn, midaz prn\n Cardiovascular: Pt HTn overnight, continue increasiing Metoprol as\n tolerated. Cont to decrease Dilt as tolerated\n Pulmonary: Trach, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: Plan for PEG today\n Nutrition: Holding for PEG\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS, FS 140-200. Would observe and increase RISS as needed\n after Feeds restart\n Infectious Disease: On Fluconazole 400mg IV bid for yeast in urine (day\n 2)\n Lines / Tubes / Drains: Foley, NGT, Trach\n Wounds:\n Imaging: CXR today\n Fluids: LR, while NPO\n Consults: General surgery\n Billing Diagnosis: Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to other facility\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2150-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412569, "text": "(Please see data flowsheet for objective measured data)\n Alteration in Nutrition\n Assessment:\n Pt npo , now w/ new tracheostomy \n Action:\n Pt started on tube feeds last eve, increased rate\n Response:\n To be determined\n Plan:\n Follow residuals, blood glucose levels,\n Electrolyte & fluid disorder, other\n Assessment:\n Serum magnesium 1.7 this a.m.\n Action:\n Receiving 2 gms IVPB per ss standing order\n Response:\n tbd\n Plan:\n Cont to follow serum electrolytes\n Hypertension, benign\n Assessment:\n Pt hypertensive last eve, as high as 160s and higher; pt s/p painful\n procedure (treacheostomy)\n Action:\n Pt receive prn IVP fentanyl 25 mcgs approx q 2-4 hours overnight; pt\n also received prn hydralazine\n Response:\n Pts b/p remained in acceptable ranges overnight\n Plan:\n Cont to medicate w/ antiphypertensives for hypertension prn, first\n assess for presence of pain or anxiety\n Pain control (acute pain, chronic pain)\n Assessment:\n As stated pt s/p trach ;\n Action:\n Pt ordered for fentanyl 12.5 mcgs-100 mcgs q 2 hrs prn, pt received\n fent 25 mcgs approx q 3-4 hrs overnight at hypertension, incsd resp\n rate despite clear airway and good O2 sat, and verbal/confirmation of\n pain (via mouthing words) from pt\n Response:\n Pt observed to be resting comfortably following receiving\n Plan:\n Continue to medicate as needed for pain, avoiding over sedation\n Impaired Skin Integrity\n Assessment:\n Pt s/p trach as stated above;\n Action:\n Trach site care received, drssg changed\n Response:\n Site w/out redness or prurulent drainage\n Plan:\n Continue trach site care q shift\n Pt pleasant, nods affirmation of questions; makes purposeful movements\n w/ arms; legs stiff;\n Further plan plan of care per a.m. rounds.\n" }, { "category": "Physician ", "chartdate": "2150-08-07 00:00:00.000", "description": "Intensivist Note", "row_id": 412479, "text": "SICU\n HPI:\n COPD on home O2 for ambulating and sometimes at night**\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n hydration, hemodynamic monitoring, continued ostomy output\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n IV access: PICC, heparin dependent Location: Right brachial, Date\n inserted: Order date: @ 1119 16. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1524\n 2. 1000 mL LR\n Continuous at 60 ml/hr Order date: @ 0433 17. Ipratropium Bromide\n MDI 2 PUFF IH Q4-6H:PRN SOB, wheeze Order date: @ 1142\n 3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Order date: @ 1819\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 1142\n 4. Albuterol MDI 6 PUFF IH Q4H Order date: @ 1142 19. Metoprolol\n Tartrate 5-10 mg IV Q2H:PRN\n hold for SBP<120 or HR<60 Order date: @ 1000\n 5. Aspirin 325 mg PO DAILY Order date: @ 2337 20. Metoprolol\n Tartrate 100 mg PO BID htn Order date: @ 0429\n 6. Calcium Gluconate IV Sliding Scale Order date: @ 1142 21.\n Midazolam 0.5-2 mg IV Q4H:PRN Order date: @ 0748\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1142 22. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @\n 0451\n 8. Diltiazem 30 mg PO TID Order date: @ 1525 23. Ondansetron 4\n mg IV Q8H:PRN Order date: @ 1142\n 9. Famotidine 20 mg PO DAILY Order date: @ 0756 24. Potassium\n Chloride IV Sliding Scale Order date: @ 0458\n 10. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain Order date: @\n 1142 25. Psyllium PKT PO BID Order date: @ 1228\n 11. Fluconazole 400 mg IV Q24H Order date: @ 0923 26. Qvar *NF*\n 1 INH IH Start: Order date: @ 2125\n 12. Heparin 5000 UNIT SC TID Order date: @ 2048 27. Sertraline\n 50 mg PO DAILY Order date: @ 0754\n 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1119 28.\n Simvastatin 40 mg PO QHS Order date: @ 2308\n 14. IV access request: CVL D/C and culture tip Urgency: Routine Order\n date: @ 1002 29. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1142\n 15. IV access request: PICC Leave port accessed Indication: Antibiotics\n Urgency: Urgent Order date: @ \n 24 Hour Events:\n none; to get PEG today\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.4\nC (99.4\n HR: 69 (62 - 103) bpm\n BP: 165/101(116) {141/51(72) - 184/101(116)} mmHg\n RR: 27 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,674 mL\n 528 mL\n PO:\n Tube feeding:\n 33 mL\n IV Fluid:\n 1,431 mL\n 408 mL\n Blood products:\n Total out:\n 1,759 mL\n 420 mL\n Urine:\n 1,059 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -85 mL\n 108 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 393 (379 - 582) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 95\n PIP: 15 cmH2O\n SPO2: 99%\n ABG: ////\n Ve: 7.9 L/min\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands\n Labs / Radiology\n 489 K/uL\n 9.3 g/dL\n 140 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 25 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.7 %\n 14.0 K/uL\n [image002.jpg]\n 05:20 AM\n 09:51 AM\n 03:30 AM\n 05:17 AM\n 02:11 AM\n 03:11 AM\n 11:54 AM\n 12:05 AM\n 01:55 AM\n 03:14 AM\n WBC\n 23.0\n 21.9\n 12.8\n 14.9\n 14.0\n Hct\n 28.2\n 28.7\n 27.4\n 32\n 28.9\n 28.7\n Plt\n 362\n 424\n 398\n 490\n 489\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 22\n 28\n 27\n Glucose\n 148\n 164\n 169\n 131\n 161\n 140\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: fentanyl prn, sertraline\n Cardiovascular: Aspirin, Beta-, , diltiazem 30''', lopressor\n 75''\n Pulmonary: Trach, pressure support to trach collar\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS, w/stable finger sticks\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT, Trach\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2150-08-08 00:00:00.000", "description": "Intensivist Note", "row_id": 412574, "text": "SICU\n HPI:\n HPI:**COPD on home O2 for ambulating and sometimes at night**\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n .\n MEDICAL:h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole\n in my heart\")\n .\n :EC Aspirin 325 mg qd, Caltrate 600+D Plus Minerals 600 mg-400 unit\n Tab , Coumadin 2 mg qd, Metformin 500 mg Tablet , monopril 20\n mg Tablet qd, MVI, Vitamin D, Simvastatin 40 mg qhs, Advair Diskus\n 1 puff Albuterol 90 mcg MDI qid, DuoNeb tid, Spiriva qd\n .\n SURGICAL Hx:tonsillectomy\n .\n SOCIAL Hx:\n .\n ALLERGIES:Sulfa (Sulfonamides)\n .\n ABX: nystatin, fluconazole\n .\n MICRO:-Urine Cx + yeast\n CDiff negative ucx 10^5 yeast\n cath tip NG urine <10^5 yeast\n sputum sparse yeast blood cx pending\n blood cx pending sputum cx pending\n .\n IMAGING: CT abd ()- R-sided diverticulitis vs. colitis,\n extensive diverticulosis throughout colon, likely free air pocket, no\n fluid collection\n : CXR ()- ? free air under R hemidiaphragm\n CT head w/o contrast - no acute bleed\n : MICRO: cath tip NG urine <10^5 yeast\n sputum sparse yeast blood cx pending\n blood cx pending sputum cx pending\n -Urine Cx + yeast\n Chief complaint:\n resp failure\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n :\n EC Aspirin 325 mg qd, Caltrate 600+D Plus Minerals 600 mg-400 unit Tab\n , Coumadin 2 mg qd, Metformin 500 mg Tablet , monopril 20 mg\n Tablet qd, MVI, Vitamin D, Simvastatin 40 mg qhs, Advair Diskus 1\n puff Albuterol 90 mcg MDI qid, DuoNeb tid, Spiriva qd\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen (Liquid) 4. Albuterol MDI 5. Aspirin\n 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Diltiazem 9. Famotidine 10. Fentanyl Citrate 11. Fentanyl Citrate\n 12. Fluconazole 13. Heparin\n 14. Heparin Flush (10 units/ml) 15. HydrALAzine 16. 17. 18. Insulin 19.\n Ipratropium Bromide MDI\n 20. Lorazepam 21. Magnesium Sulfate 22. Metoprolol Tartrate 23.\n Metoprolol Tartrate 24. Midazolam\n 25. Midazolam 26. Nystatin Oral Suspension 27. Ondansetron 28.\n Potassium Chloride 29. Psyllium 30. Qvar\n 31. Sertraline 32. Simvastatin 33. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n : PEG performed at bedside - ready for discharge to LTAC asap\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 05:04 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:00 PM\n Hydralazine - 11:00 PM\n Fentanyl - 06:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.6\nC (99.7\n HR: 72 (59 - 88) bpm\n BP: 151/56(82) {133/54(76) - 192/74(101)} mmHg\n RR: 26 (13 - 30) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,629 mL\n 754 mL\n PO:\n Tube feeding:\n 164 mL\n 334 mL\n IV Fluid:\n 1,165 mL\n 141 mL\n Blood products:\n Total out:\n 1,610 mL\n 470 mL\n Urine:\n 1,305 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n 19 mL\n 284 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (198 - 398) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 103\n PIP: 14 cmH2O\n SPO2: 95%\n ABG: ///28/\n Ve: 10.1 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Gtube site ok\n Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli), Moves all extremities\n Labs / Radiology\n 607 K/uL\n 9.8 g/dL\n 112 mg/dL\n 0.4 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 102 mEq/L\n 137 mEq/L\n 29.9 %\n 15.8 K/uL\n [image002.jpg]\n 05:17 AM\n 02:11 AM\n 03:11 AM\n 11:54 AM\n 12:05 AM\n 01:55 AM\n 03:14 AM\n 06:43 AM\n 06:56 AM\n 03:41 AM\n WBC\n 21.9\n 12.8\n 14.9\n 14.0\n 12.5\n 15.8\n Hct\n 28.7\n 27.4\n 32\n 28.9\n 28.7\n 25.7\n 29.9\n Plt\n 89\n 487\n 607\n Creatinine\n 0.5\n 0.5\n 0.4\n 0.4\n 0.3\n 0.4\n TCO2\n 22\n 28\n 27\n 29\n Glucose\n 169\n 131\n 161\n 140\n 102\n 112\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.6 mg/dL, Mg:1.7 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: stable, pain controlled\n Cardiovascular: Aspirin, Beta-blocker, HTN cont, increase Lopressor to\n 100 tid\n Pulmonary: cont to wean PS slowly\n Gastrointestinal / Abdomen: cont tube feeds advanced to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: afebrile, wbc elevated will trend\n Lines / Tubes / Drains: Foley, G-tube, Trach, PICC line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Other: resp failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:19 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2150-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412740, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. febrile overnight, tachypneic, TVs dropping w/increased RR, large\n amount secretions via trach.\n Action:\n PS increased to 15, suctioned frequently, pan-cultured, Tylenol given.\n Response:\n Pt. appearing more comfortable on PS 15, RR decreased to mid 20s\n w/adequate volumes.\n Plan:\n Continue to monitor resp status, temp curve, suction PRN, f/u cx\n results, reattempt vent wean.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412743, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\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: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: Patient was visibly fatigued and moving very low VT. PSV\n increased to 15 cm.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Bedside Procedures:\n Comments: No morning abg results at this time. No RSBI measured, due\n to the high respiratory rate.\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413133, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Increased RR, Pt c/o feeling SOB, HR elevated\n Action:\n PS increased from 12 to 14, suctioned every hour, turned q two hours\n and OOB for 4 hrs today.\n Response:\n RR 18-25 now,\n Plan:\n Continue to monitor pt pulmonary status. Wean pt 2 if tolerated.\n Suction q 1-2hr as needed. Pulmonary toilet as tolerated. Versed/Ativan\n for anxiety as needed. Continue with plan of care.\n Motor Function, Impaired\n Assessment:\n Pt side weak post old CVA, Pt x3 assist OOB with PT. Pt unable to\n move Left arm and leg. Right side weak but pt able to move on bed.\n Extreme contractures in BLE.\n Action:\n Turn pt q two hours and PRN. OOB to chair for 4 hrs. ROM to\n extremities, Assess skin for signs of breakdown.\n Response:\n Pt stiff in extremities. Skin intact.\n Plan:\n Continue to turn pt , ROM, OOB as tolerated. Assess skin for breakdown.\n Pt in to work with the pt. Plan for rehab when pt discharged from\n .\n Alteration in Nutrition\n Assessment:\n Weight down 6 lbs from admit. Copious amounts of emesis post NS fluid\n bolus per PEG. Large residual in PEG when placed to gravity >600 cc of\n undigested tube feed.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2150-08-07 00:00:00.000", "description": "Intensivist Note", "row_id": 412490, "text": "SICU\n HPI:\n COPD on home O2 for ambulating and sometimes at night**\n HPI: 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n hydration, hemodynamic monitoring, continued ostomy output\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n IV access: PICC, heparin dependent Location: Right brachial, Date\n inserted: Order date: @ 1119 16. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1524\n 2. 1000 mL LR\n Continuous at 60 ml/hr Order date: @ 0433 17. Ipratropium Bromide\n MDI 2 PUFF IH Q4-6H:PRN SOB, wheeze Order date: @ 1142\n 3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Order date: @ 1819\n 18. Magnesium Sulfate IV Sliding Scale Order date: @ 1142\n 4. Albuterol MDI 6 PUFF IH Q4H Order date: @ 1142 19. Metoprolol\n Tartrate 5-10 mg IV Q2H:PRN\n hold for SBP<120 or HR<60 Order date: @ 1000\n 5. Aspirin 325 mg PO DAILY Order date: @ 2337 20. Metoprolol\n Tartrate 100 mg PO BID htn Order date: @ 0429\n 6. Calcium Gluconate IV Sliding Scale Order date: @ 1142 21.\n Midazolam 0.5-2 mg IV Q4H:PRN Order date: @ 0748\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1142 22. Nystatin Oral Suspension 5 mL PO QID:PRN Order date: @\n 0451\n 8. Diltiazem 30 mg PO TID Order date: @ 1525 23. Ondansetron 4\n mg IV Q8H:PRN Order date: @ 1142\n 9. Famotidine 20 mg PO DAILY Order date: @ 0756 24. Potassium\n Chloride IV Sliding Scale Order date: @ 0458\n 10. Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain Order date: @\n 1142 25. Psyllium PKT PO BID Order date: @ 1228\n 11. Fluconazole 400 mg IV Q24H Order date: @ 0923 26. Qvar *NF*\n 1 INH IH Start: Order date: @ 2125\n 12. Heparin 5000 UNIT SC TID Order date: @ 2048 27. Sertraline\n 50 mg PO DAILY Order date: @ 0754\n 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ 1119 28.\n Simvastatin 40 mg PO QHS Order date: @ 2308\n 14. IV access request: CVL D/C and culture tip Urgency: Routine Order\n date: @ 1002 29. Sodium Chloride 0.9% Flush 10 mL IV PRN line\n flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1142\n 15. IV access request: PICC Leave port accessed Indication: Antibiotics\n Urgency: Urgent Order date: @ \n 24 Hour Events:\n none; to get PEG today\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.4\nC (99.4\n HR: 69 (62 - 103) bpm\n BP: 165/101(116) {141/51(72) - 184/101(116)} mmHg\n RR: 27 (16 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,674 mL\n 528 mL\n PO:\n Tube feeding:\n 33 mL\n IV Fluid:\n 1,431 mL\n 408 mL\n Blood products:\n Total out:\n 1,759 mL\n 420 mL\n Urine:\n 1,059 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n -85 mL\n 108 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 393 (379 - 582) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 95\n PIP: 15 cmH2O\n SPO2: 99%\n ABG: ////\n Ve: 7.9 L/min\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands\n Labs / Radiology\n 489 K/uL\n 9.3 g/dL\n 140 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 25 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.7 %\n 14.0 K/uL\n [image002.jpg]\n 05:20 AM\n 09:51 AM\n 03:30 AM\n 05:17 AM\n 02:11 AM\n 03:11 AM\n 11:54 AM\n 12:05 AM\n 01:55 AM\n 03:14 AM\n WBC\n 23.0\n 21.9\n 12.8\n 14.9\n 14.0\n Hct\n 28.2\n 28.7\n 27.4\n 32\n 28.9\n 28.7\n Plt\n 362\n 424\n 398\n 490\n 489\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 22\n 28\n 27\n Glucose\n 148\n 164\n 169\n 131\n 161\n 140\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan:\n Neurologic: fentanyl prn, sertraline. Pt alert\n Cardiovascular: Aspirin, Beta-, , diltiazem 30''', lopressor\n 75''\n Pulmonary: Trach, wean pressure support to trach collar as tolerated\n Gastrointestinal / Abdomen: PEG today\n Nutrition: held for PEG\n Renal: Foley, Adequate UO\n Endocrine: RISS, w/stable finger sticks\n Infectious Disease: low grade temps, on fluconazole for Yeast in Urine.\n Heme: HCt stabe\n Lines / Tubes / Drains: Foley, NGT, Trach\n Imaging: CXR today\n Fluids: KVO after peg, LR @ 60cc/hr\n Consults: General surgery\n Billing Diagnosis: Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Hep Sq, Boots\n Stress ulcer: h2 via ngt\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2150-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412970, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o severe pain in abdomen following turning/respositioning Ostomy\n continues to drain brown stool-thicker in consistency. Abdomen is soft\n with present bowel sounds and tube feedings continue at goal\n Action:\n Medicated with fentanyl ivp x 1, emotional support provided.\n Response:\n Pt resting comfortably and denied pain on subsequent turning..\n Plan:\n Continue to monitor for pain and medicate as needed. ?ultrasound of\n abdomen today. Monitor stool output.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on same vent settings overnight with respiratory rate in the\n 20s at rest and 30s with stimulation\n Action:\n Suctioning with turning and allowing patient to rest on current\n settings overnight.\n Response:\n . Pt does not complain of difficulty breathing tonight and resting\n comfortably on vent with adequate sats and respiratory rate.\n Plan:\n Vent weaning today as tolerated. VAP care. Chest PT and OOB to chair.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Pt continued with low urine output earlier in evening.\n Action:\n Albumin x 1. Fluid boluses yesterday.\n Response:\n Urine output is starting to pick up this morning to 30cc/hr approx.\n Plan:\n Continue to monitor urine output and look for signs of hypovolemia vs\n hyper: need for fluid vs lasix. If urine output remains adequate\n discuss potential to discontinue foley cath to assist with ridding\n infection.\n" }, { "category": "Nursing", "chartdate": "2150-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412465, "text": "Hypertension, benign\n Assessment:\n 140/-180/ appearing comfortable\n Action:\n Given total of 15mg IV lopressor along with regular dose of 100mg po\n lopressor\n Response:\n Bp continue to be high\n Plan:\n Monitor bp tx prn\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse to clear o2 sats 97%\n Action:\n Suctioned small amt of white sputum\n Response:\n Better aeration\n Plan:\n Vigorous pulm toliet\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Moves right side able to lift and hold right arm up, left arm edematous\n able to squeeze hand, moves toes left, lower extremities very stiff,\n pupils equal and reactive, +cough weak. NPO for peg placement today,\n medicated for pain\n Action:\n Turned q 2 hrs, oriented frequently\n Response:\n Resting comfortably\n Plan:\n for peg placement, monitor neuro status, orient frequently\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413129, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Motor Function, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413131, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Motor Function, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412462, "text": "Hypertension, benign\n Assessment:\n Bp >160/\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2150-08-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412341, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\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: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: Pt acknowledges 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, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Wean PSV as tolerated\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413100, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt I and o positive. Unable to wean down the ventitaltor.\n Action:\n Lasix gtt initiated at 1mg/hr. rate increased to 4mg/hr. electrolytes\n drawn this am.\n Response:\n u.o > 100cc/hr.\n Plan:\n Lasix gtt d/cld per team\n" }, { "category": "Nursing", "chartdate": "2150-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413102, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Pt I and o positive. Unable to wean down the ventitaltor.\n Action:\n Lasix gtt initiated at 1mg/hr. rate increased to 4mg/hr. electrolytes\n drawn this am.\n Response:\n u.o > 100cc/hr.\n Plan:\n Lasix gtt d/cld per team will check output.\n" }, { "category": "Physician ", "chartdate": "2150-08-13 00:00:00.000", "description": "Intensivist Note", "row_id": 413104, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n : spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still\n high, started DTO, PICC removed PIV placed\n : lasix gtt, albumin started (possibly volume overload causing\n tachypnea and inability to wean)\n : stopped lasix gtt, started zosyn for Pseudomonas sputum\n Chief complaint:\n respiratory faiure\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 1000 mL LR 2. Acetaminophen (Liquid) 3. Albuterol MDI 4. Aspirin 5.\n Calcium Gluconate 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Diltiazem 8. Famotidine 9. Fentanyl Citrate 10. Furosemide 11.\n Heparin Flush (10 units/ml) 12. HydrALAzine\n 13. 14. 15. 16. Insulin 17. Ipratropium Bromide MDI 18. Lorazepam 19.\n Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Metoprolol Tartrate 22. Midazolam 23. Miconazole Powder 2% 24.\n Nystatin Oral Suspension 25. Ondansetron\n 26. Piperacillin-Tazobactam Na 27. Potassium Chloride 28. Psyllium 29.\n Qvar 30. Sertraline 31. Simvastatin\n 32. Sodium Chloride 0.9% Flush 33. Vancomycin 34. Warfarin\n 24 Hour Events:\n pt with episode of tachypnea. Started on Lasix gtt, then d/c. Stated on\n Zosyn for pseudomonas\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 05:00 PM\n Midazolam (Versed) - 03:00 AM\n Other medications:\n Flowsheet Data as of 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.2\nC (100.7\n HR: 81 (68 - 91) bpm\n BP: 145/62(91) {105/39(56) - 164/68(102)} mmHg\n RR: 30 (11 - 40) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 2,713 mL\n 485 mL\n PO:\n Tube feeding:\n 1,080 mL\n 403 mL\n IV Fluid:\n 526 mL\n 74 mL\n Blood products:\n 7 mL\n 9 mL\n Total out:\n 1,538 mL\n 1,370 mL\n Urine:\n 738 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,175 mL\n -885 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 520 (319 - 653) mL\n PS : 12 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Vent Dependant\n PIP: 18 cmH2O\n SPO2: 100%\n ABG: ///26/\n Ve: 12.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Labs / Radiology\n 478 K/uL\n 8.9 g/dL\n 160 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 99 mEq/L\n 133 mEq/L\n 26.8 %\n 20.8 K/uL\n [image002.jpg]\n 03:41 AM\n 03:20 AM\n 10:00 AM\n 04:00 PM\n 03:09 AM\n 04:00 AM\n 05:20 PM\n 02:36 AM\n 02:31 AM\n 02:34 AM\n WBC\n 15.8\n 18.8\n 20.9\n 22.3\n 19.7\n 20.8\n Hct\n 29.9\n 28.2\n 29.2\n 27.9\n 28.2\n 26.8\n Plt\n 78\n 441\n 478\n Creatinine\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n Glucose\n 112\n 158\n 160\n 149\n 170\n 191\n 139\n 126\n 160\n Other labs: PT / PTT / INR:13.8/24.3/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.4 mg/dL, Mg:1.7 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan: 85 year old female s/p subtotal colectomy with CVA\n Neurologic: midaz prn, responds to anxiety\n Cardiovascular: stable, dilt, metoprolol\n Pulmonary: (Ventilator mode: CPAP + PS), wean as tolerated\n Gastrointestinal / Abdomen: PEG\n Nutrition: Tube feeding, @goal. NS with tube feeds\n Renal: Foley, Adequate UO, off lasix gtt. Goal keep even\n Hematology: Coumadin for anticoagulation, dose by coags\n Endocrine: RISS\n Infectious Disease: Check cultures, Started on Zosyn for Pseudomonas,\n on vanco for Coag negative staph in blood\n Lines / Tubes / Drains: G-tube, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:11 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:17 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Nutrition", "chartdate": "2150-08-13 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 413123, "text": "Subjective\n in w/ PT\n Objective\n Pertinent medications: RISS, Abx, Albumin, famotidine, Psyllium, Banana\n Flakes TID, SS lytes (no repletions needed today)\n Labs:\n Value\n Date\n Glucose\n 160 mg/dL\n 02:34 AM\n Glucose Finger Stick\n 188\n 08:00 AM\n BUN\n 19 mg/dL\n 02:34 AM\n Creatinine\n 0.4 mg/dL\n 02:34 AM\n Sodium\n 133 mEq/L\n 02:34 AM\n Potassium\n 4.0 mEq/L\n 02:34 AM\n Chloride\n 99 mEq/L\n 02:34 AM\n TCO2\n 26 mEq/L\n 02:34 AM\n PO2 (arterial)\n 143 mm Hg\n 06:56 AM\n PCO2 (arterial)\n 43 mm Hg\n 06:56 AM\n pH (arterial)\n 7.42 units\n 06:56 AM\n pH (urine)\n 5.0 units\n 05:00 AM\n CO2 (Calc) arterial\n 29 mEq/L\n 06:56 AM\n Albumin\n 2.7 g/dL\n 11:45 AM\n Calcium non-ionized\n 9.4 mg/dL\n 02:34 AM\n Phosphorus\n 2.8 mg/dL\n 02:34 AM\n Ionized Calcium\n 1.32 mmol/L\n 06:56 AM\n Magnesium\n 1.7 mg/dL\n 02:34 AM\n ALT\n 18 IU/L\n 11:45 AM\n Alkaline Phosphate\n 44 IU/L\n 11:45 AM\n AST\n 32 IU/L\n 11:45 AM\n Amylase\n 25 IU/L\n 11:45 AM\n Total Bilirubin\n 0.5 mg/dL\n 11:45 AM\n Triglyceride\n 252 mg/dL\n 11:47 AM\n WBC\n 20.8 K/uL\n 02:34 AM\n Hgb\n 8.9 g/dL\n 02:34 AM\n Hematocrit\n 26.8 %\n 02:34 AM\n Current diet order / nutrition support: Diet: NPO\n Tubefeeding: Start After 12:01AM; Replete w/fiber Full strength;\n Additives: Banana flakes, 3 packets per day\n Starting rate: 45 ml/hr; Do not advance rate Goal rate: 45 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 100 ml\n Flush w/ 250 ml water q6h\n Other instructions: please use Normal saline rather than water\n GI: soft (+)bs, stool via ostomy\n Assessment of Nutritional Status\n Specifics:\n Pt w/ R perforated diverticulitis/GIB sp total colectomy and end\n ileostomy; also s/p PEG/trach. Pt receiving TF via PEG; tolerating at\n goal to provide 1080calories and 67g protein. Current TF may be\n underfeeding given multiple surgeries this admit. Psyllium + Banana\n flakes given to increase stool bulk\n 800ml out via ostomy . Noted\n eventual plan for rehab\n pg 2 done.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Rec change TF to Fibersource HN @\n 45ml/hr = 1296calories and 57g protein\n Check chemistry 10 panel daily\n Continue psyllium, banana flakes\n Will cont to follow\n" }, { "category": "Nursing", "chartdate": "2150-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412329, "text": "Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Liquid bilious stool from Ileostomy, hemodynamically stable.\n Action:\n SICU team aware, close monitoring of I/O\n Response:\n Electrolytes remain stable, urine out >30cc/hr.\n Plan:\n Fluid boluses for urine output of less then 30cc/hr.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Gag and cough are impaired, currently trached, pt needs rehab.\n Action:\n Consent for PEG placement obtained from healthcare proxy\n Response:\n Consent for PEG procedure obtained and family aware of risks and\n benefits, tolerating TF via NG, unable to go to rehab with NGT.\n Plan:\n Possible PEG placement tomorrow.\n Problem\n Discharge Planning\n Assessment:\n Family visited two rehabs this morning.\n Action:\n Message left with (SICUa Case Manager) regarding\n families scouting process.\n Response:\n is to contact family, phone numbers left with CM.\n Plan:\n Discharge pt to rehab towards the beginning of next week.\n" }, { "category": "Physician ", "chartdate": "2150-08-17 00:00:00.000", "description": "Intensivist Note", "row_id": 413716, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n : admitted to SICU, s/p 7U PRBC by 0700 am(1U by OSH), s/p 6U FFP,\n East Surgical Service (), Cipro/Flagyl, Reverse coagulopathy c\n FFP, Serial Hct, transfuse pRBC as necessary, OR S/P subtotal colectomy\n : extubated, then reintubated for resp distress\n :CXR Rpt CBC 1400 Lasix 10 HLIV, afib w/RVR (rate 110-130s),\n diltiazem started and rhythm converted back to SR after approx 2 hr,\n tube feeds started :wean dilt, Wean PS, lasix 10 : vent wean,\n TFs increased : vent wean, TTE ordered, CT head given new LUE\n weakness and h/o CVA (CVA / with permanent speech deficit\n improved with rehab. also transient facial droop - unknown side),\n neurology consult (recc ASA/coumadin when permissible, carotid U/S,\n TTE, MRI head/neck to r/o CVA vs neck pathology of LUE weakness, obtain\n hospital med records from / CVA tx), start\n statin/asa, start heparin qtt\n : MRI head neck changed, TF to nutren25 : trying to wean\n patient on vent : family meeting, transfuse 2 PRBC, wean vent, d/c\n heparin qtt per neurology 8/28:2PRBC Hct 23-28\n : febrile, cx sent, persistent leukocytosis, vanc/zosyn started\n empirically, wean propofol -- intermittent versed, afib\n :Afib settled with lopressor 1 dose\n : sent off triglycerides for continued propofol requirement,\n attempted to wean vent to but became tachycardic and had increased\n work of breathing\n : increased ouput, started psyillium, TFs @ 20kcal/kg, PS trial\n : PEG performed at bedside - ready for discharge to LTAC asap\n : cont PS wean, awaiting vent rehab bed\n : spiked fevers and has positive blood cultures for GPC in clusters\n and pairs, treated with Vancomycin empirically, ostomy output still\n high, started DTO, PICC removed PIV placed\n : lasix gtt, albumin started (possibly volume overload causing\n tachypnea and inability to wean)\n : stopped lasix gtt, started zosyn for Pseudomonas sputum. Low\n urine output overnight, multiple fluid boluses. Pt with episode of\n emesis during the day when given NS bolus. NS boluses d/c, writen for\n salt tabs\n : urine output low but responsive to repletion of intravascular\n volume, CDiff sent and IV flagyl started for concern of CDiff, LFTs nl\n so RUQ U/S abdomen, continued abdominal pain and min distention\n prevented feeding today, weaned vent\n Chief complaint:\n Respiratory Failure\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 1000 mL LR 2. 1000 mL NS 3. Acetaminophen (Liquid) 4. Acetaminophen\n 5. Albuterol MDI 6. Aspirin\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Diltiazem 10. Erythromycin 11. Famotidine\n 12. Fentanyl Citrate 13. Heparin Flush (10 units/ml) 14. HydrALAzine\n 15. 16. 17. 18. Insulin\n 19. Ipratropium Bromide MDI 20. Lorazepam 21. Magnesium Sulfate 22.\n Metoprolol Tartrate 23. Metoclopramide\n 24. MetRONIDAZOLE (FLagyl) 25. Metoprolol Tartrate 26. Midazolam 27.\n Miconazole Powder 2% 28. Nystatin Oral Suspension\n 29. Ondansetron 30. Piperacillin-Tazobactam Na 31. Potassium Chloride\n 32. Psyllium 33. Qvar 34. Sertraline\n 35. Simvastatin 36. Sodium Chloride 37. Sodium Chloride 0.9% Flush 38.\n Tobramycin Inhalation Soln\n 39. Warfarin\n 24 Hour Events:\n No acute events overnight. Pt hemodynamically stable. Patient Out of\n bed to chair.\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:25 AM\n Metronidazole - 05:25 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 02:00 AM\n Metoprolol - 06:28 AM\n Fentanyl - 08:30 AM\n Other medications:\n Flowsheet Data as of 09:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.8\nC (98.3\n HR: 75 (64 - 82) bpm\n BP: 124/51(69) {105/39(56) - 141/67(79)} mmHg\n RR: 26 (19 - 35) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.1 kg (admission): 71.4 kg\n Height: 65 Inch\n Total In:\n 3,839 mL\n 1,257 mL\n PO:\n Tube feeding:\n 127 mL\n 361 mL\n IV Fluid:\n 3,523 mL\n 896 mL\n Blood products:\n Total out:\n 2,490 mL\n 940 mL\n Urine:\n 910 mL\n 470 mL\n NG:\n 1,150 mL\n Stool:\n Drains:\n Balance:\n 1,349 mL\n 317 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 335 (314 - 409) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 112\n PIP: 15 cmH2O\n SPO2: 98%\n ABG: ///29/\n Ve: 8.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 434 K/uL\n 7.8 g/dL\n 126 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 102 mEq/L\n 139 mEq/L\n 23.9 %\n 15.9 K/uL\n [image002.jpg]\n 02:31 AM\n 02:34 AM\n 06:15 AM\n 04:36 PM\n 01:33 AM\n 07:14 AM\n 09:06 PM\n 04:28 AM\n 05:34 AM\n 06:01 AM\n WBC\n 19.7\n 20.8\n 36.7\n 27.9\n 23.8\n 15.9\n Hct\n 28.2\n 26.8\n 28.8\n 24.1\n 23.7\n 24.0\n 23.9\n Plt\n \n Creatinine\n 0.4\n 0.4\n 1.1\n 1.2\n 1.2\n 1.2\n 1.0\n TCO2\n 34\n Glucose\n 126\n 160\n 138\n 140\n 147\n 160\n 158\n 126\n Other labs: PT / PTT / INR:33.7/41.6/3.5, ALT / AST:17/18, Alk-Phos / T\n bili:123/0.3, Amylase / Lipase:, Differential-Neuts:90.8 %,\n Lymph:4.7 %, Mono:2.6 %, Eos:1.7 %, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:195 IU/L, Ca:8.4 mg/dL, Mg:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n Assessment and Plan: 85 year old female s/p CVA, LGIB s/p colectomy,\n currently with respiratory failure\n Neurologic: Pain controlled, Patient appropriate, neurologic exam\n stable. Would avoid versed, Fentanyl prn pain\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker,\n Hemodynamically Stable. Will change to po B-blocker, Dilt.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Continue to wean from\n Vent as tolerated. Alternate to TC as tolerated. OOB to chair\n Gastrointestinal / Abdomen: PEG. Tolerating Tube feeds. Increased\n Ostomy output\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, INR 3.5, will hold dose coumadin and continue\n to follow INR\n Endocrine: RISS, FS slightly elevated, will tighten slidden scale\n Infectious Disease: Check cultures, Pt with Pseudomona Pneumonia, on\n Zosyn and Tobra (started )- plan for 10 days ABX.\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO, Switch fluids to KVO as pt now on feeds at goal\n Consults: General surgery\n Billing Diagnosis: Arrhythmia, CVA, (Respiratory distress: Failure),\n (Pneumonia due to procedure: Organism, NOS)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:40 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:36 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Primary to have family\n meeting today to better clarify DNR and treatment plans\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2150-08-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412562, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: No abg results at this time. RSBI = 103 on 0-PEEP and 5cm\n PSV.\n" }, { "category": "Nursing", "chartdate": "2150-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412610, "text": "Alteration in Nutrition\n Assessment:\n TF residuals 200ml\ns for 4 hrs.\n Action:\n Team notified. TF shut off. Reglan ordered and given.\n Response:\n Residuals decreasing slowly. Awaiting response of reglan.\n Plan:\n Continue to monitor residuals. Restart TF @ \n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-08-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412614, "text": "Alteration in Nutrition\n Assessment:\n TF residuals 200ml\ns for 4 hrs.\n Action:\n Team notified. TF shut off. Reglan ordered and given.\n Response:\n Residuals decreasing slowly. Awaiting response of reglan.\n Plan:\n Continue to monitor residuals. Restart TF @ \n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n U/O <20ml per hr for 3 hr. No change in SBP\n Action:\n Team notified. 2 500cc fluid bolus given\n Response:\n U/O up to 25-30hr.\n Plan:\n Continue to monitor U/O assess Ls for congestion.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412467, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount Suction / Moderate\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Patient remains on CPAP/PSV ventilatory support with no parameter\n changes made thorugh out the night.\n RSBI = 95 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 412642, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 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 Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Comments: No morning abg results at this time. RSBI = 84 on 0-PEEP\n and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2150-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412958, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic rr 35-40 w sats 92-95% on cpap ps 10 peep 5 fio2 40%.bbs\n rhonchorous.stv low to mid 300\n Action:\n Lavage and suct for sm amts thick yellow sputum, w no improvement in\n rr. Medicated for ruq pain w improvement in pain control, rr still low\n 30\ns.ps increased to 14\n Response:\n Rr down to 18-24 stv improved to 450-500 O2 sats 99-100%\n Plan:\n Aggressive pulm toilet.Vap bundle. Rest overnight, wean ps in am as\n tolerates. Check w team re: repeat pcxr in am.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413039, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\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: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 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:\n Visual assessment of breathing pattern: Nasal flaring, Accessory muscle\n use; Comments: Pt continues to be tachypnic\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt continues on CPAP/PSV with increased WOB and tachypnea as the day\n progresses. PSV increased to keep RR below 40 Will continue to follow\n closely.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413257, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\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 Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Assisted continuous ventilation\n Visual assessment of breathing pattern: Pt continues on PSV settings.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n" }, { "category": "Nursing", "chartdate": "2150-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412326, "text": "Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Liquid bilious stool from Ileostomy.\n Action:\n SICU team aware, close monitoring of I/O\n Response:\n Plan:\n Fluid boluses fro urine output of less then 30cc/hr.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Gag and cough are impaired.\n Action:\n Consent for PEG placement obtained from healthcare proxy\n Response:\n Consent for PEG procedure obtained and family aware of risks and\n benefits\n Plan:\n Possible PEG placement tomorrow.\n" }, { "category": "Nursing", "chartdate": "2150-08-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412539, "text": "Hypertension, benign\n Assessment:\n Cont to be hypertensive >160; anxious\n Action:\n Scheduled lopressor as ordered; received 10mg ivp lopressor x3\n Response:\n Hypertension improved however remains borderline\n Plan:\n Cont to monitor BP and provide prn lopressor; ?degree of anxiety\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Min secretions via trach; tol PSV 10/5\n Action:\n Weaned to PSV 5/5\n Response:\n Did not tolerate wean to PSV 5/5-tachy, hypertensive, tachypneic\n Plan:\n PSV 8/5 overnight; cont to evaluate ability to wean; anticipate rehab\n placement soon\n Ineffective Coping\n Assessment:\n Anxious; reaching out to staff with right arm and attempting to mouth\n concerns; denies pain\n Action:\n Med with fent/versed for restlessness/anxiety\n Response:\n Slept intermittently with fent/versed; 1mg ativan given as trial\n alternative\n Plan:\n Cont to provide emotional support; consider scheduled for general\n anxiety; prn fent/versed.\n" }, { "category": "Nursing", "chartdate": "2150-08-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413849, "text": "Ventilation, Impaired\n Assessment:\n Remains trached and vented on cpap. Sat down to 89%. Sxn for mod amt\n thick tan sputum\n Action:\n Sxn\nd. pulm hygiene.\n Response:\n O2 sat improved. No vent changes made.\n Plan:\n Con\nt pulm hygiene and wean vent as tol.\n Ordered for picc in am.\n" }, { "category": "Nursing", "chartdate": "2150-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412959, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Grimacing and guarding ruq at rest. Pain upon palpation to ruq.\n Ileostomy continues to put out mod to large amts of loose grn/brwn\n stool. Continues to receive banana flakes and Metamucil as ordered.\n Tf\ns at goal 45cc/hr.\n Action:\n Medicated w fentanyl 50mcg iv x2 . Dr aware continuing ruq\n pain. Recurring Pcxr\ns results continue to show large amt of\n intraabdominal gas. Wbc 22 today.(picc line dc\nd). Vanco started for +\n bld cultures.\n Response:\n Ruq pain resolving w fentanyl x2as ordered\n Plan:\n Continue to monitor frequency/intensity of abd pain. Follow wbc w\n daily labs. ? lfts w am labs given ruq pain. Check w team to? abd/gb\n ultrasound to r/o intraabd process.\n" }, { "category": "Respiratory ", "chartdate": "2150-08-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 413092, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\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 Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions;\n Comments: Weaned IOS 17 to 12 cmH20.\n Assessment of breathing comfort: Pt acknowledges dyspnea; Comments: OK\n with some sedation.\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: Continue present ICU monitoring.\n once stable, awaiting vent rehab placement.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Vent dependent.\n Respiratory Care Shift Procedures\n" }, { "category": "Physician ", "chartdate": "2150-08-06 00:00:00.000", "description": "Intensivist Note", "row_id": 412394, "text": "SICU\n HPI:\n 85F w hx of recent CVA on coumadin, present w/ nausea and large\n painless bloody bowel movements at home x2 starting today. -\n F/C/S, more large bloody BMs in ED. HCT decreased from 32.9\n to 29.4 in 1hr, INR 3.2, WBC 18.5 received 2L IVF, Levo/Flagyl, 4\n units FFP, vit K 5units, 3 unit PRBC (1 in OSH). Continued BRBPR.\n Brought to SICU for continued management\n Chief complaint:\n Lower GIB c/b post-op embolic stroke\n PMHx:\n h/o CVA, DM, HTN, severe COPD on home O2, per pt (\"i have hole in my\n heart\")\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen (Liquid) 4. Albuterol MDI 5. Aspirin\n 6. Calcium Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Diltiazem 9. Famotidine 10. Fentanyl Citrate 11. Fluconazole 12.\n Heparin 13. Heparin Flush (10 units/ml)\n 14. 15. 16. Insulin 17. Ipratropium Bromide MDI 18. Magnesium Sulfate\n 19. Metoprolol Tartrate\n 20. Metoprolol Tartrate 21. Midazolam 22. Nystatin Oral Suspension 23.\n Ondansetron 24. Potassium Chloride\n 25. Psyllium 26. Qvar 27. Sertraline 28. Simvastatin 29. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n NPO for peg today, started on LR while NPO\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.9\nC (98.4\n HR: 81 (68 - 89) bpm\n BP: 140/74(90) {133/58(83) - 188/80(109)} mmHg\n RR: 12 (12 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,056 mL\n 107 mL\n PO:\n Tube feeding:\n 888 mL\n 33 mL\n IV Fluid:\n 518 mL\n 44 mL\n Blood products:\n Total out:\n 1,449 mL\n 370 mL\n Urine:\n 999 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 607 mL\n -263 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): 425 (425 - 425) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n SPO2: 98%\n ABG: ///27/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Ostomy begin\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands\n Labs / Radiology\n 489 K/uL\n 9.3 g/dL\n 140 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 25 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.7 %\n 14.0 K/uL\n [image002.jpg]\n 05:20 AM\n 09:51 AM\n 03:30 AM\n 05:17 AM\n 02:11 AM\n 03:11 AM\n 11:54 AM\n 12:05 AM\n 01:55 AM\n 03:14 AM\n WBC\n 23.0\n 21.9\n 12.8\n 14.9\n 14.0\n Hct\n 28.2\n 28.7\n 27.4\n 32\n 28.9\n 28.7\n Plt\n 362\n 424\n 398\n 490\n 489\n Creatinine\n 0.5\n 0.5\n 0.5\n 0.5\n 0.4\n 0.4\n TCO2\n 30\n 22\n 28\n 27\n Glucose\n 148\n 164\n 169\n 131\n 161\n 140\n Other labs: PT / PTT / INR:13.8/24.2/1.2, ALT / AST:18/32, Alk-Phos / T\n bili:44/0.5, Amylase / Lipase:25/18, Fibrinogen:270 mg/dL, Lactic\n Acid:0.9 mmol/L, Albumin:2.7 g/dL, Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC ,LGIB\n Assessment and Plan: 85 year old s/p TAC for perf divertic: massive\n LGIB c/b post op embolic stroke. Pt currently awaiting PEG today and\n placement in Vent facility\n Neurologic: fentanyl prn, midaz prn\n Cardiovascular: Pt HTn overnight, continue increasiing Metoprol as\n tolerated. Cont to decrease Dilt as tolerated\n Pulmonary: Trach, (Ventilator mode: CPAP + PS) will wean PS down to\n increase RR to mid 20s. Will condition pt.\n Gastrointestinal / Abdomen: Plan for PEG today. Ostomy output\n decreasing, cont banana flakes.\n Nutrition: Holding for PEG. Will cont feeds after PEG\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS, FS 140-200. Would observe and increase RISS as needed\n after Feeds restart\n Infectious Disease: On Fluconazole 400mg IV bid for yeast in urine (day\n 2)\n Lines / Tubes / Drains: Foley, NGT, Trach. Will d/c NGT after PEG\n placement\n Wounds:\n Imaging: CXR today\n Fluids: LR, while NPO. KVO after PEG\n Consults: General surgery\n Billing Diagnosis: Respiratory failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to other facility\n Total time spent: 30\n" }, { "category": "Nursing", "chartdate": "2150-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 413033, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on 40% cpap 5, 14 ps, bs+ all lobes, course , rr 30\n Action:\n No vent changes today, sux q 2 hrs & prn\n Response:\n Ok for pt to have rr in the 30\ns per Dr. , sux sm amt loose white\n sputum, sat > 95\n Plan:\n Continue with ventilatory support, wean as tolerated\n" }, { "category": "Nursing", "chartdate": "2150-08-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412698, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic w/ volumes in the low 300\n Action:\n Team aware CXR taken. Slight vent changes made to ps.\n Response:\n CXR clear. No increase in Vt w/ decrease of PS. Remains on 5+8\n Plan:\n Continue to wean PS as tol.\n" }, { "category": "Nursing", "chartdate": "2150-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 412795, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Comfortable on PS 10/5 Free air noted on CXR, 40 cc gastrograffin and\n scout film done\n Action:\n PS . from 12 to 10\n Response:\n Became dyspneic with discordant resp pattern rate up to 30s after\n vigorous PT at side of bed, ROM to all 4s) Med with 1.0 midaz\n with excellent effect. RR down to 25 with good Vt\n Plan:\n Cont screen for rehab. Check results of scout film, cont to exercise\n with PT , advance activity level as tol. Benzos prn anxiety. Slow PS\n wean. TF on hold til results of scout film back\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Left side remains weaker than Right. Full list toward left when dangled\n at edge of bed\n Action:\n PT for ROM, activity progression\n Response:\n Exhausted after PT, dyspneic with minimal reserve\n Plan:\n Cont PT, allow rest periods. Possible tran to tomarrow if scout\n series negative.\n" } ]

[ { "category": "Radiology", "chartdate": "2157-04-18 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1184047, "text": " 10:27 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: HISTORY OF PICC LINE, QUESTION THROMBUS\n Admitting Diagnosis: NEUTROPENIC FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with neutropenia fever, source unknown. Has left PICC line\n that has been in place since .\n REASON FOR THIS EXAMINATION:\n Thrombus?\n ______________________________________________________________________________\n FINAL REPORT\n LEFT UPPER EXTREMITY DUPLEX ULTRASOUND\n\n INDICATION: 71-year-old female with neutropenic fever of unknown source.\n Left PICC line was placed in .\n\n FINDINGS: The right and left subclavian veins demonstrate normal patency and\n wall-to-wall flow with preserved cardiorespiratory variation. The left\n internal jugular vein is normally compressible with preserved wall-to-wall\n flow. The left axillary and brachial veins are patent with wall-to-wall flow,\n compressibility and normal response to augmentation. The catheter is seen\n within the subclavian, axillary, and basilic vein. There is no thrombus\n surrounding the catheter along it's length. The cephalic vein is normally\n patent and compressible.\n\n IMPRESSION: No evidence of acute deep venous thrombosis in the left upper\n extremity. The PICC is seen without surrounding thrombus.\n\n" }, { "category": "Radiology", "chartdate": "2157-04-19 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1184238, "text": " 12:42 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Intra-abdominal abscess?\n Admitting Diagnosis: NEUTROPENIC FEVER\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AML and neutropenic fever, no source identified.\n REASON FOR THIS EXAMINATION:\n Intra-abdominal abscess?\n CONTRAINDICATIONS for IV CONTRAST:\n thyroid goiter\n ______________________________________________________________________________\n WET READ: IPf TUE 1:57 PM\n RUL pneumonia.\n Interval increase in size of mediastinal lymph nodes, likely reactive.\n D/ at 2 pm on \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AML and neutropenic fever with no source identified.\n\n TECHNIQUE: CT torso with IV and oral contrast. Coronal and sagittal\n reformatted images provided.\n\n COMPARISON: CT torso and chest radiograph .\n\n FINDINGS:\n\n CT CHEST: Within the medial aspect of the right upper lobe there is dense\n consolidation with a ground glass appearance at its periphery, and with air\n bronchograms, new since the prior CT as well as chest radiograph of 4 days\n earlier. There is interval increase in size of mediastinal and right hilar\n lymph nodes, for example: precarinal lymph node was measuring 8 mm in short\n axis now measures 15 mm (2:21); enlarged right hilar lymph node measuring 12\n mm (2:23). There is new small right pleural effusion. The airways are patent\n up to segmental level. There is a left-sided PICC line with tip terminating at\n the cavoatrial junction. There is trace pericardial effusion, within\n physiologic range.\n\n There are stable small pulmonary nodules as follows: LUL, 2 mm (2:4); LUL, 2\n mm (2:9); RUL, 3 mm (2:13); LUL, 3 mm,(2:19); LLL, 2 mm (2:39).\n\n Enlargement of the thyroid gland as seen on prior, predominantly enlargement\n of the right thyroid lobe measuring 5.5 x 3.4 in the largest axial diameter,\n (2:10), similar to prior, and at remote US shown to represent multinodular\n goiter. No pathologically enlarged lymph nodes in the axilla according to CT\n size criteria.\n\n CT ABDOMEN: There are multiple hypodense liver lesions, presumably liver\n cysts and stable; some too small to be characterized. Previously seen\n hyperenhancing small liver lesion in segment VI is not appreciated on current\n scan, probably due to differences in timing. There is no intra- or\n extra-hepatic biliary duct dilatation. The portal vein is patent. The\n (Over)\n\n 12:42 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Intra-abdominal abscess?\n Admitting Diagnosis: NEUTROPENIC FEVER\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gallbladder, spleen, and right adrenal gland are normal. There is a similar\n thickenning of the left adrenal gland (2:52). There is a small hiatal hernia.\n There are few scattered small retroperitoneal lymph nodes, similar to prior.\n There is no free fluid or free air. There is no evidence of bowel\n obstruction. Loops of small and large bowel appear within normal limits.\n\n CT PELVIS: There is a stable calcified lesion in the right adnexa adjacent to\n the uterus, 2.7 x 2.3 cm (2:104), most likely calcified fibroid. There is no\n free fluid in the pelvis. The urinary bladder appears within normal limits.\n Few scattered lymph nodes are seen in the inguinal area; however, do not meet\n the CT size criteria for pathologic enlargement.\n\n OSSEOUS STRUCTURES: There is a similar retrolisthesis of L5 on S1.\n Multilevel degenerative changes in the thoracolumbar spine. There is a stable\n T7 hemangioma.\n\n IMPRESSION:\n 1. New right-sided opacity in the right upper lobe most likely pneumonia;\n other etiologies such as hemorrhage could cause a similar appearance;\n neoplastic infiltrate less likely given rapid development of findings.\n 2. Interval increase in size of mediastinal and right hilar lymph nodes,\n nonspecific, could be reactive; however, cannot exclude neoplastic\n involvement.\n 3. New small right pleural effusion.\n 4. Stable calcified right adnexal mass most likely calcified fibroid, less\n likely calcified ovarian mass or pedunculated broad ligament fibroid.\n 5. Stable liver hypodensities, some appear as liver cysts, some are too small\n to be characterized.\n 6. Stable asymmetric enlargement of the thyroid gland.\n\n RUL opacity was discussed with Dr. at 1:30 p.m. on by phone.\n\n" }, { "category": "Radiology", "chartdate": "2157-04-19 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1184239, "text": " 12:43 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: Abscess? Infected tooth?\n Admitting Diagnosis: NEUTROPENIC FEVER\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AML and neutropenic fever, no source identified.\n .\n REASON FOR THIS EXAMINATION:\n Abscess? Infected tooth?\n CONTRAINDICATIONS for IV CONTRAST:\n goiter\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj TUE 4:38 PM\n IMPRESSION:\n 1. No evidence of abscess in the neck or odontogenic infection.\n 2. Density in the right lung apex consistent with possible mass with\n post-obstructive pneumonia. Please refer to the dedicated torso imaging for\n better assessment.\n 3. Diffuse cervical adenopathy is unchanged. Increased upper mediastinal\n adenopathy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with AML and neutropenic fever of unknown\n source, submandibular lymphadenopathy, question abscess or odontogenic\n infection.\n\n COMPARISONS: Neck CT . Torso CT .\n\n TECHNIQUE: MDCT data were acquired through the neck after the administration\n of 70 cc of IV Optiray contrast. Images were reconstructed in bone and soft\n tissue algorithms and displayed in multiple planes.\n\n FINDINGS: Numerous bilateral cervical lymph nodes throughout the nodal\n stations, some of which are mildly enlarged, are grossly unchanged since the\n prior study, probably related to the known AML. Abnormally full\n nasopharyngeal soft tissues with a convex margin, and mildly prominent\n palatine tonsils, are also unchanged and probably related to the\n lymphoproliferative state. The parotid and submandibular glands are\n unremarkable. There are no periapical lucencies in the maxillary or\n mandibular alveolar ridges to suggest odontogenic infection. There is no\n evidence of a soft tissue abscess. Markedly enlarged and nodular thyroid,\n with right-sided retrosternal extension, is again seen.\n\n There is minimal mucosal thickening in the right sphenoid sinus. The mastoid\n are underpneumatized.\n\n There is a left PICC. There is persistent dilatation of the left subclavian\n vein, without clear evidence for a thrombus, suboptimally assessed.\n\n Imaged upper mediastinal lymph nodes have increased in size since the \n torso CT. There is right hilar lymphadenopathy or mass, with surrounding\n (Over)\n\n 12:43 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: Abscess? Infected tooth?\n Admitting Diagnosis: NEUTROPENIC FEVER\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right upper lobe consolidation. There is a small right pleural effusion.\n These findings are further assessed on the concurrent torso CT.\n\n There are extensive degenerative changes in the cervical spine. No lytic or\n sclerotic bone lesions suspicious for malignancy are seen.\n\n IMPRESSION:\n 1. No evidence of a cervical abscess or odontogenic infection.\n 2. Persistent diffuse cervical lymphadenopathy and prominence of the\n Waldeyer's ring structures, probably related to the known AML.\n 3. Increased mediastinal and right hilar lymphadenopathy. Right upper lobe\n consolidation. These findings are better assessed on the concurrent torso CT,\n which is reported separately.\n 4. Thyroid goiter with right retrosternal extension is again noted.\n 5. Persistent dilatation of the left subclavian vein, without clear evidence\n for a thrombus surrounding the PICC, suboptimally assessed.\n\n" }, { "category": "Radiology", "chartdate": "2157-04-19 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1184240, "text": "TABESH,BITA OMED 7F 12:43 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: Abscess? Infected tooth?\n Admitting Diagnosis: NEUTROPENIC FEVER\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AML and neutropenic fever, no source identified.\n .\n REASON FOR THIS EXAMINATION:\n Abscess? Infected tooth?\n CONTRAINDICATIONS for IV CONTRAST:\n goiter\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n 1. No evidence of abscess in the neck or odontogenic infection.\n 2. Density in the right lung apex consistent with possible mass with\n post-obstructive pneumonia. Please refer to the dedicated torso imaging for\n better assessment.\n 3. Diffuse cervical adenopathy is unchanged. Increased upper mediastinal\n adenopathy.\n\n" }, { "category": "Radiology", "chartdate": "2157-04-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1183633, "text": " 3:05 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old woman, with fever. Assess for acute process.\n\n COMPARISON: Multiple prior chest radiographs, with the latest on .\n\n PA AND LATERAL CHEST RADIOGRAPH: A left-sided PICC terminates in the lower\n SVC/cavoatrial junction, unchanged. There is no focal airspace consolidation,\n pneumothorax or pleural effusions. The cardiomediastinal silhouettes, hilar\n contours and pulmonary vasculature are normal. Multilevel degenerative\n changes are mild. Large right thyroid lobe may be smaller.\n\n IMPRESSION: No acute cardiopulmonary process. Smaller goiter.\n\n" }, { "category": "Echo", "chartdate": "2157-04-25 00:00:00.000", "description": "Report", "row_id": 69537, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 69\nWeight (lb): 225\nBSA (m2): 2.17 m2\nBP (mm Hg): 89/38\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 11:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial\nseptum.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Hyperdynamic LVEF\n>75%. Mild resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No valvular\nAS. The increased transaortic velocity is related to high cardiac output. No\nAR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Trivial\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Resting tachycardia\n(HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Left ventricular systolic function is\nhyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract\nobstruction. Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. There is no valvular aortic stenosis. The increased transaortic\nvelocity is likely related to high cardiac output. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. Trivial mitral regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is a\nsmall pericardial effusion.\n\nIMPRESSION: Mild symmetric LVH with hyperdynamic LV systolic function and a\nmild resting LVOT gradient. No significant valvular abnormality seen. Moderate\npulmonary artery systolic hypertension. Small pericardial effusion located\nnear the inferolateral wall without evidence of tamponade.\n\nCompared with the prior study (images reviewed) of , the estimated\npulmonary artery pressures are higher. The prior echo showed hyperdynamic LV\nfunction also.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-04-24 00:00:00.000", "description": "RENAL U.S.", "row_id": 1184955, "text": " 10:16 AM\n RENAL U.S. Clip # \n Reason: obstruction?\n Admitting Diagnosis: NEUTROPENIC FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AML and anuria\n REASON FOR THIS EXAMINATION:\n obstruction?\n ______________________________________________________________________________\n WET READ: MLHh SUN 3:32 PM\n Mult bilat cysts. No stones, masses, or hydro.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with AML and anuria, rising creatinine.\n\n Correlation to CT torso from .\n\n RENAL ULTRASOUND: Examination is suboptimal due to patient's body habitus,\n inability to breath-hold, and shadowing bowel gas. The right kidney measures\n 14.5 cm, without masses, stones, or hydronephrosis. Evaluation of the left\n kidney is difficult, but no obvious hydronephrosis is identified. Multiple\n small renal cysts are present. There is no free fluid.\n\n IMPRESSION: Multiple renal cysts. No evidence of obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2157-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1184714, "text": " 2:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema?\n Admitting Diagnosis: NEUTROPENIC FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AML, admitted with neutropenic fever, found to have RUL\n PNA on CT. Getting a lot of IVF, SOB but saturating well.\n REASON FOR THIS EXAMINATION:\n pulm edema?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:31 P.M., \n\n HISTORY: AML. Neutropenic fever. Right upper lobe pneumonia on CT. The\n patient short of breath.\n\n IMPRESSION: AP chest read in conjunction with CT scanning of the chest on\n :\n\n Large region of consolidation in the right lung has a dense central component,\n which could be developing abscess and peripheral consolidation filling most of\n the upper lobe, progressed since , when a chest CT showed no\n obstruction, but extensive central adenopathy.\n\n Left PIC line at or just below the level of the superior cavoatrial junction.\n Heart size is top normal.\n\n Dr. was paged, covered by Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2157-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1184816, "text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate,\n Admitting Diagnosis: NEUTROPENIC FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with possible aspiration status post bronch.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate,\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Possible aspiration, status post bronchoscopy.\n\n Portable AP chest radiograph was compared to prior study from .\n\n As compared to the prior study there is interval development of interstitial\n pulmonary edema as well as bibasilar consolidations highly concerning for\n aspiration. The known right upper lung perihilar mass/consolidation is\n redemonstrated. There is no pneumothorax. Small bilateral pleural effusion\n cannot be excluded. The left PICC line tip is at the level of low SVC.\n\n Discussed with Dr over the phone by Dr at 10:30 am on\n \n\n" }, { "category": "Radiology", "chartdate": "2157-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1184926, "text": " 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: NEUTROPENIC FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with hypoxia after BAL, also suspected PNA\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Hypoxia after BAL\n\n Comparison is made with prior study .\n\n Bibasilar consolidations left greater than right are stable. As mentioned in\n the prior study these are concerning for aspiration pneumonia. Right upper\n lung perihilar mass-like consolidation is again noted. There are no new lung\n abnormalities. If any there are small bilateral pleural effusions. Left PICC\n remains in place.\n\n" }, { "category": "ECG", "chartdate": "2157-04-22 00:00:00.000", "description": "Report", "row_id": 164586, "text": "Sinus tachycardia. Otherwise, normal tracing. Compared to the previous tracing\nof no change except for faster rate.\n\n" }, { "category": "ECG", "chartdate": "2157-04-15 00:00:00.000", "description": "Report", "row_id": 164587, "text": "Sinus tachycardia. Small Q waves in the inferior leads - cannot exclude\ninferior wall myocardial infarction, age indeterminate. Compared to the\nprevious tracing of the findings are similar.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2148-05-31 00:00:00.000", "description": "MANDIBLE SERIES INCLUD PANOREX", "row_id": 1016456, "text": " 10:28 AM\n MANDIBLE SERIES INCLUD PANOREX Clip # \n Reason: evaluate for osteomyelitis, prep for dental work\n Admitting Diagnosis: NECK INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with floor of mouth abscess, extensive dental work\n REASON FOR THIS EXAMINATION:\n evaluate for osteomyelitis, prep for dental work\n ______________________________________________________________________________\n FINAL REPORT\n MANDIBULAR SERIES.\n\n HISTORY: 69-year-old female with floor of mouth infection, assess for\n osteomyelitis.\n\n FINDINGS: Five views of the mandible are obtained including a Panorex view.\n\n Comparison is made to prior CTs of the neck from and .\n\n There is dental amalgam involving multiple maxillary and mandibular teeth.\n Changes consistent with prior root canals are seen involving multiple teeth.\n The crown of the left mandibular first molar is absent and there are changes\n of prior root canal. No periapical lucencies are seen to suggest a periapical\n abscess. There is a dental post in the position of the left mandibular first\n molar with minimal surrounding lucency which may represent post-surgical\n change versus periodontal disease. Changes of dental caries and root canal\n are seen involving the left mandibular second molar. Extraction pocket of the\n right mandibular second molar is seen.\n\n No fractures are identified.\n\n There is marked soft tissue swelling of the submental region with obliteration\n of the vallecula and thickened, blunted appearance of the epiglottis.\n\n There is minimal anterior spondylolisthesis of C3 on C4 and C4 on C5.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-05-31 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1016455, "text": " 10:27 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: NECK INFECTION\n Admitting Diagnosis: NECK INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with floor of mouth infection, will probably go to OR today\n for I&D\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Pre-op evaluation of mild infection.\n\n Cardiomediastinal contours are normal. The lungs are clear. There is no\n pleural effusion. Osseous structures are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary abnormalities.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2148-05-29 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1016258, "text": " 7:25 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval for abscess and extent of infection\n Field of view: 25 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with neck swelling, diff swallowing\n REASON FOR THIS EXAMINATION:\n eval for abscess and extent of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT NECK WITH INTRAVENOUS CONTRAST\n\n INDICATION: 69-year-old woman with neck swelling, difficulty swallowing.\n\n COMPARISON: Not available.\n\n TECHNIQUE: MDCT axial images of the neck were obtained following\n administration of 90 cc of Optiray intravenously.\n\n FINDINGS: There is a 12 x 12-mm focus of low attenuation with\n hyperattenuating rim in the left floor of the mouth, measured on series 2\n image 32. The evaluation is slightly limited by streak artifact from dental\n hardware. The adjacent bone appears intact, without evidence of osseous\n destruction. Prominent left submandibular nodes are seen, which do not meet\n strict CT criteria for pathologic enlargement. Submandibular glands appear\n unremarkable bilaterally. The airway is patent. There is an asymmetric soft\n tissue attenuation in the upper trachea, which may represent secretions. Lung\n apices are clear. Imaged paranasal sinuses and mastoid air cells are well\n aerated.\n\n IMPRESSION: Area of lower attenuation in the floor of the mouth, concerning\n for phlegmon or developing abscess. No evidence of osteomyelitis.\n\n Findings were discussed with Dr. immediately upon completion of the\n study.\n\n" }, { "category": "Radiology", "chartdate": "2148-05-31 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1016411, "text": " 2:39 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: abscess vs edema/phlegmon\n Admitting Diagnosis: NECK INFECTION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with submandibular odontogenic infection, sudden increase in\n neck and supraglottic edema. Please evaluate for progression of disease.\n REASON FOR THIS EXAMINATION:\n abscess vs edema/phlegmon\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT NECK\n\n HISTORY: 69-year-old female with floor of mouth infection with sudden\n increase in neck and supraglottic edema. Assess for progression.\n\n TECHNIQUE: CT of the neck was performed after the administration of 100 cc of\n Optiray IV contrast. Multiplanar reformats were obtained.\n\n FINDINGS: Comparison is made to .\n\n The previously seen multiloculated ring-enhancing lesion involving the left\n side of the floor of the mouth has increased in size. The more anterior\n superior collection has a transverse diameter of approximately 2.2 x 1.7 cm\n compared to prior measurement of approximately 1.2 cm. The more inferior\n posterior loculation measures approximately 2.1 x 1.5 cm, previously measuring\n approximately 1.8 x 1.1 cm. Again seen is rightward shift of the midline\n raphe. There is obliteration of the fat planes and edematous appearance to\n the submandibular region, worse on the left side, as well as edema involving\n the vallecula and the aryepiglottic folds bilaterally. The edema of the right\n aryepiglottic fold is worse compared to the prior study. There is a worsened\n thickening of the left platysma muscle, and multiple small submental and\n submandibular lymph nodes are again visualized. The edema tracks inferiorly\n to the level of the thyroid gland.\n\n The crown of the left mandibular second premolar is absent, and there is\n filling within the pulp chamber. There is a dental post in the left\n mandibular first molar region with minimal surrounding lucency, which may\n represent periodontal disease versus post-surgical change. There are no\n periapical lucencies to suggest a periapical abscess. There are no bony\n erosions to suggest osteomyelitis.\n\n The submandibular glands show prominent ducts at the hila. The left\n submandibular gland is minimally larger compared to the right. No definite\n sialoliths are seen.\n\n There is no definite thrombus involving the cervical vessels.\n\n Partially imaged are bilateral breast implants.\n\n (Over)\n\n 2:39 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: abscess vs edema/phlegmon\n Admitting Diagnosis: NECK INFECTION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The visualized lung apices show some hypoventilatory changes, but there is no\n evidence of septic emboli.\n\n Minimal degenerative changes of the cervical spine are seen but without canal\n stenosis.\n\n The visualized paranasal sinuses, mastoid air cells, and middle ear cavities\n are clear.\n\n IMPRESSION: Since , increase in size of the multiloculated ring-\n enhancing lesion within the left floor of mouth consistent with worsening\n abscess. The abscess appears to be centered in the sublingual space and may\n be related to sialadenitis of the sublingual glands, as the submandibular\n glands appear to be relatively normal.\n\n There are no periapical lucencies or lytic changes of the adjacent mandible to\n suggest an odontogenic source.\n\n There is worsened surrounding edema with worsened edema of the right\n aryepiglottic fold but with a patent airway.\n\n No evidence of venous thromboses.\n\n COMMENT: The above findings were discussed with Dr. .\n\n" }, { "category": "ECG", "chartdate": "2148-05-31 00:00:00.000", "description": "Report", "row_id": 262557, "text": "Sinus bradycardia. Non-diagnostic Q waves in leads II, III and aVF. Compared to\nthe previous tracing of there are upward coved ST segments in\nleads VI-V4 and new biphasic to inverted T waves in leads V3-V5, as well as\nST-T wave flattening in lead II and new T wave inversion in lead aVF. These\nfindings may reflect active anterolateral and apical ischemic process. Followup\nand clinical correlation are suggested.\n\n" }, { "category": "Nursing", "chartdate": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409696, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation. Nasally intubated and vented\n on AC 50% 500X12/5. scant amnt of bloody secretion via ETT. Sedated on\n fentanyl versed. Sats at 100%\n Action:\n Mechanical ventilation to maintain airway\n Response:\n pending\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n .\n # Respirtory. Stable on AC, comfortable. Sedated on fentanyl/versed\n - SBT in AM/awakening\n - sedation with Fentanyl/Midaz\n - VAP care\n - Per ENT she responds well to decadron if complains of swelling 10mg\n IV if needed once extubated.\n .\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n - CIS\n .\n # HTN: Currently elevated to 170-180s systolic. On lisinopril daily but\n currently not taking POs.\n - can use IV enalapril prn until taking POs\n - consider NGT for oral meds vs. IV until tomorrow pending extubation\n --discuss with ENT\n .\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 409717, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Pain level well\n contolled with iv morphine. Continue to sees pt\ns pain level.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. P receiving d5\n ns with 20 meq\n kcl at 75cc\ns/hr.\n Response:\n Pt Normotensive\n :\n Will most likely d/c iv maintence fluid when pt is taking adequate amts\n of liqs. Continue to follow pt\ns hemodynamics now that outpt regime of\n po meds are being restarted. Check electrolytes as ordered and replete\n as needed.\n" }, { "category": "Physician ", "chartdate": "2148-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 409718, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:13 AM\n Extubated yesterday. O2 sats fine overnight. No events.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 PM\n Clindamycin - 12:27 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Morphine Sulfate - 07:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 63 (60 - 97) bpm\n BP: 130/67(82) {111/58(73) - 169/96(143)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 688 mL\n 598 mL\n PO:\n TF:\n IVF:\n 688 mL\n 598 mL\n Blood products:\n Total out:\n 2,485 mL\n 410 mL\n Urine:\n 2,485 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,797 mL\n 188 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Vt (Spontaneous): 448 (448 - 448) mL\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Dressing C/D/I at left mandible\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 311 K/uL\n 11.9 g/dL\n 98 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 104 mEq/L\n 140 mEq/L\n 33.4 %\n 6.7 K/uL\n [image002.jpg]\n 12:57 PM\n 03:56 AM\n 03:40 AM\n WBC\n 12.8\n 9.2\n 6.7\n Hct\n 35.3\n 36.2\n 33.4\n Plt\n 333\n 321\n 311\n Cr\n 0.7\n 0.6\n 0.6\n Glucose\n 113\n 94\n 98\n Other labs: Differential-Neuts:71.0 %, Lymph:19.8 %, Mono:8.4 %,\n Eos:0.8 %, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respiratory. Extubated without difficulty. 02sats stable overnight.\n On room air today.\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place.\n -ENT following will likely pull drains today\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once taking PO\n # Hypothyroidism: Cont Levothyroxine once taking PO\n # h/o breast cancer: no active issues\n # FEN: NPO currently; will advance diet per ENT recs\n # PPX: subcutaneous heparin SQ, bowel regimen\n # Access: PIV x 2\n # Full Code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:53 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 409719, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). npw changed to oxycodene 10 mg which she received at 1350.\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. P receiving d5\n ns with 20 meq\n kcl at 75cc\ns/hr.\n Response:\n Pt Normotensive\n :\n Will most likely d/c iv maintence fluid when pt is taking adequate amts\n of liqs. Continue to follow pt\ns hemodynamics now that outpt regime of\n po meds are being restarted. Check electrolytes as ordered and replete\n as needed.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 409720, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). npw changed to oxycodene 10 mg which she received at 1350. pt\n oob to chair with steady gait\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po. Pt\n tolerated activity well.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. P receiving d5\n ns with 20 meq\n kcl at 75cc\ns/hr.\n Response:\n Pt Normotensive\n :\n Will most likely d/c iv maintence fluid when pt is taking adequate amts\n of liqs. Continue to follow pt\ns hemodynamics now that outpt regime of\n po meds are being restarted. Check electrolytes as ordered and replete\n as needed.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409714, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt extubated yesterday at 11 am. Rr~16, O2 sats 97%, on 50%\n face tent. No sob, no stridor, no wheezing. Pt c/o soreness in\n throat, and difficulty with swallowing secretions\n no change since\n extubation (not worse) pt using oral yankar sx catheter to help clear\n secretions. Pt c/o left sided neck pain ( 2 penrose drains intact\n dsg reinforced)\n medicated with 1-2 mg IV Morphine with good\n affect. Afebrile, on Clinda and Levofloxacin. Mouth care\n done. Pt remains NPO. Belly soft, + flatus. Able to nap on /off\n during the night.\n Action:\n Post extubation\n Response:\n Pt stable post extubation, no further swelling\n Plan:\n Continue to monitor resp status and oral/sublingual swelling/stridor.\n Continue supplemental O2 as needed, oral suction prn, if swelling\n give 10 mg IV Decadron. Drains to be pulled this am by ENT.\n Continue Morphine prn for pain\n Hypertension, benign\n Assessment:\n Bp stable 120/70 HR 60-70\ns SR no vea noted.\n Action:\n Monitor bp, treat pain, if SBP >160\ns, use IV Enalapril\n Response:\n Remains normotensive\n Plan:\n Monitor patient status, when able switch meds back to home meds\n IV Access: 2 peripherals infiltrated, #20 right arm\n dsg intact.\n SOCIAL: son in to visit. Husband/son called during the night\n updated\n on pt\ns condition.\n" }, { "category": "Physician ", "chartdate": "2148-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 409715, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:13 AM\n Extubated yesterday. O2 sats fine overnight. No events.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 PM\n Clindamycin - 12:27 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Morphine Sulfate - 07:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 63 (60 - 97) bpm\n BP: 130/67(82) {111/58(73) - 169/96(143)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 688 mL\n 598 mL\n PO:\n TF:\n IVF:\n 688 mL\n 598 mL\n Blood products:\n Total out:\n 2,485 mL\n 410 mL\n Urine:\n 2,485 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,797 mL\n 188 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Vt (Spontaneous): 448 (448 - 448) mL\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Dressing C/D/I at left mandible\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 311 K/uL\n 11.9 g/dL\n 98 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 104 mEq/L\n 140 mEq/L\n 33.4 %\n 6.7 K/uL\n [image002.jpg]\n 12:57 PM\n 03:56 AM\n 03:40 AM\n WBC\n 12.8\n 9.2\n 6.7\n Hct\n 35.3\n 36.2\n 33.4\n Plt\n 333\n 321\n 311\n Cr\n 0.7\n 0.6\n 0.6\n Glucose\n 113\n 94\n 98\n Other labs: Differential-Neuts:71.0 %, Lymph:19.8 %, Mono:8.4 %,\n Eos:0.8 %, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respirtory. Stable- now on pressure support.\n -wean ventilator settings and obtain RSBI\n -ENT to check for cuff leak\n -wean sedation\n -extubate if able\n -if swelling 10mg IV decadron\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once extubated\n # Hypothyroidism: Cont Levothyroxine once extubated\n # h/o breast cancer: no active issues\n # FEN: NPO currently, replete lytes prn\n # PPX: subcutaneous heparin SQ, bowel regimen\n # Access: PIV x 2\n # Full Code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:53 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 409716, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409721, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). now chnged to oxycodene 10 mg which she received at 1350. pt\n oob to chair with steady gait\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po. Pt\n tolerated activity well.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. Maintenance ivf of d5\n ns with\n 20 meq kcl d/c\nd now that pt is taking in adequate amts of po intake\n Response:\n Pt Normotensive\n :\n Continue to follow pt\ns hemodynamics now that outpt regime of po meds\n are being restarted. Check electrolytes as ordered and replete as\n needed. Encourage pt\ns po intake and monitor her fluid status. Pt to be\n transferred to medical floor bed when one is available and will go on\n telemetry.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409722, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). now chnged to oxycodene 10 mg which she received at 1350. pt\n oob to chair with steady gait\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po. Pt\n tolerated activity well.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. Maintenance ivf of d5\n ns with\n 20 meq kcl d/c\nd now that pt is taking in adequate amts of po intake\n Response:\n Pt Normotensive\n :\n Continue to follow pt\ns hemodynamics now that outpt regime of po meds\n are being restarted. Check electrolytes as ordered and replete as\n needed. Encourage pt\ns po intake and monitor her fluid status. Pt to be\n transferred to medical floor bed when one is available and will go on\n telemetry.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409723, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). now chnged to oxycodene 10 mg which she received at 1350. pt\n oob to chair with steady gait\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po. Pt\n tolerated activity well.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. Maintenance ivf of d5\n ns with\n 20 meq kcl d/c\nd now that pt is taking in adequate amts of po intake\n Response:\n Pt Normotensive\n :\n Continue to follow pt\ns hemodynamics now that outpt regime of po meds\n are being restarted. Check electrolytes as ordered and replete as\n needed. Encourage pt\ns po intake and monitor her fluid status. Pt to be\n transferred to medical floor bed when one is available and will go on\n telemetry.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 409724, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). npw changed to oxycodene 10 mg which she received at 1350. pt\n oob to chair with steady gait\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po. Pt\n tolerated activity well.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. Maintenance iv of d 5\n ns with\n 20 meq kcl d/c\nd now that pt is taking adequate amts of po intake\n Response:\n Pt Normotensive\n :\n . Continue to follow pt\ns hemodynamics now that outpt regime of po meds\n are being restarted. Check electrolytes as ordered and replete as\n needed. Encourage po intake and follow fluid balance. Pt is called out\n and awaiting medical bed onf floor. Pt will be transferred out on\n telemetry.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 409725, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Resp status stable post extubation . no wheezing, stridor or\n swelling to oral cavity. Rr low 20\ns and o2 sats 97-100%. Afebrile.\n Action:\n Pt placed on room air. Dr. to bedside and removed penrose drains\n to l mandibular area. both drain sites covered with triple antibiotic\n ointment and dressed with bandaids. Diet advanced to clear liqs. Given\n clindamycin and levofloxacin as ordered. Id consulted per request of pt\n and dr. . Medicated with iv morphine 1-2 mg for pain control(see\n \ns). npw changed to oxycodene 10 mg which she received at 1350. pt\n oob to chair with steady gait\n Response:\n Pt tolerating clear liqs. Resp stable and pt no longer requiring\n supplemental o2. Pt most likely to be d/c\nd on Tuesday or wedenesday.\n Will advance diet to soft solid diet as pt tolerates. Continue to\n assess pt\ns pain level. Pain relieved well with oxycodone 10 mg po. Pt\n tolerated activity well.\n Plan:\n Will advance diet to soft solid diet as pt tolerates. Now that pt is\n taking po;\ns will be able to change pain meds to po route of\n administration. Pt to redress mandibular wound as needed. Will advance\n pt\ns activity as tolerated. Pt may be d/c\nd home tomorrow or Wednesday.\n Hypertension, benign\n Assessment:\n Hr60-70\ns and sbp 120\ns-150\ns. k+3.6\n Action:\n Pt restarted on po antihypertensives. Maintenance iv of d 5\n ns with\n 20 meq kcl d/c\nd now that pt is taking adequate amts of po intake\n Response:\n Pt Normotensive\n :\n . Continue to follow pt\ns hemodynamics now that outpt regime of po meds\n are being restarted. Check electrolytes as ordered and replete as\n needed. Encourage po intake and follow fluid balance. Pt is called out\n and awaiting medical bed onf floor. Pt will be transferred out on\n telemetry.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n NECK INFECTION\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 50.5 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: hypothyroidism, previous sternal debridment for\n osteo\n Surgery / Procedure and date: LT submandibular /floor of mouth\n collection - I&D\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 67 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 50% %\n 24h total in:\n 1,633 mL\n 24h total out:\n 1,530 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:40 AM\n Potassium:\n 3.6 mEq/L\n 03:40 AM\n Chloride:\n 104 mEq/L\n 03:40 AM\n CO2:\n 26 mEq/L\n 03:40 AM\n BUN:\n 10 mg/dL\n 03:40 AM\n Creatinine:\n 0.6 mg/dL\n 03:40 AM\n Glucose:\n 98 mg/dL\n 03:40 AM\n Hematocrit:\n 33.4 %\n 03:40 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: yellow colored wedding band\n Transferred from: 407\n Transferred to: 1267\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2148-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 409726, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:13 AM\n Extubated yesterday. O2 sats fine overnight. No events.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 PM\n Clindamycin - 12:27 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Morphine Sulfate - 07:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 63 (60 - 97) bpm\n BP: 130/67(82) {111/58(73) - 169/96(143)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 688 mL\n 598 mL\n PO:\n TF:\n IVF:\n 688 mL\n 598 mL\n Blood products:\n Total out:\n 2,485 mL\n 410 mL\n Urine:\n 2,485 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,797 mL\n 188 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Vt (Spontaneous): 448 (448 - 448) mL\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Dressing C/D/I at left mandible\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 311 K/uL\n 11.9 g/dL\n 98 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 104 mEq/L\n 140 mEq/L\n 33.4 %\n 6.7 K/uL\n [image002.jpg]\n 12:57 PM\n 03:56 AM\n 03:40 AM\n WBC\n 12.8\n 9.2\n 6.7\n Hct\n 35.3\n 36.2\n 33.4\n Plt\n 333\n 321\n 311\n Cr\n 0.7\n 0.6\n 0.6\n Glucose\n 113\n 94\n 98\n Other labs: Differential-Neuts:71.0 %, Lymph:19.8 %, Mono:8.4 %,\n Eos:0.8 %, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respiratory. Extubated without difficulty. 02sats stable overnight.\n On room air today.\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place.\n -ENT following will likely pull drains today\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once taking PO\n # Hypothyroidism: Cont Levothyroxine once taking PO\n # h/o breast cancer: no active issues\n # FEN: NPO currently; will advance diet per ENT recs\n # PPX: subcutaneous heparin SQ, bowel regimen\n # Access: PIV x 2\n # Full Code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:53 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n No respiratory events. Extubated uneventfully. Talking, breathing\n comfortably, taking POs.\n Safe for tx to floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:06 ------\n" }, { "category": "Nursing", "chartdate": "2148-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409712, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Nasally intubated and vented on AC 50% 500X12/5. Scant amnt of bloody\n secretion via ETT. Sedated on fentanyl versed. Sats at 100%. Still\n significant oral/sublingual swelling\n Action:\n Weaned of sedation, PSV, positive cuff leak, extubated at 11:00am. On\n high flow neb at 50%, dressings removed by ENT.\n Response:\n Maintains sats at 100%, no s/s of resp distress.\n Plan:\n Continue to monitor resp status and oral/sublingual swelling/stridor.\n Provide supplemental O2 as needed, oral suction prn, -if swelling 10mg\n IV decadron\n Hypertension, benign\n Assessment:\n Normotensive, on lisinopril at home\n Action:\n Monitor b/p, treat pain, if SBP>160\ns use IV enalapril prn,\n Response:\n Remains normotensive\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: a/ox2-3 follows commands, normal extr strength,\n Resp; on high flow neb at 50%, sats at 100%, LS clear, copious oral\n secretion. Patient able to clear them\n Cardio: hr at 60\ns SR no ectopy noted. B/P at 130-150\ns/80\ns. No\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender, positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place - She\n had penrose drains placed externally and intraorally. Dressing changed\n today by ENT. Plan to remove drains tomorrow.\n IV access: 2PIV LT 20G/18G\n Social: husband/son in to visit, updated by RN/MD.\n" }, { "category": "Nursing", "chartdate": "2148-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409713, "text": "69 y.o. female with history of breast CA s/p bil mastectomy,\n hypothyroidism, HTN, dental abscess s/p I+D who presented\n After elective intubation for airway protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt extubated yesterday at 11 am. Rr~16, O2 sats 97%, on 50%\n face tent. Pt c/o soreness in throat, and difficulty with swallowing\n no change since extubation (not worse) pt using oral yankar sx\n catheter to help clear secretions. Pt c/o left sided neck pain ( 2\n penrose drains intact\n dsg reinforced)\n medicated with 1-2 mg IV\n Morphine with good affect. Afebrile, on Clinda and\n Levofloxacin. Mouth care done. Pt remains NPO.\n Action:\n Post extubation\n Response:\n Pt stable post extubation, no further swelling\n Plan:\n Continue to monitor resp status and oral/sublingual swelling/stridor.\n Continue supplemental O2 as needed, oral suction prn, if swelling\n give 10 mg IV Decadron. Drains to be pulled this am by ENT.\n Hypertension, benign\n Assessment:\n Bp stable 120/70 HR 60-70\ns SR no vea noted.\n Action:\n Monitor bp, treat pain, if SBP >160\ns, use IV Enalapril\n Response:\n Remains normotensive\n Plan:\n Monitor patient status, when able switch meds back to home meds\n" }, { "category": "Respiratory ", "chartdate": "2148-06-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 409711, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 49.9 None\n Ideal tidal volume: 199.6 / 299.4 / 399.2 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:\n Size: 6.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: 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 Pt weaned and extubated this morning to 50% cool aerosol without\n incident. ENT was present for extubation tube exchanger used due to\n possible airway edema post op. Pt had audible cuff leak prior to\n extubation and no stridor post.\n" }, { "category": "Nursing", "chartdate": "2148-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409710, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Nasally intubated and vented on AC 50% 500X12/5. Scant amnt of bloody\n secretion via ETT. Sedated on fentanyl versed. Sats at 100%. Still\n significant oral/sublingual swelling\n Action:\n Weaned of sedation, PSV, positive cuff leak, extubated at 11:00am. On\n high flow neb at 50%, dressings removed by ENT.\n Response:\n Maintains sats at 100%, no s/s of resp distress.\n Plan:\n Continue to monitor resp status and oral/sublingual swelling/stridor.\n Provide supplemental O2 as needed, oral suction prn, -if swelling 10mg\n IV decadron\n Hypertension, benign\n Assessment:\n Normotensive, on lisinopril at home\n Action:\n Monitor b/p, treat pain, if SBP>160\ns use IV enalapril prn,\n Response:\n Remains normotensive\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: a/ox2-3, , follows commands, normal extr strength,\n Resp; on high flow neb at 50% ,sats at 100%, LS clear, copious oral\n secretion . patient able to clear them\n Cardio: hr at 60\ns SR no ectopy noted. b/p at 130-150\ns/80\ns. no\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender, positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place - She\n had penrose drains placed externally and intraorally. Dressing changed\n today by ENT. Plan to remove drains tomorrow.\n IV access: 2PIV LT 20G/18G\n Social: husband/son in to visit, updated by RN/MD.\n" }, { "category": "Nursing", "chartdate": "2148-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409704, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt is alert, responding to verbal stimuli by opening eyes and following\n commands, c/o pain at incision sight, on Fentanyl drip increased to 50\n mcg/hr, versed drip increased to 5 mg/hr then weaned back to 4 mg/hr,\n still intubated nasally, no vent changes this shift, LS CTA, suctioned\n frequently from ETT and mouth for moderate thick yellowish to blood\n tinged secretions.\n Action:\n Fentanyl drip rate increased for pain control, suctioned frequently,\n continued on clidamycin IV and given levofloxacin IV as well as\n ordered. Fentanyl drip decreased to 40 mg/hr in AM preparing for\n possible extubation.\n Response:\n Pain tolerated well at incisional site, dressing soaked with minimal\n amount of serosanguinous secretions, RNT team aware, they will change\n dressing in AM, husband visited and son and husband called and updated\n on pt\ns condition.\n Plan:\n Pain control, continue antibiotics, ENT team will evaluate pt\n condition in AM, Possible extubation by ENT team as pt is known\n difficult airway, and team wants to ensure whether there is an air\n leak.\n" }, { "category": "Physician ", "chartdate": "2148-06-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 409705, "text": "Chief Complaint: dental abscess- nasal intubation for airway protection\n 24 Hour Events:\n OR RECEIVED - At 10:20 AM\n INVASIVE VENTILATION - START 10:36 AM\n ENT evaluated: will check for cuff leak this a.m. 10 a.m. and be\n present for extubation\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 PM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Pain: Mild\n Pain location: neck pain\n Flowsheet Data as of 06:41 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: 37.8\nC (100\n HR: 61 (53 - 87) bpm\n BP: 121/68(79) {121/68(79) - 187/97(118)} mmHg\n RR: 12 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,530 mL\n 177 mL\n PO:\n TF:\n IVF:\n 2,530 mL\n 177 mL\n Blood products:\n Total out:\n 2,410 mL\n 400 mL\n Urine:\n 2,190 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 120 mL\n -223 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 220 (220 - 220) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 100%\n ABG: ///22/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\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 12.1 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 137 mEq/L\n 36.2 %\n 9.2 K/uL\n [image002.jpg]\n 12:57 PM\n 03:56 AM\n WBC\n 12.8\n 9.2\n Hct\n 35.3\n 36.2\n Plt\n 333\n 321\n Cr\n 0.7\n 0.6\n Glucose\n 113\n 94\n Other labs: Differential-Neuts:71.0 %, Lymph:19.8 %, Mono:8.4 %,\n Eos:0.8 %, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respirtory. Stable- now on pressure support.\n -wean ventilator settings and obtain RSBI\n -ENT to check for cuff leak\n -wean sedation\n -extubate if able\n -if swelling 10mg IV decadron\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once extubated\n # Hypothyroidism: Cont Levothyroxine once extubated\n # h/o breast cancer: no active issues\n # FEN: NPO currently, replete lytes prn\n # PPX: subcutaneous heparin SQ, bowel regimen\n # Access: PIV x 2\n # Full Code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:51 AM\n 18 Gauge - 11:35 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2148-06-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 409706, "text": "Chief Complaint: dental abscess- nasal intubation for airway protection\n 24 Hour Events:\n OR RECEIVED - At 10:20 AM\n INVASIVE VENTILATION - START 10:36 AM\n ENT evaluated: will check for cuff leak this a.m. 10 a.m. and be\n present for extubation\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 PM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Pain: Mild\n Pain location: neck pain\n Flowsheet Data as of 06:41 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: 37.8\nC (100\n HR: 61 (53 - 87) bpm\n BP: 121/68(79) {121/68(79) - 187/97(118)} mmHg\n RR: 12 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,530 mL\n 177 mL\n PO:\n TF:\n IVF:\n 2,530 mL\n 177 mL\n Blood products:\n Total out:\n 2,410 mL\n 400 mL\n Urine:\n 2,190 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 120 mL\n -223 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 220 (220 - 220) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 100%\n ABG: ///22/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\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 12.1 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 137 mEq/L\n 36.2 %\n 9.2 K/uL\n [image002.jpg]\n 12:57 PM\n 03:56 AM\n WBC\n 12.8\n 9.2\n Hct\n 35.3\n 36.2\n Plt\n 333\n 321\n Cr\n 0.7\n 0.6\n Glucose\n 113\n 94\n Other labs: Differential-Neuts:71.0 %, Lymph:19.8 %, Mono:8.4 %,\n Eos:0.8 %, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respirtory. Stable- now on pressure support.\n -wean ventilator settings and obtain RSBI\n -ENT to check for cuff leak\n -wean sedation\n -extubate if able\n -if swelling 10mg IV decadron\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once extubated\n # Hypothyroidism: Cont Levothyroxine once extubated\n # h/o breast cancer: no active issues\n # FEN: NPO currently, replete lytes prn\n # PPX: subcutaneous heparin SQ, bowel regimen\n # Access: PIV x 2\n # Full Code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:51 AM\n 18 Gauge - 11:35 AM\n Prophylaxis:\n DVT: SQ UF Heparin- switch to lovenox and d/c heparin drip\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2148-06-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 409707, "text": "Chief Complaint: dental abscess- nasal intubation for airway protection\n 24 Hour Events:\n OR RECEIVED - At 10:20 AM\n INVASIVE VENTILATION - START 10:36 AM\n ENT evaluated: will check for cuff leak this a.m. 10 a.m. and be\n present for extubation\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 PM\n Clindamycin - 12:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Pain: Mild\n Pain location: neck pain\n Flowsheet Data as of 06:41 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: 37.8\nC (100\n HR: 61 (53 - 87) bpm\n BP: 121/68(79) {121/68(79) - 187/97(118)} mmHg\n RR: 12 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,530 mL\n 177 mL\n PO:\n TF:\n IVF:\n 2,530 mL\n 177 mL\n Blood products:\n Total out:\n 2,410 mL\n 400 mL\n Urine:\n 2,190 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 120 mL\n -223 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 220 (220 - 220) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 100%\n ABG: ///22/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\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 12.1 g/dL\n 94 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 106 mEq/L\n 137 mEq/L\n 36.2 %\n 9.2 K/uL\n [image002.jpg]\n 12:57 PM\n 03:56 AM\n WBC\n 12.8\n 9.2\n Hct\n 35.3\n 36.2\n Plt\n 333\n 321\n Cr\n 0.7\n 0.6\n Glucose\n 113\n 94\n Other labs: Differential-Neuts:71.0 %, Lymph:19.8 %, Mono:8.4 %,\n Eos:0.8 %, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respirtory. Stable- now on pressure support.\n -wean ventilator settings and obtain RSBI\n -ENT to check for cuff leak\n -wean sedation\n -extubate if able\n -if swelling 10mg IV decadron\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once extubated\n # Hypothyroidism: Cont Levothyroxine once extubated\n # h/o breast cancer: no active issues\n # FEN: NPO currently, replete lytes prn\n # PPX: subcutaneous heparin SQ, bowel regimen\n # Access: PIV x 2\n # Full Code\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:51 AM\n 18 Gauge - 11:35 AM\n Prophylaxis:\n DVT: SQ UF Heparin- switch to lovenox and d/c heparin drip\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above\n Key issue: good leak, mouth irrigated, extubated.\n Still significant oral/sublingual swelling. At risk for losing airway,\n will observe in ICU until tomorrow.\n Critically ill with airway compromise, now improved and extubated.\n Time: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:07 ------\n" }, { "category": "Nursing", "chartdate": "2148-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409708, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n # Respirtory. Stable- now on pressure support.\n -wean ventilator settings and obtain RSBI\n -ENT to check for cuff leak\n -wean sedation\n -extubate if able\n -if swelling 10mg IV decadron\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once extubated\n" }, { "category": "Nursing", "chartdate": "2148-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409709, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Nasally intubated and vented on AC 50% 500X12/5. Scant amnt of bloody\n secretion via ETT. Sedated on fentanyl versed. Sats at 100%.\n Action:\n Weaned of sedation, positive cuff leak, extubated. At 11:00am. on high\n flow neb at 50%\n Response:\n pending\n Plan:\n Plan for extubation in AM per ENT if there is an airleak.\n Hypertension, benign\n Assessment:\n Elevated b/p at 160\ns/80\ns on lisinopril at home\n Action:\n Monitor b/p, treat pain, if SBP>160\ns use IV enalapril prn\n Response:\n pending\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: sedated on fentanyl/verse, will wake up during care, moves extr.\n Resp; intubated and sedated (see note above)\n Cardio: ht at 60\ns SR no ectopy noted. b/p at 150-160\ns/80\ns. no\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender, positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place - She\n had penrose drains placed externally and intraorally. ENT said to\n monitor and change dressings only if draining pus. Leave drains in\n place.\n IV access: 2PIV LT 20G/18G\n Social: husband in to visit, updated by RN.\n # Respirtory. Stable- now on pressure support.\n -wean ventilator settings and obtain RSBI\n -ENT to check for cuff leak\n -wean sedation\n -extubate if able\n -if swelling 10mg IV decadron\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -OMFS following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n -afebrile, WBC decreasing\n -gram stain from abscess negative, cultures pending\n # HTN: currently better controlled.\n -on enalapril prn\n -restart PO meds once extubated\n" }, { "category": "Nursing", "chartdate": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409697, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation. Nasally intubated and vented\n on AC 50% 500X12/5. scant amnt of bloody secretion via ETT. Sedated on\n fentanyl versed. Sats at 100%\n Action:\n Mechanical ventilation to maintain airway, mouth care deferred due to\n oral surgery /oral drain and packing .\n Response:\n pending\n Plan:\n Plan for extubation in AM per ENT if there is an airleak.\n Hypertension, benign\n Assessment:\n Elevated b/p at 160\ns/80\nson lisinopril at home\n Action:\n Monitor b/p treat pain if >160\ns use IV enalapril prn\n Response:\n pending\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: sedated on fentanyl/versedwill wake up during care, moves extr.\n Resp; intubated and sedated( see note above)\n Cardio: ht at 60\ns SR no ectopy noted. b/p at 150-160\ns/80\ns. no\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender ,positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place. ENT\n said to monitor and change dressings only if draining pus. Leave drains\n in place.\n" }, { "category": "Respiratory ", "chartdate": "2148-06-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 409699, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 49.9 None\n Ideal tidal volume: 199.6 / 299.4 / 399.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: OR\n Reason:\n Tube Type\n ETT:\n Position: 26@Rnare cm at teeth\n Route: Nasal\n Type:\n Size: 6.5mm\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: leak with cuff down\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved; Comments: Difficult airway\n edema\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": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409700, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation. Nasally intubated and vented\n on AC 50% 500X12/5. scant amnt of bloody secretion via ETT. Sedated on\n fentanyl versed. Sats at 100%\n Action:\n Mechanical ventilation to maintain airway, mouth care deferred due to\n oral surgery /oral drain and packing.\n Response:\n pending\n Plan:\n Plan for extubation in AM per ENT if there is an airleak.\n Hypertension, benign\n Assessment:\n Elevated b/p at 160\ns/80\ns on lisinopril at home\n Action:\n Monitor b/p, treat pain, if SBP>160\ns use IV enalapril prn\n Response:\n pending\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: sedated on fentanyl/verse, will wake up during care, moves extr.\n Resp; intubated and sedated (see note above)\n Cardio: ht at 60\ns SR no ectopy noted. b/p at 150-160\ns/80\ns. no\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender, positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place - She\n had penrose drains placed externally and intraorally. ENT said to\n monitor and change dressings only if draining pus. Leave drains in\n place.\n IV access: 2PIV LT 20G/18G\n Social: husband in to visit, updated by RN.\n" }, { "category": "Nursing", "chartdate": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409701, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation. Nasally intubated and vented\n on AC 50% 500X12/5. scant amnt of bloody secretion via ETT. Sedated on\n fentanyl versed. Sats at 100%\n Action:\n Mechanical ventilation to maintain airway, mouth care deferred due to\n oral surgery /oral drain and packing.\n Response:\n pending\n Plan:\n Plan for extubation in AM per ENT if there is an airleak.\n Hypertension, benign\n Assessment:\n Elevated b/p at 160\ns/80\ns on lisinopril at home\n Action:\n Monitor b/p, treat pain, if SBP>160\ns use IV enalapril prn\n Response:\n pending\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: sedated on fentanyl/verse, will wake up during care, moves extr.\n Resp; intubated and sedated (see note above)\n Cardio: ht at 60\ns SR no ectopy noted. b/p at 150-160\ns/80\ns. no\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender, positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place - She\n had penrose drains placed externally and intraorally. ENT said to\n monitor and change dressings only if draining pus. Leave drains in\n place.\n IV access: 2PIV LT 20G/18G\n Social: husband in to visit, updated by RN.\n" }, { "category": "Respiratory ", "chartdate": "2148-06-02 00:00:00.000", "description": "Respiratory Note", "row_id": 409702, "text": "TITLE:\n Respiratory Care: Pt remains nasally intubated and on vent, no\n parameter changes made this shift. RSBI attempted, but pt has been\n sedated and not spontaneously breathing. BS clear. Plan to wean to\n extubate. PT IS KNOWN DIFFICULT AIRWAY---CHECK FOR CUFF LEAK.\n" }, { "category": "Nursing", "chartdate": "2148-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409703, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt is alert, responding to verbal stimuli by opening eyes and following\n commands, c/o pain at incision sight, on Fentanyl drip increased to 50\n mcg/hr, versed drip increased to 5 mg/hr then weaned back to 4 mg/hr,\n still intubated nasally, no vent changes this shift, LS CTA, suctioned\n frequently from ETT and mouth for moderate thick yellowish to blood\n tinged secretions.\n Action:\n Fentanyl drip rate increased for pain control, suctioned frequently,\n continued on clidamycin IV and given levofloxacin IV as well as\n ordered.\n Response:\n Pain tolerated well at incisional site, dressing soaked with minimal\n amount of serosanguinous secretions, RNT team aware, they will change\n dressing in AM, husband visited and son and husband called and updated\n on pt\ns condition.\n Plan:\n Pain control, continue antibiotics, ENT team will evaluate pt\n condition in AM, Possible extubation by ENT team as pt is known\n difficult airway, and team wants to ensure whether there is an air\n leak.\n" }, { "category": "Nursing", "chartdate": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409695, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n .\n # Respirtory. Stable on AC, comfortable. Plan for extubation in AM per\n ENT if there is an airleak. Pt has baseline left side oral edema to be\n aware of.\n - SBT in AM/awakening\n - sedation with Fentanyl/Midaz\n - VAP care\n - Per ENT she responds well to decadron if complains of swelling 10mg\n IV if needed once extubated.\n .\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n - CIS\n .\n # HTN: Currently elevated to 170-180s systolic. On lisinopril daily but\n currently not taking POs.\n - can use IV enalapril prn until taking POs\n - consider NGT for oral meds vs. IV until tomorrow pending extubation\n --discuss with ENT\n .\n" }, { "category": "Nursing", "chartdate": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409698, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation. Nasally intubated and vented\n on AC 50% 500X12/5. scant amnt of bloody secretion via ETT. Sedated on\n fentanyl versed. Sats at 100%\n Action:\n Mechanical ventilation to maintain airway, mouth care deferred due to\n oral surgery /oral drain and packing.\n Response:\n pending\n Plan:\n Plan for extubation in AM per ENT if there is an airleak.\n Hypertension, benign\n Assessment:\n Elevated b/p at 160\ns/80\nson lisinopril at home\n Action:\n Monitor b/p treat pain if >160\ns use IV enalapril prn\n Response:\n pending\n Plan:\n Monitor patient status, when able switch meds back to home meds\n Neuro: sedated on fentanyl/versed will wake up during care, moves extr.\n Resp; intubated and sedated (see note above)\n Cardio: ht at 60\ns SR no ectopy noted. b/p at 150-160\ns/80\ns. no\n peripheral edema, pulses present.\n GU: clear straw color urine, adequate amnt.\n GI; abd soft non tender, positive for BS, NPO\n Skin: s/p oral surgery with pus drainage 5 cc. Drains in place - She\n had penrose drains placed externally and intraorally. ENT said to\n monitor and change dressings only if draining pus. Leave drains in\n place.\n IV access: 2PIV LT 20G/18G\n Social: husband in to visit, updated by RN.\n" }, { "category": "Physician ", "chartdate": "2148-06-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 409691, "text": "Chief Complaint: Airway protection\n HPI:\n 69 yo F with PMH of breast ca s/p bilateral mastectomy, hypothyroidism\n and dental abscess who presents after dental surgery for airway\n monitoring. Per chart and history, she had dental surgery three weeks\n ago for a dental implant stump to be placed and to have a temporary\n bridge placed. Plan was to go back for implant in the future. Then she\n developed swelling under the tongue and odynaphagia. She saw outpatient\n physicians and received multiple outpt regimens of antibiotics but the\n swelling and pain worsened. She was referred to Dr. as an ENT\n outpatient. She saw left sided oralpharyngeal edema down to false vocal\n folds but her true cords were always fine. She was admitted for\n monitoring to the hospital on . She was given decadron, benadryl\n and clindamycin/levofloxacin antibiotics. When steroids wore off she\n would develop SOB again and edema. She had CT scans which showed\n infection and progression of the edema. Oral surgery was consulted and\n she was taken to the OR for dental extraction and drainage. The surgery\n went smoothly with 5ml of pus removed. She received 1200ml of IVF in\n the OR with minimal blood loss. She had penrose drains placed\n externally and intraorally. She was transferred to the ICU for close\n monitoring given the amount of OP edema prior to surgery and concern\n for post-op edema causing airway compromise.\n .\n Currently intubated and sedated. No ROS was able to be obtained.\n Patient admitted from: from ENT\n History obtained from Medical records, ENT team\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 75 mcg/Kg/min\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Medications at home:\n Levothyroxine 100 daily\n Lisinopril 10 daily\n Fosamax weekly\n .\n Medications on transfer:\n 1000 mL LR\n Continuous at 125 ml/hr for 1000 ml\n Dexamethasone 10 mg IV ONCE\n Dexamethasone 10 mg IV ONCE severe swelling Duration: 1 Doses\n Clindamycin 600 mg IV Q8H\n DiphenhydrAMINE 25 mg IV ONCE\n Docusate Sodium 100 mg PO BID\n Fentanyl Citrate 12.5-50 mcg/hr IV DRIP INFUSION\n OxycoDONE (Immediate Release) 5-15 mg PO Q6H:PRN\n Morphine Sulfate 1-4 mg IV Q4H:PRN\n Lisinopril 10 mg PO DAILY\n Levothyroxine Sodium 100 mcg PO DAILY\n Heparin 5000 UNIT SC TID\n Levofloxacin 500 mg PO Q24H\n Past medical history:\n Family history:\n Social History:\n # Dental work years ago\n # Hemorrhoid injections osteo of sternum years ago.\n # Breast cancer in past\n # Previous sternal debridement for osteo\n # Hypothyroidism\n # HTN\n # Sciatica/chronic low back pain, right buttock pain and radiation down\n her right leg who is status post piriformis injection on the right in\n \n Not obatined\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: not obtained --patient intubated and sedated\n Review of systems:\n Flowsheet Data as of 11:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35\nC (95\n Tcurrent: 35\nC (95\n HR: 53 (53 - 75) bpm\n BP: 185/87(113) {172/81(100) - 187/96(117)} mmHg\n RR: 12 (12 - 16) insp/min\n SpO2: 100%\n Height: 62 Inch\n Total In:\n 1,343 mL\n PO:\n TF:\n IVF:\n 1,343 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,043 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 220 (220 - 220) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: nasal intubation, head wrapped in bandages,\n oral drain\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no c/c/e\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\nnon today --PENDING\n [image002.jpg]\n Assessment and Plan\n 69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .\n # Respirtory. Stable on AC, comfortable. Plan for extubation in AM per\n ENT if there is an airleak. Pt has baseline left side oral edema to be\n aware of.\n - SBT in AM/awakening\n - sedation with Fentanyl/Midaz\n - VAP care\n - Per ENT she responds well to decadron if complains of swelling 10mg\n IV if needed once extubated.\n .\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n - CIS\n .\n # HTN: Currently elevated to 170-180s systolic. On lisinopril daily but\n currently not taking POs.\n - can use IV enalapril prn until taking POs\n - consider NGT for oral meds vs. IV until tomorrow pending extubation\n --discuss with ENT\n .\n # Hypothyroidism: Cont Levothyroxine\n .\n # h/o breast cancer: no active issues\n .\n # FEN: NPO currently, consider NGT, replete lytes prn, bolus IVF prn\n .\n # PPX: subcutaneous heparin SQ, bowel regimen\n .\n # Access: PIV x 2\n .\n # Full Code\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 20 Gauge - 10:51 AM\n 18 Gauge - 11:35 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care until extubated\n" }, { "category": "Physician ", "chartdate": "2148-06-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 409692, "text": "Chief Complaint: Airway protection, intubated\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 69 yo woman underwent dental prep 3 wks ago with plan for dental\n implant. 2 wks ago developed malaise, lethargy. 1 wk ago developed\n odynophagia. z-pack prescribed. Completed . Had increased pain,\n swelling, bilateral submandibular swelling. Sent to Dr , ENT,\n admitted . Treated with dex, benadryl, clindamycin, levofloxacin. CT\n scans demonstrated infection and progression of swelling/edema.\n Consulted maxillofacial surgery for drainage today in OR, where they\n removed 5cc pus from abscess (unclear site- op note not available\n now). Nasal intubation, requires ICU for airway compromise/protection.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: intubated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 75 mcg/Kg/min\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n breast cancer\n hypothyroidism\n sternal osteomyelitis s/p debridement\n HTN\n see Dr note for meds.\n No PO meds now.\n not obtained\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: not obtained\n Review of systems:\n Pain: Unable to answer\n Flowsheet Data as of 12:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35\nC (95\n Tcurrent: 35\nC (95\n HR: 53 (53 - 75) bpm\n BP: 185/87(113) {172/81(100) - 187/96(117)} mmHg\n RR: 12 (12 - 16) insp/min\n SpO2: 100%\n Height: 62 Inch\n Total In:\n 1,353 mL\n PO:\n TF:\n IVF:\n 1,353 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,053 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 220 (220 - 220) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: head bandaged, packed orally, 2 penrose\n drains in place\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: see resident note for labs\n Mild leukocytosis at 11.6K\n Imaging: preop CXR normal\n left maxillary/floor of mouth abscess, edema in sublingual space\n Assessment and Plan\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation.\n Will decrease sedation, treat pain as needed.\n Will check for airway leak and extubate when present, in presence of\n anesthesia for possible stridor/complicated reintubation.\n Dental abscess. Continue clinda and levofloxacin.\n HTN- not getting PO meds.\n Will give IV hydralazine or ACE-I until she is extubated.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 10:51 AM\n 18 Gauge - 11:35 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Critically ill with airway compromise.\n" }, { "category": "Physician ", "chartdate": "2148-06-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 409693, "text": "Chief Complaint: Airway protection, intubated\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 69 yo woman underwent dental prep 3 wks ago with plan for dental\n implant. 2 wks ago developed malaise, lethargy. 1 wk ago developed\n odynophagia. z-pack prescribed. Completed . Had increased pain,\n swelling, bilateral submandibular swelling. Sent to Dr , ENT,\n admitted . Treated with dex, benadryl, clindamycin, levofloxacin. CT\n scans demonstrated infection and progression of swelling/edema.\n Consulted maxillofacial surgery for drainage today in OR, where they\n removed 5cc pus from abscess (unclear site- op note not available\n now). Nasal intubation, requires ICU for airway compromise/protection.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: intubated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 75 mcg/Kg/min\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n breast cancer\n hypothyroidism\n sternal osteomyelitis s/p debridement\n HTN\n see Dr note for meds.\n No PO meds now.\n not obtained\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: not obtained\n Review of systems:\n Pain: Unable to answer\n Flowsheet Data as of 12:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35\nC (95\n Tcurrent: 35\nC (95\n HR: 53 (53 - 75) bpm\n BP: 185/87(113) {172/81(100) - 187/96(117)} mmHg\n RR: 12 (12 - 16) insp/min\n SpO2: 100%\n Height: 62 Inch\n Total In:\n 1,353 mL\n PO:\n TF:\n IVF:\n 1,353 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,053 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 220 (220 - 220) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: head bandaged, packed orally, 2 penrose\n drains in place\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: see resident note for labs\n Mild leukocytosis at 11.6K\n Imaging: preop CXR normal\n left maxillary/floor of mouth abscess, edema in sublingual space\n Assessment and Plan\n Airway compromise s/p maxillary surgery I&D of dental abscess in left\n sublingual space, with 2 drains in place.\n Laryngeal swelling requiring intubation.\n Will decrease sedation, treat pain as needed.\n Will check for airway leak and extubate when present, in presence of\n anesthesia for possible stridor/complicated reintubation.\n Dental abscess. Continue clinda and levofloxacin.\n HTN- not getting PO meds.\n Will give IV hydralazine or ACE-I until she is extubated.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 10:51 AM\n 18 Gauge - 11:35 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Critically ill with airway compromise.\n" }, { "category": "Nursing", "chartdate": "2148-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 409694, "text": "69 F with Breast CA s/p b/l mastectomy, hypothyroidism, HTN, dental\n abscess s/p I&D who presents after elective intubation for airway\n protection and monitoring.\n .\n # Respirtory. Stable on AC, comfortable. Plan for extubation in AM per\n ENT if there is an airleak. Pt has baseline left side oral edema to be\n aware of.\n - SBT in AM/awakening\n - sedation with Fentanyl/Midaz\n - VAP care\n - Per ENT she responds well to decadron if complains of swelling 10mg\n IV if needed once extubated.\n .\n # Dental abscess: s/p oral surgery with pus drainage 5 cc. Drains in\n place. ENT said to monitor and change dressings only if draining pus.\n Leave drains in place.\n -ENT following\n -Continue clindamycin and levofloxacin until cultures from surgery\n return.\n - CIS\n .\n # HTN: Currently elevated to 170-180s systolic. On lisinopril daily but\n currently not taking POs.\n - can use IV enalapril prn until taking POs\n - consider NGT for oral meds vs. IV until tomorrow pending extubation\n --discuss with ENT\n .\n" } ]

[ { "category": "Radiology", "chartdate": "2180-01-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 850633, "text": " 12:51 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Patient needs STAT noncontrast head CT prior to angiography\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with right ICA stroke. Going to angio.\n REASON FOR THIS EXAMINATION:\n Patient needs STAT noncontrast head CT prior to angiography (per Dr. .\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute stroke. Follow/up exam.\n\n COMPARISON: Comparison is made to the prior exam of .\n\n FINDINGS: No intracranial hemorrhage is identified. Within a large\n distribution of the right middle cerebral artery vascular territory, there is\n loss of /white matter differentiation consistent with acute infarction.\n This involves mostly the posterior frontal and parietal territories on the\n right. There is no shift of the normally midline structures. Ventricle size\n is normal.\n\n Note is made of mucosal thickening within the maxillary sinuses and ethmoid\n air cells as was previously seen.\n\n IMPRESSION\n 1. Acute right middle cerebral artery territory infarct.\n 2. No intracranial hemorrhage identified.\n 3. Stable ventricle size.\n\n" }, { "category": "Radiology", "chartdate": "2180-01-01 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 850630, "text": " 12:07 PM\n CAROT/CEREB Clip # \n Reason: ?aneurysm\n Admitting Diagnosis: STROKE\n Contrast: OPTIRAY Amt: 277\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/CERVICAL BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n * EXT UNILAT A-GRAM -52 REDUCED SERVICES *\n * C1760 CLOSURE DEVICE VASC IMP/INS C1769 GUID WIRES INFU/PERF *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with ?aneurysm\n REASON FOR THIS EXAMINATION:\n ?aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Right carotid dissection with distal embolization.\n\n POSTOPERATIVE DIAGNOSIS: Focal right internal carotid artery cervical\n dissection with intimal flap and small pseudoaneurysmal false lumen with no\n significant flow restriction from a hemodynamic point.\n\n ANESTHESIA: Conscious sedation with local filtration of right groin.\n\n INDICATION: Mr. presented with a carotid dissection and\n underwent treatment with intravenous TPA for an acute thrombus. He had\n undergone a cerebral angiogram to determine whether the dissection is\n hemodynamically significant and whether it would benefit from endovascular\n intervention.\n\n CONSENT: The patient's family was given a full and complete explanation of\n the procedure. Specifically, the indications, risks, and benefits and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient's family understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood a 4 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Right common carotid artery left common carotid artery left subclavian artery,\n left vertebral artery.\n\n (Over)\n\n 12:07 PM\n CAROT/CEREB Clip # \n Reason: ?aneurysm\n Admitting Diagnosis: STROKE\n Contrast: OPTIRAY Amt: 277\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n RESULTS: Injection of the right common carotid artery reveals a normal\n carotid artery bifurcation. Evaluation of the right internal carotid artery\n at the high cervical segment shows an intimal dissection with a false and true\n lumen. There is an associated stenosis at the level of the high cervical\n petrous junction which is greater than 70% however hemodynamically it does not\n appear to be limiting. Intracranially the bilateral intracranial hemisphere\n is well profused by the right internal artery injection. The right external\n carotid artery shows normal arteriovenous shunting. Given the lack of\n hemodynamically restrictive pattern of flow decision was made not to proceed\n with endovascular intervention but rather to initiate a trial of medical\n intervention. Injection of the left common carotid artery revealed normal\n appearance of the left common carotid artery bifurcation intracranial left\n internal carotid artery shows normal intracranial flow with no evidence of\n aneurysm or the vessel malformation. The left subclavian artery shows normal\n anatomy with no evidence of subclavian or vertebral origin stenosis. And the\n posterior circulation is within normal limits.\n\n IMPRESSION: High cervical carotid intimal dissection resulting in a false\n lumen and flow restriction and stenosis of 70% which is hemodynamically not\n critical and accordingly a trial of medical therapy will be attempted prior to\n consideration of interventional revasculization.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2180-01-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 850699, "text": " 10:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: observe teritory of mca to see if there is any improvement\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with Right carotid dissection and left hemiparesis\n REASON FOR THIS EXAMINATION:\n observe teritory of mca to see if there is any improvement\n CONTRAINDICATIONS for IV CONTRAST:\n don't wont to increase icp\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 55-year-old male with right carotid dissection, and left\n hemipareses.\n\n TECHNIQUE: CT of the brain without intravenous contrast.\n\n COMPARISON: .\n\n FINDINGS: There has been no interval change in the appearance of the brain.\n Again seen, is extensive hypodensity and loss of the /white matter\n differentiation in the high right frontal parietal regions, consistent with\n the patient's known evolving infarct. There is no evidence of hemorrhagic\n transformation. There is no shift of the normally midline structures. The\n ventricles are not effaced. The structures reveal aerosolized fluid within\n the maxillary sinuses and ethmoid air cells.\n\n IMPRESSION\n 1. Continued evoluation of a known right MCA territory infarct.\n 2. No intracranial hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2180-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 850868, "text": " 6:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please r/o infiltrate.\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with stroke, now low grade fever.\n REASON FOR THIS EXAMINATION:\n Please r/o infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 55-year-old man with history of stroke, now with low-grade\n fever. Please rule out infiltrate.\n\n Comparison is made with a prior study dated .\n\n FINDINGS: The heart size is normal. The mediastinal and hilar contours are\n normal. The pulmonary vasculature is normal. There is mild horizontal\n atelectasis within the left lung base. There is no evidence of pleural\n effusion. There are no pulmonary infiltrates identified. The soft tissue and\n osseous structures are normal.\n\n IMPRESSION: No evidence of acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-12-31 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 850573, "text": " 9:04 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: look for stroke/hemorrhage\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with acute L weakness\n REASON FOR THIS EXAMINATION:\n look for stroke/hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK SAT 1:38 AM\n R ICA occlusion. No bleed. grey-white differentiation preserved at this point\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old with acute left-sided weakness.\n\n TECHNIQUE: CT of the brain with and without IV contrast. 100 cc of Optiray\n was used for this examination due to the need for fast bolus protocol.\n Multiplanar reformatted images were obtained.\n\n COMPARISON: .\n\n CT BRAIN W/O IV CONTRAST\n\n There is no acute intracranial hemorrhage, shift of normally midline\n structures, or hydrocephalus. The /white matter differentiation appears\n preserved throughout. There is no hyperdense middle cerebral artery sign.\n Circumferential mucosal thickening is seen in the left maxillary sinus. There\n is also some minor mucosal thickening seen in the right maxillary sinus and\n ethmoid air cells. The mastoid air cells are patent. The osseous structures\n are unremarkable.\n\n CT ANGIOGRAM\n\n On the inferior-most images, contrast enhancement is seen in both right and\n left internal carotid artery. However, beginning on series 3, image 3, there\n is the beginning of loss of contrast seen within the right internal carotid\n artery. By image 25, no contrast enhancement is seen in the right internal\n carotid artery. Normal contrast enhancement is seen in the right external\n carotid artery, left internal, and left external carotid arteries. Contrast\n enhancement is not seen in the right internal carotid artery within the region\n of the cavernous sinus. However, as the right internal carotid artery becomes\n intracranial within the cavernous sinus, contrast enhancement is again seen\n within the right internal carotid artery.\n\n Contrast enhancement is seen in both right and left middle cerebral, anterior\n cerebral, right and left vertebral, basilar, right posterior cerebral, and\n right and left posterior communicating arteries. Contrast enhancement is not\n definitively seen in the left posterior cerebral artery. No definite areas of\n aneurysmal dilatation are seen. The /white\n matter distinction appears preserved on the post-contrast enhanced images.\n (Over)\n\n 9:04 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: look for stroke/hemorrhage\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Coronal and sagittal reformatted images aided in evaluation of the study.\n\n IMPRESSION\n 1. Occlusion of the right internal carotid artery distal to the bifurcation\n of the common carotid artery within the neck. There is, however,\n reconstitution of flow within the intracranial right internal carotid artery\n and middle cerebral artery branches, possibly from collateral flow through\n the anterior communicating artery.\n 2. /white matter distinction is preserved.\n\n These findings were communicated to Dr. at the completion of this study.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-12-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 850576, "text": " 10:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: look for hemorrhage\n Admitting Diagnosis: STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with stroke, given TPA\n REASON FOR THIS EXAMINATION:\n look for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old with acute CVA given TPA, now worsening.\n\n TECHNIQUE: CT of the brain without IV contrast.\n\n COMPARISON: Comparison is made to study performed 90 minutes earlier.\n\n FINDINGS: Residual contrast is seen within the arterial vasculature and the\n venous sinuses. There is no large intraparenchymal hemorrhage identified.\n /white matter differentiation appears preserved throughout. There have\n been no other changes compared to the prior study.\n\n IMPRESSION: No definite intracranial hemorrhage is seen on this study\n performed 90 minutes after a contrast-enhanced study. Contrast enhancement\n limits evaluation for subtle intra or extra-axial hemorrhage.\n\n" }, { "category": "Echo", "chartdate": "2180-01-01 00:00:00.000", "description": "Report", "row_id": 94662, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Source of embolism.\nBP (mm Hg): 120/70\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 12:57\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: Dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. Normal RV\nsystolic function.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Normal mitral valve leaflets. Prolonged (>250ms) transmitral\nE-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\n\nConclusions:\nThe left atrium is normal in size. The right atrium is dilated. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF 60-70%). The right ventricular cavity is dilated. Right ventricular\nsystolic function is normal. The aortic valve is not well seen. The mitral\nvalve leaflets are structurally normal. There is no pericardial effusion.\n\nAir bubble contrast imaging did not demonstrate the presence of right-to-left\nshunt across the interatrial septum, but the study is technically suboptimal.\nThe presence of right heart chamber enlargement raises the suspicion of the\npresence of an atrial septal defrect with left-to-right shunt, but this\nabnormality was not demonstrated on limited color-flow imaging.\n\n\n" }, { "category": "ECG", "chartdate": "2180-01-01 00:00:00.000", "description": "Report", "row_id": 271369, "text": "Compared to the previous tracing no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2180-01-01 00:00:00.000", "description": "Report", "row_id": 271370, "text": "Compared to the previous tracing normal sinus rhythm, rate 86, has given way to\nsinus bradycardia, rate 59. Ventricular ectopic activity is abolished. Apart\nfrom borderline sinus bradycardia, the tracing is normal.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-12-31 00:00:00.000", "description": "Report", "row_id": 271371, "text": "Sinus rhythm, rate 86. Occasional ventricular premature beat. Compared to the\nprevious tracing of the sinbus rate is faster and ventricular ectopy is\nnew.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2180-01-03 00:00:00.000", "description": "Report", "row_id": 1423261, "text": "ADDENDUM1900-0700\nCV: LAST EVENING PT HAD 6 BEAT RUN (STRIP PLACED IN CHART) AND OCCASIONAL PVCS BEGINNING OF SHIFT. AT 2200 AFTER 6 BEAT RUN OF MD ORDERED ALL WNL. NO FURTHER ECTOPY NOTED\n" }, { "category": "Nursing/other", "chartdate": "2180-01-01 00:00:00.000", "description": "Report", "row_id": 1423257, "text": "MICU NPN 0700-1900\nPt remains with left sided hemiparesis with little improvement through the day. Had TTE which ruled out PFO. Had repeat Head CT prior to angio. Angio showed dissection of Rt ICA. No intervention done.\nPt's SO informed me today that the pt has a history of DVT which she did not tell the team initially. Team made aware.\n\nNeuro: Pt with paralysis to left side. No sensation to left arm or leg except that he states he can feel something on the bottom of his left foot. Some left neglect, but will turn head when called from the left. A&Ox3, slow to respond to simple questions at times. Gaze drifts up when trying to focus.\n\nCV: HR 80's-90's, SR with occasional PVC's. Continues on neo gtt to keep SBP 150-170, presently running at 0.65 mcg/kg/min. Tmax 99.1 axillary. Post-angio site to Rt groin with bandaid, angio-seal placed post-procedure. Strong pedal pulses. Left groin with TLCL, site c/d/i. Rt radial aline, dampened at times. Blood cultures sent today per neuromed.\n\nResp: LS's CTA throughout. O2 sat 98-100% on 2L NC. +dry non-productive cough. RR 16-20, non-labored.\n\nGI: Abd soft, +bs's. Has remained NPO through the day for procedures. Able to swallow pills without evidence of aspiration. Has not required RISS coverage for BS's.\n\nGU: Condom cath in place. Pt is voiding in large amounts, clear, yellow urine.\n\nSkin: No breakdown noted to backside, pt able to make changes in his position on own. Remains on bedrest.\n\nSocial: Pt's sig other in with patient throughout day along with other family members. supported family.\n\nPlan: Awaiting to hear from TSICU for further plans. need Head CT tonight at 2130 which will be 24 hours post onset of symptoms. also need TEE.\n" }, { "category": "Nursing/other", "chartdate": "2180-01-02 00:00:00.000", "description": "Report", "row_id": 1423258, "text": "NURSING PROGRESS NOTES 1900-0700\nNEURO: PERL4MM BRISK, PT'S HEAD AND EYES DO DRIFT OFF TO THE RIGHT WHEN HE TRIES TO FOCUS ON SOMETHING. NO FACIAL DROOP SEEN TONGUE MIDLINE. SPEECH NORMAL. PT C/O HEADACHE THROUGHOUT SHIFT PAIN LEVEL W/ MS 1MG IV AND TYLENOL AND ICE PACKS GIVEN W/ SOME RELIEF. RIGHT UPPER AND LOWER EXTREMITY HAS NORMAL STRENGTH. LEFT UPPER & LOWER EXT HAS NO MOVEMENT, HOWEVER WHEN THIS RN PRESSES ON LEFT NAIL BEDS HE STATES HE CAN FEEL SOMETHING DEEP IN HIS ARM AND LEG. TMAX 99.6 ORAL. WIFE STATES THAT PT SLIPPED AND FELL BACKWARDS ON ICE. THIS INFORMATION WAS GIVEN TO ONE OF THE MEMBERS OF THE NEURO TEAM. CT INFARCT OF POST, FRONTAL, PARIETAL TERRITORIES OF THE RIGHT SIDE. ANGIO: DISSECTION OF THE RIGHT ICA ? WHIPLASH TYPE OF INJURY.\n\nRESP: LS CLEAR O2 ON 2L NC\n\nCV: TELE SR 60-70S NEO GTT ON AT .95MCQ/KG/MIN TO MAINTAIN HIS SBP 150-170 THROUGHOUT SHIFT. HRT SOUNDS S1S2. ALINE RIGHT RADIAL INTACT.\nACCESS LEFT FEMORAL TLCL INTACT W/ 2 PERIPHERAL SL #18 RIGHT WRIST AND LEFT AC. #18SL. PEDAL PULSES +4 W/ NO EDEMA NOTED. WBC THIS AM 11.8 FROM 9 H&H 15/45, LYTES K+4.1 MG1.9\n\nGI: PT NPO X SIPS OF WATER W/ MEDS TOLERATES WELL\nABD SOFT BS+\n\nGU: CONDOM CATH INTACT AND FOLEY DRAINING YELLOW URINE\n\nSKIN: INTACT\n\nENDO: BS QID W/ SSC\n\nID: BCX2 TAKEN NO ANTIBX NEEDED YET\n\nCODE: FULL\n\nSOCIAL: WIFE AT BEDSIDE\n\nPLAN:\n\n1. CONT TO CHECK NEURO SIGNS\n2. TITRATE NEO GTT TO MAINTAIN SBP 150-170\n3. MAINTAIN PTS COMFORT LEVEL BY GIVING MS 1-5MG IV Q3HRS AND TYLENOL 650MG PO Q4HRS FOR HEADACHE\n4. ? REPLACE MG 1.9\n5. ? NEED FOR TEE & CT\n6. CONT TO INFORM PT AND WIFE OF PLAN OF CARE\n\n" }, { "category": "Nursing/other", "chartdate": "2180-01-01 00:00:00.000", "description": "Report", "row_id": 1423256, "text": "Nursing Admission and Progress Note\n 0045->0730\n\nS/O\n\nPt arived from ER with NS and neo infusing via femoral TLC; right radial a0line transducing, condom cath in place. Pt transferred to MICU A bed and monitor.\n\nNEURO: Pt lethargic at times, occasionally alert spontaneously but easily arouses to alert state with minimal stimulation; occasionally requires sternal rub to elicit alert state but maintains alertness without further noxious stim.\nPt has flaccid paralysis of LUE, LLE; occasional inoluntary movement of LUE when yawning. When SBP > 168, pt able to wiggle left toes and slightly flex left knee on command. Pt has no sensation of touch 3 fingerbreadths to the left of medial \"line\" as measured by umbilicus and sternum. Eyes deviate up and to right, and pt has right facing torticollis with chin almost over right shoulder. Pt also has bilateral left visual filed neglect. Over course of night, pt is noted to have improvement in left -sided neglect when SBP > 168; improvement is measured by visual field expanding from right side of nose to millimeters beyond lef side of nose; ability to track and follow finger through right upper visual field whereas upon arrival and with lower SBP, pt was unable to fix and follow any object d/t eye being linited to right upper EOM .\nPt has uncoordinated movement of RUE and RLE as measured by inability to move extremities to desired locations without multiple attempts and encouragement. Once pt tightens a muscle group, he seems unable to relax those muscles without assistance.\nPupils equal and react briskly to light when pt is able to cooperate with eye exam. Tongue is midline. Smile shows left-sided asymmetry and facial droop, but eyes and eyebrows appear equal in movement.\n\nCV: Arrived on neo to maintain SBP 150-170; neo off d/t BP being maintained offo neo, Gtt restarted and titrated to SBP -> see flowsheet. With neo at 1.5-1.8mcg/kg-min, pt had onset of ectopy as evidenced by presence of transient bigeminy and frequent PVCs. Neo rate lowered, and ectopy and dysrhythmia.\nSee flowsheet for details.\n\nRESP: No distress. LS clear. Placed on nc @ 2LPM to prmotoe oxygenation.\n\nGI: Abd soft, BS +. No BM.\n\nFEN: On NS @ 100mL/hr. Labs this a,m well witin nornail limits. BS at therapeutic level, requires no sliding scale insaulin.\n\nHAEM: No acute issues. Completed tPA in ER. Caogs and Hct stable and WNL.\n\nGU: Condom cath on. Voiding qs yellow urine.\n\nPSYCHOSOC: Live-in girlfirend () of 15 years is health care proxy. signed and in chart. at bedside overnight, appropriate and helpful; works as psych nurse.\n\nA/P\n\nCheck with neuromed re: possibility of angio today to treat right ICA occluson.\nContinue neuro monitoring and inrventions.\nContinue monitoring VS, chemistroes, coags, haematlolgy as osrdered and as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2180-01-02 00:00:00.000", "description": "Report", "row_id": 1423259, "text": "NPN 0700-1900\nNeuro: Neuro status unchanged. PERRL at 2-3mm, bsk. No movement in L arm or L leg, nl movement in R arm and leg. Repeat CT scan today. Cont to c/o headache, given tylenol x2 and Morphine 1mg iv x1 c good relief. Pt also took Neurontin 400mg po (prn x2 during day) which he takes at home for anxiety. Pt will have speech and swallow study ., but took sips of water at bedside well, so team ordered house diet with nectar thickened liquids. Pt swallowed well during each meal s coughing.\n\nCV: Neosyn was d/c'd ~ 1100, team wants BP >120. SBP running 120s-130s since Neo off. Pt can now be at 45 degrees. HR 69-89, nsr, occ pvcs. Tmax 99.0, po.\n\nResp: LS clear. RR12-18. On 2L nc. Has rare cough from previous cold.\n\nGI: +BS, no stool. Ate sm amt of 2 meals, drank thickened flds well.\n\nGU: Condom in place. Voiding infreq, currently positive 1143mls from midnoc.\n\nSkin: Intact\n\nSocial: Family visiting most of day, daughter, wife, friend.\n\nPlan: Cont to monitor neuro signs. ? will be called out. Monitor BP for >120.\n" }, { "category": "Nursing/other", "chartdate": "2180-01-03 00:00:00.000", "description": "Report", "row_id": 1423260, "text": "NURSING PROGRESS NOTES 1900-0700\nNEURO: PERL 4MM BRISK, PT LEFT UPPER EXTREMITY FLACCID., LEFT LOWER EXTREMITY FLACCID, BUT HE DOES HAVE SOME FEELING IN HIS LOWER LEFT EXTREMITY BUT HE IS UNABLE TO MOVE IT. HE HAS A LEFT FACIAL DROOP, TONGUE MIDLINE, RIGHT UPPER AND LOWER EXTREMITIES HAVE NORMAL STRENGTH. TMAX 100.1 ORALLY. CT OF HEAD: NOTED NO CHANGE FROM PRIOR SCAN.\n\nRESP: O2 ON 2L NC LS CLEAR DIMINISHED BASES\n\nCV: TELE SR 80S, @ 2130 SBP 108 NEO GTT RESTARTED AND MAINTAINED AT 1MCQ/KG/MIN, TITRATING TO KEEP HIS SBP > 120. HRT SOUNDS S1S2. PEDAL PULSES +4 NO EDEMA NOTED. ASA DC'D AND HEPARIN GTT STARTED AT 2130 AT 1200UNITS/HR PTT THIS AM 52.6 NO CHANGE NEEDED IN GTT RATE ( GOAL PTT 40-60)\n\nGI: PT CAN TAKE HOUSE DIET W/ NECTAR THICK LIQUIDS UNTIL SWALLOW EVAL TODAY. ABD SOFT BS+. NO STOOL SINCE AT HOME, WIFE REQUESTING STOOL SOFTENER BE GIVEN.\n\nGU: PT HAS CONDOM CATH IN ADEQUATE AMOUNTS. BEGINNING OF SHIFT HIS BLADDER WAS DISTENDED AND HIS FOLEY WAS EMPTY, THIS NURSE INSTRUCTED PT TO TRY RELAX AND URINATE. AFTER 10MIN PT 650CC YELLOW URINE.\n\nSKIN: INTACT\n\nACCESS: RIGHT RADIAL ALINE BLEEDING AND SMALL HEMATOMA NOTED ALINE REMOVED AND NEW LINE PLACED LEFT RADIAL, THIS SITE IS MORE SLUGGISH TO DRAW BLOOD FROM AND WAVEFORM IS NOT AS SHARP AS RIGHT ALINE WAS, WIFE STATES THAT ARM HAS SOME NEUROPATHY AND HAVE CIRCULATION PROBLEMS FROM OLD SHRAPNAL INJURY FROM . SL X2\n\nSOCIAL: WIFE SHE STAYED AT PT BEDSIDE THROUGHOUT NIGHT\n\nCODE: FULL\n\nCOMFORT: PT HAS MS 1-5MG IV Q 3HRS FOR PAIN AND TYLENOL 650 MG PO FOR PAIN. PT WAS GIVEN MS X1 AND TYLENOL X1 W/ GOOD EFFECT FROM PAIN LEVEL 4 TO A 2.\n\nPLAN:\n1. CONT TO MONITOR NEURO SIGNS\n2. CONT MAINTAIN SBP >120S TITRATE NEO GTT AS NEEDED\n3. MAINTAIN PT COMFORT LEVEL BY USING MS/TYLENOL/NEUROTIN\n4. FOLLOW GUIDELINES FROM SPEECH/SWALLOW EVAL TODAY\n5. CONT TO MONITOR PTTS NOW THAT PT ON HEP GTT Q 6HRS AS ORDERED NEXT PTT AT 0930\n6. CONT NS AT 100CC/HR\n7. CONT QID BS AND USE SSC AS NEEDED\n8. CONT TO INFORM PT AND WIFE OF PT'S PLAN OF CARE\n9. ? STOOL SOFTENERS ORDER FOR PT\n\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522729, "text": "Pt is a 51 yo man with pmed hx of asthma, OSA, and HTN. Admitted after\n 1 week of worsening SOB, cough, and falling asleep during the day. In\n EW was found to have a RA o2 sat of 79%, placed on NRB, eventually\n weaned to 40% venti mask and transferred to MICU for monitoring\n Asthma\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522730, "text": "Pt is a 51 yo man with pmed hx of asthma, OSA, and HTN. Admitted after\n 1 week of worsening SOB, cough, and falling asleep during the day. In\n EW was found to have a RA o2 sat of 79%, placed on NRB, eventually\n weaned to 40% venti mask and transferred to MICU for monitoring.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Asthma\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522784, "text": "HPI: Pt is a 51 yo man with pmed hx of asthma, OSA, and HTN. Admitted\n after 1 week of worsening SOB, cough, and falling asleep during the\n day. In EW was found to have a RA o2 sat of 79%, placed on NRB,\n eventually weaned to 40% venti mask and transferred to MICU for\n monitoring.\n Code: Full Allergies: NKDA\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt has low grade temp beginning of shift: 99 F oral. LS dim on R side\n w/ insp-exp wheezes. WBC 6.0. Lactate 1.6. Received pt on venti-mask\n 40%, Sp02 96%. RR 15-23. DOE, peri-orbital and LE edema. Pt has dry\n cough. Pt is tachycardic to 100s.\n Action:\n Admin standing nebs and MDI\ns. Transition pt to 4 L NC for 1 hr then\n auto-set bipap (10 L) hs. Admin abx as dir.\n Response:\n Pt sleeping well through most of night w/ minimal initial adjustment to\n bipap. Sp02 92-99%. Tachycardia resolving overnight to 90s. Temp\n down to 97.3. Pt states that he feels comfortable w/ the bipap and\n slept\nlike a log\n. Lactate 1.4. WBC 4.9.\n Plan:\n Cont abx and inhalers / nebs. Follow up as outpatient so pt can have\n bipap at home.\n Electrolyte & fluid disorder, other\n Assessment:\n Na 132, K 5.4, Ph 5.0. Pt is A + O x 3, NSR-ST w/no ectopy.\n Action:\n Admin 1 L NS FB overnight.\n Response:\n Pt voided 600 ml overnight. AM labs: Na 134, K 5.1, Ph 5.3.\n Plan:\n Cont to monitor lytes. ? tx Ph today.\n Knowledge Deficit\n Assessment:\n Pt has had sleep study here w/ dx of OSA but he has opted not to wear\n bipap at home.\n Action:\n Discuss importance of respiratory mgt. Trial of bipap tonight.\n Response:\n Pt tolerated bipap very well overnight and states that he will consider\n one for home.\n Plan:\n ? another sleep study on discharge.\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522767, "text": "Pt is a 51 yo man with pmed hx of asthma, OSA, and HTN. Admitted after\n 1 week of worsening SOB, cough, and falling asleep during the day. In\n EW was found to have a RA o2 sat of 79%, placed on NRB, eventually\n weaned to 40% venti mask and transferred to MICU for monitoring.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt has low grade temp beginning of shift: 99 F oral. LS dim on R side\n w/ insp-exp wheezes. WBC 6.0. Lactate 1.6. Received pt on venti-mask\n 40%, Sp02 96%. RR 15-23. DOE, peri-orbital and LE edema. Pt has dry\n cough. Pt is tachycardic to 100s.\n Action:\n Admin standing nebs and MDI\ns. Transition pt to 4 L NC for 1 hr then\n auto-set bipap (10 L) hs. Admin abx as dir.\n Response:\n Pt sleeping well through most of night w/ minimal initial adjustment to\n bipap. Sp02 92-99%. Tachycardia resolving overnight to 90s. Temp\n down to 97.3. Pt states that he feels comfortable w/ the bipap and\n slept\nlike a log\n. Lactate 1.4. WBC 4.9.\n Plan:\n Cont abx and inhalers / nebs. Follow up as outpatient so pt can have\n bipap at home.\n Electrolyte & fluid disorder, other\n Assessment:\n Na 132, K 5.4, Ph 5.0. Pt is A + O x 3, NSR-ST w/no ectopy.\n Action:\n Admin 1 L NS FB overnight.\n Response:\n Pt voided 600 ml overnight. AM labs: Na 134, K 5.1, Ph 5.3.\n Plan:\n Cont to monitor lytes. ? tx Ph today.\n Knowledge Deficit\n Assessment:\n Pt has had sleep study here w/ dx of OSA but he has opted not to wear\n bipap at home.\n Action:\n Discuss importance of respiratory mgt. Trial of bipap tonight.\n Response:\n Pt tolerated bipap very well overnight and states that he will consider\n one for home.\n Plan:\n ? another sleep study on discharge.\n" }, { "category": "Physician ", "chartdate": "2174-02-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 522704, "text": "Chief Complaint: shortness of breath\n HPI:\n 51 yo M with h/o asthma and right lung volume loss of unclear etiology\n (?congenital hypoplasia), recurrent bronchitis in winter, OSA, obesity,\n HTN who presented with 1 week of productive cough, progresssive SOB,\n and over the past 2 days weakness and fatigue to the point he was\n falling asleep at work. He tried increasing his albuterol use but this\n did not help so he came to the emergency room.\n In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on\n presentation, 100% on NRB. The ED resident noted that he was not\n particularly wheezy on exam. Labs notable for WBC of 5, HCT 34.5,\n sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and\n azithromycin, nebs and 125 IV methylprednisone. He had a CXR which was\n inconclusive, possible RML pneumonia. Also be very tachycardic, EKG\n shows sinus tach. Got a CTA for concern of PE-but no PE, but some\n increased interstitial markings in RUL and RLL, more likely chronic\n process vs. pneumonia. Tried to wean him down on 02, as soon as he\n would fall asleep would desat. Right now, 40% venti mask and he is\n %. Vitals on transfer, 99/5, HR 106, 127/87, 23.\n .\n On the floor, the patient notes that he feels fine while lying still,\n but worse with movement. Denies sick contacts, recent travel, new\n pets. Only recent med change is stopping zoloft 1 month ago. He worked\n previously in the printing business and thinks he could have been\n exposed to some chemicals.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Meds:\n # Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler\n 2 puffs inhaled every 4 hr as needed for asthma\n # Amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day\n # Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with\n Device 1 (One) puff twice a day\n # Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily\n # Lisinopril 40 mg Tablet\n 1 Tablet(s) by mouth once a day\n # Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule,\n w/Inhalation Device one diskus inhaled once a day\n Past medical history:\n Family history:\n Social History:\n right lung volume loss of unclear etiology (?congenital hypoplasia)\n diagnosed on CT after abnormal CXR for PNA\n Asthma: on Advair and Spiriva.\n Hypertension: on hydrochlorothiazide, lisinopril, and Norvasc.\n Hyperkalemia: intermittent elevations of his potassium.\n Obesity:\n Glucose intolerance:\n Obstructive sleep apnea: declined CPAP therapy.\n Anxiety: on Zoloft 100 mg once daily.\n Vitamin B12 deficiency: not on b12 currently\n Twin sister with asthma\n Occupation: Currently works for , previously worked in printing\n with inhalation of chemicals\n Drugs: denies\n Tobacco: 30 pack year history quit 10 years ago\n Alcohol: 2 glasses a night and more on weekends\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 07:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 108 (106 - 110) bpm\n BP: 128/83(116) {128/83(93) - 132/83(116)} mmHg\n RR: 19 (19 - 22) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 16 mL\n PO:\n TF:\n IVF:\n 16 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 16 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical adenopathy\n Cardiovascular: tachycardic, no audible murmur\n Peripheral 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: No(t)\n Wheezes : no wheezing, Diminished: on the right)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person place and time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 363 K/uL\n 12.4 g/dL\n 135 mg/dL\n 1.1 mg/dL\n 18 mg/dL\n 22 mEq/L\n 100 mEq/L\n 5.4 mEq/L\n 132 mEq/L\n 36.6 %\n 6.0 K/uL\n [image002.jpg]\n \n 2:33 A2/27/ 05:30 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 6.0\n Hct\n 36.6\n Plt\n 363\n Cr\n 1.1\n Glucose\n 135\n Other labs: PT / PTT / INR:13.2/28.2/1.1, Differential-Neuts:92.7 %,\n Lymph:4.5 %, Mono:2.2 %, Eos:0.4 %, Lactic Acid:1.6 mmol/L, Mg++:1.9\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan: 51 year old male with asthma and decreased lung\n volume on the right(? congenital), OSA who presentw with progressive\n dyspnea on exertion with symptoms and imaging consistent with pneumonia\n .\n # Hypoxia: Increased cough, infiltrate seen on CT and CXR make\n hypoxia most likely due to pneumonia in the setting of poor reserve\n given righ lung abnormalities. Patient only mildly wheezing on exam\n and unlikely asthma exacerbation. PE ruled out by CTA. Patient denies\n any aspiration event and slow progression over the last week makes this\n unlikely. Patient has OSA and does not wear CPAP at home, so\n progressive pulmonary hypertension could be contributing but unlikely\n to be causing symptoms of 1 week. CHF unlikely as no JVP, no periphral\n edema, no cardiomegaly on CXR. Valvular disease or pericardial effusion\n cannot be ruled out.\n -Ceftriaxone/Azithromycin for CAP\n -ECHO\n -no more steroids for now unless worsening or increase in wheezing\n -CPAP for sleeping\n -02 to maintain sats >90%\n -f/u final read of CXR and CTA\n -patient will need follow up with Dr. for his right lung.\n .\n #Tachycardia: Sinus Tach on EKG from ED, likely due to hypoxia. Patient\n denies any cardiac symptoms. Also denies any decrease in PO intake.\n -1L IVF bolus and reassess rate\n -repeat EKG\n .\n #Hyponatremia: be intrapulmonary process (SIADH) or to HCTZ\n (salt wasting with diuretics). Patient appears euvolemic.\n -urine lytes and osms, serum osms\n -recheck sodium in the AM\n -continue HCTZ for now\n .\n #. Hypertension:\n -continue hydrochlorothiazide, lisinopril and Norvasc.\n -monitor lytes for hyperkalemia as patient has had this in the past\n .\n #. Obstructive sleep apnea: Declined CPAP therapy in the past but\n will likely benefit from positive pressure as he is desatting when he\n falls asleep. He is now agreeable to trialing CPAP\n -CPAP autoset with respiratory consult\n .\n #. Glucose intolerance: SSI while on steroids\n -SSI.\n .\n .\n #Anemia: Slightly lower than recent baseline, likely secondary to known\n Vitamin B12 deficiency.\n -recheck HCT\n -send iron studies and b12 and folate\n .\n #. Alcohol use: Mr. has more than recommended amount of wine\n on weekends (approx 3 bottles) but denies any symptoms of withdrawl now\n or in the past.\n -monitor for signs of withdrawl no indication for CIWA at this point\n .\n # FEN: 1L IVF, replete electrolytes, NPO for tonight, if respiratory\n status improves can eat in the AM\n # Prophylaxis: Subcutaneous heparin\n # Access:2 peripherals\n # Communication: Patient and his wife\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with Dr.\n 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 51 y/o with PMHx asthma and pulmonary hypoplasia, here with hypoxemia.\n Recent history notable for productive cough, dyspnea, and fatigue.\n Tried increasing his albuterol without effect. Was not wheezing as he\n usually is with his asthma flares. Prior history of pneumonia.\n In ED O2 sat in the 70\ns; got CTA with no PE but scattered GGO (new)\n and underlying hypolucencies, nodular / rim shaped densities (old).\n PMHx as above, also OSA, HTN, anxiety. Social hx notable for tobacco.\n Family hx\n twin sister with asthma but no known pulmonary\n abnormalities.\n Home meds notable for advair and spiriva, antihypertensives.\n Tm99.8 P108 BP 128/80, Sat 97% on 40%, RR 19.\n Lying in bed in NAD, tachycardia, diminished BS on R > L, coarse with\n crackles b/l, scattered.\n RRR S1 S2 no m. Abd soft obese NT. No edema. No rashes, no clubbing.\n Labs with WBC 6 with L shift, Hct 22, Cr 1.1\n Agree that most likely scenario is CAP in setting of underlying\n pulmonary hypoplasia (other chronic abnormalities ?scar,\n ?atelectasis). Treat for CAP, supportive O2. Would consider echo at\n some point (nonurgent) to assess for pulm HTN, LVEF though CHF\n unlikely. Would re-establish outpt follow up to ensure clearance of\n infiltrates.\n Remainder of plan as outlined above.\n Pt is critically ill.\n Total time 35 minutes.\n Patient is critically ill\n Total time: 50 min\n 51 y/o with PMHx asthma and pulmonary hypoplasia, here with hypoxemia.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:43 ------\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522871, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt weaned t RA\n Action:\n Pt weaned to RA with o2 sats >94%\n Ambulated in on RA, o2 sats, HR increased to 120\ns, sats 92-97%\n Pt changed to levaquin po\n Flu swabs neg and droplet precautions d/c\n Pt insistent on being d/c home\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 522872, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt weaned t RA\n Action:\n Pt weaned to RA with o2 sats >94%\n Ambulated in on RA, o2 sats, HR increased to 120\ns, sats 92-97%\n Pt changed to levaquin po\n Flu swabs neg and droplet precautions d/c\n Bp low 89/, received NS 1l bolus\n Pt voiding in urinal, last void ~6am\n Tachycardic to 120\n Response:\n Improved oxygenation\n Plan:\n Po abx as ordered\n Pulmonary toilet\n IVf as ordered\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 522875, "text": "51 yo history of asthma and hypoplasia of right lower lobe, frequent\n exacerbations of lung disease, sleep apnea - both central and OSA.\n llow reserve. Presented with hypoxemia and SOB that has been\n progressively worsening over a week. Had sat in 70s in ED, put on 100%\n NRB. CTA negative for PE, was not wheezing. CT did show consolidation\n in RML. Improved with nebs and Bipap. Now weaned to room air oxygen.\n Allergies\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt weaned t RA\n Action:\n Pt weaned to RA with o2 sats >94%\n Ambulated in on RA, o2 sats, HR increased to 120\ns, sats 92-97%,\n pt dyspnic with exertion, but able to ambulate and speak at same time\n Pt changed to levaquin po\n Flu swabs neg and droplet precautions d/c\n Bp low 89/, received NS 1l bolus\n Pt voiding in urinal, last void ~6am\n Tachycardic to 120\n Response:\n Improved oxygenation\n Plan:\n Po abx as ordered\n Pulmonary toilet\n IVf as ordered\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 99.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH: Hypertension\n Additional history: diagnosed with OSA, but does not wear Bipap,\n hypoplasia in right lung\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:89\n D:71\n Temperature:\n 96.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 116 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,660 mL\n 24h total out:\n 625 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 03:59 AM\n Potassium:\n 5.1 mEq/L\n 03:59 AM\n Chloride:\n 103 mEq/L\n 03:59 AM\n CO2:\n 22 mEq/L\n 03:59 AM\n BUN:\n 20 mg/dL\n 03:59 AM\n Creatinine:\n 1.0 mg/dL\n 03:59 AM\n Glucose:\n 155 mg/dL\n 03:59 AM\n Hematocrit:\n 35.8 %\n 03:59 AM\n Finger Stick Glucose:\n 167\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cell phone\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 516\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2174-02-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 522697, "text": "Chief Complaint: shortness of breath\n HPI:\n 51 yo M with h/o asthma and right lung volume loss of unclear etiology\n (?congenital hypoplasia), recurrent bronchitis in winter, OSA, obesity,\n HTN who presented with 1 week of productive cough, progresssive SOB,\n and over the past 2 days weakness and fatigue to the point he was\n falling asleep at work. He tried increasing his albuterol use but this\n did not help so he came to the emergency room.\n In the ED, initial vs were: T: 99.5 P109 BP101/56 R24 79% on RA on\n presentation, 100% on NRB. The ED resident noted that he was not\n particularly wheezy on exam. Labs notable for WBC of 5, HCT 34.5,\n sodium of 131 and creatinine of 1.0. Patient was given ceftriaxone and\n azithromycin, nebs and 125 IV methylprednisone. He had a CXR which was\n inconclusive, possible RML pneumonia. Also be very tachycardic, EKG\n shows sinus tach. Got a CTA for concern of PE-but no PE, but some\n increased interstitial markings in RUL and RLL, more likely chronic\n process vs. pneumonia. Tried to wean him down on 02, as soon as he\n would fall asleep would desat. Right now, 40% venti mask and he is\n %. Vitals on transfer, 99/5, HR 106, 127/87, 23.\n .\n On the floor, the patient notes that he feels fine while lying still,\n but worse with movement. Denies sick contacts, recent travel, new\n pets. Only recent med change is stopping zoloft 1 month ago. He worked\n previously in the printing business and thinks he could have been\n exposed to some chemicals.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Meds:\n # Albuterol Sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler\n 2 puffs inhaled every 4 hr as needed for asthma\n # Amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day\n # Fluticasone-Salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with\n Device 1 (One) puff twice a day\n # Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily\n # Lisinopril 40 mg Tablet\n 1 Tablet(s) by mouth once a day\n # Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule,\n w/Inhalation Device one diskus inhaled once a day\n Past medical history:\n Family history:\n Social History:\n right lung volume loss of unclear etiology (?congenital hypoplasia)\n diagnosed on CT after abnormal CXR for PNA\n Asthma: on Advair and Spiriva.\n Hypertension: on hydrochlorothiazide, lisinopril, and Norvasc.\n Hyperkalemia: intermittent elevations of his potassium.\n Obesity:\n Glucose intolerance:\n Obstructive sleep apnea: declined CPAP therapy.\n Anxiety: on Zoloft 100 mg once daily.\n Vitamin B12 deficiency: not on b12 currently\n Twin sister with asthma\n Occupation: Currently works for , previously worked in printing\n with inhalation of chemicals\n Drugs: denies\n Tobacco: 30 pack year history quit 10 years ago\n Alcohol: 2 glasses a night and more on weekends\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Rash\n Flowsheet Data as of 07:13 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 108 (106 - 110) bpm\n BP: 128/83(116) {128/83(93) - 132/83(116)} mmHg\n RR: 19 (19 - 22) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 16 mL\n PO:\n TF:\n IVF:\n 16 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 16 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical adenopathy\n Cardiovascular: tachycardic, no audible murmur\n Peripheral 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: No(t)\n Wheezes : no wheezing, Diminished: on the right)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person place and time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 363 K/uL\n 12.4 g/dL\n 135 mg/dL\n 1.1 mg/dL\n 18 mg/dL\n 22 mEq/L\n 100 mEq/L\n 5.4 mEq/L\n 132 mEq/L\n 36.6 %\n 6.0 K/uL\n [image002.jpg]\n \n 2:33 A2/27/ 05:30 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 6.0\n Hct\n 36.6\n Plt\n 363\n Cr\n 1.1\n Glucose\n 135\n Other labs: PT / PTT / INR:13.2/28.2/1.1, Differential-Neuts:92.7 %,\n Lymph:4.5 %, Mono:2.2 %, Eos:0.4 %, Lactic Acid:1.6 mmol/L, Mg++:1.9\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n Assessment and Plan: 51 year old male with asthma and decreased lung\n volume on the right(? congenital), OSA who presentw with progressive\n dyspnea on exertion with symptoms and imaging consistent with pneumonia\n .\n # Hypoxia: Increased cough, infiltrate seen on CT and CXR make\n hypoxia most likely due to pneumonia in the setting of poor reserve\n given righ lung abnormalities. Patient only mildly wheezing on exam\n and unlikely asthma exacerbation. PE ruled out by CTA. Patient denies\n any aspiration event and slow progression over the last week makes this\n unlikely. Patient has OSA and does not wear CPAP at home, so\n progressive pulmonary hypertension could be contributing but unlikely\n to be causing symptoms of 1 week. CHF unlikely as no JVP, no periphral\n edema, no cardiomegaly on CXR. Valvular disease or pericardial effusion\n cannot be ruled out.\n -Ceftriaxone/Azithromycin for CAP\n -ECHO\n -no more steroids for now unless worsening or increase in wheezing\n -CPAP for sleeping\n -02 to maintain sats >90%\n -f/u final read of CXR and CTA\n -patient will need follow up with Dr. for his right lung.\n .\n #Tachycardia: Sinus Tach on EKG from ED, likely due to hypoxia. Patient\n denies any cardiac symptoms. Also denies any decrease in PO intake.\n -1L IVF bolus and reassess rate\n -repeat EKG\n .\n #Hyponatremia: be intrapulmonary process (SIADH) or to HCTZ\n (salt wasting with diuretics). Patient appears euvolemic.\n -urine lytes and osms, serum osms\n -recheck sodium in the AM\n -continue HCTZ for now\n .\n #. Hypertension:\n -continue hydrochlorothiazide, lisinopril and Norvasc.\n -monitor lytes for hyperkalemia as patient has had this in the past\n .\n #. Obstructive sleep apnea: Declined CPAP therapy in the past but\n will likely benefit from positive pressure as he is desatting when he\n falls asleep. He is now agreeable to trialing CPAP\n -CPAP autoset with respiratory consult\n .\n #. Glucose intolerance: SSI while on steroids\n -SSI.\n .\n .\n #Anemia: Slightly lower than recent baseline, likely secondary to known\n Vitamin B12 deficiency.\n -recheck HCT\n -send iron studies and b12 and folate\n .\n #. Alcohol use: Mr. has more than recommended amount of wine\n on weekends (approx 3 bottles) but denies any symptoms of withdrawl now\n or in the past.\n -monitor for signs of withdrawl no indication for CIWA at this point\n .\n # FEN: 1L IVF, replete electrolytes, NPO for tonight, if respiratory\n status improves can eat in the AM\n # Prophylaxis: Subcutaneous heparin\n # Access:2 peripherals\n # Communication: Patient and his wife\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2174-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522682, "text": "Pt is a 51 yo man with pmed hx of asthma, OSA, and HTN. Admitted after\n 1 week of worsening SOB, cough, and falling asleep during the day. In\n EW was found to have a RA o2 sat of 79%, placed on NRB, eventually\n weaned to 40% venti mask and transferred to MICU for monitoring\n Allergies\n Asthma\n Assessment:\n Pt remains on venti mask\n Action:\n CTA done in EW, neg for PE\n Received on 40% venti mask with o2 sats >95%\n Pt with poor activity tolerance\n Placed on droplet precautions and flu swabs sent\n Lung sounds decreased in right lung fields\n Ordered for sputum and urine cx when available\n MRSA swab sent\n Response:\n Improved o2 sats\n Plan:\n Bipap while sleeping\n Follow up flu swabs\n Sputum and urine cx when available\n" }, { "category": "Physician ", "chartdate": "2174-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 522834, "text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 09:52 PM\n .\n - Auto-set bipap (10 L) overnight for OSA with central component\n - \"Slept like a log\" overnight, felt great and wants to consider a\n machine for home\n - Hungry\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and 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 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.3\n HR: 99 (90 - 121) bpm\n BP: 112/73(82) {73/50(54) - 132/87(116)} mmHg\n RR: 15 (13 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1,068 mL\n 75 mL\n PO:\n TF:\n IVF:\n 1,068 mL\n 75 mL\n Blood products:\n Total out:\n 600 mL\n 625 mL\n Urine:\n 600 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n NAD, jittery?\n Expiratory wheeze on R?\n S1 S2 no murmur\n Soft NT ND abdomen\n Labs / Radiology\n 393 K/uL\n 11.9 g/dL\n 155 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 20 mg/dL\n 103 mEq/L\n 134 mEq/L\n 35.8 %\n 4.9 K/uL\n [image002.jpg]\n 05:30 PM\n 03:59 AM\n WBC\n 6.0\n 4.9\n Hct\n 36.6\n 35.8\n Plt\n 363\n 393\n Cr\n 1.1\n 1.0\n Glucose\n 135\n 155\n Other labs: PT / PTT / INR:13.2/28.2/1.1, Differential-Neuts:92.7 %,\n Lymph:4.5 %, Mono:2.2 %, Eos:0.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.5\n mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n 51M h/o asthma and decreased lung volume on the right (?congenital),\n OSA p/w progressive DOE, imaging c/w pneumonia\n .\n # Hypoxia: Increased cough, infiltrate on CT and CXR make hypoxia\n likely due to pneumonia in the setting of poor reserve given right lung\n abnormalities. Urine legionella negative. Patient mildly wheezing on\n exam and unlikely asthma exacerbation. PE ruled out by CTA. Patient\n denies any aspiration event and slow progression over the last week\n makes this unlikely Patient has OSA and does not wear CPAP at home, so\n progressive pulmonary hypertension could be contributing but unlikely\n to be causing symptoms of 1 week. CHF unlikely as no JVP, peripheral\n edema, or cardiomegaly. Valvular disease or pericardial effusion cannot\n be ruled out. Did well o/n with CPAP. Patient agitating to go home this\n AM.\n - Ceftriaxone / Azithromycin for CAP (Day for CTX, for\n Azithromycin)\n - Ambulatory O2 sat this AM\n - Echo ordered\n - No more steroids for now unless worsening or increase in wheezing\n - CPAP for sleeping, encourage outpt sleep study\n - 02 to maintain sats >90%\n - f/u final read of CXR and CTA\n - patient will need follow up with Dr. for his right lung\n .\n # Tachycardia: Sinus Tach on EKG, likely due to hypoxia. Patient denies\n any cardiac symptoms. Also denies any decrease in PO intake.\n -Continue to monitor, especially during ambulatory O2 sat today\n .\n #Hyponatremia: Resolved. have been intrapulmonary process\n (SIADH) or to HCTZ (salt wasting with diuretics). Patient appears\n euvolemic. Urine lytes and osms, serum osms suggest: SIADH\n -continue HCTZ for now\n .\n #. Hypertension:\n -continue hydrochlorothiazide, lisinopril and Norvasc.\n -monitor lytes for hyperkalemia as patient has had this in the past\n .\n #. Obstructive sleep apnea: Declined CPAP therapy in the past but\n will likely benefit from positive pressure as he is desatting when he\n falls asleep. He is now agreeable to trialing CPAP\n -CPAP autoset with respiratory consult\n .\n #. Glucose intolerance: SSI while on steroids\n -SSI.\n .\n #Anemia: Slightly lower than baseline, likely known Vitamin B12\n deficiency. B12 and folate within normal limits. Stable since\n admission.\n - Iron level is low but remainder of iron studies normal (ferritin may\n be acute phase reactant)\n - Continue to monitor\n .\n #. Alcohol use: Mr. has more than recommended amount of wine\n on weekends (approx 3 bottles) but denies any symptoms of withdrawal\n now or in the past.\n -monitor for signs of withdrawal no indication for CIWA at this point\n .\n # FEN: 1L IVF, replete electrolytes, NPO for tonight, if respiratory\n status improves can eat in the AM\n # Prophylaxis: Subcutaneous heparin\n # Access: 1 peripheral\n # Communication: Patient and his wife\n # Code: Full (discussed with patient)\n # Disposition: Call out\n" }, { "category": "Physician ", "chartdate": "2174-02-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 522835, "text": "Chief Complaint: hypoxemia/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 51 yo history of asthma and hypoplasia of right lower lobe, frequent\n exacerbations of lung disease, sleep apnea - both central and OSA.\n llow reserve. Presented with hypoxemia and SOB that has been\n progressively worsening over a week. Had sat in 70s in ED, put on 100%\n NRB. CTA negative for PE, was not wheezing. CT did show consolidation\n in RML. Improved with nebs and Bipap. Now weaned to room air\n oxygen. Currently getting mildly SOB while talking.\n 24 Hour Events:\n URINE CULTURE - At 09:52 PM\n CALLED OUT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n azithro/CTX\n advair\n atrovent\n albuterol\n HCTZ\n norvasc\n lisinopril\n SSI\n Changes to medical and family history:\n He has a history of\n hypertension, gastroesophageal reflux disease\n Shx: former 20 pack year smoker. Works in data entry on a computer.\n Lives with wife.\n : grandmother with diabetes\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 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.8\n HR: 108 (90 - 121) bpm\n BP: 102/72(79) {73/50(54) - 132/87(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n 1,068 mL\n 255 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,068 mL\n 155 mL\n Blood products:\n Total out:\n 600 mL\n 625 mL\n Urine:\n 600 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : left side)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.9 g/dL\n 393 K/uL\n 155 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 20 mg/dL\n 103 mEq/L\n 134 mEq/L\n 35.8 %\n 4.9 K/uL\n [image002.jpg]\n 05:30 PM\n 03:59 AM\n WBC\n 6.0\n 4.9\n Hct\n 36.6\n 35.8\n Plt\n 363\n 393\n Cr\n 1.1\n 1.0\n Glucose\n 135\n 155\n Other labs: PT / PTT / INR:13.2/28.2/1.1, Differential-Neuts:92.7 %,\n Lymph:4.5 %, Mono:2.2 %, Eos:0.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.5\n mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Hypoxemia/SOB: unclear . Has evidence of underlying\n chronic lung disease on right with blebs emphysema. CT consistent with\n PNA on Left side in upper and lower lobes.\n , but likely he has baseline hypoxemia. Will walk him around and\n determine if he desats with movement. Continue antibiotics\n should get outpatient pulmonary follow up.\n OSA: will benefit from outpatient repeat study and treatment.\n hyponatremia: improving\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:15 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: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2174-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522849, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt weaned t RA\n Action:\n Pt weaned to RA with o2 sats >94%\n Ambulated in on RA, o2 sats, HR increased to 120\ns, sats 92-97%\n Pt changed to levaquin po\n Flu swabs neg and droplet precautions d/c\n Pt insistent on being d/c home\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2174-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 522679, "text": "Asthma\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2174-02-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 522804, "text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Comments: Placed on autoset full FM W 10 L bled in at base of tubing.\n Pt tolerated CPAP very well. Upon auscultating upperairway distally it\n was noted that pt was having several attempts to breathe prior to air\n moving . Once autoset ramped up to 9cm H2O pressure the movements\n decreased. Sats remained in mid 90\n" }, { "category": "Physician ", "chartdate": "2174-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 522806, "text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 09:52 PM\n .\n - Auto-set bipap (10 L) overnight for OSA with central component\n - \"Slept like a log\" overnight, felt great and wants to consider a\n machine for home\n - Hungry\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and 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 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.3\n HR: 99 (90 - 121) bpm\n BP: 112/73(82) {73/50(54) - 132/87(116)} mmHg\n RR: 15 (13 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1,068 mL\n 75 mL\n PO:\n TF:\n IVF:\n 1,068 mL\n 75 mL\n Blood products:\n Total out:\n 600 mL\n 625 mL\n Urine:\n 600 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 99%\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 393 K/uL\n 11.9 g/dL\n 155 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 20 mg/dL\n 103 mEq/L\n 134 mEq/L\n 35.8 %\n 4.9 K/uL\n [image002.jpg]\n 05:30 PM\n 03:59 AM\n WBC\n 6.0\n 4.9\n Hct\n 36.6\n 35.8\n Plt\n 363\n 393\n Cr\n 1.1\n 1.0\n Glucose\n 135\n 155\n Other labs: PT / PTT / INR:13.2/28.2/1.1, Differential-Neuts:92.7 %,\n Lymph:4.5 %, Mono:2.2 %, Eos:0.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.5\n mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n 51 year old male with asthma and decreased lung volume on the right(?\n congenital), OSA who presentw with progressive dyspnea on exertion with\n symptoms and imaging consistent with pneumonia\n .\n # Hypoxia: Increased cough, infiltrate seen on CT and CXR make\n hypoxia most likely due to pneumonia in the setting of poor reserve\n given right lung abnormalities. Urine legionella negative. Patient\n only mildly wheezing on exam and unlikely asthma exacerbation. PE ruled\n out by CTA. Patient denies any aspiration event and slow progression\n over the last week makes this unlikely. Patient has OSA and does not\n wear CPAP at home, so progressive pulmonary hypertension could be\n contributing but unlikely to be causing symptoms of 1 week. CHF\n unlikely as no JVP, no periphral edema, no cardiomegaly on CXR.\n Valvular disease or pericardial effusion cannot be ruled out.\n -Ceftriaxone/Azithromycin for CAP (Day for CTX, for\n Azithromycin)\n -ECHO\n -No more steroids for now unless worsening or increase in wheezing\n -CPAP for sleeping\n -02 to maintain sats >90%\n -f/u final read of CXR and CTA\n -patient will need follow up with Dr. for his right lung\n .\n #Tachycardia: Sinus Tach on EKG from ED, likely due to hypoxia. Patient\n denies any cardiac symptoms. Also denies any decrease in PO intake.\n -Continue to monitor\n .\n #Hyponatremia: be intrapulmonary process (SIADH) or to HCTZ\n (salt wasting with diuretics). Patient appears euvolemic. Serum sodium\n level improving\n -urine lytes and osms, serum osms suggest: SIADH\n -continue HCTZ for now\n .\n #. Hypertension:\n -continue hydrochlorothiazide, lisinopril and Norvasc.\n -monitor lytes for hyperkalemia as patient has had this in the past\n .\n #. Obstructive sleep apnea: Declined CPAP therapy in the past but\n will likely benefit from positive pressure as he is desatting when he\n falls asleep. He is now agreeable to trialing CPAP\n -CPAP autoset with respiratory consult\n .\n #. Glucose intolerance: SSI while on steroids\n -SSI.\n .\n #Anemia: Slightly lower than recent baseline, likely secondary to known\n Vitamin B12 deficiency. B12 and folate within normal limits. Stable\n since admission.\n - Iron level is low but remainder of iron studies normal (ferritin may\n be acute phase reactant currently)\n - Continue to monitor\n .\n #. Alcohol use: Mr. has more than recommended amount of wine\n on weekends (approx 3 bottles) but denies any symptoms of withdrawl now\n or in the past.\n -monitor for signs of withdrawl no indication for CIWA at this point\n .\n # FEN: 1L IVF, replete electrolytes, NPO for tonight, if respiratory\n status improves can eat in the AM\n # Prophylaxis: Subcutaneous heparin\n # Access:2 peripherals\n # Communication: Patient and his wife\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n KNOWLEDGE DEFICIT\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n HYPERTENSION, BENIGN\n ELECTROLYTE & FLUID DISORDER, OTHER\n ASTHMA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2174-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 522802, "text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 09:52 PM\n .\n - Auto-set bipap (10 L) overnight for OSA with central component\n - \"Slept like a log\" overnight, felt great and wants to consider a\n machine for home\n - Hungry\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and 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 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.3\nC (97.3\n HR: 99 (90 - 121) bpm\n BP: 112/73(82) {73/50(54) - 132/87(116)} mmHg\n RR: 15 (13 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 1,068 mL\n 75 mL\n PO:\n TF:\n IVF:\n 1,068 mL\n 75 mL\n Blood products:\n Total out:\n 600 mL\n 625 mL\n Urine:\n 600 mL\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 99%\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 393 K/uL\n 11.9 g/dL\n 155 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 5.1 mEq/L\n 20 mg/dL\n 103 mEq/L\n 134 mEq/L\n 35.8 %\n 4.9 K/uL\n [image002.jpg]\n 05:30 PM\n 03:59 AM\n WBC\n 6.0\n 4.9\n Hct\n 36.6\n 35.8\n Plt\n 363\n 393\n Cr\n 1.1\n 1.0\n Glucose\n 135\n 155\n Other labs: PT / PTT / INR:13.2/28.2/1.1, Differential-Neuts:92.7 %,\n Lymph:4.5 %, Mono:2.2 %, Eos:0.4 %, Lactic Acid:1.4 mmol/L, Ca++:8.5\n mg/dL, Mg++:2.0 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n HYPERTENSION, BENIGN\n ELECTROLYTE & FLUID DISORDER, OTHER\n ASTHMA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Echo", "chartdate": "2174-02-14 00:00:00.000", "description": "Report", "row_id": 59771, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Left ventricular function. Tachycardia.\nHeight: (in) 64\nWeight (lb): 206\nBSA (m2): 1.98 m2\nBP (mm Hg): 100/66\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 09:45\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%\ndecrease during respiration (estimated RA pressure indeterminate).\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.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Echocardiographic results were reviewed by\ntelephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The right atrial\npressure is indeterminate. Mild symmetric left ventricular hypertrophy with\nnormal cavity size, and global systolic function (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThe right ventricular cavity is moderately dilated with moderate global free\nwall hypokinesis. There is abnormal systolic septal motion/position consistent\nwith right ventricular pressure overload. The aortic valve leaflets are mildly\nthickened (?#). There is no aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is moderate pulmonary artery systolic hypertension. There\nis no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement\nwith free wall hypokinesis and moderate pulmonary artery systolic\nhypertension. Mild symmetric left ventricular hypertrophy with normal cavity\nsize and global systolic function.\nThis constellation of findings is suggestive of a primary pulmonary process,\ne.g., pulmonary embolism.\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": "2174-02-14 00:00:00.000", "description": "Report", "row_id": 106767, "text": "Sinus tachycardia. Right bundle-branch block. Indeterminate axis. Delayed\nR wave progression. Findings are non-specific. Clinical correlation is\nsuggested. Since the previous tracing of there is no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2174-02-12 00:00:00.000", "description": "Report", "row_id": 106768, "text": "Sinus tachycardia. Right bundle-branch block. No previous tracing available\nfor comparison.\n\n" }, { "category": "Radiology", "chartdate": "2174-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1123327, "text": " 11:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cough, hypoxia\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Cough and hypoxia.\n\n COMPARISON: Multiple chest radiographs and chest CT with the most recent from\n .\n\n SINGLE FRONTAL PORTABLE VIEW OF THE CHEST: As compared to prior study there\n is minimal increase in right mid - lower lung opacity . Right lower lobe\n pleural thickening is grossly stable. Bullous changes denoted by relative\n lucency in the right upper lobe are again noted and unchanged. Prominent\n right mediastinal - paratracheal soft tissue remains unchanged. Left lung is\n clear. Heart is not enlarged. The aortic contour is grossly unremarkable.\n\n IMPRESSION: Minimal interval increase in opacification of the right mid -\n lower lung is better evaluated on subsequent CT from same day.\n\n" }, { "category": "Radiology", "chartdate": "2174-02-12 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1123340, "text": " 2:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please assess for thromboembolic event or acute infectious p\n Admitting Diagnosis: PNEUMONIA\n Field of view: 42.9 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with h/o asthma, 1 week of shortness of breath, hypoxia to 70s\n on RA.\n REASON FOR THIS EXAMINATION:\n Please assess for thromboembolic event or acute infectious process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: One week of shortness of breath and hypoxia. Assess for\n thromboembolic event or acute infectious process.\n\n COMPARISON: CT of the thorax, and several previous chest\n radiographs, the most recent dated .\n\n TECHNIQUE: Axial non-contrast images were obtained through the thorax. Images\n were then obtained with intravenous contrast according to the pulmonary\n embolus protocol. Sagittal, coronal, and oblique reformats were structured.\n\n FINDINGS:\n\n Again seen is right-sided lung volume loss, marked bullous emphysema in the\n right upper lobe and right lung base, and shift of the mediastinum to the\n right, likely congenital. Right pleural thickening, most significant at the\n posterolateral right lung base is noted. Again seen is a round opacity in the\n right lower lobe with a broad area of contact with the thickened pleura.\n Spiraling bronchi extend toward the opacity, in keeping with round\n atelectasis. This area of round atelectasis demonstrates increased density\n since the previous study. Linear bands of scar and/or atelectasis extend from\n the mass-like area of atelectasis towards the right hilum.\n\n Moderate centrilobular emphysema seen in the left lung. There is peripheral\n septal thickening with some confluent areas at the left lung apex, inferior\n left upper lobe, and the medial basal segment of the left lower lobe, new\n since . There is no left lung consolidation. There are no pleural\n effusions.\n\n There is no pulmonary embolus. The main pulmonary artery is mildly enlarged\n measuring 3.6 cm in diameter, increased since the previous study, and\n suggestive of possible pulmonary hypertension.\n\n The heart is normal in size and there is no pericardial effusion.\n\n Enlarged prevascular lymph node measures 13 mm in short axis, increased\n significantly since . Several other subcentimeter mediastinal lymph nodes\n are seen.\n\n Images through the upper abdomen are within normal limits.\n (Over)\n\n 2:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please assess for thromboembolic event or acute infectious p\n Admitting Diagnosis: PNEUMONIA\n Field of view: 42.9 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There are no osseous lesions. Mild old fracture deformity of a right lateral\n rib is noted.\n\n IMPRESSION:\n 1. No pulmonary embolus.\n 2. Right lung volume loss could be due to a congenital anomaly or pulmonary\n infection early in life.\n 3. Persistent area of round atelectasis in the right lower lobe with\n increased size slightly since .\n 4. New subpleural septal thickening in the left upper lobe and medial basal\n left lower lobe, new since and suggestive of an interstitial fibrosis.\n 5. Mildly enlarged 13-mm prevascular lymph node.\n\n Given the pulmonary interstitial findings and mildly enlarged lymph node,\n followup high-resolution CT is suggested, preferrably in 3 months if not\n needed earlier.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2144-07-12 00:00:00.000", "description": "P CHEST (BOTH OBLIQUES ONLY) PORT", "row_id": 1241313, "text": " 12:23 AM\n CHEST (BOTH OBLIQUES ONLY) PORT Clip # \n Reason: please eval line placement with oblique films\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with new PICC line placement\n REASON FOR THIS EXAMINATION:\n please eval line placement with oblique films\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman with new PICC line placement, assess.\n\n COMPARISONS: .\n\n Oblique views of the chest were obtained. Right PICC terminates in the distal\n SVC. The lungs are otherwise unchanged in appearance from numerous previous\n exams with right greater than left pleural effusions and cardiomegaly.\n\n These findings were discussed with of IV nursing at 0100 on \n by Dr. by phone.\n\n" }, { "category": "Radiology", "chartdate": "2144-07-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1241310, "text": " 10:52 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Please evaluate PICC line location\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with new R PICC placement s/p revision of location\n REASON FOR THIS EXAMINATION:\n Please evaluate PICC line location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman with new PICC line. Assess line placement\n after retraction.\n\n COMPARISONS: Radiograph from earlier the same day.\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: Right PICC appears to terminate in\n the distal SVC; however, focal contour irregularity could reflect that the\n line is still turned back on itself and reevaluation with oblique images is\n recommended. The lungs are otherwise low in volume with unchanged right\n greater than left effusions and cardiomegaly.\n\n These findings were discussed with of IV nursing at 2320 by Dr.\n by phone.\n\n" }, { "category": "Radiology", "chartdate": "2144-07-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1241307, "text": " 9:53 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval PICC placement\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with new R PICC placement - 51cm, R basilic vein\n REASON FOR THIS EXAMINATION:\n eval PICC placement\n ______________________________________________________________________________\n WET READ: LLTc SAT 10:22 PM\n The right PICC extends to the low SVC, but loops backwards, with the tip\n oriented superiorly, terminating at the level of the carina. Pullback and\n repeat radiograph are advised.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: Patient with placement of a PICC line.\n\n FINDINGS: Comparison is made to prior study performed on .\n\n There is a right-sided PICC line whose distal tip is in the mid SVC; however,\n this is due to a single 180-degree kink within the distal portion with the\n most distal aspect of the PICC line at the cavoatrial junction. This should\n be readjusted. No pneumothoraces are seen. There are bilateral pleural\n effusions and a left retrocardiac opacity which is stable.\n\n" }, { "category": "Radiology", "chartdate": "2144-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241258, "text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulmonary congestion\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with CHF, increased oxygen requirement\n REASON FOR THIS EXAMINATION:\n eval pulmonary congestion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 88-year-old woman with CHF and increased oxygen requirement.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is unchanged cardiomegaly. There are stable bilateral pleural\n effusions, which are moderate in size. There is mild improvement of the\n pulmonary edema since the previous study. No pneumothoraces are seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-07-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1241181, "text": " 9:26 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 88F with epigastric discomfort\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female with epigastric discomfort, rule out\n pneumothorax.\n\n COMPARISONS: Portable AP chest radiograph from .\n\n FINDINGS: There is prominence of the pulmonary vasculature both centrally and\n peripherally with upper zone re-distribution of vessels consistent with\n moderate pulmonary edema. Linear opacity in the right lower lung likely\n represents fluid in the fissure. There are bilateral pleural effusions. The\n cardiomediastinal silhouette is unchanged from prior exam; there is no\n pneumothorax. There are no acute skeletal abnormalities.\n\n IMPRESSION: Findings consistent with congestive heart failure. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-07-10 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1241182, "text": " 9:27 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: JAUNDICE EVAL FOR CBD STONE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with painless jaundice, elevated bilirubin s/p whipple\n REASON FOR THIS EXAMINATION:\n eval for CBD stone\n ______________________________________________________________________________\n WET READ: RJab FRI 9:57 PM\n Increased intra and extrahepatic biliary dilation since with debris\n within the CBD. Small right pleural effusion. Right renal cyst. MR would be\n best for further assessment due to obstruction once the acute symptoms of\n heart failure resolve.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman with painless jaundice, elevated bilirubin,\n status post distal pancreatectomy, evaluate for CBD or stone.\n\n COMPARISON: CTA of the abdomen with and without contrast from .\n\n FINDINGS: The liver demonstrates normal echotexture without focal lesions.\n There is increased intra- and extra-hepatic biliary dilatation since the prior\n CT scan with echogenic material/debris within the common bile duct. The CBD\n is dilated measuring 1.2 cm. The portal vein is patent. There is a 6.7 x 5.2\n cm lobulated cyst arising from the right kidney and a right pleural effusion.\n\n IMPRESSION:\n 1. Increased biliary dilatation since the prior study with debris in the\n common bile duct. Recommend MR for further evaluation once symptoms of acute\n heart failure resolve.\n 2. Right pleural effusion.\n 3. Right renal cyst.\n\n" }, { "category": "ECG", "chartdate": "2144-07-10 00:00:00.000", "description": "Report", "row_id": 215100, "text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock. Compared to the previous tracing of atrial fibrillation with a\nrapid ventricular response has appeared and right bundle-branch block has\nreappeared, as recorded on . Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2102-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 791219, "text": " 11:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man S/P CABG AND CT REMOVAL\n REASON FOR THIS EXAMINATION:\n R/O PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG and chest tube removal.\n\n PORTABLE AP VIEW OF THE CHEST: Comparison . Patient is status\n post CABG. Multiple surgical clips overlie the upper abdomen. A right IJ\n sheath is present extending to the level of the IJ/brachycephalic junction.\n There is obscuration of the left hemidiaphragm, consistent with effusion,\n atelectasis and/or consolidation in this post-CABG patient.\n\n IMPRESSION: Left basilar consolidation and/or effusion in post-CABG patient.\n\n" }, { "category": "Radiology", "chartdate": "2102-05-05 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 790740, "text": " 9:02 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD\n REASON FOR THIS EXAMINATION:\n pre op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67 year old man with CAD. Endotracheal tube placement.\n\n PA/LATERAL VIEWS OF THE CHEST: No prior images for comparison. Numerous\n surgical clips overlie the upper abdomen and lower mediastinum. A 2 cm soft\n tissue density overlies the mediastinal clips, best appreciated on the lateral\n radiograph. The heart size is enlarged. The lungs are otherwise clear.\n\n IMPRESSION: Small soft tissue density overlying surgical clips within the\n region of the gastroesophageal junction. Although this may represent post-\n surgical changes, comparison with prior study or if none are available, a\n barium swallow is recommended for further evaluation.\n\n" }, { "category": "ECG", "chartdate": "2102-05-10 00:00:00.000", "description": "Report", "row_id": 162529, "text": "Sinus rhythm\nMarked left axis deviation\nIncomplete right bundle branch block\nInferior (and ? posterior) myocardial infarction - age indeterminate - clinical\ncorrelation is suggested\nSince previous tracing of : precordial T waves are more prominent\n\n" }, { "category": "ECG", "chartdate": "2102-05-04 00:00:00.000", "description": "Report", "row_id": 162530, "text": "Normal sinus rhythm. Inferior-posterior myocardial infarction. Possible left\nventricular hypertrophy. Non-diagnostic repolarization abnormalities. No\nprevious tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-05-10 00:00:00.000", "description": "Report", "row_id": 1525893, "text": "Pt s/p CABG x4\nPt vent weaned and extubated tol well\n1liter LR fluid bolus given and neo gtt for SBP>95\nCI>2.5 CT minimal output MP Paced 84 with occas PVC underlying SR 70's with BBB Mg/K repleted\nNeuro-A/A Ox3 MAEW=strong speach clear voice hoarse med with fentanyl for comfort with effect\nCV-CO/CI WNL CSM WNL Apaced see above note\nResp-FT 40% LS clear dim at bases enc to CDB/ICS sao2 98\nGI-absent BS insulin gtt on 2u/hr NPO\nGU-U/O great\nPlease see flow sheet\nPlan-fast track post op Cabg/ cont to monitor wean neo as tol cont pulm toilet\n" }, { "category": "Nursing/other", "chartdate": "2102-05-11 00:00:00.000", "description": "Report", "row_id": 1525894, "text": "PATIENT DOING WELL, COMFORTABLE AFTER LAST DOSE OF FENTANYL ABLE TO BE TURNED FAIRLY EASILY, INSTRUCTED ON DEEP BREATHING EXERCISES.. BS UP INCREASED DRIP TO 4U/HR. 4BEAT RUN OF , MAG GIVEN AT 1800, PER CT RESIDENT REPEAT WITH 2GMS IF MORE PVC, AT 2420, COUPLET, PLAN TO GIVE 2GM MAGSO4.. ALSO K PENDING.. CI GOOD, U/O GOOD\n" }, { "category": "Nursing/other", "chartdate": "2102-05-11 00:00:00.000", "description": "Report", "row_id": 1525895, "text": "PATIENT REMAINS APACED AT 92 WITH NO PVC, SR IN THE 60'S UNDERLYING.. WEANING NEO DOWN TO .75MCG/KG/MIN. 400CCLR GIVEN FOR ATTEMPT TO WEAN NEO, LOW CVP.. GREAT CI CONTINUES ??? D/C SWAN IN AM.. GU REMAINS ADEQUATE . GI MEDICATED X2 WITH REGALN D/T NAUSEA... ENDO BS FAIRLY WELL CONTROLLED ON INSULIN DRIP AS PER PROTOCOL. K/MAG REPLACED.. MEDICATED WITH FENTANYL 50MCG IVPX2 WITH GOOD RESULTS..\n" } ]

[ { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620634, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD. K 4.8 this am.\n Action:\n PM labs sent. Last HD was yesterday Wednesday with 1 liter off.\n Patient given dulcolax today with no effect yet.\n Response:\n Patient remains hemodynamically stable. PM k pending.\n Plan:\n Monitor lytes, hemodynamics. MWF HD. Follow up on PM lytes which are\n pending. Patient can receive Perocets for generalized body pain.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean. Derm is\n following. Urology is consultued, awaiting consult.\n At 0500 this am pt BS 61, given D50% per protocol. After D50%\n amp BS\n 121,please cont follow.\n Pt starts coughing after sips of water, given pills with jelly.\nPer S/S evaluation\n1. PO diet of thin liquids and ground solids.\n2. 1:1 supervision for all POs.\n3. Meds crushed with purees.\n4. TID oral care.\n5. Plan for video swallow with interpreter at 9:30am. Will need to coordinate w\nith Dialysis.\n" }, { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620635, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD. K 4.8 this am.\n Action:\n PM labs sent. Last HD was yesterday Wednesday with 1 liter off.\n Patient given dulcolax today with no effect yet.\n Response:\n Patient remains hemodynamically stable.\n Plan:\n Monitor lytes, hemodynamics. MWF HD. Patient can receive Perocets\n for generalized body pain.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean. Derm is\n following. Urology is consultued, awaiting consult.\n At 0500 this am pt BS 61, given D50% per protocol. After D50%\n amp BS\n 121,please cont follow.\n Pt starts coughing after sips of water, given pills with jelly.\nPer S/S evaluation\n1. PO diet of thin liquids and ground solids.\n2. 1:1 supervision for all POs.\n3. Meds crushed with purees.\n4. TID oral care.\n5. Plan for video swallow with interpreter at 9:30am. Will need to coordinate w\nith Dialysis.\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620361, "text": "Chief Complaint: Reason for MICU Admission: Hyperkalemia\n .\n Primary Care Physician: , . \n .\n CC: Hyperkalemia\n HPI:\n This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt with elevated K of 7.4 on adm to the ED. Pt received calcium,\n insulin/glucose, bicarb and kayexalate in the ED. Repeat K 6.5. pt\n showed slight peaked to waves. Unclear as to why K is elevated. No\n dietary chg\ns. pt is speaking but understands a little English.\n No c/o pain except for some muscle achiness. Pt in nsr with rare pvc\n noted. Bp hypertensive prior to HD. Pt\ns last dialysis . pt is\n anuric.\n Action:\n Pt dialyzed for 2 hours, removing 500cc fluid. Will repeat lytes 3/hrs\n post dialysis.\n Response:\n Pt tolerated dialysis well. Bp down to 120-140. am k down to 4.8\n Plan:\n Monitor lytes with am blood work.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water.\n Response:\n Area very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n Pt has not stooled since receiving kayexalate in the ED.\n Pt with upper left arm AV fistula with dsd.\n Pt with very congested prod cough, coughing and raising but swallowing.\n Lung sounds occ rhonchorous.\n Pt with low grade temps. Awaiting K level labs.\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620464, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient\ns K this am after run of HD last night was 4.8. Patient in NSR\n rate of 70\ns to 80\ns. Slightly peaked T waves on EKG. Patient is\n anuric.\n Action:\n Pt dialyzed for 2 additional 2 hours this morning, removing 1000cc\n fluid.\n Response:\n Patient remains hemodynamically stable. Due for PM labs at 1800.\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water.\n Response:\n Area very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n Pt with upper left arm AV fistula with dsd.\n Pt with very congested cough, coughing and raising but swallowing.\n Unable to produce sputum. Lung sounds occ rhonchorous., but upper\n airway. Patient placed on droplet precautions when temp was 100.5 at\n 12pm. Nasal aspirate sent. Blood cultures are pending.\n Patient had speech and swallow , as he was scheduled for an\n outpatient barium swallow due to coughing. Patient passed speech and\n swallow , have regular HD diet. Has no dentures, but wife\n mashes food for him. Speech and swallow still recommended getting\n formal barium swallow in future as already scheduled.\n Patient receiving Percocet PRN for generalized body pain.\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620340, "text": "Chief Complaint: Reason for MICU Admission: Hyperkalemia\n .\n Primary Care Physician: , . \n .\n CC: Hyperkalemia\n HPI:\n This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt with elevated K of 7.4 on adm to the ED. Pt received calcium,\n insulin/glucose, bicarb and kayexalate in the ED. Repeat K 6.5. pt\n showed slight peaked to waves. Unclear as to why K is elevated. No\n dietary chg\ns. pt is speaking but understands a little English.\n No c/o pain except for some muscle achiness. Pt in nsr with rare pvc\n noted. Bp hypertensive prior to HD. Pt\ns last dialysis . pt is\n anuric.\n Action:\n Pt dialyzed for 2 hours, removing 500cc fluid. Will repeat lytes 3/hrs\n post dialysis.\n Response:\n Pt tolerated dialysis well. Bp down to 120-140.\n Plan:\n Monitor lytes with am blood work.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water.\n Response:\n Area very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n Pt has not stooled since receiving kayexalate in the ED.\n Pt with upper left arm AV fistula with dsd.\n Pt with very congested prod cough, coughing and raising but swallowing.\n Lung sounds occ rhonchorous.\n Pt with low grade temps. Awaiting K level labs.\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620447, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient\ns K this am after run of HD last night was 4.8. Patient in NSR\n rate of 70\ns to 80\ns. Slightly peaked T waves on EKG. Patient is\n anuric.\n Action:\n Pt dialyzed for 2 additional 2 hours this morning, removing 1000cc\n fluid.\n Response:\n Patient remains hemodynamically stable. Due for PM labs at 1800.\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water.\n Response:\n Area very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n Pt with upper left arm AV fistula with dsd.\n Pt with very congested cough, coughing and raising but swallowing.\n Unable to produce sputum. Lung sounds occ rhonchorous., but upper\n airway. Patient placed on droplet precautions when temp was 100.5 at\n 12pm. Nasal aspirate sent. Blood cultures are pending.\n Patient had speech and swallow , as he was scheduled for an\n outpatient barium swallow due to coughing. Patient passed speech and\n swallow , have regular HD diet. Has no dentures, but wife\n mashes food for him. Speech and swallow still recommended getting\n formal barium swallow in future as already scheduled.\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620449, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient\ns K this am after run of HD last night was 4.8. Patient in NSR\n rate of 70\ns to 80\ns. Slightly peaked T waves on EKG. Patient is\n anuric.\n Action:\n Pt dialyzed for 2 additional 2 hours this morning, removing 1000cc\n fluid.\n Response:\n Patient remains hemodynamically stable. Due for PM labs at 1800.\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water.\n Response:\n Area very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n Pt with upper left arm AV fistula with dsd.\n Pt with very congested cough, coughing and raising but swallowing.\n Unable to produce sputum. Lung sounds occ rhonchorous., but upper\n airway. Patient placed on droplet precautions when temp was 100.5 at\n 12pm. Nasal aspirate sent. Blood cultures are pending.\n Patient had speech and swallow , as he was scheduled for an\n outpatient barium swallow due to coughing. Patient passed speech and\n swallow , have regular HD diet. Has no dentures, but wife\n mashes food for him. Speech and swallow still recommended getting\n formal barium swallow in future as already scheduled.\n Patient receiving Percocet PRN for generalized body pain.\n" }, { "category": "Physician ", "chartdate": "2148-01-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 620452, "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 24 Hour Events:\n K+ improved s/p HD.\n Complains of pain on penis\n Mental status not yet at baseline according to wife\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:56 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:04 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 (99.2\n HR: 71 (71 - 83) bpm\n BP: 145/47(72) {119/34(55) - 156/84(100)} mmHg\n RR: 22 (13 - 28) insp/min\n SpO2: 94%\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 500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal)\n Peripheral Vascular: s/p B BKA\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: s/p B BKA\n Skin: Warm, penile ulcer and associated hard lymphadenopathy on the\n left\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal, oriented x2\n Labs / Radiology\n 11.7 g/dL\n 198 K/uL\n 100 mg/dL\n 4.7 mg/dL\n 34 mEq/L\n 4.8 mEq/L\n 24 mg/dL\n 101 mEq/L\n 145 mEq/L\n 37.5 %\n 9.4 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 9.4\n Hct\n 37.5\n Plt\n 198\n Cr\n 4.7\n Glucose\n 100\n Other labs: PT / PTT / INR:12.2/27.9/1.0, Differential-Neuts:76.6 %,\n Lymph:13.5 %, Mono:5.3 %, Eos:4.2 %, Ca++:9.1 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Imaging: CXR ? minimal atelectasis in the right base.\n Assessment and Plan\n Hyperkalemia: improved s/p HD, unclear etiology. CK normal, other\n electrolytes within normal limits, ? related to ACE inhibitor. Will\n educate re dietary control. If this becomes a recurrent problem will\n need further work up.\nPenile ulcer and lymphadenopathy, will consult urology\n Cough and sputum: improving per wife but will rule out flu\n regardless. Likely resolving viral infection, CXR clear, will continue\n to monitor off antibiotics if develops fever will reconsider.\n ICU Care\n Nutrition: ADAT\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 10:29 PM\n 18 Gauge - 10:29 PM\n Dialysis Catheter - 12:39 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 :Floor\n Total time spent: 35\n" }, { "category": "Rehab Services", "chartdate": "2148-01-24 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 620440, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 86 y/o speaking male\nwith ESRD on HD M/W/F, bilateral BKA, DM and CAD admitted on\n after being found hyperkalemic while at HD. Pt was\nasymptomatic without chest pain or SOB. EKG showed mild peaked T\nwave. Pt required emergent HD on admission. CXR showed no\nacute cardiopulmonary abnormality. Pt is currently on special\nairborne precautions. We were consulted to evaluate for oral and\npharyngeal dysphagia. Pt is currently ordered for a regular diet\nwith thin liquids.\nPer review of records, pt was recently ordered for an outpatient\nvideo swallow for concern of coughing / choking after meals. We\nhad called to schedule, but had not received a call back from his\ndaughter to schedule. He was with his wife and the \ninterpreter. She reports coughing o POs after almost all drinks\nat home, occasionally on solid food. All foods are mashed and\nblended as pt is edentulous.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the MICU.\nCognition, language, speech, voice:\nPt was awake but minimally interactive. His wife responded to\nmost questions. Pt was intermittently verbal and speech and voice\nwere grossly wfl. He was able to follow basic commands with\nfrequent prompts and cues.\nTeeth: edentulous- wife reports he does not wear dentures\nSecretions: wfl in the oral cavity- congested cough not\nproductive while I was present\nORAL MOTOR EXAM:\nSymmetrical facial appearance with mildly reduced lip seal.\nUnable to assess further difficulty following commands.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp, straw), purees\nand soft solids. Mastication was prolonged, but adequate and\nwithout oral cavity residue. Pt without overt coughing, throat\nclearing or changes in vocal quality and O2 SATs remained stable.\nPt unable to answer questions regarding residue or aspiration.\nLaryngeal elevation felt timely, but mildly reduced to palpation.\nSUMMARY / IMPRESSION:\nMr. thin liquids and soft solids without\naspiration, but his wife reports persistent aspiration at home,\nprogressing over the last 3 years. He was ordered for a video\nswallow as an outpatient, but was admitted before it could be\nscheduled. GIven his CXR was clear and there were no concern s on\nmy exam, would suggest a PO diet of thin liquids and ground\nsolids for now. We can take him for a video swallow once he is\ncleared from airborne precautions for further evaluation.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5.\nRECOMMENDATIONS:\n1. Suggest a PO diet of thin liquids and ground solids.\n2. 1:1 supervision for all POs.\n3. Meds crushed with purees.\n4. TID oral care.\n5. Video swallow once off airborne precautions for further\nevaluation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 14:20-14:45\nTotal time: 60 minutes\n [BUTTON Input] (not implemented)_____\n 15:01\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620328, "text": "Chief Complaint: Reason for MICU Admission: Hyperkalemia\n .\n Primary Care Physician: , . \n .\n CC: Hyperkalemia\n HPI:\n This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt with elevated K of 7.4 on adm to the ED. Pt received calcium,\n insulin/glucose, bicarb and kayexalate in the ED. Repeat K 6.5. pt\n showed slight peaked to waves. Unclear as to why K is elevated. No\n dietary chg\ns. pt is speaking but understands a little English.\n No c/o pain except for some muscle achiness. Pt in nsr with rare pvc\n noted. Bp hypertensive prior to HD. Pt\ns last dialysis . pt is\n anuric.\n Action:\n Pt dialyzed for 2 hours, removing 500cc fluid. Will repeat lytes 3/hrs\n post dialysis.\n Response:\n Pt tolerated dialysis well. Bp down to 120-140.\n Plan:\n Monitor lytes with am blood work.\n .H/O Problem\n Penile ulcer\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2148-01-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 620611, "text": "Chief Complaint: Hyperkalemia\n I saw and examined the patient, and was physically present with 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 Swab of penile ulcer.\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 05:14 AM\n Heparin Sodium (Prophylaxis) - 09:11 AM\n Other medications:\n lisinpril, xanax, oxycodone, sevalemer, metoprolol 25 , insulin\n sliding scale, asa 81, heparin s/c.\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 10:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.4\nC (99.3\n HR: 77 (70 - 96) bpm\n BP: 141/48(68) {97/34(54) - 162/60(85)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 400 mL\n 225 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,100 mL\n 225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), s/p\n bilateral BKA.\n Respiratory / Chest: (Breath Sounds: Clear : anterioly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, s/p bilateral BKA\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 10.6 g/dL\n 170 K/uL\n 57 mg/dL\n 5.1 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 98 mEq/L\n 146 mEq/L\n 34.0 %\n 8.6 K/uL\n [image002.jpg]\n 03:41 AM\n 04:07 PM\n 04:31 AM\n WBC\n 9.4\n 8.6\n Hct\n 37.5\n 34.0\n Plt\n 198\n 170\n Cr\n 4.7\n 3.7\n 5.1\n Glucose\n 100\n 95\n 57\n Other labs: PT / PTT / INR:12.2/27.9/1.0, Differential-Neuts:76.6 %,\n Lymph:13.5 %, Mono:5.3 %, Eos:4.2 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:4.8 mg/dL\n Imaging: none\n Microbiology: no herpes preliminary. GC pending. respiratory viral\n panel.\n Assessment and Plan\n Hyperkalemia: resolved s/p HD\n Dysphagia: on dysphagia diet with crushed pills.\n Penile lesion: d/w urology if they are willing to perform biopsy.\n Appreciate dermatology\ns input. DFA for herpes virus sent. Plan is for\n derm to perform skin biopsy tomorrow. Will need to consider biopsy of\n left inguinal lymph nodes.\n Call out waiting for a floor bed\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:07 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: wife updated\n status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30\n" }, { "category": "Physician ", "chartdate": "2148-01-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 620313, "text": "Chief Complaint: Reason for MICU Admission: Hyperkalemia\n .\n Primary Care Physician: , . \n .\n CC: Hyperkalemia\n HPI:\n This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Patient admitted from: ER\n History obtained from Patient, Medical records\n Patient unable to provide history: Language barrier\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 AM\n Other medications:\n Medications:\n ASPIRIN 81mg daily\n Lantus 13U daily\n LISINOPRIL 10mg daily\n METOPROLOL SUCCINATE - 50 mg daily\n EPOETIN ALFA [EPOGEN] 13200U three times a week\n SEVELAMER HCL 800mg TID\n NEPHROCAPS daily\n OXYCODONE-ACETAMINOPHEN 2 tabs TID:prn\n BISACODYL - 5 mg qweek prn\n DOCUSATE SODIUM \n FERROUS SULFATE - 325 mg (daily\n SENNA - 8.6 mg \n ALPRAZOLAM - 0.25 mg qhs:prn\n Past medical history:\n Family history:\n Social History:\n #DM type II- insulin dependent\n #ESRD (m,w,f dialysis dependent @ )\n #HTN\n #Hyperlipidemia\n #CAD s/p MI\n #h/x osteo L heel/foot\n #PVD- s/p angioplasty of the left anterior tibial\n peroneal,tibioperoneal trunk and posterior tibial arteries on\n \n Surgical History:\n #avf \n #arteriogram gram \n #s/p r bka \n #L AKA \n Strong family history of diabetes. Father died from\n complications of diabetes. Denies hx of heart disease or cancer.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Originally from . Lives with his wife. Retired\n . Tob: smoked for 15 years approx 3-4packs per day; quit\n 50yrs ago. EtOH: h/o abuse, no longer drinks. Illicits: denies\n use. Pt lives with wife and daughter.\n Review of systems:\n The patient denies any fevers, chills, weight change, nausea, vomiting,\n abdominal pain, diarrhea, constipation, melena, hematochezia, chest\n pain, shortness of breath, orthopnea, PND, cough, urinary frequency,\n urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness,\n headache, rash or skin changes.\n Flowsheet Data as of 02:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 78 (71 - 83) bpm\n BP: 119/56(69) {119/41(62) - 156/84(100)} mmHg\n RR: 16 (13 - 28) insp/min\n SpO2: 93%\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 500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -500 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 93%\n Physical Examination\n GEN: no acute distress\n HEENT: PERRL, dry MM, OP Clear\n NECK: No JVD, trachea midline\n COR: RRR, no M/G/R, normal S1 S2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/ b/l BKA\n GENITAL: uncircumsized, retracted foreskin showed 1cmx0.5cm ulcer with\n yellowish/clear discharge. Painful to touch. left inguinal hard\n nodules, immobile\n NEURO: alert, oriented to person, place, and time. Moves all 4\n extremities. non-focal\n Labs / Radiology\n [image002.jpg]\n ECG: Sinus rhythm at 69 bpm, Left axis, peaked T waves when compared\n to . No significant ST or T-wave changes.\n .\n Imaging:\n CXR: No acute pulmonary/cardiac process\n Assessment and Plan\n Assesment: This is a 86 year-old male with a history of ESRD on HD\n (M/W/F), DM, CAD who presents with hyperkalemia.\n .\n Plan:\n #. Hyperkalemia: The patient was found to have an elevated potassium of\n 7.4. He received calcium, insulin/glucose, bicarb and kayexalate in\n the ED. Last K was 6.5. ECG showed peaked t-waves. Pt otherwise asx\n except for muscle aches. Pt last dialysis yesterday, unclear as to why\n he is hyperkalemic. He denied dietary changes. Pt is on an ACE-I, but\n no new changes in meds. Evaluated by Nephrology.\n -- seen by Nephrology, plan for emergent HD tonight and then again\n tomorrow\n -- trend potassium and will check 3 hrs after HD\n -- ECG on arrival to the ICU\n -- hold lisinopril\n -- monitor on tele\n -- no additional kayexalate per renal\n .\n #. ESRD: Pt last HD yesterday. Schedule is M/W/F. Plan for HD\n overnight and hyperkalemia management as above.\n -- HD tonight and again tomorrow\n -- cont Epo at HD\n -- cont sevelamer\n -- f/u renal recs\n .\n #. Penile Ulcer: Pt with single painful ulcer on exam. Unclear sexual\n history. DDx: HSV, syphilis, chancroid,\n -- obtain collateral information via translator in the AM\n -- send RPR\n -- HSV culture\n -- send GC/chlymadia\n -- consider HIV\n .\n #. Leukocytosis: Pt with WBC of 11.2. Pt remains afebrile and no\n localizing symptoms. CXR showed no acute process.\n -- cont to trend WBC and fever curve\n -- Blood cx, UA\n -- Penile ulcer management as above\n .\n #. HTN: Will cont home metoprolol and hold lisinopril given\n hyperkalemia. Cont to monitor BP\n .\n # FEN: Low salt, low potassium, diabetic\n .\n # Access: left AV fistula, PIV\n .\n # PPx: bowel regimen, heparin sq\n .\n # Code: FULL- presumed. Need to confirm with interpreter\n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:29 PM\n 18 Gauge - 10:29 PM\n Dialysis Catheter - 12:39 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2148-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620324, "text": "Chief Complaint: Reason for MICU Admission: Hyperkalemia\n .\n Primary Care Physician: , . \n .\n CC: Hyperkalemia\n HPI:\n This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n" }, { "category": "Physician ", "chartdate": "2148-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 620581, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n WOUND CULTURE - At 12:00 PM\n Swab of penile ulcer.\n DIALYSIS CATHETER - STOP 08:56 PM\n CALLED OUT\n -Speech/Swallow:thin liquids and ground solids, 1:1 supervision for all\n POs, Meds crushed with purees, Video swallow once off airborne\n precautions for furtherevaluation.\n -Urology: not worrisome of acute infection at this time. Although\n there are no heaped up edges orunderlying induration or firmness\n worrisome for malignancy, it cannot be excluded. The lesion deserves a\n biopsy for further assessment; needs outpt follow up with Dr .\n -Penile swabs pending\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:05 AM\n Dextrose 50% - 05:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.7\nC (98.1\n HR: 72 (70 - 96) bpm\n BP: 97/39(54) {97/34(54) - 162/60(85)} mmHg\n RR: 17 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 400 mL\n 225 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,100 mL\n 225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 10.6 g/dL\n 95 mg/dL\n 3.7 mg/dL\n 32 mEq/L\n 4.8 mEq/L\n 15 mg/dL\n 97 mEq/L\n 142 mEq/L\n 34.0 %\n 8.6 K/uL\n [image002.jpg]\n RSV screen negative\n 03:41 AM\n 04:07 PM\n 04:31 AM\n WBC\n 9.4\n 8.6\n Hct\n 37.5\n 34.0\n Plt\n 198\n 170\n Cr\n 4.7\n 3.7\n Glucose\n 100\n 95\n Other labs: PT / PTT / INR:12.2/27.9/1.0, Differential-Neuts:76.6 %,\n Lymph:13.5 %, Mono:5.3 %, Eos:4.2 %, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n Assesment: This is a 86 year-old male with a history of ESRD on HD\n (M/W/F), DM, CAD who presents with hyperkalemia.\n .\n Plan:\n #. Hyperkalemia/ESRD: The patient was found to have an elevated\n potassium of 7.4. He received calcium, insulin/glucose, bicarb and\n kayexalate in the ED. Last K was 6.5. ECG showed peaked t-waves. Pt\n otherwise asx except for muscle aches. Pt last dialysis day prior to\n admission unclear as to why he is hyperkalemic. He denied dietary\n changes. Pt is on an ACE-I, but no new changes in meds. Evaluated by\n renal and has been dialyzed x2 since arrival with improvement..\n -- cont Epo at HD\n -- cont sevelamer\n -- f/u renal recs\n .\n #. Penile Ulcer: Pt with single painful ulcer on exam. Urology\n consulted who felt unlikely infectious in nature; concern for vascular\n vs malignancy and recommended outpatient follow up\n -Follow up GC/chlamygia and swab cultures\n -Will call derm consult to get biopsy while in house\n .\n #. Leukocytosis: Pt with WBC of 11.2 and temp 100.5 overnight. Flu\n swab negative\n -- cont to trend WBC and fever curve\n -- Blood cx, UA\n -- Penile ulcer management as above\n .\n #. HTN: Metoprolol and Lisinopril per home regimen\n .\n # FEN: Low salt, low potassium, diabetic\n .\n # Access: left AV fistula, PIV\n .\n # PPx: bowel regimen, heparin sq\n .\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition: crushed meds in puree, thin liquids, ground solids\n Glycemic Control:\n Lines:\n 20 Gauge - 12:07 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2148-01-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 620583, "text": "Chief Complaint: Hyperkalemia\n I saw and examined the patient, and was physically present with 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 WOUND CULTURE - At 12:00 PM\n Swab of penile ulcer.\n DIALYSIS CATHETER - STOP 08:56 PM\n CALLED OUT\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 05:14 AM\n Heparin Sodium (Prophylaxis) - 09:11 AM\n Other medications:\n lisinpril, xanax, oxycodone, sevalemer, metoprolol 25 , insulin\n sliding scale, asa 81, heparin s/c.\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 10:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.4\nC (99.3\n HR: 77 (70 - 96) bpm\n BP: 141/48(68) {97/34(54) - 162/60(85)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 400 mL\n 225 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,100 mL\n 225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///36/\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Absent), (Left DP pulse: Absent), s/p\n bilateral BKA.\n Respiratory / Chest: (Breath Sounds: Clear : anterioly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, s/p bilateral BKA\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 10.6 g/dL\n 170 K/uL\n 57 mg/dL\n 5.1 mg/dL\n 36 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 98 mEq/L\n 146 mEq/L\n 34.0 %\n 8.6 K/uL\n [image002.jpg]\n 03:41 AM\n 04:07 PM\n 04:31 AM\n WBC\n 9.4\n 8.6\n Hct\n 37.5\n 34.0\n Plt\n 198\n 170\n Cr\n 4.7\n 3.7\n 5.1\n Glucose\n 100\n 95\n 57\n Other labs: PT / PTT / INR:12.2/27.9/1.0, Differential-Neuts:76.6 %,\n Lymph:13.5 %, Mono:5.3 %, Eos:4.2 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:4.8 mg/dL\n Imaging: none\n Microbiology: no herpes preliminary. GC pending. respiratory viral\n panel.\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA): resolved s/p HD\n Dysphagia: on dysphagia diet with crushed pills.\n Penile lesion: d/w urology if they are willing to perform biopsy.\n Call out waiting for a floor bed\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:07 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2148-01-24 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 620308, "text": "Chief Complaint: Hyperkalemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yom Spanish-speaking ESRD--> HD reportedly in USOH until day of\n admission when determined to have serum K= 7.3 (noted at outpatient\n dialysis facility in ) . Recommended evaluation in ER.\n ER evalution revealed BP= 185/86; HR= 72; RR= 16; SaO2= 99% RA.\n Ulcer noted on glans penis. Labs revealed K= 7.3; ECG with peaking of\n T-waves --> received D50, NaHCO3, Insulin and Kayexalate. Repeat K=\n 6.5. Transferred to MICU for emergent hemodialysis.\n Apparently reports pain in tip of penis and generalized \"achiness in\n bones\" (according to interpreter). Otherwise, no complaints. Upon\n transfer to MICU, HD initiated (most recent session the day PTA).\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Language barrier, Spanish-speaking\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\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 ESRD --> HD\n NIDDM\n CAD -- s/p MI\n HTN\n HYPERLIPIDEMIA\n PVD --> right BKA ; left AKA \n h/o OSTEOMYELITIS\n Occupation: Retired Minister\n Drugs: None\n Tobacco: Remote, >50 pack years\n Alcohol: REmote abuse\n Other: Emigrated from \n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: Penile ulcer\n Flowsheet Data as of 02:31 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 83 (71 - 83) bpm\n BP: 141/84(100) {127/54(71) - 156/84(100)} mmHg\n RR: 25 (19 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -500 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\n Conjunctiva pale, No(t) Sclera edema, Right eye enucleation\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, Ulcerated lesion on glans penis, clean\n borders, well-demarcated 1.5 cm\n Musculoskeletal: No(t) Muscle wasting, Unable to stand, Right BKA; Left\n AKA\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 175\n 39.3\n 168\n 7.1\n 49\n 30\n 100\n 7.3\n 143\n 11.2\n [image002.jpg]\n Fluid analysis / Other labs: Troponini= 0.25\n Imaging: CXR (): right hemidiaphragm with obscuring of medial\n aspect.\n Assessment and Plan\n HYPERKALEMIA -- evidence for physiological effect by ECG. Unclear\n etiology (?dietary indiscretion, ?acidosis). No new medications to\n implicate. Now s/p HCO3, Glucose, Insulin, Kayexalate, HD against low\n K bath. Plan monitor K serially. f/u ECG.\n ERSD -- Continue HD as planned. Maintain 'dry weight'\n PENILE LESION -- ulcer. Unclear whether this represents infectious\n (esp. viral or syphilis), ishemic, granulomatous, or local trauma\n (pressue sore). Check swab. Plan Dermatology or ID consultation.\n Consider HIV testing.\n NIDDM -- monitor glucose. Maintain <150.\n HTN -- improved after HD\n CAD -- no evidence for active ischemia.\n NUTRITIONAL SUPPORT -- encourage PO.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 10:29 PM\n 18 Gauge - 10:29 PM\n Dialysis Catheter - 12:39 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 55 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2148-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 620559, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n WOUND CULTURE - At 12:00 PM\n Swab of penile ulcer.\n DIALYSIS CATHETER - STOP 08:56 PM\n CALLED OUT\n -Speech/Swallow:thin liquids and ground solids, 1:1 supervision for all\n POs, Meds crushed with purees, Video swallow once off airborne\n precautions for furtherevaluation.\n -Urology: not worrisome of acute infection at this time. Although\n there are no heaped up edges orunderlying induration or firmness\n worrisome for malignancy, itcannot be excluded. The lesion deserves a\n biopsy for further assessment; needs outpt follow up with Dr .\n -Penile swabs pending\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:05 AM\n Dextrose 50% - 05:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.7\nC (98.1\n HR: 72 (70 - 96) bpm\n BP: 97/39(54) {97/34(54) - 162/60(85)} mmHg\n RR: 17 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 400 mL\n 225 mL\n PO:\n 400 mL\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,100 mL\n 225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 10.6 g/dL\n 95 mg/dL\n 3.7 mg/dL\n 32 mEq/L\n 4.8 mEq/L\n 15 mg/dL\n 97 mEq/L\n 142 mEq/L\n 34.0 %\n 8.6 K/uL\n [image002.jpg]\n 03:41 AM\n 04:07 PM\n 04:31 AM\n WBC\n 9.4\n 8.6\n Hct\n 37.5\n 34.0\n Plt\n 198\n 170\n Cr\n 4.7\n 3.7\n Glucose\n 100\n 95\n Other labs: PT / PTT / INR:12.2/27.9/1.0, Differential-Neuts:76.6 %,\n Lymph:13.5 %, Mono:5.3 %, Eos:4.2 %, Ca++:8.3 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n Assesment: This is a 86 year-old male with a history of ESRD on HD\n (M/W/F), DM, CAD who presents with hyperkalemia.\n .\n Plan:\n #. Hyperkalemia: The patient was found to have an elevated potassium of\n 7.4. He received calcium, insulin/glucose, bicarb and kayexalate in\n the ED. Last K was 6.5. ECG showed peaked t-waves. Pt otherwise asx\n except for muscle aches. Pt last dialysis yesterday, unclear as to why\n he is hyperkalemic. He denied dietary changes. Pt is on an ACE-I, but\n no new changes in meds. Evaluated by Nephrology.\n -- seen by Nephrology, plan for emergent HD tonight and then again\n tomorrow\n -- trend potassium and will check 3 hrs after HD\n -- ECG on arrival to the ICU\n -- hold lisinopril\n -- monitor on tele\n -- no additional kayexalate per renal\n .\n #. ESRD: Pt last HD yesterday. Schedule is M/W/F. Plan for HD\n overnight and hyperkalemia management as above.\n -- HD tonight and again tomorrow\n -- cont Epo at HD\n -- cont sevelamer\n -- f/u renal recs\n .\n #. Penile Ulcer: Pt with single painful ulcer on exam. Unclear sexual\n history. DDx: HSV, syphilis, chancroid,\n -- obtain collateral information via translator in the AM\n -- send RPR\n -- HSV culture\n -- send GC/chlymadia\n -- consider HIV\n .\n #. Leukocytosis: Pt with WBC of 11.2. Pt remains afebrile and no\n localizing symptoms. CXR showed no acute process.\n -- cont to trend WBC and fever curve\n -- Blood cx, UA\n -- Penile ulcer management as above\n .\n #. HTN: Will cont home metoprolol and hold lisinopril given\n hyperkalemia. Cont to monitor BP\n .\n # FEN: Low salt, low potassium, diabetic\n .\n # Access: left AV fistula, PIV\n .\n # PPx: bowel regimen, heparin sq\n .\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:07 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2148-01-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 620394, "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 24 Hour Events:\n K improved s/p HD.\n Allergies:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:56 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:04 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 (99.2\n HR: 71 (71 - 83) bpm\n BP: 145/47(72) {119/34(55) - 156/84(100)} mmHg\n RR: 22 (13 - 28) insp/min\n SpO2: 94%\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 500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///34/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), s/p B BKA\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: s/p B BKA\n Skin: Warm, penile ulcer and associated hard lymphadenopathy on the\n right\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal, oriented x2\n Labs / Radiology\n 11.7 g/dL\n 198 K/uL\n 100 mg/dL\n 4.7 mg/dL\n 34 mEq/L\n 4.8 mEq/L\n 24 mg/dL\n 101 mEq/L\n 145 mEq/L\n 37.5 %\n 9.4 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 9.4\n Hct\n 37.5\n Plt\n 198\n Cr\n 4.7\n Glucose\n 100\n Other labs: PT / PTT / INR:12.2/27.9/1.0, Differential-Neuts:76.6 %,\n Lymph:13.5 %, Mono:5.3 %, Eos:4.2 %, Ca++:9.1 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.0 mg/dL\n Imaging: CXR ? minimal atelectasis in the right base.\n Assessment and Plan\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA): improved s/p HD,\n unclear etiology. Ck normal, other electrolytes within normal limits, ?\n related to ACEI. Will educate re. dietary control. IF this becomes a\n recurrent problem will need further work up.\n H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS: Penile ulcer and\n lymphadenopathy, will consult urology\n Cough and sputum: improving per wife, resolving recnet viral\n infection, CXR clear, will continue to monitor off antibiotics if\n develops fever will reconsider.\n ICU Care\n Nutrition: ADAT\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 10:29 PM\n 18 Gauge - 10:29 PM\n Dialysis Catheter - 12:39 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 :Floor\n Total time spent: 40\n" }, { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620556, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD. In the beginning of shift desat to 88% ,\n put NC 2L, sat 98-99%.pm K 4.8\n Action:\n Response:\n Patient remains hemodynamically stable. Morning k pending\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n At 0500 pt BS 61, given D50% per protocol. After D50%\n amp BS\n 121,please cont follow.\n Pt starts coughing after sips of water, given pills with jelly.\nPer S/S evaluation\n1. PO diet of thin liquids and ground solids.\n2. 1:1 supervision for all POs.\n3. Meds crushed with purees.\n4. TID oral care.\n5. Video swallow once off airborne precautions for further\nevaluation.\n" }, { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620497, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD.inthe begining of shift desat to 88% ,\n put NC 2L, sat 98-99%.pm K 4.8\n Action:\n Response:\n Patient remains hemodynamically stable. Morning k\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n" }, { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620554, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD. In the beginning of shift desat to 88% ,\n put NC 2L, sat 98-99%.pm K 4.8\n Action:\n Response:\n Patient remains hemodynamically stable. Morning k\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n At 0500 pt BS 61, given D50% per protocol.\n Pt starts coughing after sips of water, given pills with jello.\nPer S/S evaluation\n1. PO diet of thin liquids and ground solids.\n2. 1:1 supervision for all POs.\n3. Meds crushed with purees.\n4. TID oral care.\n5. Video swallow once off airborne precautions for further\nevaluation.\n" }, { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620539, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD. In the beginning of shift desat to 88% ,\n put NC 2L, sat 98-99%.pm K 4.8\n Action:\n Response:\n Patient remains hemodynamically stable. Morning k\n Plan:\n Monitor lytes, hemodynamics.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean.\n At 0500 pt BS 61, given D50% per protocol.\n Pt starts coughing after sips of water, given pills with jello.\n" }, { "category": "Nursing", "chartdate": "2148-01-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620644, "text": "This is a 86 year-old male with a history of ESRD on HD (M/W/F), DM,\n CAD who presents with hyperkalemia. The patient last HD session was\n yesterday (). He was called by his outpatient dialysis unit\n after being found to be hyperkalemic. He reports aches in his \"bones\"\n everywhere, but denied chest pain, palpitations, SOB, nausea, vomiting\n or other complaints.\n .\n In the ED, 98.2 72 185/86 17 99%. His potassium on admission was 7.4.\n He was given 1g calcium gluconate, 1 amp D50, 10U Regular insulin 50mEQ\n Bicarb and kayexalate 30g. The patient's ECG showed mildly peaked\n t-waves. Repeat potassium was 7.3 then 6.5. The patient was evaluated\n by Nephrology in the ED. He did not have a BM in the ED.\n .\n On arrival to the ICU the patient was initiated on HD. He had\n complaints of \"body pains,\" but denied fevers, chills, SOB, URI\n symptoms, feeling sick or other complaints. The Spanish interpreter\n was called, but the patient was unable to hear the interpreter over the\n phone. The patient's history was based on patient interview and prior\n history obtained via interpreter in the ED.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Patient in NSR rate of 70\ns to 80\ns. Slightly peaked T waves on\n EKG. Patient is anuric on HD. K 4.8 this am.\n Action:\n PM labs sent. Last HD was yesterday Wednesday with 1 liter off.\n Patient given dulcolax today with no effect yet.\n Response:\n Patient remains hemodynamically stable.\n Plan:\n Monitor lytes, hemodynamics. MWF HD. Patient can receive Perocets\n for generalized body pain.\n .H/O Problem\n Penile ulcer\n Assessment:\n Pt with lrg open penile ulcer, under his foreskin, pt states is very\n painful. Unable to determine how long he has had it d/t language\n barrier.\n Action:\n Area swabbed for culture to test for HSV, syphyllis, RPR, Chlamydia.\n Foreskin retracted and cleansed with soap and water. Given percoset to\n pain and Xanax fro anxiety, pt yelled out fro his wife.\n Response:\n very painful to pt when touched.\n Plan:\n Check cultures. Follow wbc, temp curve, keep area clean. Derm is\n following. Urology is consultued, awaiting consult.\n At 0500 this am pt BS 61, given D50% per protocol. After D50%\n amp BS\n 121,please cont follow.\n Pt starts coughing after sips of water, given pills with jelly.\nPer S/S evaluation\n1. PO diet of thin liquids and ground solids.\n2. 1:1 supervision for all POs.\n3. Meds crushed with purees.\n4. TID oral care.\n5. Plan for video swallow with interpreter at 9:30am. Will need to coordinate w\nith Dialysis.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Height:\n Admission weight:\n 51.7 kg\n Daily weight:\n Allergies/Reactions:\n Pravachol (Oral) (Pravastatin Sodium)\n myalgias;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: CAD, Hypertension, MI\n Additional history: ESRD, bilat bk , HD M/W/F, AKA LEFT ,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:138\n D:50\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 225 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 04:31 AM\n Potassium:\n 4.0 mEq/L\n 04:31 AM\n Chloride:\n 98 mEq/L\n 04:31 AM\n CO2:\n 36 mEq/L\n 04:31 AM\n BUN:\n 26 mg/dL\n 04:31 AM\n Creatinine:\n 5.1 mg/dL\n 04:31 AM\n Glucose:\n 57 mg/dL\n 04:31 AM\n Hematocrit:\n 34.0 %\n 04:31 AM\n Finger Stick Glucose:\n 109\n 06:00 PM\n Valuables / Signature\n Patient valuables: clothes only\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: CC723\n Date & time of Transfer: \n" }, { "category": "ECG", "chartdate": "2148-01-24 00:00:00.000", "description": "Report", "row_id": 117611, "text": "Sinus rhythm. Compared to tracing #1 diffusely peaked T waves have somewhat\nimproved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-01-23 00:00:00.000", "description": "Report", "row_id": 117612, "text": "Sinus rhythm. Left axis deviation with left anterior fascicular block.\nCompared to the previous tracing of there is diffuse peaked T waves\nsuggestive of hyperkalemia. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2148-01-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1120671, "text": " 9:32 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hx of hyperkalemia\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hyperkalemia.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The cardiac, mediastinal and hilar\n contours are within normal limits. The lungs are clear. The pulmonary\n vascularity is normal. No pleural effusion or pneumothorax is seen.\n Multilevel degenerative changes are redemonstrated in the thoracic spine.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-01-26 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1121097, "text": " 10:10 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Please evaluate for aspiration per bedside eval\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with ESRD, dysphagia\n REASON FOR THIS EXAMINATION:\n Please evaluate for aspiration per bedside eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coughing with meals, dysphagia, patient with end-stage renal\n disease.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was conducted in collaboration with\n speech pathology. Various consistencies of barium were administered by mouth.\n There is a delay in the oral phase of swallow. There is premature spill into\n the valleculae and piriform sinuses. There is large aspiration seen with thin\n consistency only. There is a mild amount of residual seen in the valleculae\n and intermittently seen in the piriform sinuses.\n\n IMPRESSION: Aspiration with thin barium. Mild-to-moderate residual in the\n valleculae and piriform. Delay in oral phase of swallow with premature spill\n seen into the valleculae and piriform sinuses.\n\n Please refer to the complete report from speech pathology that is available on\n CareWeb.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021092, "text": " 4:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with sob\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old male with shortness of breath, to assess for heart\n failure.\n\n TECHNIQUE: Single AP portable chest radiograph was performed of the chest.\n\n COMPARISON: With CT of and chest radiograph of .\n\n FINDINGS: There are increased interstitial markings in both lungs with ill-\n defined scattered more confluent perihilar opacities. The heart is not\n enlarged, the mediastinal silhouette is unremarkable. There are small\n bilateral effusions.\n\n CONCLUSION: The appearances could represent a combination of fluid overload\n due to known renal failure and superimposed infection. Followup chest\n radiograph is advised following appropriate diuresis ot assess for underlying\n infection.\n\n" }, { "category": "Radiology", "chartdate": "2193-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1021147, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with ESRD on PD admitted with dyspnea and volume overload\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 48-year-old male with end-stage renal disease, on\n peritoneal dialysis, with dyspnea and volume overload. Evaluate for interval\n change.\n\n Single AP chest radiograph compared to shows decreased lung\n volumes and worsening pulmonary edema. Two areas of more confluent opacities\n in the left upper and right lower lung zones may also be related to edema,\n however, a focal airspace process cannot be entirely excluded. Recommend\n followup after dialysis. The cardiomediastinal contour is within normal\n limits. There is no pneumothorax or substantial pleural effusion.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-06-25 00:00:00.000", "description": "Report", "row_id": 1645226, "text": "FOCUS; NURSING PROGRESS NOTE\n48 YEAR OLD MALE WITH ESRD ON PD, HX OF TYPE 2 DM, AND HYPERTENSION. ADMITTED WITH HYPERTENSION, SOB AND CP. TX WITH IV NTG. TRANSFERRED TO MICU FOR FURTHER CARE. PD EXCHANGES CHANGED TO Q 3HOURS. TRANSITIONED TO PO LABETELOL. IV NTG WEANED TO OFF EARLY THIS AM.\nREVEIW OF SYSEMS-\nNEURO- ALERT AND ORIENTED X3. COOPERATIVE WITH CARE. MAE. GOOD STRENGTH. WITHOUT C/O OF PAIN THIS SHIFT.\nRESP- ON RA WITH RESP 16-21. SATS 94-99%. BS COARSE DIMINISHED LLL.\nCARDIAC- HR 70-90 NSR WITHOUT ECTOPI. SBP 120-160'S. LABETELOL INCREASED TO 800MG TID FROM 600MG TID. CONT ON AMLODIPINE 10MG QD.\nON ASA. HOME DOSE OF LASIX STARTED TODAY 80MG .\nGI- ABD SOFT DISTENDED WITH HYPOACTIVE BS. ON , 2GM NA LOW PROTEIN DIET. TOL FAIR. HAD ON SOFT BROWN GUIAC NEG STOOL THIS AM.\nGU- VOIDING IN URINAL SMALL AMOUNTS 25-100CC AT A TIME OF CLEAR YELLOW URINE.\n- ON Q 3 HOUR RUNS OF PD THIS AM 2.5% 2L DWELLS. DRAINED 1000-1600CC PER RUN. RETURNS CLEAR YELLOW. UP AND EXCHANGES CHANGED TO Q 6HOURS.\nENDO- BS UP TO 280 AT NOON. LANTUS DOSE INCREASED TO 22U THIS PM. CONT ON HUMOLOGUE SLIDING SCALE.\nACCESS- HAS A # 18 AND 20 PERIPHERAL CATHETER IN PLACE. SITES WNL.\nSOCIAL- PATIENT'S PARTNER IN AND UPDATED ON POC.\nDISPO- IN MICU FULL CODE. ? C/O TO FLOOR IF TOLERATES Q 6 HOUR DWELLS.\nPLAN- GOAL SBP <160.\n MONITOR BS Q 6 HOURS.\n MONITOR FLUID STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2193-06-24 00:00:00.000", "description": "Report", "row_id": 1645223, "text": "Nursing Progress Note:\nENDO: pt written for humalog SS and standing hs lantus, pt reports not taking SS at home, it has not been needed, and will sometimes take lantus depending on if he feels he needs it, but most of the time does not take it; refused lantus tonight\n" }, { "category": "Nursing/other", "chartdate": "2193-06-24 00:00:00.000", "description": "Report", "row_id": 1645224, "text": "MICU 7 RN Note 0700-1900:\n\nEVENTS: PD Q3 hours; Metoprolol DCd, Labetolol started; NTG drip continues; Trops trending up.\n\nNEURO: AAO; MAE; Turns self; Cooperative. Reports some neuropathic pain left foot transiently. Denies numbness. Reported discomfort during one PD session (1300 net out) during dwell.\n\nCV: Hypertensive. SR 80s-90s. Lat S-T changes noted prior to this shift. Trops trending up; last two 0.74, 0.78; ++DP/PT; Significant decrease in LE edema after PD with 1300 out.\n\nRESP: LS dim bases with faint crackles; Deep breathing encouraged. RR 14-22; Sats 93-99% on 3L. Cough frequent, dry, non prod except for small amount sent for C&S (yellow/tan).\n\nGU: Voids to urinal; 150-175 each time; yellow w/o sed. PD Q3: in; Ultrafiltrate out this shift: 250cc; 1300cc; 0cc; 4th draining until 1850: all light yellow.\n\nGI: ABD soft, n/t except as noted during one dwell. Tolerable other times. +BS; No BM.\n\nPLAN: Monitor CEs and Lytes; Trops trending up; K trending down from 6.0 to 4.9. Follow culture data; BC/Urine sent overnight; Sputum sent today. PD per recs; currently ml; 2.5% dextrose Q3 hours; see order (printout on board in room). Last dwell started at 1850.\n" }, { "category": "Nursing/other", "chartdate": "2193-06-25 00:00:00.000", "description": "Report", "row_id": 1645225, "text": "NURSING SHIFT NOTE, 7P-7A\nPT IS A 48 YR OLD MALE ADMITTED WITH DYSPNEA,AND CHEST TIGHTNESS.PMH SIGNIFICANT FOR HTN,DM,ESRD ON PD.\n\nCODE STATUS:FULL CODE\nALLERGIES:LIPITOR.\nPRECAUTIONS:CONTACT (MRSA)\n\nIV ACCESS:2 PIV.\n\nEVENTS:NITRO WEANED,LABETELOL INCREASED,CONTD PD,SERIAL CE'S\n\nROS:\n\nNEURO;AOX3.VERY AND CO OPERATIVE.HAS INTERMITTENT NEUOROPATHIC PAIN IN THE LEFT FOOT,BETTER WITH NEURONTIN.ALSO STARTED OXYCODONE FOR BREAKTHROUGH PAIN.\n\nCVS:NSR,HR 90-105,SBP 130-160,NITRO GTT WEANED SUCCESSFULLY, PO LABETELOL INCREASED. NO CP/SOB.CE TROPONIN UP TO .81(FROM 0.78)BUT CK TRENDING DOWN.B/L LE EDEMA R>L.\n\nRESP:ON RA SATTING 93-96%. FINE CRACKLES,R>L.NO SOB.OCC DRY CONGESTED COUGH,NO SPUTUM.\n\nGI:ABD SOFT DISTENDED,BOWEL SOUNDS+,NO BM.\n\nGU:VOIDING YELLOW CLEAR URINE 50-100 CC AT A TIME.PD CONTD Q3H,2500CC IN. FLUID BALANCE EVEN, NOTED TO DRAIN BETTER IF THE PT IS IN SUPINE POSITION. RECEIVED IVP LASIX 80 MG X1. VOIDED ONLY 100CC AFTER THAT.LAST K 4.4 (IN AM LABS).\n\nENDO:ON Q6H FS WITH HUMALOG SLIDING SCALE AND SCH LANTUS.\n\nPLAN:CONT PD Q3H,FOLLOW LYTES,FOLLOW BP AND ADJUST MEDS,FOLLOW CE'S.\n" }, { "category": "Nursing/other", "chartdate": "2193-06-24 00:00:00.000", "description": "Report", "row_id": 1645222, "text": "Nursing Progress Note:\nALLERGIES: statins\n\nFULL CODE\n\nCONTACT PRECAUTIONS\n\nOvernight, pt remains on nitro gtt, started PD, K+ cont elevated @ 6, rec'd additional kayexalate, CE's trending down\n\nNEURO: pt A+Ox3, denies pain, moves all extremiteis, pupils 3mm and brisk bilaterally, able to make needs known, no deficits; neurontin qhs for peripheral neuropathy with relief\n\nCV: HR NSR/ST no ectopy; SBP 150's-170 on nitro gtt @ 35 mcg/kg/min +PP to palpation; + pitting edema L>R; K+ elevated, given kayexalate, will re-check am labs; CE's ttrending down, on admission troponin 0.68; peaked T waves on EKG now new finding; denies CP; recieved 1 dose IV lasix 40 mg with little effect\n\nRESP: LSCTA except RLL with expiratory wheezing despite poor CXR and volume overload, repeat this am pending; satting >92% 3LNC; RR regular, c/o slight SOB with talking/activity; alb/atr nebs prn, given alb neb on admission with relief\n\nGI: +BS, regular diet ( at home), abd soft non-tender, non-distended, loose stools tonight d/t kayexalate; no NVD\n\nGU/: pt make urine, voiding in urinal, although last void pt forgot to use urinal and unable to measure: PD q3h started this shift, see orders\n\nACCESS: 20G and 18G PIV WNL\n\nPOC: wean nitro gtt as tol for SBP 150-160's, goal -1L for 24hrs, may start heparin gtt if ^ in CE's cont PD q3h; follow lytes, treat hyperkalemia prn, replete lytes prn\n\n\n" }, { "category": "ECG", "chartdate": "2193-06-25 00:00:00.000", "description": "Report", "row_id": 159814, "text": "Sinus rhythm\nBorderline left axis deviation - could be left anterior fascicular block but is\nnondiagnostic\nST-T wave abnormalities with prominent precordial lead/anterior T waves - are\nnonspecific but clinical correlation is suggested for possible in part ischemia\nor left ventricular hypertrophy\nSince previous tracing of , precordial lead T waves appear slightly more\nprominent but may be no significant change\n\n" }, { "category": "ECG", "chartdate": "2193-06-24 00:00:00.000", "description": "Report", "row_id": 159815, "text": "Sinus rhythm. Compared to the previous tracing the sinus rate is slower.\nOtherwise, no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2193-06-23 00:00:00.000", "description": "Report", "row_id": 159816, "text": "Normal sinus rhythm, rate 100. Borderline left axis deviation. Possible\nleft ventricular hypertrophy. Non-specific inferolateral repolarization\nchange. Compared to the previous tracing of probably no significant\nchange.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2152-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1212027, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sob and GIB\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: chest radiograph.\n\n FINDINGS: Portable erect radiograph of the chest was obtained. The lungs are\n clear bilaterally with no evidence of consolidation or effusion. Accounting\n for patient rotation, the trachea appears midline and the cardiomediastinal\n silhouette is normal with evidence of stable cardiomegaly. Mild mitral\n annulus calcification is noted. There is no pneumothorax. Bony structures\n and soft tissue are unremarkable.\n\n IMPRESSION: No acute intrathoracic process.\n\n\n" }, { "category": "ECG", "chartdate": "2152-10-03 00:00:00.000", "description": "Report", "row_id": 270905, "text": "Irregularly irregular rhythm in the absence of P waves suggests atrial\nfibrillation. Intraventricular conduction defect and the QRS is widened\nover 120 milliseconds. Left axis deviation is present. ST segment depression in\nthe lateral leads raising a question of lateral myocardial ischemia. Clinical\ncorrelation is required.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2152-10-04 00:00:00.000", "description": "Report", "row_id": 270903, "text": "Atrial fibrillation, average ventricular rate 60. The non-specific ST-T wave\nchanges have resolved in the lateral leads. Otherwise, the tracing is unchanged\nfrom prior studies.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2152-10-03 00:00:00.000", "description": "Report", "row_id": 270904, "text": "Atrial fibrillation, average ventricular rate 74. Non-specific intraventricular\nconduction delay. Persistent ST-T wave changes are present in the lateral leads\nraising a question of myocardial ischemia. Clinical correlation is suggested.\nThere is no interval change.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-02-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 951633, "text": " 8:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p EVD removal. ICH/HC\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with ho cerebellar hemorrhage\n REASON FOR THIS EXAMINATION:\n s/p EVD removal. ICH/HC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Status post cerebellar hemorrhage with ventricular drain removal.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n COMPARISON STUDY: Non-contrast head CT scan from , reported by Dr.\n and me as revealing \"improvement in posterior fossa postoperative\n pneumocephalus as well as mass effect. Overall, there has been no significant\n change in ventricular size from the prior examinations.\n\n FINDINGS: Compared with the prior study, there has been progressive reduction\n in the degree of posterior fossa pneumocephalus. The drainage catheter has\n been removed. There may be very slight increase in size of the temporal \n tips, but overall, the remainder of the ventricular system is unchanged in\n size, with mild-to-moderate generalized supratentorial ventricular dilatation.\n The fourth ventricle is normal in size, and there is negligible mass effect\n exerted upon it at this time. There remains a small amount of blood layering\n in both occipital horns. The right frontal burr hole is seen. There is\n minimal mucosal thickening in the right ethmoid sinus. The mesh spanning the\n left occipital craniotomy defect is again seen.\n\n CONCLUSION: At most, questionable slight minimal interval dilatation of the\n temporal tips. The study is otherwise stable in appearance.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 950728, "text": " 6:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for SDH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with s/p fall SDH at OSH\n REASON FOR THIS EXAMINATION:\n Please evaluate for SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JK WED 8:46 AM\n Large left cerebellar hemispheric hemorrhage causing obstructive\n hydrocephalus. EMERGENCY NEUROSURGICAL CONSULTATION MANDATED. We have\n attempted to call ED X2 with results.\n ______________________________________________________________________________\n FINAL REPORT\n EMERGENCY HEAD CT SCAN\n\n HISTORY: Status post fall. Subdural hemorrhage identified at outside\n hospital. Evaluate for subdural hemorrhage.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n COMPARISON STUDIES: None.\n\n FINDINGS: The head CT scan is poorly positioned, with a substantial portion\n of the anterior facial structures cut off by the scanning field. Additionally,\n there are motion artifacts, obscuring some of the images.\n\n FINDINGS: There is a nearly 4 cm left cerebellar hemispheric hemorrhage, with\n a substantial degree of surrounding edema medial to the hemorrhage itself.\n There is marked compression of the fourth ventricle, with moderate obstructive\n hydrocephalus. Additionally, there is likely upward herniation of the\n cerebellar vermis. Slight increase in density in the region of the tentorium\n could indicate a small quantity of subdural hemorrhage. There is no\n supratentorial subdural hemorrhage seen at this time. There is subtotal loss\n of aeration of the left maxillary sinus and sclerosis of the sinus walls, a\n combination of findings, which could indicate chronic inflammatory disease or\n trauma (i.e., intrasinus hemorrhage). There is a fracture of the left lateral\n orbital wall, with approximately 2 mm medial displacement of the anterior\n fracture fragment adjoining the left lateral rectus muscle.\n\n CONCLUSION: Large left cerebellar hemispheric hemorrhage creating obstructive\n hydrocephalus. There is upward herniation of the cerebellar vermis. Emergent\n neurosurgical intervention is mandated.) Apparently, the patient was being\n taken to the operating room for treatment of these abnormalities.\n\n ADDENDUM: There is likely a deformity of the left maxillary sinus lateral\n wall, a finding which could indicate a fracture.\n\n Lastly, it is difficult, on the basis of this CT scan, to assess the position\n of the cerebellar tonsils for possible herniation secondary to the hemorrhage.\n\n (Over)\n\n 6:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for SDH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n This report has been telephoned to Dr. , attending physician, \n \"wet read\" has been placed on the ED dashboard.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-20 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 950729, "text": " 6:40 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: evaluate for facial fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with s/p fall w/ ? maxillary/zygomatic arch/ orbital fracture\n on outside head CT\n REASON FOR THIS EXAMINATION:\n evaluate for facial fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EMERGENCY FACIAL BONES CT\n\n HISTORY: Status post fall with question maxillary and zygomatic as well as\n orbital fractures on outside head CT.\n\n TECHNIQUE: Axial non-contrast imaging of the facial bones was obtained with\n coronal reformatted images.\n\n FINDINGS: The outside CT scan, reported in your history is not available for\n our independent review.\n\n FINDINGS: Mildly displaced fractures of the lateral wall of the left orbit\n and left maxillary sinus, as well as extreme posterior aspect of the left\n orbital floor, are seen. There is no entrapment of orbital contents within\n the orbital floor fracture.\n\n There is apparent confirmation of the presence of the non- displaced left\n zygomatic arch fracture. There is a large air- fluid level within the left\n maxillary sinus, which in view of the multiple fractures, likely represents\n hemorrhage. No other fractures are seen.\n\n Approximately 5 mm, relatively well circumscribed areas of bony lysis are\n noted, one within each C1 lateral mass. The left- sided lesion appears to\n slightly thin the adjacent medial cortical margin. The etiology for these\n findings is uncertain but their sharp margination suggests that they are\n benign. No other definite signs of fractures are appreciated.\n\n CONCLUSION: Multiple facial fractures as noted above.\n\n ADDENDUM: There is multilevel, relatively prominent facet joint degeneration\n in the visualized upper cervical vertebral segments. There is no definite\n sign for spinal cord compression.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-20 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 950812, "text": " 2:46 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, malalignment\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture, malalignment\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old woman status post fall, evaluate fracture or\n malalignment.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial images of the lumbar spine were obtained with coronal and\n sagittal reformatted images. Additionally, axial non-enhanced images of the\n abdomen were also reformatted.\n\n CT L-SPINE: No fracture or subluxation is identified. There is degenerative\n change, predominantly within the L4-L5 and L5-S1 levels, and there is grade I\n retrolisthesis of L5 on S1 and grade 1 anterolisthesis of L4 on L5. Disc\n calcification is seen, most predominantly at the L3-4 level, degenerative in\n origin. The vertebral body heights are preserved. No fractures are\n identified.\n\n On non-contrast enhanced images of the abdomen, there is low attenuation fluid\n around the liver. There is limited evaluation of solid organs without\n intravenous contrast. The spleen is normal in appearance. There is\n calcification of the aortic wall. There is focal coarse calcification\n involving the left adrenal gland. There is a tiny hyperdensity within the mid\n pole of the left kidney, which is not completely characterized on this study.\n There is a focal fluid-filled cystic region medial to the right renal hilum,\n which may represent a right UPJ obstruction. There is a focal area of well-\n circumscribed fluid and increased density inferior to the margin of the liver,\n which likely represents a sludge-filled slightly ectopic gallbladder. No free\n intraperitoneal air is seen.\n\n IMPRESSION:\n 1. No fracture of the lumbar spine are identified. Degenerative changes,\n including likely degenerative antero- and retrolisthesis are noted, as stated\n above.\n 2. There is a small amount of low attenuation fluid around the liver. This\n is of uncertain significance. There is limited evaluation of solid organs for\n injury without intravenous contrast.\n 3. There is a focal coarse calcification of the left adrenal gland.\n 4. There is a tiny hypodensity within the mid pole of the left kidney, which\n is not completely characterized on this study, and may represent a small\n hyperdense cyst - further evaluation with ultrasound could be obtained if\n indicated.\n 5. There is a prominent fluid filled structure adjacent to the mid pole of\n (Over)\n\n 2:46 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, malalignment\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the right kidney, which likely represents UPJ obstruction.\n 6. Given the small amount of free fluid within the abdomen, which is of\n uncertain significance, if there is any concern for traumatic intra-abdominal\n organ injury, further evaluation with a contrast-enhanced study should be\n obtained.\n\n These findings were discussed with Dr. at 5:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2193-02-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 951467, "text": " 5:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval hydrocephalus after post EVD clamp.***** please do at 5\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with\n REASON FOR THIS EXAMINATION:\n eval hydrocephalus after post EVD clamp.***** please do at 5am on ******\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE HEAD.\n\n INDICATION: 86-year-old female with EVD clamp, evaluate for hydrocephalus.\n\n TECHNIQUE: CT axial images were obtained from the skull base to the vertex\n without intravenous contrast.\n\n Comparison is made to the prior MR of and the prior head CT of .\n\n FINDINGS: As compared to the prior CT scan, there has been a decrease of the\n postoperative pneumocephalus within the posterior fossa as well as a decrease\n in the mass effect within the cerebellum and upon the fourth ventricle.\n Postoperative changes are still noted with mesh spanning the craniotomy\n defect posteriorly. The ventricular system is otherwise unchanged in size as\n compared to both the head CT of and the MRI of the brain of . As\n before, there is a right frontal shunt catheter, which crosses the midline and\n terminates in the left lateral ventricle.\n\n There has been no significant change in the confluent hypodensities involving\n the periventricular and subcortical white matter of both cerebral hemispheres,\n consistent with small vessel infarction. No new intracranial hemorrhage or\n major vascular territorial infarct is seen. There is a minimal amount of\n blood layering in both lateral ventricles posteriorly.\n\n IMPRESSION: Improvement in posterior fossa postoperative pneumocephalus as\n well as mass effect. Overall, there has been no significant change in\n ventricular size from the prior examinations.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-20 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 950810, "text": " 2:45 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture, malalignment\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture, malalignment\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old woman status post fall, evaluate for fracture or\n malalignment.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial images of the thoracic spine were obtained with coronal and\n sagittal reformatted images\n\n CT T-SPINE: No fracture or subluxation is identified. There is limited\n evaluation of intrathecal contents; however, the contour of the thecal sac is\n within normal limits. Minimal degenerative change and endplate depression is\n noted involving the superior endplate of T5, without significant vertebral\n body loss of height. Heavy atherosclerotic calcification is seen along the\n course of the aorta. There is bilateral bibasilar atelectasis and a small\n amount of pleural fluid bilaterally. An ET tube is seen, with the tip in the\n mid trachea.\n\n IMPRESSION: No fracture or dislocation is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-21 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 950877, "text": " 4:49 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: r/o tumor. please include DWI sequence per surgeon request.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with traumatic head bleed s/p evacuation\n REASON FOR THIS EXAMINATION:\n r/o tumor. please include DWI sequence per surgeon request.\n ______________________________________________________________________________\n FINAL REPORT\n Comparison is made with prior head CT from .\n\n ROUTINE MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM.\n\n FINDINGS:\n\n Again noted are changes from the left suboccipital. There is a postoperative\n cavity in the left cerebellum with a hemorrhage fluid level within it.\n Postoperative air within the cavity has decreased, replaced by hemorrhage in\n the posterior aspect of the cavity. There is a small focus of restricted\n diffusion along the medial and inferior aspect of the operative cavity\n suggesting an acute infarct. Unchanged, there are small foci of hemorrhage in\n the left frontal and left parietal sulci. There is a right frontal\n ventriculostomy catheter with its tip in the midline. The ventricles are\n prominent, but stable.\n\n There continues to be mass effect on the fourth ventricle, which is displaced\n to the right. There is a tiny right parietal extraaxial hematoma, without\n mass effect.\n\n There are fluid levels in the left maxillary sinus and mild bilateral\n scattered mastoid opacification.\n\n There are periventricular hyperintensities, which likely represent small\n vessel ischemic sequela.\n\n There is FLAIR sulcal hyperintensity in bilateral high convexities, which may\n be related to minimal subarachnoid hemorrhage or high-inspired FiO2.\n\n IMPRESSION:\n\n Cavity in the left cerebellum from evacuation of hematoma with continued\n surrounding edema and mass effect in the fourth ventricle. There is a very\n small focus of acute ischemia along the medial and inferior aspect of the\n cavity.\n\n Ventricles are prominent, but stable.\n\n\n (Over)\n\n 4:49 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: r/o tumor. please include DWI sequence per surgeon request.\n Admitting Diagnosis: SUBDURAL HEMATOMA\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2193-02-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 950808, "text": " 2:44 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check post op - r/o bleed, check drain placement\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p suboccipital crani for left cerebellar hemorrhage and\n placement R EVD\n REASON FOR THIS EXAMINATION:\n please check post op - r/o bleed, check drain placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old woman status post suboccipital craniotomy for the\n left cerebellar hemorrhage and placement of a right ventricular drain,\n evaluate for postoperative bleeding.\n\n COMPARISON: Prior study from the same day, .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: Patient has undergone interval left occipital\n craniotomy, and placement of a mesh device. Postoperative changes, including\n pneumocephalus can be seen within the left posterior fossa. There has been\n evacuation of the previously seen hematoma adjacent to the left cerebellum.\n The caliber of the ventricles is stable in appearance. No new areas of acute\n hemorrhage are seen within the postoperative bed. A tiny focus of parenchymal\n contusion is seen within the left parietal lobe. Additionally, there is a\n tiny focal hyperdensity within the sulcus in the region of the left parieto-\n occipital region which likely represents a tiny amount of subarachnoid\n hemorrhage. These are stable in size in comparison to prior study, and there\n are no changes in appearance consistent with evolution of the blood products.\n There has been interval placement of a ventricular drain traversing the right\n frontal lobe, with the tip within the left lateral ventricle. Again seen are\n low-attenuation changes within the periventricular white matter, consistent\n with changes related to chronic small vessel ischemic infarct.\n\n Again seen are fractures involving the left maxillary sinus, left lateral wall\n of the orbit, and the zygomatic arch on the left, which are stable in\n comparison to prior study.\n\n IMPRESSION: Interval evacuation of a left cerebellar hemorrhage, and\n performance of a mesh craniotomy. Stable caliber of the ventricles\n bilaterally. Placement of a right ventricular drain. No new areas of\n intracranial hemorrhage are identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-20 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 950809, "text": " 2:45 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P FALL EVAL FOR FRACTURE\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture, malalignment\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old woman status post fall, evaluate for fracture or\n malalignment.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images of the cervical spine were obtained with\n coronal and sagittal reformatted images.\n\n CT C-SPINE: Again seen are postsurgical changes within the posterior fossa\n from recent mesh craniotomy overlying the left occipital region. There is\n soft tissue air tracking posterior to the spine, and within the spinal canal,\n related to recent surgery.\n\n No cervical spine fractures are seen. Extensive degenerative changes are seen\n within the mid cervical spine level, including prominent posterior and\n anterior osteophyte formation at the C4-7 levels. There is no evidence of\n spondylolisthesis or fracture.\n\n There is an ET tube, with the tip positioned within the mid trachea. Within\n the visualized portion of the lung apices, no pneumothorax is seen. The soft\n tissues are within normal limits.\n\n There is limited evaluation of the intrathecal contents on CT; however, the\n contour of the thecal sac appears to be within normal limits.\n\n IMPRESSION:\n 1. Post-surgical changes are seen related to the patient's recent the left\n occipital mesh craniotomy.\n 2. No fracture or subluxation of the cervical spine is obtained. Degenerative\n changes are seen at multiple levels.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-02-22 00:00:00.000", "description": "Report", "row_id": 1311607, "text": "Progress Note, 1900-0730\nNo significant events overnoc.\n\nReview of Systems:\n\nRESP: Face tent 15L, FiO2 70%. 7.47/40/108/30. SpO2 95-99%, RR 11-16, LS clear to coarse bilaterally. Expectorates sm to moderate amts tannish/rusty secretions. + productive cough. No c/o SOB.\n\nCVS: NSR to ST, no ectopy. HR 76-113, SBP 117-158, Tmax 99.3, Hct 28.1, INR 1.2, WBC 12.6. +PP, cap refill <3 sec. Pt ordered for lopressor 10 mg Q6H to maintain SBP <160. For sustained period of time SBP 160-170s, pt was given 10 mg hydralazine x1 w/ decrease in SBP to 140s. Receiving Vit K x3 days. Heparin & pboots for prophylaxis.\n\nID: Afebrile. Clindamycin x 5days for facial fxs & cefazolin for EVD.\n\nNeuro: A+Ox1- to self only, GCS (e4-3,v2-4,m6), garbled, slurred speech. Follows commands appropriately. MAEs, however demonstrates L sided weakness esp in pt unable to lift & hold extremity. Pupils 3mm/3mm, briskly reactive. Slept for majority of night. C/O R hip discomfort, given 0.5mg Morphine Sulfate x1 & repositioned w/ moderate relief of discomfort. R ventric @ 15cm H20 above tragus, open to drain- drained total of 12 cc clear fluid- ICP 6-11, CPP 71-92. C-collar intact.\n\nGI: Abd soft, NT, ND. Hypoactive BS. No BM. NPO. FS 120-140s, coverage required w/ RISS. PPI for GI prophylaxis.\n\nGU: Foley draining adequate amts c/y/u. u/o 30-100 cc/hr. BUN 15, creatinine 0.6, Na 141, K 4.1, Mg 2.4.\n\nAccess/Skin: PIV x2, Lf Radial Aline. Craniotomy incision to posterior neck- dsg C/D/I. Coccyx pink, duoderm applied to stage 2 pressure sore on upper back- otherwise skin intact.\n\nSocial: Sons & into see pt yesterday.\n\nPlan of Care: Wean face mask settings/FiO2 as appropriate\n Maintain SBP <160\n Q4H neuro assessments\n Clear c-spine\n ? transfer to neuro stepdown\n" }, { "category": "Nursing/other", "chartdate": "2193-02-20 00:00:00.000", "description": "Report", "row_id": 1311603, "text": "TSICU Nursing Admission Note\nPt is an elderly female who lives in due to history of falls and mild dementia. History also significant for HTN, skin CA, and DVT 6 months ago for which pt was taking coumadin. Pt fell at her , was alert and without change in mental status. She was taken to for nose bleed where CT revealed right cerebellar SDH. She was transfered to for evacuation.\n\nPt admitted to TSICU after craniotomy and evacuation of SDH. Ventriculostomy in place. Pt sedated on propofol. CT of head, neck and spine done postoperatively.\n\nROS:\n\nNeuro - Pt sedated on propofol to tolerat intubation and mechanical ventilation. ICP -3 to 5, not draining at 10 above tragus. When lightened for neuro exams, pt opens eyes to stimulation, does not attend. PERRL. Moves spontaneously to remove wires and gown, but does not follow commands. Moving extremities x4. Logroll maintained. C-collar on. CT of spine pending.\n\nCV - HR 60s to 70s, SR to sinus arrhythmia. Occ PACs. Nitroprusside to keep SBP < 140. Peripheral pulses palpable. No edema.\n\nResp - Tolerating current vent settings on propofol. Lungs CTA. Dark bloody drainage suctioned from mouth.\n\nGI - Abdomen flat, absent bowel sounds.\n\nGU - Large amounts clear urine after mannitol and lasix in OR.\n\nHeme - 2 units FFP to reverse coumadin before OR.\n\nSocial - Sons in to visit. Son is HCP, document in chart. Other son is rehab physician.\n\nA - Neuro exam stable post-operatively.\n\nP - Continue serial exams. Propofol as needed for sedation. Monitor ICP. Preventive skin care. VAP prevention. Continue to support family. Await final read of CT to clear TLS.\n" }, { "category": "Nursing/other", "chartdate": "2193-02-21 00:00:00.000", "description": "Report", "row_id": 1311604, "text": "Progress Note, 1900-0730\nShift Events: Head MRI r/o tumor\n\nReview of Systems:\n\nRESP: A/C 500 x12, FiO2 40%, peep 5. SpO2 >99%, RR 12-20. 7.44/43/172/30/5. LS clear bilaterally. Sxn for minimal amts thick rusty/bloody secretions.\n\nCVS: NSR, no ectopy. HR 70-83. Aline BP 113-150/43-57. Nipride weaned off, pt receiving hydralazine 10-20mg IV Q4H to maintain SBP 110-140. Tmax 99.3, however temp decreased to 96.3 at 0300, whereupon bair hugger placed on pt- temp gradually increased to 97.7. Hct 29.3. +PP. Cap refill <3 sec. Pboots for prophylaxis.\n\nID: Afebrile. Receiving clindamycin x5 days & cefazolin while EVD in.\n\nNeuro: Pt sedated on 60 mcg/kg/min propofol- when off sedation arouses to stimulation/voice. GCS (e2-3v1m6). Follows commands appropriately- sticks out tongue, squeezes hands, wiggles toes. MAES- demonstrates L sided weakness, esp in LLE. Pt able to lift and hold BUE & RLE, however only able to move LLE on bed. Pt able to localize pain, responds to simple questions w/ non-verbal cues. Pupils 2-3mm/2-3mm, briskly reactive. R Ventric @ 10cm H20 above tragus, open to drain. ICP 6-9, CPP 64-84. Ventric draining sm amts clear CSF. Pt on logroll precautions, c-collar intact. Receiving 1-2mg Morphine Sulfate PRN for relief of discomfort. MRI obtained for r/o tumor.\n\nGI: Abd soft, NT, ND. Absent BS. no BM. NPO. FS 140s, requiring sm amts insulin according to RISS.\n\nGU: Foley draining brisk amts c/y/u. u/o 30-140cc/hr. BUN 13, creatinine 0.7, Na 141, K 3.7, Ca 8.3, Mg 1.8. 10 mEq KCL currently infusing, 2nd bag to be infused & Mg waiting to be repleated w/ 2 gm Magnesium Sulfate. NS w/ 20 KCL infusing at 80cc/hr.\n\nAccess/Skin: PIV x2, Lf radial Aline wnl. Pink, stage 2 pressure sore noted along upper mid back- duoderm applied. Craniotomy incision along posterior neck- primary OR dsg dry/intact.\n\nSocial: Pt lives in facility, has 2 sons- , spoke w/ him last night & updated him as to POC.\n\nPlan of Care: Wean vent settings & extuabte when appropriate\n Maintain SBP 110-140\n Wean propofol\n Cont w/ Q1H neuro assessments\n Clear TLS & c-spine\n Replete lytes as needed\n" }, { "category": "Nursing/other", "chartdate": "2193-02-21 00:00:00.000", "description": "Report", "row_id": 1311605, "text": "Respiratory Care\nPt extubated after being on CPAP/PSV for approximately five hours. Placed on 50% face tent.\n" }, { "category": "Nursing/other", "chartdate": "2193-02-21 00:00:00.000", "description": "Report", "row_id": 1311606, "text": "TSICU Nursing Progress Note\nNeuro - Pt opens eyes to voice, attends speaker. PERRL. Nodding appropriately but not speaking since extubation. Follows commands with encouragement. Right arm strong and purposeful. Moves all extremities R>L. Ventriculostomy at 15 above tragus. Draining small amounts clear CSF. ICP 2-11.\n\nCV - HR 70s to 90s with occ PACs. SBP 100s to 140s by arterial line, hydralazine held this afternoon. Peripheral pulses palpable. No edema.\n\nResp - Extubated this afternoon to 50% mist tent. FiO2 increased after ABG showed PO2 of 80 with adequate ventilation. Lungs clear to coars. Strong cough productive of thick, dark bloody secretions.\n\nGI - Abdomen soft, hypoactive BS. No BM.\n\nGU - Brisk UOP via foley.\n\nEndo - RISS with minimal coverage.\n\nHeme - 2 units FFP given. Vitamin K ordered x3 days. PTT pending this PM.\n\nSocial - Son in to visit (rehab MD). He is already looking into facilities and eager to discuss rehab vs . Son will visit this PM.\n\nA - Neuro exam stable. Tolerating extubation.\n\nP - Continue serial exams. Continue to monitor resp status. Maintain SBP < 160. Continue to support pt and family.\n" }, { "category": "ECG", "chartdate": "2193-02-20 00:00:00.000", "description": "Report", "row_id": 227416, "text": "Sinus rhythm. Left atrial enlargement. Occasional atrial ectopy. ST segment\ndepression in the inferolateral leads, which may represent active ischemic\nprocess. Followup and clinical correlation are suggested. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2107-04-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 371307, "text": "Chief Complaint: SOB\n HPI:\n 68 yo M with severe COPD p/w shortness of breath and subjective fevers\n and chills for the past five days. He states that he has not felt well\n and has been taking his inhalers as directed. Patient called EMS and\n received nebs. Patient denies any chest pain or dizziness associated\n with his shortness of breath. Patient has had multiple\n hospitalizations requiring intubation in the past for COPD.\n .\n On arrival to the ED, patient appeared better. Patient had an episode\n where he desaturated to the low 80s and received Mg, solumedrol, nebs.\n His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with\n these measures. He also had transient altered mental status, that\n resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and\n received ceftriaxone and azithro.\n .\n On arrival to , patient denies any nausea, vomiting. Admits to\n diarrhea over past several days and persistent lumbar pain. All other\n ROS is otherwise negative\n" }, { "category": "General", "chartdate": "2107-04-14 00:00:00.000", "description": "Generic Note", "row_id": 371301, "text": "TITLE: Resp Care,\n Pt. placed on BIPAP 12/5 4L (home settings). O2 sat varied from\n 85-89% on O2 10L. O2 tubing changed, now on 8L. O2 sat 93%.\n" }, { "category": "Respiratory ", "chartdate": "2107-04-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 371406, "text": "Respiratory Care Service: Pt appears more comfortable this AM and close\n to baseline respiratory status. Wearing O2 at 2 LPM and SPO2 90-94 %\n and RR 18-24 BPM. BS are very diminished/ absent. Given tx\ns w/\n Albuterol and Atrovent SVN x 3 today. Pt will likely go to floor today.\n" }, { "category": "Physician ", "chartdate": "2107-04-14 00:00:00.000", "description": "Overnight Intensivist Admission", "row_id": 371294, "text": "TITLE: Overnight Intensivist Admission\n Agree with the resident note, and would like to add / emphasize:\n 68 y/o with severe COPD, recurrent COPD exacerbations, also CAD, last 1\n month ago. Since then had seen his pulmonologist and was doing well\n until a few days ago when he felt subjective chills, dyspnea, as well\n as cough with sputum. The chills are different from his usual COPD\n flares.\n In the ED here, he had an episode of O2 desaturation to the low 80\n and received IV Mg, as well as IV steroids and nebs, to which he had\n improvement. CXR demonstrated sl worsening of R inifiltrate and he\n received CTX and azithro.\n On arrival to the ICU, reported feeling improved dyspnea, still\n complained of feeling cold.\n PMHx, Allergies, Meds reviewed. Is on chronic prednisone, ppx bactrim\n On exam:\n Sat 97% on 4L NC. BP 110/50s, P70\n Sleeping but arousable, NAD.\n RRR S1 S2\n Decreased BS b/l\n Abd soft\n No edema.\n Labs with WBC 16.5 (4% eos), Hct 35, chemistries with bicarb 37\n (baseline), ABG 7.32/77 (in .36/65)\n CXR: Sl worsening in RLL retrocardiac opacity.\n A/P:\n 68 y/o with severe COPD/bronchiectasis, here with cough, subjective\n chills, leukocytosis. Agree with treatment for pneumonia (covering\n MRSA and pmonas). Notably, however area in R base appears to be waxing\n / and may not represent new active infection, with leukocytosis\n also has eosinophilia\n unusual for acute infection esp given chronic\n steroid use. Will also treat for COPD flare with steroids. Will\n consider repeat chest CT. Minimize O2 and consider NIPPV (is on at\n home in evenings, per pulm note).\n DNR/DNI per housestaff discussion\nwill discuss with his PCP / Pulm.\n" }, { "category": "Nursing", "chartdate": "2107-04-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 371390, "text": "68 yo M with severe COPD p/w shortness of breath and subjective fevers\n and chills for the past five days. He states that he has not felt well\n and has been taking his inhalers as directed. Patient called EMS and\n received nebs. Patient denies any chest pain or dizziness associated\n with his shortness of breath. Patient has had multiple\n hospitalizations requiring intubation in the past for COPD.\n .\n On arrival to the ED, patient appeared better. Patient had an episode\n where he desaturated to the low 80s and received Mg, solumedrol, nebs.\n His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with\n these measures. He also had transient altered mental status, that\n resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and\n received ceftriaxone and azithro.\n .\n On arrival to , patient denies any nausea, vomiting. Admits to\n diarrhea over past several days and persistent lumbar pain. All other\n ROS is otherwise negative\n Respiratory failure, chronic\n Assessment:\n Received pt on 4l nc , sat 95-97, , moving very little air upon\n auscultation, no crackles.pt able to talk in sentences\n Action:\n Weaned o2 encourage cdb nebs as scheduled.\n Response:\n Remained on n/c at 2l throughout day with scheduled nebs\n Plan:\n Nasel cannula in day goal 02 sats 88-92 pt wears 4l at home. Plan\n cpap at night nebs q6h and prn. w/u pna\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o pain in lumbar region of back. Rolling self off back. . Pt states\n usually takes percocet but gets constipated with .\n Action:\n Changed pain med to elixir oxycodone-tylenol per pt request\n Response:\n Excellent relief from 5 cc. pt able to participate in adl\n Plan:\n Cont to eval for pain and medicate PRN\n" }, { "category": "Physician ", "chartdate": "2107-04-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 371399, "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 No new clinical developments overnight.\n States to feel improved, approaching usual baseline.\n Now on 4 L NP (home regimen).\n History obtained from Medical records\n Allergies:\n Levofloxacin\n Last dose of Antibiotics:\n Vancomycin - 04:28 AM\n Cefipime - 05:27 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, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.2\nC (97.1\n HR: 90 (74 - 97) bpm\n BP: 120/61(76) {72/36(45) - 127/73(86)} mmHg\n RR: 24 (15 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 322 mL\n PO:\n TF:\n IVF:\n 322 mL\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.32/77/65/35/9\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, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , Diminished: Bilaterally, No(t) Absent : , No(t)\n Rhonchorous: ), Very distant BS with limited air movement.\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 9.8 g/dL\n 285 K/uL\n 224 mg/dL\n 0.6 mg/dL\n 35 mEq/L\n 5.6 mEq/L\n 20 mg/dL\n 92 mEq/L\n 133 mEq/L\n 31.2 %\n 7.5 K/uL\n [image002.jpg]\n 11:17 PM\n 05:18 AM\n WBC\n 7.5\n Hct\n 31.2\n Plt\n 285\n Cr\n 0.6\n TCO2\n 42\n Glucose\n 224\n Other labs: Mg++:2.3 mg/dL\n Assessment and Plan\n 68 yom severe COPD, now with recurrent COPD exacerbation\n COPD -- advanced; now with acute exacerbation. Making progress with\n current regimen. Continue current regimen, including steroids,\n supplimental oxygen.\n HYPOXEMIA\n goal SaO2 88-92%.\n LUNG INFILTRATE -- cough, subjective chills, fever, leukocytosis and\n new RLL infiltrate --> plan continue empirical antimicrobials.\n HYPERGLYCEMIA -- exacerbated by increased steroids and infection.\n Monitor glucose, with goal to maintain <150.\n CONSTIPATION -- maintain bowel regimen.\n PAIN, CHRONIC -- back pain; symptomatic management.\n NUTRITIONAL SUPPORT -- PO. Check phosphage level. Encourage intake.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:05 AM\n 22 Gauge - 05:38 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2107-04-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 371401, "text": "68 yo M with severe COPD p/w shortness of breath and subjective fevers\n and chills for the past five days. He states that he has not felt well\n and has been taking his inhalers as directed. Patient called EMS and\n received nebs. Patient denies any chest pain or dizziness associated\n with his shortness of breath. Patient has had multiple\n hospitalizations requiring intubation in the past for COPD.\n .\n On arrival to the ED, patient appeared better. Patient had an episode\n where he desaturated to the low 80s and received Mg, solumedrol, nebs.\n His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with\n these measures. He also had transient altered mental status, that\n resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and\n received ceftriaxone and azithro.\n .\n On arrival to , patient denies any nausea, vomiting. Admits to\n diarrhea over past several days and persistent lumbar pain. All other\n ROS is otherwise negative\n Respiratory failure, chronic\n Assessment:\n Received pt on 4l nc , sat 95-97, , moving very little air upon\n auscultation, no crackles.pt able to talk in sentences\n Action:\n Weaned o2 encourage cdb nebs as scheduled.\n Response:\n Remained on n/c at 2l throughout day with scheduled nebs\n Plan:\n Nasel cannula in day goal 02 sats 88-92 pt wears 4l at home. Plan\n cpap at night nebs q6h and prn. w/u pna\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o of lower back pain relieved with percocet 5mls.pt c/o of\n being constipated despite c/o of diarrhea before admission\n Action:\n Changed pain med to elixir oxycodone-tylenol per pt request\n Response:\n Excellent relief from 5 cc. pt able to participate in adl\nd. last\n percocet given at 1530.\n No BM as yet.\n Taking adequate po\n Plan:\n Cont to eval for pain and medicate PRN\n Am labs significant for k of 5.6 given albuterol nebs k at 1600 down to\n 5 no ekg changes noted.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ASTHMA/COPD EXACERBATION\n Code status:\n Height:\n Admission weight:\n 54.8 kg\n Daily weight:\n Allergies/Reactions:\n Levofloxacin\n Precautions: Contact\n PMH: Asthma, COPD, GI Bleed\n CV-PMH:\n Additional history: dyspnea, hx rectal bleeding, abd pain,\n diverticulitis, enlarged prostate\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:98\n D:55\n Temperature:\n 99\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 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 92% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,855 mL\n 24h total out:\n 600 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 05:18 AM\n Potassium:\n 5.0 mEq/L\n 04:09 PM\n Chloride:\n 92 mEq/L\n 05:18 AM\n CO2:\n 35 mEq/L\n 05:18 AM\n BUN:\n 20 mg/dL\n 05:18 AM\n Creatinine:\n 0.6 mg/dL\n 05:18 AM\n Glucose:\n 224 mg/dL\n 05:18 AM\n Hematocrit:\n 31.2 %\n 05:18 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: transferred with pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 411\n Transferred to: 1163\n Date & time of Transfer: 1900\n" }, { "category": "General", "chartdate": "2107-04-14 00:00:00.000", "description": "ICU Event Note", "row_id": 371375, "text": "Clinician: Resident\n Spoke with patient to confirm his code status. Understanding the risks\n and benefits, the patient clearly states his wishes to be DNR/DNI -\n which is that he does not want to be resuscitated or intubated.\n Total time spent: 15 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2107-04-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 371343, "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 No new clinical developments overnight.\n States to feel improved, approaching usual baseline.\n Now on 4 L NP (home regimen).\n History obtained from Medical records\n Allergies:\n Levofloxacin\n Last dose of Antibiotics:\n Vancomycin - 04:28 AM\n Cefipime - 05:27 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, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.2\nC (97.1\n HR: 90 (74 - 97) bpm\n BP: 120/61(76) {72/36(45) - 127/73(86)} mmHg\n RR: 24 (15 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 322 mL\n PO:\n TF:\n IVF:\n 322 mL\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -78 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.32/77/65/35/9\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, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , Diminished: Bilaterally, No(t) Absent : , No(t)\n Rhonchorous: ), Very distant BS with limited air movement.\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 9.8 g/dL\n 285 K/uL\n 224 mg/dL\n 0.6 mg/dL\n 35 mEq/L\n 5.6 mEq/L\n 20 mg/dL\n 92 mEq/L\n 133 mEq/L\n 31.2 %\n 7.5 K/uL\n [image002.jpg]\n 11:17 PM\n 05:18 AM\n WBC\n 7.5\n Hct\n 31.2\n Plt\n 285\n Cr\n 0.6\n TCO2\n 42\n Glucose\n 224\n Other labs: Mg++:2.3 mg/dL\n Assessment and Plan\n 68 yom severe COPD, now with recurrent COPD exacerbation\n COPD -- advanced; now with acute exacerbation. Making progress with\n current regimen. Continue current regimen, including steroids,\n supplimental oxygen.\n HYPOXEMIA\n goal SaO2 88-92%.\n LUNG INFILTRATE -- cough, subjective chills, fever, leukocytosis and\n new RLL infiltrate --> plan continue empirical antimicrobials.\n HYPERGLYCEMIA -- exacerbated by increased steroids and infection.\n Monitor glucose, with goal to maintain <150.\n CONSTIPATION -- maintain bowel regimen.\n PAIN, CHRONIC -- back pain; symptomatic management.\n NUTRITIONAL SUPPORT -- PO. Check phosphage level. Encourage intake.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:05 AM\n 22 Gauge - 05:38 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2107-04-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 371316, "text": "Chief Complaint: SOB\n HPI:\n 68 yo M with severe COPD p/w shortness of breath and subjective fevers\n and chills for the past five days. He states that he has not felt well\n and has been taking his inhalers as directed. Patient called EMS and\n received nebs. Patient denies any chest pain or dizziness associated\n with his shortness of breath. Patient has had multiple\n hospitalizations requiring intubation in the past for COPD.\n .\n On arrival to the ED, patient appeared better. Patient had an episode\n where he desaturated to the low 80s and received Mg, solumedrol, nebs.\n His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with\n these measures. He also had transient altered mental status, that\n resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and\n received ceftriaxone and azithro.\n .\n On arrival to , patient denies any nausea, vomiting. Admits to\n diarrhea over past several days and persistent lumbar pain. All other\n ROS is otherwise negative\n Respiratory failure, chronic\n Assessment:\n Received pt on 4l nc , sat 95-97, pt SOB with talking , moving very\n little air upon auscultation, no crackles. Per ew pt improved\n dramatically after nebs, solumedrol, and mag sulfate iinfusion. Cxr\n shows poss pna in LLL. Per house staff pt uses cpap and was placed on\n it.\n Action:\n Placed on cpap\n Response:\n Initially sat dropped to 84-87 on cpap but o2 tubing diameter\n increased and sat improved to 94-95. pt slept soundly until 0600\n sleeping through blood draw. Pt had not gotten good sleep in a few\n days\n Plan:\n Nasel cannula in daytime, pt uses 4l at home. Plan cpap at night nebs\n q6h and prn. w/u pna\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Poss pna per cxr pt c/o fever and chills x several days. T max 100.1\n orally. Pt found to be very diaphoretic after Tylenol-oxyconone admin.\n Pt also c/o diarrhea x several days\n Action:\n Monitored fever, changed linen, administered antibx. Last bld cult x2\n in ew. LEVOFLOXICIN ordered but pt states he has hx of rash allergy\n Response:\n Temp 97/4 axillary at o500. held levofloxicin. Pharmacy to address\n with MD\n Plan:\n Admin antibx and monitor fever. Checking freq for sweating. Await\n diagnosis\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o pain in lumbar region of back. Rolling self off back. Requesting IV\n mORPHINe. Pt had MS changes in ew with dyspnea. Pt states usually takes\n percocet but gets constipated with t.\n Action:\n Changed pain med to elixir oxycodone-tylenol per pt request\n Response:\n Excellent relief from 5 cc. pt able to move off side and onto back.\n Slept from approx 0200-0600\n Plan:\n Cont to eval for pain and medicate PRN\n" }, { "category": "Physician ", "chartdate": "2107-04-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 371285, "text": "TITLE:\n Chief Complaint: SOB\n HPI:\n 68 yo M with severe COPD p/w shortness of breath and subjective fevers\n and chills for the past five days. He states that he has not felt well\n and has been taking his inhalers as directed. Patient called EMS and\n received nebs. Patient denies any chest pain or dizziness associated\n with his shortness of breath. Patient has had multiple\n hospitalizations requiring intubation in the past for COPD.\n .\n On arrival to the ED, patient appeared better. Patient had an episode\n where he desaturated to the low 80s and received Mg, solumedrol, nebs.\n His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with\n these measures. He also had tranient altered mental status, that\n resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and\n received ceftriaxone and azithro.\n .\n On arrival to , patient denies any nausea, vomiting. Admits to\n diarrhea over past several days and persistent lumbar pain. All other\n ROS is otherwise negative.\n Allergies:\n Levofloxacin\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Alendronate 70 mg Tablet qsunday.\n Calcium Carbonate 500 mg \n Cholecalciferol 800 unit qday.\n Fluticasone-Salmeterol 250-50 mcg/Dose \n Lorazepam 0.5 mg qHS prn.\n Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO once a day.\n Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4H prn\n Pravastatin 40 mg DAILY\n Sertraline 50 mg Daily\n Tiotropium Bromide 18 mcg Capsule Daily\n Aspirin 81 mg qday.\n Trimethoprim-Sulfamethoxazole 160-800 mg qMWF\n Prednisone 30 mg qDaily\n Prednisolone Acetate 1 % Drops \n Lisinopril 5 mg qday.\n Albuterol Sulfate 2.5 mg /3 mL 2puffs Q4H\n Finasteride 5 mg qDaily\n Montelukast 10 mg qdaily\n Past medical history:\n Family history:\n Social History:\n CAD s/p NSTEMI in - cath showed 10% LMCA stenosis, TTE\n showed mild RV enlargement and preserved BiV function\n COPD on baseline 4L NC, nightly BiPAP 12/5\n Iron-deficiency anemia b/l Hct ~30%\n GERD\n Diverticulosis\n VRE and Pseudomonas UTI\n HTN\n Hyperlipidemia\n Chronic low back pain s/p L1-L2 laminectomy\n Bilateral cataract surgery\n BPH s/p TURP\n Mother w/ asthma, Alzheimer's disease. Father w/ cancer.\n The patient currently lives in with his wife. is\n initially from , now retired but previously employed as a\n mechanic for .\n Tobacco: Patient quit 30 years ago, previous 20 pk-year history. ETOH:\n Rare social use\n Illicits: + Marijuana use up to 1 to 2 marijuana cigarettes daily\n Review of systems:\n Flowsheet Data as of 02:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 90 (90 - 97) bpm\n BP: 100/48(61) {100/48(61) - 103/51(64)} mmHg\n RR: 26 (26 - 26) insp/min\n SpO2: 92%\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 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.32/77/65//9\n Physical Examination\n GENERAL: Pleasant, well appearing male 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 not appreciated.\n LUNGS: Mild basilar crackles, poor air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A4/8/ 11:17 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 TC02\n 42\n Assessment and Plan\n 68 y/o M with a history of COPD who presents with COPD exacerbation\n .\n #. COPD: Patient is currently at basline, on 4L NC. Patient's last\n ABG was 7.32/77/65/42 and is consistent with his propensity to be a CO2\n retainer. Patient's mental status was altered while he was in the ER,\n and may be related to either hypercapnea or hypoxia, but is now\n resolved. He is currently on his home oxygen requirement.\n - Continue albuterol nebs q4hrs prn\n - Continue montelukast daily\n - Ipratropium Bromide Neb q6hrs prn\n - Start IV Methylprednisolone 125mg q8hrs for 3 days\n - Continue Bactrim M-W-F\n .\n #. Hospital Acquired Pneumonia, RLL: Patient had 5 days of subjective\n fevers and chills, has leukocytosis, and has hospitalization within\n past three months. Will treat as HAP and cover for MRSA, and have\n double gram negative coverage.\n - Start Vancomycin, Cefepime, Levofloxacin\n - Trend WBC and lactate\n .\n #. CAD: Stable.\n - Continue ASA, Statin, ACE-I\n .\n #. Glaucoma:\n - Continue eye drops\n .\n FEN: Regular diet\n .\n PPX:\n -DVT ppx with SCH\n -Bowel regimen with senna\n -Pain management with percocet elixer\n .\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI - confirmed, but will readdress in am again as\n patient has had multiple intubations in past\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: Pending\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "ECG", "chartdate": "2107-04-13 00:00:00.000", "description": "Report", "row_id": 128348, "text": "Baseline artifact makes P and T wave morphology difficult\nSinus tachycardia\nShort PR interval\nIncomplete right bundle branch block\nLow QRS voltage in limb leads\nSince previous tracing of , sinus tachycardia, baseline artifact, and\natrial premature complexes are absent\n\n" }, { "category": "ECG", "chartdate": "2107-04-18 00:00:00.000", "description": "Report", "row_id": 128345, "text": "Sinus tachycardia with atrial premature complexes\nIncomplete right bundle branch block\nLow QRS voltage is nonspecific but clinical correlation is suggested\nSince previous tracing of the same date, may be no significant change but\nbaseline artifact on previous tracing makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2107-04-18 00:00:00.000", "description": "Report", "row_id": 128346, "text": "Baseline artifact\nSinus tachycardia with atrial premature complexes\nIncomplete right bundle branch block\nLow QRS voltage is nonspecific but clinical correlation is suggested\nSince previous tracing of , sinus tachycardia and atrial ectopy are now\npresent\n\n" }, { "category": "ECG", "chartdate": "2107-04-14 00:00:00.000", "description": "Report", "row_id": 128347, "text": "Sinus rhythm. Generalized low voltage. Early R wave progression. Since the\nprevious tracing of the rate has decreased. Axis is less right\ninferior. Artifact is less prominent.\n\n" }, { "category": "Radiology", "chartdate": "2107-04-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072154, "text": " 6:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with sob, copd\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , AT 18:28 HOURS.\n\n HISTORY: Shortness of breath and COPD.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Although the lungs again demonstrate features suggestive of\n underlying obstructive lung disease, the actual lung volumes are somewhat\n diminished, particularly in the lung bases. The somewhat irregular focus of\n opacity in the medial right lung base has grown and the margins remain\n irregular. There is suggestion of much smaller focus of possibly scarring\n versus nodule medially in the left lung base as well overlying the left heart\n shadow on frontal view. No definite focal consolidation is noted elsewhere.\n There is no superimposed edema. Again seen is a tortuous atherosclerotic\n aorta. The cardiac silhouette is within normal limits for size. No definite\n effusion is noted, although a meniscus is again seen in the right. This is\n felt more likely due to chronic scarring rather than effusion. Degenerative\n changes are noted throughout the thoracic spine. There is no underlying\n pneumothorax.\n\n IMPRESSION: The focus in the retrocardiac right lower lobe has increased in\n size. While this may be indicative of either a slowly-developing pneumonia or\n possibly aspiration, possibility of an underlying bronchoalveolar cell\n carcinoma cannot be dismissed. It is likely prudent to obtain a followup CT\n scan to compare with the one obtained on soon as an\n outpatient.\n\n" }, { "category": "Radiology", "chartdate": "2107-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1072208, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with COPD exacerbation, PNA\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD exacerbation and pneumonia.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The cardiomediastinal silhouette is within normal\n limits. The pulmonary vasculature is normal. In the right and left lower\n lobes there is mild tram tracking and bronchial wall thickening consistent\n with bronchiectasis. Patchy bibasilar opacities likely representing\n aspiration. No pleural effusion or pneumothorax.\n\n IMPRESSION:\n\n 1. Bibasilar bronchiectasis.\n\n 2. Patchy bibasilar opacities likely representing aspiration/aspiration\n pneumonia.\n\n\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2140-12-27 00:00:00.000", "description": "Report", "row_id": 1317324, "text": "NURSING NOTE: 7A-7P\n PT RECEIVED ON VERSED GTT AT 8MG/H AND FENTANYL AT 125MCG/H. SEDATION WEANED TODAY IN ATTEMPT TO EXTUBATE. GTTS NOW AT 2MG/H AND 50MCG/H. PT REMAINS SEDATED. AROUSES TO STIMULI BUT STILL UNABLE TO FOLLOW COMMANDS AMD INTERACT. PERLA. MAE.\n\nRESP- REMAINS INTUBATED ON A/C 450X12 40% PEEP5 SRR OCCASIONAL 2-3 BPM. SATS MAINTAINED 95-100%. SUCTIONED FOR MODERATE AMOUNTS CLEAR TO WHITE SECRETIONS. LARGE AMONUT OF ORAL SECRETIONS SEEM TO BE TRIGGERING PT TO COUGH.\n\nCV- HR 90- PVC/S OCCASIONAL. SBP 89-110 WHEN CALM. WHEN AGITATED DUE TO COUGHING SBP UP TO 170'S. K 4.1 THIS AM, GIVEN 20MEQ IV KCL X1.\n\nGI- ABD SOFT HYPO BS. NO STOOL. TF HELD MOST OF DAY FOR ? EXTUBATION. TF WERE RESTARTED AT 1800.\n\nGU- FOLEY PATENT FOR ADEQUATE AMOUNTS OF CLEAR YELLOW URINE.\n\n- OFF INSULIN GTT SINCE 8AM. FSBS 80-120. AT 1800 FSBS WAS 54. DR MADE AWARE AND 1 AMP DEXTROSE 50% IV WAS GIVEN\n\n SISTER CALLED, WAS UPDATED BY NSG. FIANCE VISITED. AUNT FROM CALLED AND WAS REFERRED TO PT'S SISTER FOR INFO.\n\nDISPO- REMAINS IN MICU, FULL CODE. CONTINUE TO KEEP SEDATION LIGHT IN HOPES OF EXTUBATION TOMORROW. PER DR PROPOFOL CAN BE USED IF NECESSARY FOR AGITATION RATHER THAN INCREASING VERSED AND FENTANYL.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317318, "text": "MICU Nursing Progress Note\nPt had 3pt hct drop now 25.9, MD incresed to 450 to attempt to fix metabloic alkalosis and decrease CO2 level of 51. Pts RSBI 43.5\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317319, "text": "Resp. Note\nPt is sedated on vent support. ACV 450/12/50%/+5. Gases in am acceptable-see flowsheet. BBS course. Received albuterol/atrovent prn. Sx thick yellow.\nPlan-wean fio2, wean sedation, switch to PSV, then SBT as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317320, "text": "MICU-B NPN 0700-1900\n Pt. remains intubated and sedated on Versed @ 2 mg./hr and Fentanyl @ 100 mcg./hr. Pt. requiring numerous boluses t/o shift as well for agitation, sitting upright in bed. Given 1-2 mg. boluses Versed & 50-100 mcg. boluses Fentanyl. Fentanyl increased this a.m as well from 50 mcg. to current setting of 100 mcg/kg. Pt. opening eyes spontaneously, making purposeful movements, but not following commands; will withdraw to pain. MAE+\n\nC/ Pt. with HR 90'S-130'S, NSR-ST, increased with stimulation. PAC'S and PVC's noted. EKG per team done this eve. Pt. to be started on Haldol prn., need to monitor for QTC ^ since when pt. started on Haldol before, QTc increased. ABP 80-90/50's (MAP >60). CVP 7-6. ACE- inhibitor not being started as of yet d/t low bp. Peripheral pulses palpable.\n\nResp. - Pt. remains on A/C 450/12/ .40/ PEEP 5. Last ABG @ 0900; See care vue for ABG results. Per team no vent changes today. Pt. with clear-coarse/ clear-coarse/diminished. Sx. t/o shift for mod.-copious secretions; thick,yellow. ETT rotated.\n\n Pt. with OGT in place/ position verified by auscultation/patent currently delivering 30 cc/hr. Had been off since 0800-just restarted @ 1800. Pt. with high residuals; 170 this a.m. ; 50 @ 1100 with TF off, and kept off due to pending line placement. Pt. with soft, NTND abd. with hypoactive BS. No stool again this shift. Given Dulcolax suppository this am with standing order Colace and Senna. On Reglan for motility.\n\n Pt. with indwelling foley; patent draining cloudy, yellow urine. U/O > 100/HR. Pt. with pelvic exam yest. which appreciated a golfball size mass/ sent to pathology for testing/results pending, mass appeared to be comprised of tissue. Trich. & chlamydia tests also pending. U/S also performed yes., results benign. Pt. continues to have foul vaginal odor, no discharge noted.\n\n Pt. continues on Insulin gtt. being titrated with Q1-2/hr FS to attain goal BS 80-120. FS very labile. Down to 51 this afternoon requiring amp. D5W. Insulin gtt. off for a few hours and restarted @ 1600 @ 1 U/hr. . stim. test done early a.m. before start of shift; results pending as well. Pt. with hyponatremia/ yest. osmo's sent; urine and blood, serum osmo. 287 and urine osmo. 225. Bactrim being diluted in NS instead of D5W now.\n\n Pt. with a.m. HCT 24.9, down from yest. of 29.6. Ordered for 2U PRBCs. First Unit given. CLOT sent early a.m. Consent on file. Anemia w/u added on to a.m. labs/pending.\n\n Pt. with TMAX. 100.0 axillary this a.m. 2 sets blood cx's sent. Both peripheral sticks. Pt. grew gram + cocci with last cx. Line re-sighted today @ 1600. Per chest x-ray, needed to be pulled back a bit; second chest x-ray pending. RIJ triple-lumen remains until xray read, tip be be sent for cx. when removed. Started on Vanco. this a.m. @ 0500. Continues on Bactrim for PCP. dc'd this eve.\n\n Pt. with RIJ triple-lumen, to be dc'd when line placement of new site okayed. New LSC\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317321, "text": "MICU-B NPN 0700-1900\n(Continued)\ntriple-lumen in place, site wnl. New RAC in place, patent, site wnl. (R) Art. line re-wired yest. patent, good draw, good wave form, site wnl.\n\nSocial - Pt's. sisters called today, and son in to visit. All updated on pt's current status and continued plan of care.\n\n , ,RN\n" }, { "category": "Nursing/other", "chartdate": "2140-12-28 00:00:00.000", "description": "Report", "row_id": 1317325, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT REMAINS SEDATED ON FENTANYL 50MCG/HR AND VERSED 2MG/HR. PT WAS NOT W/ EITHER MED OVERNIGHT PER TEAM. PT AGITATED AND RESTLESS AT . PT GIVEN 5MG IV VALIUM W/ NO EFFECT. AT 2100 PT STARTED ON PROPOFOL GTT. GTT CURRENTLY AT 25MCG/KG/. PT WILL AT TIMES SIT UP IN BED, SBP INCREASES TO 160'S. PT NOT ABLE TO FOLLOW COMMANDS. PERLA2MM.\n\nRESP: PT RECIEVED ON AC 450X12, PEEP5 40%. PT OVERBREATHING BY 1-3B/M. AM GAS 7.41/39/103. RISBI THIS AM 85, PT FAILED BREATHING TRAIL. PT REMAINS ON ORIGINAL SETTINGS. PT Q1HR FOR COPIUS AMTS ORAL AND ETT SECRETIONS, THIN WHITE/CLEAR. 02 STAS 89-100%. PT W/ AGITATION. LS CLEAR.\n\nCV: HR 70-110'S ST, PT HAS OCCASIONAL PAC'S. SBP 70-110'S. SBP DECREASED TO 70'S AFTER PROPOFOL BOLUS. 250CC NS FLUID BOLUS W/ GOOD RESULT. MAX TEMP 102.6, BLOOD CULTURES SENT. PT GIVEN 650 TYLENOL. MAG 1.5, 2GM GIVEN, AM MAG 1.9 REPLEATED W/ ANOTHER 2GM. AM K+ 3.5 CURRENTLY BEING REPLEATED W/ 20MEQ.\n\nGI/GU: ABD SOFT, HYPO BS. PT GIVEN DOSE LACTULOSE AT 2100. AT 0500 PT HAD LG GOLDEN MUCOUS STOOL. RECTAL BAG APPLIED. PT TOLERATING TF, LOW RESIDUALS, TF INCREASED TO 30CC/HR AT 0400. FOLEY INTACT DRAINING YELLOW URINE W/ SEDIMENT. UAC&S SENT. U/O ~60CC/HR UNITL 0300 PT BEGAN TO AUTO DIURESS. PT HAS PUT OUT 1L SINCE O400.\n\n: INSULIN GTT HAS BEEN OFF ALL SHIFT. BS 100-120'S.\n\nDISPO: PLAN IS TO WEAN OFF SEDATION AND PLAN TO EXTUBATE. PT REMAINS ON AC AND HAS COPIUS AMTS SECREATION, NOT SURE IF PT IS READY FOR EXTUBATION TODAY. PT FINALLY MOVING BOWELS, CONTIUE W/ BOWEL REGIME. NO CONTACT FROM FAMILY OVERNIGHT. PT REMAINS A FULL CODE IN MICU.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-27 00:00:00.000", "description": "Report", "row_id": 1317322, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: RECEIVED PT SEDATED ON FENTANYL 100MCG/HR AND VERSED 2MG/HR. MULTIPLE TIMES OVERNIGHT PT HAD EPISODES OF AGITIATION, SITTING UP IN BED, ON ETT. PT WAS W/ BOTH SEDATIVES, AND VERSED WAS INCREASED TO 10MG/HR AND FENTANYL 150MCG/HR. TEAM WAS AWARE. GAVE 2MG HALDOL AT 2100 W/ NO EFFECT. GTT CURRENTLY AT VERSED 8MG/HR AND FENTANYL AT 125MCG/HR. PT WILL BECOME AGITATED W/ STIMULI, W/ SEDATION FOR PT CARE W/ LITTLE RESULT.\n\nRESP: NO CHANGES MADE TO VENT OVERNIGHT. PT REMAINS ON AC 450X12 PEEP5 40%. PT BY 1-2B/M. AM ABG 7.45/37/111. PT SUCTIONED FOR MOD AMT WHITE SECREATIONS. LS DIMINSHED AT BASES. O2 SATS 97-100%.\n\nCV: HR 80-110'S NS, RARE PAC'S. SBP 80-160'S. PT HAD 5 BEAT RUN VTACH AT 2130. CHEM10 SENT. MAG 1.7 REPLACED W/ 2GMS MAG. PT 2ND UNIT PRBC'S OVERNIGHT. AM HCT 29.5. MAX TEMP 99.9.\n\nGI/GU: AND SOFT, HYPO BS, NO BM. PT WAS GIVEN DOSE LACTULOSE OVERNIGHT W/ NO RESULT. RECEIVED PT ON TF VIA OGT AT 30CC/HR. PT HAD NO RESIDUALS AT , AT 2400 PT HAD 150CC RESIDUAL. TF HELD. 0400 25CC RESIDUAL, TF RESTARTED AT 10CC/HR. FOLEY INTACT DRAINING ~100CC/HR YELLOW CLOUDY URINE.\n\n: PT HAS BEEN ON AND OFF INSULIN GTT THROUGH OUT NIGHT. BS 75-140'S. LAST BS 110 GTT HAS BEEN OFF SINCE 0100.\n\nACCESS: RIGHT SUBCLAVIN TLC D/C'D AT 2100. TIP SENT FOR CULTURE. PT HAS LEFT SUBCLAVIN AND RIGHT .\n\nDISPO: PLAN IS TO CONTNIUE TO MONITOR TEMPS, ATTEMPT TO DECREASE SEDATION. NO CONTACT FROM FAMILY OVERNIGHT. PT REMAINS A FULL CODE IN MICU.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-27 00:00:00.000", "description": "Report", "row_id": 1317323, "text": "Resp. Note\nRemains intubated on vent support. Current settings ACV 12/450/+5/40%. Receiving atrovent and albuterol inhalers Q4. BBS mildly course. NSG presently weaning sedation. Pt gets extremely agitated when sedation is decreased. When Pt more awake the plan is to switch to PSV as quickly as tolerated then extubate.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-25 00:00:00.000", "description": "Report", "row_id": 1317312, "text": "npn 7-7pm\n\nneuro: Pt is sedated on fentanyl 50mcg/h and versed 4mg/h. Receiving diazepam q2-3h prn. Weaning versed and replacing with diazepam. Pt does not follow commands,moves all extremities on the bed, PERL.\n\nresp: 12/400/40% PEEP 5. RR 15-16 with current sedation. LS coarse. Suctioned fro thick white sputum.\n\nCV: Sinus tach 100-120 with frequent PVC. Mag and K repleted.\n\nAccess: R SC TLC and L radial .\n\nGI/GU: Belly soft with + BS. TF at goal (residual at 1600 was 100cc).\nPatent foley with good u/o.\n\nGyn: Multiple pelvic exams today. Dr performed initial exam and found a golf ball size, black piece of what looked like tissue. It was sent for pathology. Gyn consulted and examined pt. Pt also had an a pelvic US.\n\n: On and off insulin gtt today. Gtt currently\n\nSkin: Small open area near anus, no drainage.\n\nSocial: Pt sister called and was updated by RN. Sister will be in to visit Thursday.\n\nPlan: Monitor BS, wean versed to off, stim test in am.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-25 00:00:00.000", "description": "Report", "row_id": 1317313, "text": "Resp. Care;\n Pt. remains intubated, sedated and on vent.support-A/C 400 x 12 50% 5P. Resp. is stable. Albut/ atrovnet MDI's q4-6. Please see flow sheet for more information.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317314, "text": "Respiratory Care:\n\nPatient remain intubated/sedated on mechanical support. Vent settings Vt 400, A/c 12, Fio2 50%, and Peep 5. PAP/Plateau 18/14. Bs coarse bilaterally. Minimal secretions. Sx'd for scant amount of thick white sputum. Albuterol/Atrovent MDI's given Q4hr. Adequate O2 sats. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317315, "text": "Repeated Abg results this am 7.38, 51, Fio2 128, 31 +4. Vt increased to 450.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317316, "text": "MICU Nursing Progress Note\nNeuro: Pt con't to be very comfprtably sedated on 2mg/hr versed, 50mcg/hr of fentanyl and 20mg valium via NGT q2 hr. Pt opens eyes to verbal command and still MAE. Pt does not follow commands.\n\nCardiac: Pt in SR/ST HR 90-110 with frequent PAC's and occ PVC's. Pts BP essentially high 80-110's sys, with MAP > 60 at all times. Pts CVP initially10, current 6, given slow 500 cc bolus.\n\nResp: Pt remains intubated on AC 12*400, .4%, 5/. AM ABG is good! Pt occ overbreathing vent. Pt suctioned sess frequently for mod amt of thick white sputum. BS coarse and clear with suctioning. O2 sat 98%.\n\nGI: Pt on promote with fiber at goal of 60cc/hr. Pt had high residuals so TF held for about 3hr. Tolerating TF currently. Pt has not had BM in multiple days, given lactulose PRN without effect ON. BS present, abd soft.\n\nGU: Pt had good u/o until about 0300 when in dropped below 30. Pt given 500 cc's over 1hr, results of that are still pending. Pt has f/c with yellow cloudy urine, MD aware.\n\n: Pts BG stable with insulin gtt at 1u/hr. BG q2hr. Core stem test done this am.\n\nID: Pt con't on bactrium and started on flagyl, pt given one time dose of vanco for mass found in vagina. Pt remains afebrile.\n\nSkin: Pt has small stage 1 decub around anus, OTA.\n\nAccess: Pt has R IJ TL and R rad , changed on .\n" }, { "category": "Nursing/other", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 1317317, "text": "MICU Nursing Progress Note\nPt had 3pt hct drop now 25.9, MD incresed to 450 to attempt to fix metabloic alkalosis and decrease CO2 level of 51. Pts RSBI 43.5\n" }, { "category": "Nursing/other", "chartdate": "2140-12-21 00:00:00.000", "description": "Report", "row_id": 1317307, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT CONTINUES ON ATIVAN GTT AT 15MG/HR. NO BOLUSES OF SEDATION GIVEN. PT NOT ABLE TO FOLLOW COMMANDS, WILL NOT OPEN EYES TO PAIN. PT WITHDRAWS FROM PAIN STIMULI. SPONTANEOUS MOVT NOTED IN BIL EXTREMITIES.\n\nRESP: PT CONTINUES ON FULL FACE MASK BIPAP AT PS 15/5 40%, AT RATE 10-45. TV 400-500. O2 SATS 95-100%. LAST ABG 7.46/31/67. PT HAS REQUIRED FREQUENT ENT SUCTION OF WHITE FROTHY SPUTUM. LS COARSE BIL.\n\nCV: HR 110-140'S ST, W/ OCCASIONAL PAC'S. SBP 80-120. PT AFEBRILE, MAX TEMP 99 AX.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT REMAINS NPO. FOLEY INTACT DRAINING CLEAR YELLOW URINE ~150CC/HR. PT WAS GIVEN 20IV LASIX W/ GOOD RESULT, 700CC OUT.\n\n: PT REMAINS ON INSULIN GTT. BS AT 2100 69. 1 AMP D50 GIVEN. GTT OFF FOR 1HR. GTT CURRENTLY AT 2U/HR.\n\nDISPO: CONTINUE TO MONITOR RESP STATUS. ?INTUBATION. PT RESPONDED WELL FROM LASIX OVERNIGHT, PT COULD FROM DOSE DURING DAY. PT REMAINS A FULL CODE IN MICU.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-21 00:00:00.000", "description": "Report", "row_id": 1317308, "text": "NPN MICU-B 7AM-7PM\nS/O: Respir: Unstable most of shift, rec'd pt on Bi-Pap 15/5 FIO2 40%, with RR 30's, O2 sats 97-99%. Became acutely hypotensive with BP's in the 70'/40, with RR down to 6-10 from 30's. ABG- 7.35/38/160/-. Required IVB's and was started on NEO and Ativan Gtt was weaned from 15mg to off for an hr. This afternoon RR back up to 40-50's, was taken off of Bi-Pap and placed on 50% cool neb, and was started back on Ativan Gtt up to 15mg/hr. Suctioned for lrge amts of frothy white sputum, rec'd Lasix 10mg IVP with good response in u/o but RR still 40-50's. O2 sats remain 96-99%, ABG to be obtained.\n\nC/V: Became hypotensive this AM with BP to 70's/40 HR 100'-120s', was approx 700cc neg overall @ that time, rec'd a total of 2L's NS with no effect, required NEO Gtt to max of 15.mcq/kq/. responded well to and BP back up to 100-120's, NEO weaned to off @ 1700. HR down to 60's, when hypotensive, EKG obtained but no new changes noted as per MICU team, CPK-60. HR back up to 100-120's ST with frequ PVC's and APC's. K+-3.8 rec'd 40mEq KCL IV, to be repeat this evening.\n\nNeuro: Unresponsive this AM with hypotension, Ativan was weaned to off\nfor about one hr. Increased agitation with increased BP, HR and RR increased, Ativan back up to 15mg/hr with frequ boluses needed. PERL, but unable to talk, unable to obey commands, does move extremites on bed occ.\n\n: BS's also very labile, Insulin Gtt on/off over the course of the day. BS down to 64 this AM requireing D50W one amp IVP with good response. Insulin Gtt restarted back on when BS's to 244, @ present is on 2units/hr, checking FS's qhr.\n\nGI: Remains NPO, has not had Nutrition since extubation, will most likely require TPN. No stool noted, BS's noted.\n\nGU: With hypotension this AM u/o down to 5-10cc/hr and overall I&O's were 700cc neg., then rec'd 2L's NS, with increased response to 50-60cc/hr. Rec'd Lasix 10mg IV with 800cc response in hour still responding now. BUN/CRE WNL's.\n\nSkin: No open areas noted turning s/s when tolerating activity.\n\nID: No temps, WBC 9.0, still rec'ing IV Bactrim.\n\nSocial: No calls from family so far today(1700).\n\nA/P: Continue to follow I&O's closely, aggressive pulmon toilet as tolerated, assess O2 sats and ABG's Bi-Pap as needed. Continue with Ativan Gtt to prevent withdrawl adjust as needed. Monitor VS's.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-22 00:00:00.000", "description": "Report", "row_id": 1317309, "text": "NPN 7a-7p\n\nEvents: Pt. intubated at 12p for worsening resp. distress as indicated by worsening lactate, tachycardia and tachypnea. Pt. has no gag and an adequate airway had to be established. Also, bile was being sx'd from the bag of pt.'s throughout indicating severe risk for aspiration. At that time, pt. was also on 20mg of Ativan and obtunded. PRIOR to intubation, pt became hypotensive. 500cc NS given with minimal effect. Neosynephrine added at that time to maintain MAP >60. Team thought that the proplyne glycol addative in Ativan infusions could be contributing to hypotension. Therefore, pt. was transitioned to a Versed gtt at 15mg/hr. Ativan was subsequently turned off. BS labile today ranging from 51-140.\n\nReview of Systems:\n\nNeuro: Pt. remains obtunded. Pt. received on 20mg of Ativan. Pt. transitioned from Ativan to Versed this afternoon after receiving 1 dose of 10mg of Valium. Pt. off Ativan d/t addatives as described above. Plan- will cont. to treat DTs with benzo (Versed) and use Propofol for extreme aggitation . start librium protocal for ETOH detox tom'row.\n\n Pt. received on BIPAP 15/5 50%. Sx'ing q 30-45min for frothy white sputum. Decision made to intubate for airway protection and worsening lactic acidosis. Intubated with 7.5cm ETT at 19 @ lip about 12pm without incident. Sx'd for COPIOUS amounts of thick, white sputum thereafter. LS- clear at bases, coarse upper airways when requiring sx'ing. Sat's maintained at 97-99%. ABG post intubation with PCO2 to 30, pH 7.36. A second ABG sent now. Plan- cont. aggressive pulm toilet, will remain vented for airway protection.\n\nCV- HR to 130's this am prior to intubation. Post intubation, HR down to 90's. EKG done this am for questionable prolonged PR interval. However, unchanged. Pt. with much ectopy this am. Mag repleted and with intubation, ectopy resolved. BP an issue today. Hypotensive to systolic of 80's. 500cc NS given with little to no effect. Neo added and titrated to 0.55 mcg/kg/ to maintain MAP >60 and adequate u/o. CVP 2-8 today. Plan is to run CVP <9 d/t cardiac issues. Pt. was 1.5L negative this am, remains about 1L negtive now. However, team does not feel pt. is dry. Rather, they feel her hypotension is d/t ativan gtt... Plan- Neo , consider fluids if u/o drops off...\n\nGI- ABD soft. + BS. Started TF at 1600 Promote with fiber, goal of 60cc/hr. No stool.\n\nGU- U/O adequate today 80-120cc/hr. Dilute yellow.\n\nID- Afebrile. Conts on Bactrim for PCP .\n\nSocial- MULTIPLE calls from sisters; updated appropriately. Fiance called as well and will call again tom'row.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-23 00:00:00.000", "description": "Report", "row_id": 1317310, "text": "micu npn 1900-0700\nresp- patient remains on a/c, no vent changes 50% fio2, 500x12, breathing above. sats 100%, no abg ordered this shift. patient conts to have COPIOUS secretions, clear oral and white via ett. sxn via ett q1/2 hour-2 hrs o/n. l/s rhonchi/coarse.\ncv- pt remains in sinus 1 degree hb, ventricular ectopy and different bundle pathways eliciting a lot of \"ectopy'. hr 1teens, bp 90-120. map >60, remains on 0.4 mcg/kg/ of neo, unable to wean further at this time.\nneuro- versed gtt remains at 15mg/hr. pt sedated well, opens eyes w/stimuli, nopt fighting vent or care. not following commands.\ngi/gu- abd soft/dist, +bs. tube feeds, replete w/fiber incresed to goal of 60cc this am, conts on reglan, no residulas o/n. pt does not appear to have had a bm since admission, bowel regimine + lactolose added last night, pleas cont until pt stools. u/o remains excellent o/n.\n- blood sugars remain labile, low of 51 this am, on recheck 1.5 hrs later, in the 200's (after bactrum dose). restarted into piggyback line to hope better regulate sugars.\nid- low grade fevers o/n, high of 99.8. remains on bactrim for pcp .\n" }, { "category": "Nursing/other", "chartdate": "2140-12-23 00:00:00.000", "description": "Report", "row_id": 1317311, "text": "review of systems:\n\nNeuro: Pt is sedated on 12 mg/hr of midazolam. pt is being started on diazepam, and midazolam being weaned down. Pt is slightly arousable to stim but will not follow commands. PT MAE, PERLA.\n\nResp:Pt remains on vent AC/.4/450/12/5, pt sao2 > 95% on current settings pt requires frequent suctioning for mod tan thick secreations. pt tolearted decrease in Fio2.\n\nCV: pt remains on neo gtt to maintain MAP > 60, pt currently on .4 mcg/kg/. pt BP is currently 110/65 will continue to titrate neo as tolerated. pt had periods on bigeminy and is in NST @ base line.\n\nGI/GU: pt is tolerating tubefeeds @ goal, pt had no BM today. pt has had good UO per foley cath.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-20 00:00:00.000", "description": "Report", "row_id": 1317303, "text": "Resp Care Note:\n\nPt on and off NIPPV all shift. Pt extremely restless with tachycardia and tachypnea despite sedation. CXR shows failure/pneumonia with pleural effusions. Pt diuresed for 2L but pt has not improved. Pt may require reintub so that more aggressive sedation can be administered and secretions can be cleared.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-20 00:00:00.000", "description": "Report", "row_id": 1317304, "text": "micu npn 1900-0700\n patient continues to be tenuous from a resp stand point since extubation on sunday.\n\n patient continues to be persistantly tachypnic to the 40-50's range and tachycardic to 120-130's. ativan gtt titrated up to 15 mg/hr w/multiple 5 and 10 mg bolus' all without achieving goal of lowering heart rate to desired 90's.\n after reviewing cxr from monday am and discussing w/housestaff that it appeared she was in failure w/bilat pl effusions, 20 mg iv lasix was ordered. patient put out nearly 3 L of urine over the next several hours. she sounded less congested and had a hr in the 90's. we took her off bipap at this point and decreased her ativan gtt back to 5 mg/hr. this effect was short lived. after an hour, despite continuing to put out more fluid, she began to sound junky again and her hr began to climb up to the 120's again. she was placed back on bipap settings and her ativan was increased to 15 mg/hr. she continues on bipap presently hr 120, bp 121/74 rr 56 sats 100%.\n\nsystems review-\n\nneuro- pat conts to alternate between sedated, although tachypnic, and yelling out and attempting to sit up and thrash. sedated on ativan as above. does not follow commands. unable to understand what pt is saying.\ncv- hr mostly 1teens-130, occ to rare pvc's. k wnl this am, ivf w/kcl about to finish. bp has been constant overnight 120-140's despite high hr. ???. haldol held as qtc .62, pt w/baseline 1st degree and vasicular block.\nresp- on bipap most of night ps12/5. tachypnic as above. nts several times, although never clearing secretions after each time(constant sounding junky). abg this am w/po2 in 60's, will repeat after cpt and nts done short while ago. conts to have po2 in the 28-25 range w/pH close to 7.50.\ngi/gu- no bm. ?increasing bowel regimine once patient has improved/stabilized resp status. npo. u/o excellent before/after lasix.\n- insulin gtt titrated o/n currentl on 2.5 u/hr\n\nplan continues to be to avoid extubation by sedating to try and bring down hr and use of bipap.. have not appeared to achieve this as of yet. cont pulm toilet, follow abg's and cont to support and protect airway.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-20 00:00:00.000", "description": "Report", "row_id": 1317305, "text": "NPN 7AM-7PM MICU-B\nS/O: RESPIR: Very unstable day, rec'd pt on Bi-Pap- , with RR 30-40s looking very uncomfortable, O2 sats 93-98%, L/S extrememly course bilat. Required -trach suctioning q30min-1hr throughout the shift. ABG on Bi-PAP 7.50/25/83/20/-1. Taken off of Bi-Pap and placed on cool neb 50%, did not tolerate it RR 40-50's, repeat ABG-7.48/25/55, attempted C-Pap but did not tolerate it, placed back on Bi-Pap-15/5 with FIO2-40%, RR still high in the 40's still looking extremely uncomfortable. Remains on Ativan Gtt 15mg /hr, rec'ing 5-10mg boluses as needed for agitation. Suctioning q1hr of white frothy sputum, rec'd 20mg IV Lasix @ 1700. RR down to 25-28, BP and HR down also, looking more comfortable. L/S still course bilat.\n\nC/V: BP- 90-120/60, HR 120-130's first degreeHB, most of day, with frequ PCV's and APC's. One episode of hypotension with BP 84/60, rec'd 250 NS IVB with good response, BP remains 90-110/60. HR s/p Lasix-100-114 ST.\n\nNeuro: Remains on Ativan Gtt 10-15mg HR with occ boluses 5-10mg. Started on Valium 10mg IV q6hr with no response noted. Unable to respond to commands, no verbal response noted, does respond to painful stimuli. No acute agitation noted other than high BP, HR and RR. PERL, only occ spon movements noted.\n\nGU: U/O before Lasix 50-100cc/hr, BUN/CRE WNL's. Is overall neg. by 900cc/hr. Will be assessing Lasix response @ 6pm.\n\nGI: Is NPO no NGT in place and is unable to PO's due to Neuro status. soft with +BS's, no stool noted.\n\n: Continues on Insulin Gtt and adjusting as per q1hr FS's, 1-3 units/hr.\n\nID: Temp 98.9 Ax, remains on Bactrim IV. No new cultures PND.\n\nSocial: Sister called and updated on pt's condition.\n\nA/P: Continue with aggressive pulmon toilet, monitor O2 sats and ABG's, sedate as needed for comfort on Bi-Pap, intubate if needed. Monitor VS's and I&O's, Lasix as needed for Pulmon edema.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-21 00:00:00.000", "description": "Report", "row_id": 1317306, "text": "Resp Care Note:\n\nPt cont on NIPPV via full face mask as per Carevue. Lung sounds coarse rhonchi NTS for mod clear/white sput. MDI given as per order. Pt cont needing intub for adequate airway clearance.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-28 00:00:00.000", "description": "Report", "row_id": 1317326, "text": "npn 7- 7pm\n\nneuro: Pt is sedated on 25mcg/kg/ propofol, 1 mg versed and 25 fentanyl mcg/kg/. Pt opens eyes to verbal stimuli, but does not follow commands. Sedation was lightened during rounds and pt was following commands.\n\nresp: Attempted to wean. Placed on PS , but did not tolerate due to incresed HR, BP 170's, RR 42 and COPIOUS SECRETIONS. Placed back on A/C at 450/12/40% with PEEP 5. Placed back on propofol and is now comfortable with TV 450-500 and RR in low 20's. Still with copious secretions.\n\nCV: Sinus to sinus tach with occasional PVC's.\n\nAccess: R radial and L SC TLC.\n\nGI/GU: Not tolerating TF. Shut off at 8am. Will start PPN today and TPN tomorrow. Belly soft with hypoactive BS, no BM. Rectal bag in place.\n\n: BS checked q 3 hours ranging from 78-132. Insulin gtt off all day.\n\nSkin: 1st step mattress ordered this eve.\n\nSocial: RN updated pt sister this am.\n\nPlan: Re-attempt wean tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-29 00:00:00.000", "description": "Report", "row_id": 1317327, "text": "MICU NURSING NOTE 7P-7A\n\nNUERO: PT REMAINS SEDATED ON PROPOFOL 30MCG/KG/. FENTANYL 25MCG/HR AND VERSED 1MG/HR W/ NO BOLUSES GIVEN. PT RESPONDS TO PAIN, NOT FOLLOWING COMMANDS. PERLA2MM.\n\nRESP; NO CHANGES MADE TO VENT. PT CONTINUES ON AV 450X12 PEEP5, 40% O2 SATS 90-97%. AM ABG 7.44/34/83. PT HAS AMT ORAL AND ETT SECRETIONS, THIN WHITE. LS COARSE.\n\nCV: HR 70-90'S, ST RARE PAC'S. SBP 90-120'S. MAX TEMP 101.3, TYLENOL GIVEN. AM HCT 28.5.\n\nGI/GU: ABD SOFT, HYPO BS, NO BM. TPN STARTED LAST NIGHT. FOLEY INTACT DRAINING ~80CC/HR.\n\n: PT REMAINS OFF INSULIN GTT. BS 100-110'S.\n\nDISPO: PLAN TO WEAN OFF FENTANLY AND VERSED TODAY. ATTEMPT TO WEAN VENT TO PS. CONTINUE TO MONITOR TEMPS, RECULTURE TODAY IF SPIKES.\nPT A FULL CODE IN MICU.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-29 00:00:00.000", "description": "Report", "row_id": 1317328, "text": "NURSING NOTE: 7A-7P\n PT RECEIVED ON VERSED GTT AT 1MG/H, FENTANYL GTT AT 25 MCG/H AND PROPOFOL GTT AT 30MCG/KG/. ON THOSE MEDS PT WAS VERY MINIMALLY RESPONSIVE, AT TIMES ONLY RESPONDING TO NOXIOUS STIMULI. VERSED AND FENTANYL WERE BOTH SHUT OFF AND PROPOFOL WAS DECREASED TO 10MCG/KG/ IN HOPES OF WAKING PT UP TO WORK TOWARDS EXTUBATION. PT THEN BEGAN TO RESPOND TO PAIN AND OPENED EYES TO NAME. SINCE EXTUBATION WAS POSTPONED PROPOFOL WAS INCREASED TO 20MCG/KG/ AND PT APPEARS COMFORTABLE AND NOW AROUSES TO STIMULI. MAE. UNABLE TO FOLLOW COMMANDS. PERLA.\n\nRESP- REMAINS INTUBATED ON AC 450X12 40%. COPIOUS AMOUNTS OF CLEAR-WHITE SECRETIONS ORALLY, NASALLY, AND ENDOTRACHEALLY. TEAM MADE AWARE OF THE AMOUNT OF SECRETIONS AND EXTUBATION WAS POSTPONED. LUNG SOUNDS COARSE BUT DO CLEAR AFTER SUCTIONING. SATS 98-100%. SRR 4-10. ETT WAS ROTATED AND RETAPED. CAREVUE DEFAULTED TO ETT AT POSITION OF 19 AT LIP HOWEVER THE TUBE WAS FOUND AT 23 AT LIP AND HAD BEEN TAPED AT THAT POSITION SINCE THE . ACCORDING TO CXR FROM ETT HAD BEEN IN NEED OF ADVANCING 4CM AND CXR ON SHOWED GOOD PLACEMENT, THERFORE THE ETT WAS LEFT AT 23 AT LIP.\n\nCV- HR 82-115 SR-ST NO ECTOPY NOTED. SBP 100-130'S. CAPTOPRIL INCREASED TO 25MG TID AND PT TOLERATED WELL. K 3.9 THIS AM, WAS REPLETED WITH 40MEQ IV KCL. HCT STABLE THIS AM AT 28.5.\n\nGI- ABD SOFT HYPOACTIVE BS NO STOOL. PPN CHANGED TO TPN THIS AFTERNOON. TF RESTARTED PER NUTRITION CONSULT, HAD BEEN HELD DUE TO HIGH RESIDUALS PREVIOUSLY. PER NUTRITION ONLY HOLD TF IF RESIDUAL >150. CURRENTLY TF AT 20CC/H WITH ONLY 10CC RESIDUAL.\n\nGU- FOLEY PATENT FOR LARGE AMOUNTS OF YELLOW URINE. ABOUT 90-260CC/H.\n\nID- TMAX 100.4 PO. WBC DOWN TO 2.6. BACTRIM D/C'D AND ATOVAQUONE STARTED INSTEAD FOR PCP. ON VANCO AND CEFTAZ.\n\n- FSBS 157 AND 181 NO COVERAGE GIVEN. REMAINS OFF INSULIN GTT. NEW TPN NOW HAS INSULIN IN IT.\n\nACCESS- RAC PIV, R RADIAL AND LEFT SC TLCL. ALL SITES WNL.\n\nSKIN- NO AREAS OF BREAKDOWN NOTED. PLACED ON FIRST STEP MATTRESS TO PREVENT BREAKDOWN SINCE SHE HAS POOR NUTRITION AND A PROLONGED HOSPITALIZATION.\n\n TWO SISTERS, SON AND FIANCE IN TO VISIT. UPDATED BY DR .\n\nDISPO- REMAINS IN MICU, FULL CODE. CONTINUE TO AGGRESSIVELY PULMONARY TOILET. PLAN TO AVOID SEDATIVES AND USE ONLY PROPOFOL SO THAT PT CAN BECOME MORE INTERACTIVE AND WORK TOWARDS EXTUABTION. CONTINUE TO MONITOR FSBS NOW THAT TPN AND TF ARE INFUSING. KEEP FAMILY INFORMED.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-30 00:00:00.000", "description": "Report", "row_id": 1317329, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY.\n\nNEURO: PT IS CURRENTLY LIGHTLY SEDATED ON 20MCG/KG/ OF PROPOFOL. ALL OTHER SEDATIVES HAVE BEEN DISCONTINUED DUE TO PLAN OF WANTING PT TO BE MORE ACTIVE IN ORDER TO EXPIDITE EXTUBATION AS PT. CAN TOLERATE. PT WILL RESPOND TO PAINFUL STIMULI, WILL GRIMACE WHEN BEING OR TURNED. MAE X 4 ON BED WITHOUT ANY APPARANT DIFFICULTY. PERRLA AT 4MM. AFEBRILE. NO SEIZURE ACTIVITY NOTED. DOES NOT FOLLOW COMMANDS BUT WILL OPEN EYES AT TIMES TO VERBAL STIMULI.\n\nRR: PT REMAINS INTUBATED. OETT IS SECURE AND PATENT. VCURRENT VENT SETTINGS ARE CMV/12/450/40%/5. SP02 > OR = TO 95%. BBS= COARSE THROUGHOUT FOUR LOBES. BILATERAL CHEST EXPANSION NOTED. PT HAS REQUIRED FREQUENT SUCTIONING FOR COPIOUS AMOUNTS OF ORAL AND FOR WHITE THICK SECRETIONS.\n\nCV: PT HAS REMAINED AT A ST WITH HR 110-120. NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 100 WITH NO HYPO OR HYPERTENSIVE CRISIS NOTED. S1 AND S2 AS PER AUSCULTATION. NO RUBS, GALLOPS OR MURMURS AUSCULTATED. PALPABLE PULSES TO BILATERAL DORSALIS AND RADIALS. ELECTROLYTE REPLETION OF 40MEQ OF POTASSIUM FOR A 3.6 LEVEL AND 2 GMS OF MAG FOR 1.3 LEVEL. TLC TO LEFT SCL IS SECURE AND PATENT WITH GOOD FLUSH AND BLOOD DRAWBACK. RIGHT RADIAL IS SECURE AND INTACT WITH GOOD WAVEFORM, GOOD BLOOD DRAWBACK AND FLUSH. THIS WAS REZEROED AND RECALIBRATED DURING THE SHIFT.\n\nGI: PT REMAINS ON PPN AS WELL AS TF OF PROMOTE AT 20CC/HR. SO FAR, PT HAS BEEN TOLERATING THIS WELL WITH MINIMAL GASTRIC RESIDUALS. BS X 4 QUADRANTS. ABDOMEN IS SOFT, NON-DISTENDED. NO BM THIS SHIFT BUT POSITIVE FLATUS NOTED.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT WITH YELLOW URINE IN ADEQUATE AMOUNTS NOTED-APPROX. 100CC/HR.\n\nINTEG: SMALL AREA OF BREAK DOWN TO COCCYX, DOUDERM APPLIED. FREQUENT TURNING.\n\nSOCIAL: SISTER IN THIS PM- DISCUSSED AT LENGTH, PT'S CONDITION, ALL QUESTIONS ANSWERED.\n\nPLAN: CONTINE PROPOFOL- PLANS TO WEAN AND EXTUBATE PATIENT WHEN SHE CAN TOLERATE THIS. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDTIONAL INFORMATION. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-30 00:00:00.000", "description": "Report", "row_id": 1317330, "text": "MICU-B, NPN:\nNeuro: Pt. sedated on 20mcg/kg/ @ start of shift, have weaned sedation down to 16mcg/kg/ throughout shift. be necessary to cont. weaning dose by 20% qd d/t pt.'s substance abuse/anxiety history. Opens eyes spont., unable to track. PERRLA, unable to follow commands. Spont. movement to q 4 extrems.\n\nCV: HR 100's-110's, ST w/ rare 3-4 beat runs VT. SBP 100's-140's, held 12:00 Captopril.\n\nResp: Received pt. on A/C, TV 450, RR 14, PEEP 5, FiO2 40%, O2Sat 94%-100%. Lungs coarse throughout. Pt. began overbreathing vent. w/ rate up to 40- no change in TV or O2Sat. pt. w/o results, w/ Propofol w/o results Sent ABG- pH 7.55. RT checked vent tubing and sensitivity for breath trigger, made adjustments to sensitivity. Pt. began breathing w/ set rate. Following ABG had pH 7.45. Vent changed to CPap during rounds- PEEP 5, PS 15, FiO2 40%, RR 14, O2Sat 100%, TV 500's, following ABG unchanged. Will rest on A/C o/n if needed. Suxn'd q 1-2 hrs for copious amnts. thin clear sputum. Pt. also has copious amnts. clear oral secretions.\n\nHeme/lytes/micro: K+/Mg repleted IV this a.m. FSBG qid. Vanco./ Ceftaz for pnx. T-max today 100.3. Will send sputum spec. today.\n\nGI: Advancing TF's to goal of 60cc/hr. No order for TPN. No BM this shift. Active BS. be NPO after 24:00 tonight for ? extubation tomorrow.\n\nGU: Foley to gravity.\n\nDerm: Stage II to coccyx. Turn q 2 hrs.\n\nSocial: Sister called, may visit this p.m. FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2141-01-01 00:00:00.000", "description": "Report", "row_id": 1317336, "text": "NURSING NOTE: 7A-7P\n PT AROUSES TO VOICE. ORIENTED X2, DISORIENTED TO TIME. GARBLED SPEECH, BUT MAKING NEEDS KNOWN. MAE. PERLA. RESTLESS AND AGITATED AT TIMES. MEDICATED WITH ATIVAN PRN X2 AND SCH HALDOL. STARTED KLONIPIN TODAY. ONE-ONE SITTER NOW INITIATED FOR SAFETY AND ASPIRATION PRECAUTIONS.SOFT WRIST RESTRAINTS IN PLACE SINCE PT REACHING AND PULLING AT TUBES AND LINES.\n\nRESP- LUNG SOUNDS CLEAR. OCCASIONAL PRODUCTIVE COUGH WITH MUCH ENCOURAGEMENT. CPT Q2-4H. PT NOT COOPERATIVE FOR NTS, BUT ABLE TO EXPECTORATE SOME WITH YANKUER. VERY WEAK IMPAIRED GAG BUT GOOD COUGH.\nRR 18-30. SATS >95% WITH O2 NOW AT 2LN/C.\n\nCV- HR ST 100-120. OCCAS PVC'S. SBP 120-160'S. ANTIHYPERTENSIVES MEDS GIVEN AFTER GI ACCESS MADE. SBP 120'S WHEN CALM. NO EDEMA NOTED.\n\nGI- ABD SOFT NT ND POSITIVE BS. NO STOOL. NGT PLACED FOR NUTRITION AND MEDS SINCE GAG VERY WEAK. NGT CONFIRMED WITH AIR INSTILLATION AND CXR.\nPROMOTE WITH FIBER STARTED AT 10CC/H. BLUE DYE ADDED FOR ASPIRATION MONITORING.\n\nGU- FOLEY PATENT FOR ADEQUATE AMOUNTS OF URINE.\n\nID- CONTINUES ON ATOVAQUONE FOR PCP . CEFTAZ FOR VAP, AND STARTED TODAY FOR PAP SMEAR RESULT +TRICH. AFEBRILE.\n\nACCESS- R RADIAL D/C'D WITHOUT DIFFICULTY. LSC TLCL INTACT WNL.\n\n SISTERS UPDATED VIA TELEPHONE. FIANCE ALSO CALLED AND UPDATED. FAMILY INFORMED OF PENDING TRANFER TO MED/ FLOOR.\n\n PT TRANSFER TO MED/ FLOOR. PT REQUIRES ONE TO ONE OBSERVATION FOR SAFTEY DUE TO AGITATION AND ASPIRATION RISK. CONTINUE TO ASSESS GAG, WHEN RETURNS D/C NGT AND ADVANCE DIET. CONTINUE AGGRESSIVE PULMONARY TOILETING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-17 00:00:00.000", "description": "Report", "row_id": 1317291, "text": "NPN MICU-B 7PM-7AM\nS/O: RESPIR: Remains intubated on A/C 550/12 FIO2 40%, Peep-5, O2 sats 98-100%, ABG-PND. Suctioned times one for mod amt thick white/light yellow sputum. L/S course @ bases bilat.\n\nC/V: Remains on Neo Gtt @ .60mcq/kq/. was able to wean down to .40 mcq/kq but BP's down to 86/60, Neo back up to .60mcq/kq with BP's 90-118/70, HR 60-76 SR with frequ PVC's& APC's. PA pressures very stable, PA-30-34/18-22, CVP-, PW-18, CO-3.96. R/I'd for NSTEMI, and ?'ing HIV Cardiomypathy. CPK's trending down with peaks-130 and TI-19. Remains on Heparin Gtt @ 500units/hr, PTT PND with AM labs.\n\nGI: TF's still @ 20cc/hr, due to high aspirates, unable to increase rate. soft non-distended, with +BS's, no stool, but does have her period.\n\nGU: U/O 100-120cc/hr, BUN/CRE PND.\n\nEndo: FS's labile, on/off Insulin Gtt, depending on FS's, @ present is on 3units/hr with last FS-180.\n\nNeuro: Remains on Fentanyl and Ativan Gtts, Ativan remains @ 3.5mg/hr and Fentanyl was up to 100mcq/hr due to increased agitation, will be decreased to 50mcq/hr @ 6am. When does wake up becomes very agitated, attempting to get OOB and restless.\n\nID: No temps, remains on IV Bactrim.\n\nA/P: Continue to monitor vs's, PA pressures, assess u/o. Follow FS's and adjust Insulin Gtt as needed. Assess aspirates and increase Tf's if able.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-17 00:00:00.000", "description": "Report", "row_id": 1317292, "text": "RESP CARE NOTE:\n\nPt cont intub on mech vend as per Carevue. Lung sounds coarse. Suct sm th white. MDI given as per order. No changes made overnoc. Cont mech vent.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-17 00:00:00.000", "description": "Report", "row_id": 1317293, "text": "MICU-B NPN 0700-1900\n Pt. remains intubated and sedated on Fentanyl gtt. currently @ 40 mcg./kg, down from start of shift @ 50 mcg./kg. & Ativan @ 3.5 mg/hr. Order in place to wean Fentanyl 20% per day until off. Pt. more alert today, opening eyes spontaneously, making purposeful movements, following commands, though inconsistently. MAE+. No S&S ETOH withdrawal.\n\nC/ Pt. with ? Alcohol or HIV related Cardiomyopathy. S/P ischemic event secondary to hypoxia. RIJ vip-swan ganz most of shift, changed to triple-lumen @ 1600. C.O. @ 0800 3.45/C.I. 2.12/ SVR 1252/ PCWP 18/CVP 10 & PAP 30/18. C.O. numbers @ 1300 @ C.O. 4.94/ C.I. 3.03/ SVR 1004/PCWP 15/ CVP 8/ & PAP 25/17. HR 60'S-120'S, NSR - ST with frequent PAC'S & PVC'S. K+ this a.m. @ 4.5. Neo. gtt weaned to off @ 1100; well tolerated. ABP 90's-100's/ 50's-60's. Extremities warm. LOS fluid balance @ -2260, 24 hr. net fluid balance @ -535.\n\nResp. - Pt. received on A/C 40% FiO2/550/12/PEEP 5. RSBI @ 1100 (20). Pt. changed to CPAP+PS/ , with RR in the low teens, pulling vT's 500-700's. ABG @ 1200 showing 7.38/33/85. Pt. currently on CPAP+PS 5/5, RR teens to low 20's with agitation, vT's 500-700, with ABG 7.34/34/90. Per team pt. is to be rested over/noc. on CPAP+PS 10/5. LS clear/coarse upper - clear/coarse RLL & diminished LLL. Sx. t/o shift for small amts. thick, tan secretions. O2Sats. 97-100%.\n\n Pt. with OGT in place/patent. Currently clamped secondary to high TF residual, @ 1600 residual 140cc's of which 120 was discarded. TF had been delivering Promote w/Fiber @ a rate of 20cc/hr with a goal to advance to goal rate 60cc/hr. Plan to restart as tol. Abdomen, soft ND, with +BS. No stool this shift. Bowel regime ordered this eve.\nPt. recieving Famotidine for prophylaxis.\n\n Pt. with indwelling foley/ patent draining clear, yellow urine. U/O averaging 100/hr. Pt. with menses.\n\nHeme. - Heparin gtt. dc'd this afternoon @ 1200. PTT 56.9 this a.m. HCT stable @ 31.7.\n\nID - Pt. afebrile. On Bactrim for PCP. prophylactic viral coverage a this time. All 3 AFB's sent, the first with negative results.\n\n Pt. remains on Insulin gtt. Currently running @ 2U/hr. Titrated t/o shift per Insulin gtt. guideline sheet. FS labile requiring Q1hour FS. See carevue for results.\n\n Pt. with warm, dry, & grossly intact skin.\n\nAccess - Pt. with RIJ vip-swan-ganz changed @ 1600 to triple-lumen, repositioned twice for poor placement, latest c-xray pending. Pt. with 2 (L) peripherals, patent, sites wnl. (L) arterial line with good wave-form, site wnl.\n\nSocial - One of pt's sisters and fiance called today. Given update on pt. status and current plan of care.\n\n , ,RN\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-17 00:00:00.000", "description": "Report", "row_id": 1317294, "text": "Resp. Note\nPt switched to PSV/CPAP. Now on %. TVs 400-600cc with RR teens. Acceptable gases. RSBI done with no peep or PSV was 18. Received albuterol/atrovent inhalers. Will keep on PSV as tol. Possible extubated tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-18 00:00:00.000", "description": "Report", "row_id": 1317295, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct sm th pale yellow sput. MDI given as per order. Pt tol PSV @ 5cm. No vent changes overnoc. Extub today?\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-18 00:00:00.000", "description": "Report", "row_id": 1317296, "text": "micu b npn 1900-0700\n patient remains on cpap+ps 5/5, fio2 40%, rr 15-22, vt 360-440, sats 100%. patient sedated and sleeping most of evening night, waking and fighting with turning and suctioning but going back to sleep when left alone. patient more awake this am, opening eyes, coughing on ett, requiring 2 bolus' of 1 and 2 mg ativan this am between 4-6am. suctioning ett q3-4hrs for thick small amts sputum. afebrile. vss o/n per carevue. foley w/ good urine output. cvp 5-7. tube feedings back on at midnight, increased to 20cc/hr at 4am, cont to eval and increase to goal of 60. no contact from family o/n.\n plan to cont to support on vent. ??attempt to extubate today if conts to look good. secretions less. pt with good gag and cough.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-18 00:00:00.000", "description": "Report", "row_id": 1317297, "text": "MICU-B NPN 0700-1900\n Pt. extubated this shift @ 1200. Remains on Ativan gtt. @ 2.8 mg/hr. Fentanyl gtt. dc'd @ 1100. Pt. extremely agitated early afternoon - eve, requiring constant attention and requiring 2 mg. Haldol X1 & 2 mg. Ativan bolus. CIWI scale ordered this eve. Pt. alert and oriented X1, following commands, making purposeful movements. MAE+.\n\n Pt. extubated @ 1200 today. Placed on cool neb. face mask with 40% O2. Initial ABG good, see carevue. Pt. with subsequent need to increase O2 secondary to tachypnea, copious oral secretions, rhonchorous LS t/o, Pt. with good cough, productive for thick yellow secretions. Sx. back of throat numerous times. NT sx. X1 for med. amt. sx. RT administered neb. tx. Currently on 100% O2 via cool neb. face mask, continues to have RR in high 30's @ times, even @ rest. O2Sats 97-100%.\n\nC/ Pt. with HR 87-130's/ NSR-ST, with frequent ectopy; PVC'S & occasional vent. bigeminy. ABP labile 89-173/50-100's, with MAP as high as 125 with agitation. Given Lasix 20 mg. X1. LOS fluid balance -2725. 24 hour net balance @-554. Extremities warm, + peripheral pulses. No ACE-Inhibitor on baord yet. Per team plan to add on to med. regime when BP able to tol.\n\n Pt. NPO since 0800. OGT in place this am delivering TF @ 20/hr. TF residual @ 100cc so discontinued and kept off in anticipation of extubation. OGT dc'd with extubation. Abdomen soft, NTND. +BS. No stool this shift. Continues on bowel regime.\n\n Pt. with indwelling foley, patent and draining clear, yellow urine. Good u/o.\n\n Pt. with TMAX 99.2 (AX.) Remains on Bactrim for PCP. 2 neg. AFB's to date, third pending. U/A /legionella pending. No antiviral coverage.\n\n Pt. with warm, dry, and grossly intact skin.\n\n - Pt. remains on Insulin gtt. being titrated per insulin guideline to attain BS <140. Currently @ 4 Units/hr.\n\n Pt's. family in to visit today, spoke with MD and update on pt's current status and plan of care. Sister called and spoke with nurse and updated as well.\n\n\n , , RN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-01 00:00:00.000", "description": "Report", "row_id": 1317337, "text": "NURSING ADDENDUM:\nPT BECAME INCREASINGLY RESTLESS AND AGITATED THIS AFTERNOON. WITH THIS SHE WAS TACHYCARDIC HYPERTENSIVE AND TACYPNEIC. DR NOTIFIED AND SHE AND DR UP TO ASSESS PT. SHE WAS MEDICATED WITH A TOTAL OF 6MG IV ATIVAN, AND 4MG IV HALDOL FOR AGITATION WITH SLIGHT EFFECT ON BEHAVIOR AND VERY LITTLE ON VS. HYDRALIZINE X1 FOR SBP 180 WITH SLIGHT EFFECT. CXR EKG,ABG AND LABS WERE OBTAINED. PT WAS WITH 500CC NS WITH NO CHANGE IN HR. PT IS NOW LESS AGITATED BUT HR REMAINS 130'S. SBP 160-170'S AND RR 40'S. OBJECTIVE DATA PENDING. TRANSFER TO MED/ FLOOR CANCELLED.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-16 00:00:00.000", "description": "Report", "row_id": 1317287, "text": "NPN 11P-7A MICU B\nResp: Remains intubated. Received pt on AC 550 X12 PEEP10 FIO2 60%. Able to wean settings overnight to AC550 X12 PEEP5 FIO2 40%. Last ABG 4am 7.36/33/151/19/-5. Lungs clear t/o at 12AM, 4AM crackles noted LLL. O2 sats 100%. RT Suctioned pt x1 for minimal thick/ white secretions. Pt on q4hr nebs. Remains on TB precautions for R/O. Needs PPD plant today. On Bactrim for PCP PNA, awaiting ID approval for Levaquin. Afebrile, T max 99- core temp.\n\nCV: Tele NSR with frequent PVC's/ rare APC's. HR 70's. Able to titrate Neo Gtt down to 1.04mcg/kg/ with BP's 113-100/60'swith MAP >70. Heparin @500u/hr- decreased from 600u/hr @3am for PTT 111 per heparin scale. Needs repeat PTT @0900. Swan intact. 12AM readings: PAP 37/23, Wedge 18, CVP 13, CO 4.02, SVR 1214.\n\nNeuro: Pt breaks through on sedation, abruptly opens eyes and moves on bed wuith purposeful mvmts. Titrated Ativan up to @4mg/hr and Fent to @200mcg . Occ Boluses of Ativan 2mg and Fent 100mcg needed for abrupt awakenings with good effect. No s/s ETOH withdrawl.\n\nGI: NPO. OGT placement confirmed with auscultation of air bolus, and bilious secretions noted. Pt on RISS for glucose control- on steroids. FBS 170's.\n\nGU: U/O 60-100cc/ hr. Clear/ yellow.\n\nLines: R cordis patent with Neo gtt infusing. Dressing intact. LIJ with VIP swan, dressing intact sharp waveforms, both sights WNL. L radial WNL, sharp waveform.\n\nSocial: Pts sister in to visit this PM.\n\nPlan: Needs PTT @0900, sputum for r/o TB, PPD planting, Nutrition, **levoquin-needs ID approval, CO's,\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-16 00:00:00.000", "description": "Report", "row_id": 1317288, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 550, A/c 12, Fio2 40%, and Peep 5. PAP/Plateau 25/21. Albuterol/Atrovent MDI's given Q4hr. Bs clear bilaterally. Minimal ssecretions. Sx'd for sm amount of thick white sputum. Metabolic acidosis and oxygenation slowly improving. A/c rate weaned to 12. Fio2 weaned from 80% to 40% and Peep to 5. Pt. maintaining good O2 sats. Plan: Repeat Abg. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-16 00:00:00.000", "description": "Report", "row_id": 1317289, "text": "Addend: Fent @200mcg/hr. Swan via R IJ cordis, no line in LIJ.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-16 00:00:00.000", "description": "Report", "row_id": 1317290, "text": "MICU-B NPN 0700-1900\n Pt. remains intubated and sedated on Ativan 3.5 mg/kg and Fentanyl @ 50 mcg/kg. Opening eyes to stimuli, making purposeful movements, localizing pain. PERRLA 3mm/3mm with brisk response. MAE+ though minimal.\n\nC/ Pt. with vip-swan ganz. C.O. t/o day 4.11/3.93/3.90 and C.O. FICK @ 0900 was 4.8. PCWP 21-18; requiring full 1 1/2 cc's air to wedge. CVP 11-13. HR 60's-70's, NSR, PAC'S with irregular rhythm noted @ 1400. EKG grossly unchanged from last. AM ionized Ca+ @ 1.09 repleted with 2 gm. Ca.+ Gluc. Remains on Neo. gtt. titrated down from 1.05 mcg/kg this a.m. to current dose .60 with ABP 90's/50's with MAP 67-69. performed @ 1600; results pending. 24 hour fluid status -356 cc. Extremities warm. Per team Neo. gtt. to be titrated to off, then pt. will be started on ACE-Inhibitor.\n\nResp. - Pt. remains on A/C .40 FiO2/ vT 550/RR 12/ PEEP 5. Last ABG @ 0900 @ 7.35/32/118/18. O2Sats. 100%. LS coarse upper - diminished right/insp. wheezing LLL. Sx. Q3-4 hrs for sm.-mod. amts. thick, tan secretions. Continues on TB precautions. 1st AFB negative, 2 more to be sent. Per team, spontaneous breathing trial in a.m. to be performed.\n\n Pt. with OGT, patent. Placement verified by auscultation. TF/ Promote with Fiber initiated @ 1100 @ 10/hr. Increased to 20/hr, residual 40. TF goal 60. Abd. soft, NTND. Hypoactive BS, no stool. Pt. currently not on bowel regime.\n\n Pt. with indwelling foley; patent draining clear/yellow urine >180 cc/hr. Pt. with apparent menses noted with bathing.\n\n Pt. continues on Heparin gtt. Currently @ 500 U/hr. To complete 48 hour course per team. PTT @ 0900 76.4, down from 111.7 yest. HCT stable @ 31.2.\n\n Pt. afebrile. WBC 3.0. Being tx. for PCP with Bactrim and Methylprednisolone.\n\n Pt. started on Insulin gtt. @ 1100 with initiation of TF. Currently @ 4U/hr being titrated according to insulin gtt. protocol. Q/hr FS.\n\n Pt. with grossly intact skin, warm & dry.\n\nAccess - Pt. with RIJ vip-swan-ganz, good wave-form, site wnl. (L) Arterial line with good wave form, good draw, site wnl. Two (L) peripherals patent both patent, sites wnl.\n\nSocial - Pts' fiance and sister's in to visit. Updated on current status and plan of care.\n\nPlan - Wean Neo. to off, as tolerated. Wean sedation t/o eve. to light in lieu of a.m. spontaneous breathing trial. Continue to closely monitor hemodynamic and respiratory status. Advance TF as tolerated. 2 more AFB's to be obtained, in interim continue airborne precautions. Continue to titrate Insulin gtt. according to Insulin gtt. protocol. Consider initiating bowel regime.\n\n , ,RN\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-12-31 00:00:00.000", "description": "Report", "row_id": 1317333, "text": "NPN: Initial 7p-7a Assessment- received pt from previous RN. pt in standard bed with air mattress 1 with HOB elevated 45 degrees.\n\n pt AA0x3, pt mildly anxious. MAE spont with generalized weakness noted. L pupil at 5mm R pupil @ 4mm both react briskly to light. weak gag noted. speech garbled at times- content approp.\n\nCV- ST noted on monitor without ectopy. R rad a-line to pressure system with good waveform noted. positive correlation with cuff pressure. B/P stable at this time. pt with low grade temp. pulses palp bilat. skin warm and dry.\n\n pt on 50% o2 via FT. course to clear BS anteriorly. Diminished at bilat bases. pt tachypnic with shallow resp. pt with copious amt's of clear thick secretions. pt requiring aggressive pulm toilet with NT suctioning. o2 sat @ 97-100%.\n\nGI- Abd soft non-tender. BS present. pt NPO. no stool noted.\n\nGU- Foley intact with amt of amber urine noted + sediment.\n\nMain Events: -2200: 500 cc NSS bolus adm per Dr. for low UO.\n Pt increasingly anxious HR and B/P increasing.\n Ativan 2.5 mg adm IVP. Hydralizine 20 mg adm.\n IVP for elevated B/P.\n 2200-2400: HR and B/P persistently increasing. Pt moaning\n Dr. at BS Morphine 6 mg adm IVP. pt\n responded well to pain meds. pt resting ABG\n sent Dr. aware of results- no orders given\n" }, { "category": "Nursing/other", "chartdate": "2141-01-01 00:00:00.000", "description": "Report", "row_id": 1317334, "text": "Con't of care: 0000-0300 Pt at rest. VSS HR @ 98-100/ and B/P stable. Am labs sent. Meds adm without difficulty.\n0300-0500-- pt for scant am't of clear secretions. Pt repositioned CPT done. Pt tolerated well. RN\n" }, { "category": "Nursing/other", "chartdate": "2141-01-01 00:00:00.000", "description": "Report", "row_id": 1317335, "text": "Con't of care: 0500-0700 Mgso4 2 gm and 40 meq KCl adm at this time. Pt placed on 4l 02 via NC. O2sat at 97- 100%. pt tolerating well. pt repositioned. PCXR done. . RN\n" }, { "category": "Nursing/other", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 1317285, "text": " pm Nsg Admit Note\n49 y.o female admitted to MICU from EW w/ HIV (CD4 127, VL>100K in ), presented to w/ complaints of productive cough, SOB, fever, chills, N/V - symptoms have progressed over past 3 months. pt +PCP, ruling in for posterior MI w/ positve enzymes and EKG changes.\n\nIn EW - pt w/ sob, intubated, intermittent chest pain (pt ruling for MI) - pt received ASA, lopressor IV and po, started on IV Heparin, pan cultured, received Levoquin, Bactrim and Prednisone,\n\nPMH: HIV - contracted after rape in 97, dx at ETOH detox , last CD4 127, off meds sec to etoh abuse/poor compliance, thrush , Varicella Zoster , HIV meds~Viracept, Epivir, Retrovir -, PPD neg , ETOH abuse x 30 years, HTN, mild MR , now EF20%, bipolar disorder, migraines, ORIF left ankle \n\nALLERGIES: Codeine\n\nROS:\n\nRESP: pt intubated in EW vented on IMV 100%/600/14 10 Peep ABG~367/26/7.43 FIO2 decreased to 80% repeat ABG~364/25/7.44 vent changed to AC 60%/550/12 repeat ABG to be done pt suctioned for scant white secretions sputum in EW +PCP ~?increase interstitial markings, ? atypical pneumonia , Chest CT~PE ruled out pt being ruled out for TB - on Resp isolation.\nOn IV steroids\n\nCV: pt ruling in for MI CPK 130, trop 7.6, index 14.6 pt on IV Heparin gtt @ 700 u/hr, PTT 116.8 Heparin gtt decreased to 600 u/hr , repeat PTT due @ 1am. BP labile pt on Levophed gtt, titrated to keep MAP 60, on .093 mcg/kg/, wean Levophed to off, change to Neo gtt~ will wean as tolerated. BP range 80-110/70 HR 70-80's SR, pt will change to CHB for a few seconds, rate 50's EKG done - team aware. currently pt in SR (monitor closely) pt on ASA\nSWAN inserted - readings~~ PAP 29/19, Wedge~16, CVP~13, C.O. 3.71, SVR 1596\n\nID: afebrile WBC 4.5 with 0 bands. pt fully cultured in EW (blood cultures x2, urine, sputum), nasal swab done in MICU. pt on Bactrim 250 mg IV q 8 hrs.\n\nNEURO: upon arrival to MICU - pt awake, agitated, trying to sit up, sedated w/ Ativan 2mg/hr (received two 2 mg boluses), started on IV Fentanyl gtt, currently @ 100 mcg/hr hands restrained for safety. pt adequately sedated. SR up x 4\n\nGI/GU: OGT inserted, placement checked -okay, belly soft, +BS, no stool, pt is NPO will need to be fed. foley inserted in EW~ UO good 100 cc/hr pt negative 1400 cc's\n\nENDOCRINE: FS @8pm~260 pt received 4 units regular insulin sq, continue to FS q 6 hrs, and cover w/ regular insulin ss.\n\nSOCIAL: lives w/ sister (pt has 3 sisters) spokesperson # ETOH - one pint vodka qd, last drink Tuesday, tobacco 2 ppd, cocaine use in past\n\nIV LINES: 2 peripheral lines #16, left radial A-Line, right subclavian cortis, swan inserted in MICU.\n\nA: +PCP, out TB\n Posterior MI by EKG\n Potential for ETOH w/drawal\n\nP: check cultures, on Bactrim, steroids, wean vent as tolerated, rule out TB, chec\n" }, { "category": "Nursing/other", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 1317286, "text": " pm Nsg Admit Note\n(Continued)\nk 2 more sputums. on RESP Isolation\n\n IV Heparin, ASA, follow enzymes, ? in am, lasix prn wean Neo as tolerated, check PTT - adjust gtt accordingly\n\n Ativan gtt/Fentanyl gtt - adjust as needed. safety precautions.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-19 00:00:00.000", "description": "Report", "row_id": 1317298, "text": "micu npn 1900-0700\n patient continuing to require vigerous pulm tolieting. cpt nasotracheal and oral suctioning required almost continuous at times in the evening. patient with poor gag and weak cough. when pt manages to cough secretions they appear to just sit in the back of her throat with ? that she is aspirating them. po2 up from low of 55 at change of shift. pt weaned off nrb to 35% cool neb presently w/sats 98-100%. rr all night 37-55. remains on ativan gtt dialed down this am ~20% to 2 mg/hr. patient very agitated and restless most of the night. ativan and fentanyl bolus' given with little effect on patient. fentanyl bolus decreasing hr ~20 points. otherwise pt squirming all night, yelling out and agitated. pt disconnected a line from angiocath at one point.\n patient conts to be hypertensive and tachycardic overnight. hr 1teens-140 sinus w/rare to occasional pvc's. bp 130-140/sys via a line. t max 99. rectally. conts on bactrum for pcp pneumonia, awaiting last afb culture result to come off droplet precautions. remains npo.\n plan w/ cont vigerous pulm toilet through day, monitor abg's, ? need for intubation if unable to keep up with patient agitation/ secretions.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-19 00:00:00.000", "description": "Report", "row_id": 1317299, "text": "Resp Care Note:\n\nPt received standard dose ALB/ATR as per Carevue. Pt suct for mod loose clear sput. Also suct for large amt oral secretions. Pt very restless overnoc. Though in pt cont to be tachypneic (RR~35-45). Cont good pulm toilet.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-19 00:00:00.000", "description": "Report", "row_id": 1317300, "text": "Respiratory Care Note:\n Mask albuterol/atrovent unit dose aerosol treatment given for app 15 minutes f/w NT suctioning for small amount of thick whitish sputum. Patient with strong cough with suctioning. BS remain coarse bilat. RR remains elevated with RR of 37-48BPM. HR>116-122. ABG noted on 35% cool neb. Patient agitated and non-coop with requests during tx.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-19 00:00:00.000", "description": "Report", "row_id": 1317301, "text": "Respiratory Care Note:\n Patient remains tachypneic, tachycardic. (HR=125, RR40-55). She is on 35% cool neb. BS are coarse with rhochi scattered t/o even after atrovent neb and NT suctioning for mod amt of thick yellow-tinged sputum. She appears agitated when stimulated and appears to have an increased resp effort. I would recommend mask BIPAP if she would tolerate it. Physician to be notified.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-19 00:00:00.000", "description": "Report", "row_id": 1317302, "text": "NPN 0700-1900\nsee careview for details\n\nNEURO:increasing need for sedation, hyperdynamic, HR 1teens - 120's, BP up to 160's systolically,RR 30-50. Ativan boluses and maintainance dose adjusted per CIWA w/ little relief.Haldol 5mg IV Q 2hours also w/ no effect.One dose of fentynal also effect. Pt speech unintelligable,thrashing about at times, does not follow commands.\n\nRESP:Pt now off resp isolation. lungs coarse w/ scattered rhonchi, loose non productive cough.\nTachypeniec throughout day.HO aware.Last ABG showed move toward alkalosis,Ho decieded to try PAP.Resp setting up Pap at this time.\n\nC/V: Hyperdynamic as stated. ST , w/ occ pvc's.\n\nF/E/N: Started on maintainance fluid of D51/2 c 20k @ 100 /hr.UO 50-100cc/hr, abd soft , no stool. insulin gtt titrated to BS.\n\nPLAN : Bipap, follow ABGS, cont antibiotics,re intubate if neccessary.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-31 00:00:00.000", "description": "Report", "row_id": 1317331, "text": "MICU NPN 7P-7A\nNEURO: RECEIVED PATIENT ON PROPOFOL @16MCG. OM THIS DOSE PATIENT SEDATED ADEQUATELY. PT COULD OPEN EYES TO VOICE AND WITHDRAW FROM PAINFUL STIMULI. PATIENT WITH NONPURPOSEFUL MOVEMENTS OF ALL EXTREMITIES. PATIENT ON OCCASION WOULD BREATH INTO THE 30'S BUT WOULD RETURN TO RR OF TEENS. THIS AM PATIENT HAVING APNIEC EPISODES AND PROPOFOL WAS DEREASED TO 12MCG THEN TO 6MCG. PATIENT NOW WITH RR IN THE 20'S WITH NO FURTHER APNIEC EPISODES. PERL @3MM AND BRISK. PATIENT APPEARS NO MORE AWAKE ON 6MCG OF PPF AS SHE DID ON 16MCG. PATIENT WITH +COUGH AND IMPAIRED GAG.\n\nCARDIAC: HR 91-120 SR/ST WITH NO ECTOPY NOTED. ^HR NOTED WHEN PATIENT COUGHING OR MOVING AROUND IN BED. AM LABS SHOWED K+ 3.9 AND MAG 1.4. BEING REPLETED WITH 20MEQ KCL AND 2GMS MGSO4. BP 87-136/49-85, TOLERATING CAPTOPRIL AT CURRENT DOSE. MINIMAL PERIPHERAL EDEMA AND PEDAL PULSES PRESENT. HCT 33 THIS MORNING.\n\nRESP: RECEIVED ON CPAP +5 15PS 40%. PATIENT BREATHING 8-40 WITH SATS 99-100%. EPISODES OF INCREASED RESP ASSOCIATED WITH COUGHING AND NEED FOR SXTING. ONCE SXT PATIENT WOULD DROP BACK TO TEENS. THIS MORNING SETTING OFF APNEA ALARM, SO SEDATION DECREASED WITH IMPROVEMENT. TV'S 200-600 DEPENDING ON RR. AM ABG 7.44/36/92. LS CLEAR WITH DIMINISHED, COARSE BASES. SXT FREQUENTLY FOR THICK WHITE SPUTUM. PATIENT ALSO WITH COPIOUS CLEAR ORAL SECRETIONS. RSBI HAS NOT BEEN DONE YET. TEAM WOULD LIKE TO EXTUBATE BUT CONCERNED ABOUT AMOUNT OF SECRETIONS DESPITE STRONG COUGH.\n\nGI: ABD SOFT WITH +BS. NO STOOL. WAS TOLERATING TUBE FEEDS AT 40/HR VIA OGT WITH MINIMAL RESIDUALS. SHUT OFF AT MN FOR POSSIBLE EXTUBATION. SEE CAREVUE FOR FS.\n\nGU: U/O 20-55/HR YELLOW AND CLEAR. BUN/CRE 11/0.4.\n\nID: TMAX 99.8 WITH WBC 4.8 THIS MORNING. CONTINUES ON CEFTAZ, AND VANCO WILL FINISH TODAY. PATIENT WITH MANY CX'S PENDING.\n\nSKIN: INTACT.\n\nACCESS: LSC CL, R ART LINE.\n\nSOCIAL: NO CONTACT FROM FAMILY. PATIENT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2140-12-31 00:00:00.000", "description": "Report", "row_id": 1317332, "text": "NPN MICU-B 7AM-7PM\nS/O: RESPIR: pt on PS-15 and CPAP-5, on Propofol 6mcq/. Was changed to PS-5, Peep-5, RR 28-45, with VT's 250-450, for lrge amts white secretions before extubation, having copious amts oral secretions requiring very frequent suctioning. ABG- 7.43/36/113/, on PS. Was extubated and was placed on 50% face tent, RR 20-30. Requiring almost constant oral suctioning for copious amts secrections and -trach suctioning. ?'ing being able to handle her secretions, might require re-intubation for airwas protection. L/S course bilat. ABG on 50% face tent- 7.43/36/113/0/25, O2 sats difficult to pick up- 92-97%.\n\nNeuro: Increased responsiveness noted able to grasp hand on command but no other commands, opening eyes and moving all extremities. Can become very agitated and is very restless. Propofol was d/c'd for extubation is rec'ing Haldol , with little effect noted. Attempting to speak s/p extubation, but unable to understand, speech is very garbled.\n\nC/V: BP-120-150/70, HR 90-120 ST no ectopy noted. When was sedate HR90's, BP-100-110/60, both increased s/p extubation. Was rec'ing Captopril 37.5 PO per OGT, dose was increased but is @ present unable to take PO's.\n\nID: Temp 99.1 PO max WBC- WNL's. Vanco was d/c'd s/p 1700 dose this evening. Continues on Ceftaz.\n\nGU: U/O has decreased from 80cc/hr to 30-40cchr, urine is very dark and concentrated. BUN/CRE WNL's. Will address need for IVF's with IOC.\n\nGI: FT's were d/c'd for planned extubation last night @ MN and OGT was\nd/c'd when extubated. But is unable to take PO's ?'ing need to replace OGT or to start TPN, port has been saved. Mod amt formed brown stool noted s/p ducolox supp this AM. soft with + BS's.\n\nSKIN: Small skin tears noted on coccyx tegaderm placed, position changed as tolerated and remains on 1st step mattress.\n\nSocial: Sister called and was updated on pt's condition.\n\nA/P: Continue with aggressive pulmon toilet, assess O2 sats and ABG's, assess the need for re-intubation. Monitor VS's and I&O's.\n" }, { "category": "Nursing/other", "chartdate": "2141-01-02 00:00:00.000", "description": "Report", "row_id": 1317338, "text": "Initial 7p-7a Assessment as follows: received pt from previous RN in standard bed with HOB elevated 30 degrees. Reveiw of Systems\n\n pt to self only. pt anxious and restless. pt MAE spont with mod strength noted x 4 ext. speech garbled and difficult to understand. pt denies pain. PERRL @ 3mm. pt with strong cough and weak gag. pt with B/L upper wrist restraints noted.\n\nCV- ST noted on monitor with occas. PVC's noted. HR 125-135/ . B/P elevated via cuff pressure. HR and B/P elevated d/t anxiety. Morphine 2 mg adm. IVP per Dr. . pulses palp. bilat. no edema. skin warm, dry and intact. afebrile.\n\n pt on 2l O2 via NC. pt tachypnic with anxiety. resp rate 35-40/. pt coughs up thin clear sputum. resp shallow and mildly labored. Lungs CTA bilat. pulmonary toilet maintained. O2 sat @ 99-100%.\n\nGI- Abd soft and mildly distended. NGT clamped with positive placement. pt NPO. no BM noted. BS positive x 4 quads.\n\nGU- Foley intact with adeq. amt of clear yellow urine noted.\n\n pt remains on for trich, ceftaz for PCP. .\n\n- 2400: pt received 2 mg morphine (total 4mg) with good response. HR and B/P decreased - pt at rest with resp 24-26/. Complete bath given. sacrum with two small areas of breaksown noted ( ulcerations noted without drainage) left pt repositioned on to right side.\n\n0100-0400: pt intermittently resting with . AM labs sent with CK and troponin. afebrile. Will con't to monitor.\n\n RN\n" }, { "category": "Echo", "chartdate": "2140-12-16 00:00:00.000", "description": "Report", "row_id": 96432, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 92/56\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:45\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 normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is moderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is moderately depressed. Moderate diffuse hypokinesis with\nposterior akinesis is present.\n2.. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n4. Compared with the prior study of , there is no probably significant\nchange.\n\n\n" }, { "category": "Echo", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 96496, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 121/84\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 03:51\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\nLEFT VENTRICLE: Overall left ventricular systolic function is severely\ndepressed.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. The right\nventricular cavity is mildly dilated. There is focal hypokinesis of the apical\nfree wall of the right ventricle.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. Overall left ventricular systolic function\nis severely depressed (worst at bases, better at apex). The right ventricular\ncavity is mildly dilated. There is focal hypokinesis of the apical free wall\nof the right ventricle. The aortic valve leaflets (3) are mildly thickened but\nnot stenotic. The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral\nregurgitation jet is eccentric. There is no pericardial effusion.\n\nCompared to the previous study of , there has been major\ndeterioration of left ventricular contractile function.\n\n\n" }, { "category": "ECG", "chartdate": "2140-12-29 00:00:00.000", "description": "Report", "row_id": 264157, "text": "Sinus rhythm. Since the previous tracing of the axis is now leftward.\nRight bundle-branch block is no longer noted. There is ST segment elevation in\nleads V2-V3 with loss of R wave in lead V2. The abnormalities are consistent\nwith an acute anteroseptal myocardial infarction. Serial tracings asre\nrecommended.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-12-28 00:00:00.000", "description": "Report", "row_id": 264158, "text": "Sinus rhythm. Compared to the previous tracing of there is new T wave\ninversion in leads II, III and aVF consistent with acute inferior ischemic\nprocess. Rule out infarction. The rate has slowed. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2140-12-27 00:00:00.000", "description": "Report", "row_id": 264159, "text": "Sinus rhythm. Compared to the previous tracing of there is further\nimprovement in the ST-T wave abnormalities previously recorded in\nleads I, aVL and V5-V6. Otherwise, no change.\n\n" }, { "category": "ECG", "chartdate": "2140-12-26 00:00:00.000", "description": "Report", "row_id": 264160, "text": "Sinus tachycardia. Left atrial enlargement. Left axis deviation. Compared to\nthe previous tracing of the rate has slowed. The ST segment\ndepressions, previously recorded in leads I and aVL, are less prominent.\nParoxysmal atrial tachycardia has abated. There is variation in precordial lead\nplacement. Otherwise, no change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-12-25 00:00:00.000", "description": "Report", "row_id": 264161, "text": "Sinus tachycardia with paroxysms of atrial tachycardia. Occasional ventricular\nectopy. Compared to the previous tracing of atrial ectopy has increased\nand there is occasional ventricular ectopy. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2140-12-23 00:00:00.000", "description": "Report", "row_id": 264162, "text": "Sinus tachycardia and increase in rate compared to the previous tracing\nof . Otherwise, no change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-12-23 00:00:00.000", "description": "Report", "row_id": 264163, "text": "Sinus tachycardia. Left bundle-branch block. Since the previous tracing\nof no change.\n\n" }, { "category": "ECG", "chartdate": "2140-12-21 00:00:00.000", "description": "Report", "row_id": 264164, "text": "Probable sinus tachycardia\nIntraventricular conduction delay - incomplete left bundle branch block\nLeft ventricular hypertrophy with ST-T abnormalities\nCannot exclude ischemia - clinical correlation is suggested\nSince previous tracing of : tachycardia, further intraventricular\nconduction delay and marked ST-T wave changes present.\n\n" }, { "category": "ECG", "chartdate": "2140-12-16 00:00:00.000", "description": "Report", "row_id": 264165, "text": "Sinus rhythm. Since the previous tracing of the rate has slowed, but no\nother diagnostic changes have occurred.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 264166, "text": "Sinus rhythm. Since tracing #2 of earlier this date sinus rhythm has rewsumed.\nThe current tracing is similar to tracing #1 except that the rate is slower and\nST-T wave abnormalities are less.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 264167, "text": "Wide complex rhythm at 93 beats per minute consistent with accelerated\nidioventricular rhythm. There are now inferior ST-T wave abnormalities.\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 264168, "text": "Sinus tachycardia. Since the previous tracing of the rate is increased\nand anterolateral ST-T wave abnormalities are worse.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-12-15 00:00:00.000", "description": "Report", "row_id": 264169, "text": "Sinus rhythm\nFirst degree A-V block\nLong QTc interval\nConsider left atrial abnormality\nLeft axis deviation - anterior fascicular block\nIncomplete right bundle branch block\nConsider left ventricular hypertrophy\nST-T wave abnormalities - could be due to ischemia, left ventricular\nhypertrophy and/or metabolic/drug effect - clinical correlation is suggested.\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-12-14 00:00:00.000", "description": "Report", "row_id": 264391, "text": "Sinus tachycardia\nLong QTc interval\nLeft axis deviation - anterior fascicular block\nIncomplete right bundle branch block\nConsider left ventricular hypertrophy\nST-T wave abnormalities - could be due in part to ischemia, left ventricular\nhypertrophy and/or metabolic/drug effect - clinical correlation is suggested.\nSince previous tracing of the same date: no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-12-14 00:00:00.000", "description": "Report", "row_id": 264392, "text": "Sinus tachycardia\nMarked left axis deviation\nRBBB with left anterior fascicular block\nConsider left ventricular hypertrophy\nProlonged Q-Tc interval\nST-T wave abnormalities - could be due in part to ischemia, left ventricular\nhypertrophy and/or metabolic/drug effect - clinical correlation is suggested.\nSince previous tracing of the same date: no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-12-14 00:00:00.000", "description": "Report", "row_id": 264393, "text": "Sinus tachycardia\nLong QTc interval\nLeft axis deviation - anterior fascicular block\nRight bundle branch block\nConsider left ventricular hypertrophy\nST-T wave abnormalities - could be due in part to ischemia, left ventricular\nhypertrophy and/or metabolic/drug effect - clinical correlation is suggested\nSince previous tracing of : above changes present\n\n" }, { "category": "ECG", "chartdate": "2141-01-03 00:00:00.000", "description": "Report", "row_id": 263940, "text": "Sinus tachycardia\nProbable left atrial enlargement\nAnteroseptal infarct - age undetermined\nInferior/lateral T changes may be due to myocardial ischemia\nAnterolateral ST-T abnormalities\nSince previous tracing of , increased rate, and evolution of anterior\nmyocardial infarction is seen\n\n" }, { "category": "ECG", "chartdate": "2141-01-04 00:00:00.000", "description": "Report", "row_id": 263941, "text": "Sinus rhythm\nPremature ventricular contractions\nProbable anterseptal myocardial infarct, age indeterminate\nInferior T wave changes are nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2141-01-02 00:00:00.000", "description": "Report", "row_id": 263942, "text": "Normal sinus rhythm. Compared to the previous tracing of there are now\nST segment elevations in leads V2-V3 which are similar to the prior tracing\nof . In addition, T wave inversions in leads III and aVF are more\nprominent but unchanged from the tracing of .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-01-01 00:00:00.000", "description": "Report", "row_id": 264155, "text": "Sinus tachycardia. QS deflections in leads VI-v2 suggestive of prior\nanteroseptal myocardial infarction. Probable voltage for left ventricular\nhypertrophy. Non-specific ST-T wave abnormalities. Compared to the previous\ntracing of the rate has increased. Otherwise, no diagnostic interim\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-12-29 00:00:00.000", "description": "Report", "row_id": 264156, "text": "Sinus rhythm. There is no diagnostic change from earlier this date.\nTRACING #2\n\n" } ]

[ { "category": "Echo", "chartdate": "2104-12-04 00:00:00.000", "description": "Report", "row_id": 93907, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 70\nWeight (lb): 210\nBSA (m2): 2.13 m2\nBP (mm Hg): 108/77\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 09:41\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - akinetic; mid inferolateral - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Very small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements.\n\nConclusions:\nThere is mild regional left ventricular systolic dysfunction with\ninferolateral akinesis. The remaining segments contract normally (LVEF =\n45-50%). Right ventricular chamber size and free wall motion are normal. There\nis a very small pericardial effusion. The effusion is echo dense, consistent\nwith blood, inflammation or other cellular elements.\n\nIMPRESSION: Very small pericardial effusion. Mild regional left ventricular\nsystolic dysfunction, c/w CAD.\n\n\n" }, { "category": "Echo", "chartdate": "2104-12-03 00:00:00.000", "description": "Report", "row_id": 93908, "text": "PATIENT/TEST INFORMATION:\nIndication: Follow-up pericardial effusion s.p. MI.\nHeight: (in) 70\nWeight (lb): 205\nBSA (m2): 2.11 m2\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 07:36\nTest: TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction.\n\nAORTIC VALVE: Three aortic valve leaflets.\n\nPERICARDIUM: Moderate to large pericardial effusion. Effusion echo dense, c/w\nblood, inflammation or other cellular elements. No RV diastolic collapse.\n\nConclusions:\nFOCUSED STUDY TO COMPARE TO EARLIER TTE: There is moderate regional left\nventricular systolic dysfunction with focal severe hypokinesis to akinesis of\nthe inferior wall, inferolateral wall, inferoseptum, and apex. The remaining\nsegments contract well. (EF 30-35%). There are three aortic valve leaflets.\nThere is a moderate to large sized pericardial effusion which is\ncircumferential (1.7 cm) and echodense. No right ventricular diastolic\ncollapse is seen.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is slightly increased in size (anterior to right ventricle, in\nsubcostal views).\n\n\n" }, { "category": "Echo", "chartdate": "2104-12-02 00:00:00.000", "description": "Report", "row_id": 93806, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p STEMI. Evaluation for effusion.\nHeight: (in) 70\nWeight (lb): 205\nBSA (m2): 2.11 m2\nBP (mm Hg): 95/73\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 20:42\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Moderately\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid\ninferior - akinetic; basal inferolateral - hypo; mid inferolateral - hypo;\ninferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. Effusion\necho dense, c/w blood, inflammation or other cellular elements. No RV\ndiastolic collapse. Brief RA diastolic collapse. Significant, accentuated\nrespiratory variation in mitral/tricuspid valve inflows, c/w impaired\nventricular filling.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nFOCUSED STUDY: There is mild to moderate regional left ventricular systolic\ndysfunction with akinesis of the inferior wall and severe hypokinesis of the\ninferolateral wall, basal to mid inferior septum, and apex. The remaining\nsegments contract normally (LVEF = 30-35 %). The number of aortic valve\nleaflets cannot be determined. No aortic regurgitation is seen. No mitral\nregurgitation is seen. There is a moderate sized pericardial effusion. The\neffusion appears circumferential. The effusion is echo dense, consistent with\nblood, inflammation or other cellular elements. No right ventricular diastolic\ncollapse is seen. There is brief right atrial diastolic collapse. There is\nsignificant, accentuated respiratory variation in mitral/tricuspid valve\ninflows, consistent with impaired ventricular filling.\n\nIMPRESSION: Suboptimal image quality.Regional left ventricular systolic\ndysfunction c/w multivessel CAD. Moderate-sized, echodense pericardial\neffusion without echocardiographic evidence of frank tamponade physiology.\n\n\n" }, { "category": "ECG", "chartdate": "2104-12-02 00:00:00.000", "description": "Report", "row_id": 248715, "text": "Baseline artifact. Probable sinus rhythm with an atrial premature beat.\nAbnormal axis probably related to arm lead reversal. Precordial leads show\nST segment elevation in leads V3-V6 suggest lateral myocardial infarction.\nSuggest repeat tracing and clinical correlation. No previous tracing available\nfor comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2104-12-05 00:00:00.000", "description": "Report", "row_id": 248709, "text": "Sinus rhythm. Compared to tracing #2 inferolateral myocardial infarction\npattern persists. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2104-12-04 00:00:00.000", "description": "Report", "row_id": 248710, "text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2104-12-03 00:00:00.000", "description": "Report", "row_id": 248711, "text": "Sinus rhythm. Q waves and ST segment elevation in the inferolateral leads\nconsistent with ongoing inferolateral myocardial infarction. Compared to the\nprevious tracing of inferolateral myocardial infarction pattern\npersists.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2104-12-02 00:00:00.000", "description": "Report", "row_id": 248712, "text": "Sinus rhythm. Inferolateral myocardial infarction in evolution. Since\ntracing #3 reciprocal changes in leads aVR, aVL and V1 are now somewhat less.\nEarly R wave progression persists. Clinical correlation is suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2104-12-02 00:00:00.000", "description": "Report", "row_id": 248713, "text": "Sinus rhythm. Inferior Q waves with ST segment elevation and reciprocal\ndepression in leads aVR and aVL. ST segment elevation with small Q waves in\nleads V3-V6. Inferolateral myocardial infarction in evolution. Since tracing #2\nthere is probably no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2104-12-02 00:00:00.000", "description": "Report", "row_id": 248714, "text": "Sinus rhythm. Non-diagnostic inferior Q waves with ST segment elevation.\nReciprocal depressions in leads I, aVR and aVL. ST segment elevation in\nleads V3-V6 without development of Q waves. Probable extensive inferolateral\nmyocardial infarction in evolution. Clinical correlation is suggested.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-03-25 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 958860, "text": " 3:41 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? pe\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxia.\n REASON FOR THIS EXAMINATION:\n ? pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb SUN 6:46 AM\n 1. No pulmonary embolism.\n 2. Small bilateral pleural effusions and small pericardial effusion.\n 3. Bibasilar opacities - differential includes atelectasis and\n infection.\n 4. Multiple enlarged mediastinal lymph nodes may be related to underlying\n infectious etiologies, though neoplastic causes not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with hypoxia. Evaluate for pulmonary embolism.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the lung bases with coronal and sagittal reformatted images.\n\n CONTRAST: Images were obtained without and with 80 cc of IV Optiray contrast.\n\n CTA CHEST: No filling defects or pulmonary emboli identified to the level of\n the subsegmental branches. The aorta demonstrates normal caliber and contour\n throughout its course. Aortic wall calcification and coronary artery\n calcifications are noted.\n\n CT CHEST WITH IV CONTRAST: Soft tissue window images demonstrate confluent\n bibasilar opacities, with associated small effusions. There are air\n bronchograms within these areas as well. There is a small pericardial\n effusion. Multiple prominent lymph nodes are seen in a subcarinal region (13\n mm, series 3, image 55), and within the hilar regions bilaterally, greater on\n the right, and in the AP window and precarinal regions as well.\n\n Lung windows demonstrate these confluent opacities in the lung bases\n bilaterally. Tiny inflammatory nodular opacities are also seen scattered\n within the left upper lobe (series 3, image 44.). Fluid can be seen within\n the lower lobe bronchi.\n\n Limited images through the upper portion of the abdomen demonstrate no\n definite abnormalities in the liver, spleen, adrenal glands, and visualized\n portion of the stomach. A tiny hypodensity is seen within the left kidney,\n which is not completely characterized. There is a large hypodensity on the\n noncontrast enhanced images within the superior pole of the right kidney,\n which likely represents a cyst.\n\n (Over)\n\n 3:41 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? pe\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating\n the anatomy and pathology.\n\n IMPRESSION:\n 1. No pulmonary embolism.\n 2. Small pericardial effusion and bilateral pleural effusions.\n 3. Confluent opacities at the lung bases bilaterally may represent areas of\n atelectasis and/or consolidation, aspiration or infection.\n 4. Multiple enlarged lymph nodes within the mediastinum, which may reflect\n reactive lymph nodes related to infection, though other causes such as\n neoplastic sources cannot be excluded.\n 5. Large hypodensity within the superior pole of the right kidney likely\n represents a cyst, though this is not completely assessed on this study.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958858, "text": " 2:46 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with sepsis line.\n\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old woman with sepsis, status post line placement.\n\n COMPARISON: Study from approximately two hours prior on the same day.\n\n PORTABLE AP CHEST RADIOGRAPH: There has been placement of a left IJ line,\n with the tip in the mid SVC. No pneumothorax is seen. There is persistent\n left retrocardiac opacity. No definite left pleural effusion is seen. The\n remainder of the study is not significantly changed in comparison to most\n recent exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958852, "text": " 12:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with sob.\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with shortness of breath, evaluate for acute\n cardiopulmonary abnormality.\n\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: There is an area of increased opacity in the\n left retrocardiac region which obscures the left hemidiaphragm. There may be\n a small associated left pleural effusion. The pulmonary vasculature is within\n normal limits. There is minimal linear atelectasis at the right costophrenic\n angle. No pneumothorax is seen. Several left-sided healed rib fractures are\n noted.\n\n IMPRESSION: Left retrocardiac opacity, which likely represents an area of\n consolidation and/or atelectasis, with an associated small left pleural\n effusion. No overt CHF.\n\n" }, { "category": "ECG", "chartdate": "2170-03-25 00:00:00.000", "description": "Report", "row_id": 115091, "text": "Normal sinus rhythm with rate at the upper limits of normal. Very low voltage\nin the limb leads, low voltage in the precordial leads. QS deflections in\nleads VI-V3 with ST segment elevations and T wave inversions in leads V3-V4.\nT wave inversions in leads V5-V6 without ST segment elevations. Tracing is\ncompatible with acute anterior wall myocardial infarction. Compared to the\nprevious tracing of T waves are now inverted in leads V5-V6.\n\n" }, { "category": "ECG", "chartdate": "2170-03-25 00:00:00.000", "description": "Report", "row_id": 115092, "text": "Sinus tachycardia\nLeft axis deviation\nLeft anterior fascicular block\nInferior infarct - age undetermined\nAnteroseptal infarct - age undetermined\nLow QRS voltages in limb leads\nSince previous tracing of , heart rate faster, low lead voltage,\ninferior myocardial infarction and anterior myocardial infarction are new,\nanterior myocardial infarction may be acute\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2170-03-25 00:00:00.000", "description": "Report", "row_id": 115093, "text": "Sinus arrhythmia\nAnteroseptal infarct - age undetermined\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of the same date , heart rate slower, axis less\nleftward, QT interval prolonged, anterior T wave abnormalities more marked, and\ninferior myocardial infarction less apparent\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2170-03-25 00:00:00.000", "description": "Report", "row_id": 1431295, "text": "NPN 07:00\nPlease refer to Carevue for additional patient information\n*DNR/DNI\n\n y/o woman chief c/o respiratory distress, brought to ED from rehab after being found with O2 sat's in 70's, and RR ~44. Patient was very lethargic, prior to event was given Ativan, Ambien, and Seroquel (patients normal sleep regimen.) While in ED EKG done showing ?changes ST depression, Cardiology involved. Transferred to MICU on CPAP 15/5/40% O2 sat's high 90's however patient continued to be very lethargic, with and only following simple commands, and BP continued to be low sbp 75 at lowest. Started on Levophed 0.08mcg/kg/min with good results.CPAP d/c at ~9am, placed on venti-mask, woke within minutes, Levophed d/c'd. Throughout shift patient became increasingly agitated, stating that all she wanted to do was sleep. Given Haldol 0.5mg IV x1, per Dr. . At ~14:30, patient soon after c/o nausea, and became very sleepy, with sat's dropping to mid 80's, but not rebounding. Placed back on CPAP, bp dropped, back on Levophed, RR and minute volumes dropping intermittenly, O2 sat's remaining high 90's. Currently very lethargic, opening eyes to loud voice, not following commands.\nCV: Levophed currently on, 0.04mcg/kg/min, BP 120's/40's, afebrile. HR 80's, NSR no ectopy, CK's flat, troponin pndg.\nResp: CPAP 15/5/40, RR6-15, o2 sat's 98%. LS rhonchorus throughout.\nGI/GU: NPO, u/o wnl.\nAccess: TLC LIJ, slight bleeding around site. PIV x2 bilateral feet wnl.\nPlan: monitor resp status, ?need for diuresis if u/o should drop. Haldol 0.25mg next time. Attempt venti mask if tolerated. Provide support to daughter.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-03-25 00:00:00.000", "description": "Report", "row_id": 1431296, "text": "resp care - Pt brought to unit on NIV from ED. Pt taken off NIV and put on .40 venti mask for 6 hours. Pt returned to following increasing SOB. ABG showed hypercarbia with adequate oxygenation. Trial on VM attempted again after 2H on NIV. BLBS are coarse t/o. \rContinued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-26 00:00:00.000", "description": "Report", "row_id": 1431297, "text": "NPN-MICU\nMrs has been unrsp and comfortable overnight\n\nNeuro: pt anxious and uncomfortable at beginning of shift, asking to be put to sleep or given somthing for her abd pain. She was just started on IV MSO4. She was given some ativan 2mg and has since been unsrsp and comfortble with family at bedside. Dr spoke with pt's daughter/family and they decided to make her full comfort measures and stop all meds except comfort meds at this time. She has been afebrile but her HR ansd BP have been slowly dropping over time. Her O2 sat is also dropping slowly.\n\nA/P: Will cont to keep comfortable with family at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-26 00:00:00.000", "description": "Report", "row_id": 1431298, "text": "Please See carevue for Specifics.\n\nPt expired at 0805, MICU team aware. Emotional support offer to family. Family and pt's needs were met.\n" } ]

[ { "category": "Radiology", "chartdate": "2199-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140830, "text": " 9:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna/failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with concern for acute cardiopulmonary process\n REASON FOR THIS EXAMINATION:\n eval for pna/failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute shortness of breath.\n\n TECHNIQUE: Single frontal portable chest radiograph.\n\n FINDINGS: There is opacity in the left mid and lower lung concerning for\n aspiration or pneumonia with associated pleural effusion. Blunting of the\n right costophrenic angle is compatible with a small pleural effusion. No\n pneumothorax is seen. No pneumothorax.\n\n IMPRESSION: Left lower lobe aspiration vs pneumonia. Bilateral pleural\n effusions, left > right.\n\n" }, { "category": "Radiology", "chartdate": "2199-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140965, "text": " 7:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with respiratory failure.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:15 \n\n HISTORY: Respiratory failure, evaluate for change.\n\n IMPRESSION:\n AP chest compared to :\n\n Infiltrative abnormality in the left lung has expanded from the mid and basal\n lung to the apex extending above the aortic arch, accompanied by increasing\n moderate left pleural effusion and progression of a similar but less severe\n process in the right lower lung, also accompanied by increasing right pleural\n effusion. Since the heart is not enlarged and the azygos vein is not\n distended pulmonary edema, even severely asymmetric as this would be, cannot\n be assumed. Atypical pneumonia, pulmonary hemorrhage and noncardiogenic edema\n must be considered. No pneumothorax. was paged.\n\n\n" }, { "category": "Echo", "chartdate": "2199-05-22 00:00:00.000", "description": "Report", "row_id": 68606, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Right ventricular function.\nHeight: (in) 60\nWeight (lb): 110\nBSA (m2): 1.45 m2\nBP (mm Hg): 114/42\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 12:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and 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).\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. No MS. 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 visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor suprasternal views. Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is\n10-20mmHg. Left ventricular wall thickness, cavity size, and global systolic\nfunction are normal (LVEF>65%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. The estimated cardiac index\nis normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is an anterior space which most\nlikely represents a prominent fat pad.\n\nIMPRESSION: Moderate pulmonary artery systolic hypertension. Normal\nbiventricular cavity sizes with preserved global biventricular systolic\nfunction. Mild mitral regurgitation with normal valve morphology.\n\n\n" }, { "category": "ECG", "chartdate": "2199-05-21 00:00:00.000", "description": "Report", "row_id": 148524, "text": "Sinus rhythm. Left atrial abnormality. Borderline low limb lead voltage.\nNon-specific ST-T wave changes. Slight right ventricular conduction delay. No\nprevious tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2183-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997163, "text": " 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CHF\n REASON FOR THIS EXAMINATION:\n ? change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: In comparison to previous examination, the endotracheal tube has\n been inserted. The tip of the tube is 1 to 2 cm above the carina and should\n be retracted by 3 to 4 cm. The tip of the nasogastric tube is not visible,\n the course of the tube is unremarkable. Status post CABG. In comparison to\n previous examination, the size of the cardiac silhouette is unchanged.\n However, there is retrocardiac atelectasis and homogeneous opacification of\n the right lower lung, most likely due to effusion. Signs of substantial\n overhydration are not present. No air bronchograms, no opacities suggestive\n of pneumonia. No pneumothorax.\n\n IMPRESSION: Newly inserted endotracheal tube should be retracted by 3 to 4\n cm. Retrocardiac atelectasis. Evidence of small right-sided pleural\n effusion. No evidence of pneumonia. No signs of fluid overload.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2183-01-10 00:00:00.000", "description": "VENOUS DUP EXT UNI (MAP/DVT)", "row_id": 998041, "text": " 1:00 PM\n VENOUS DUP EXT UNI (MAP/DVT) Clip # \n Reason: PLEASE ASSESS FOR DVT, PSEUDOANEURYSM, HEMATOMA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION OF EXAM: This is a 75-year-old woman with left arm hematoma.\n\n RADIOLOGISTS: The exam was read by Drs. and .\n\n TECHNIQUE AND FINDINGS: Left upper extremity venous system was evaluated with\n B-mode, color and spectral Doppler ultrasound modes.\n\n The left jugular vein, subclavian vein, axillary, brachial, cephalic and\n basilic veins present with normal compressibility. Left basilic vein presents\n with PICC line artifact. No signs of pseudoaneurysm or hematoma in the left\n upper extremity.\n\n COMPARISON: None available.\n\n IMPRESSION:\n 1. There is no deep venous thrombosis within the left upper extremity venous\n system.\n 2. PICC line seen in the left basilic vein/axillary vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997139, "text": " 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with resp failure chf. intubated\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old with respiratory failure secondary to CHF. Evaluate\n tube placement.\n\n No prior examinations.\n\n SINGLE AP SUPINE CHEST RADIOGRAPH: The ET tube is satisfactorily positioned,\n terminating approximately 4.6 cm above the carina. NG tube descends below the\n diaphragm with tip not visualized. Median sternotomy wires and CABG clips are\n noted. There is moderate cardiomegaly and moderate interstitial edema without\n evidence of alveolar edema. No sizable effusion or pneumothorax on these\n supine films. A dense 5-mm nodule in the left upper lung zone is likely a\n granuloma. The osseous structures are unremarkable.\n\n IMPRESSION: Cardiomegaly and moderate CHF. ET tube in satisfactory position.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-01-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 997238, "text": " 12:50 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check picc tip position. #5f, dl, 55cm, picc for mult\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with CHF\n REASON FOR THIS EXAMINATION:\n please check picc tip position. #5f, dl, 55cm, picc for multiple meds. please\n page beeper # with wet read asap. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a PICC line that extends to the mid portion of the SVC. Hazy\n opacification with preservation of lung markings is again seen at the right\n base, consistent with pleural effusion. The endotracheal and nasogastric\n tubes have been removed.\n\n\n" }, { "category": "Echo", "chartdate": "2183-01-06 00:00:00.000", "description": "Report", "row_id": 102099, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 190\nBSA (m2): 1.98 m2\nBP (mm Hg): 133/50\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 09:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RAP (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. [Intrinsic LV systolic function likely depressed given\nthe severity of valvular regurgitation.] TDI E/e' >15, suggesting PCWP>18mmHg.\nNo 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. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (AoVA 1.2-1.9cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Moderate (2+) MR. [Due\nto acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mild [1+] TR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Significant PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular\ncavity is moderately dilated. There is severe global left ventricular\nhypokinesis with best preserved motion in the anteroseptum (LVEF = 25 %).\n[Intrinsic left ventricular systolic function is likely more depressed given\nthe severity of valvular regurgitation.] Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). Right ventricular\nchamber size is normal. with mild global free wall hypokinesis. There are\nthree aortic valve leaflets. The aortic valve leaflets are moderately\nthickened. There is mild aortic valve stenosis (area 1.6 cm2). Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is borderline pulmonary artery systolic hypertension.\nMild pulmonic regurgitation is seen. There is a trivial/physiologic\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , regional left\nventricular dysfunction now extends to the anterior and anterolateral walls.\nThe overall ejection fraction is likely decreased. The severity of aortic\nregurgitation may have increased slightly.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-01-06 00:00:00.000", "description": "Report", "row_id": 1379711, "text": "Nursing Progress Note -0700\n*Full code\n\n*Allergies: Beta Blockers (increased wheezing)\n\n*Access: 18g 's x2 (L and R arms)\n\n** Please see admit note/FHP for admit info and hx.\n\nNeuro: Pt started shift sedated on fent/versed, but decided later that he may extubate in AM so changed to Propofol, currently on 30mcg, pt mildly sedated, comfortable, opens eyes to voice, aggitated w/ treatments, not following commands, MAE in bed and w/ good strength, no signs of pain per vitals.\n\nCardiac: pt w/ significant cardiac hx, had been scheduled for pacemaker this month, not yet received. Cardiac service is following, ? move pt to CCU or call out to cardiac floor if pt is extubated and stable. This shift, ST/NSR w/ frequent PVC's, HR 83-102 but mostly in the 80's, SBP 119-156, had come from ED w/ Nitro gtt, soon dc'd. Trending cardiac enzymes, now elevated (trop 0.2 from 0.03), next labs @ 1000. hct stable @ 34.4, lytes wnl. ECHO ordered for today, follow up EKG ordered as well.\n\nResp: From ED on A/C 50%/550/18/5, was overbreathing, increased sedation steadily, ABG 7.37/45/91/27. Plan to possibly extubate this AM after diuresis since lungs sounds have improved. Now on CPAP 5/5, 40%, RSBI 47. MDI's to be given. CXR done this AM, results pending. This shift, o2sat 95-100%, rr 18-28, LS rhonchorous-coarse upper, rhonchorous-diminished lower, some insp wheezing earlier in shift. Sm amt bloody sputum sxn by RT earlier in shift.\n\nGi/Gu: OGT clamped, NPO, minimal bilious residuals, +BS, no stool this shift, abd soft/distended. Urine out foley yellow/clear, 80-430cc/hr w/ higher amts following 250mg IV diuril and 100mg IV Lasix, given @ MN and 0030 but still puttin out volumes >250cc (over 1L out since doses). BUN/Creat 32/2.6 from 31/2.5 w/ baseline creat 1.5-2.0. FSBG 183 covered per sliding scale.\n\nID: Temp 97.0-98.4, WBC 5.5. No abx @ this time. Son stated to MD that pt c/o coughing for about the last week, but no other symptoms. Skin w/d/i, iv sites wnl, some dry skin in LE's, also noted BLE edema.\n\nPsychosocial: son lives in same building w/ father, checks on him occasionally. Some question by MD's if pt is taking meds properly, may require VNA, med/diet teaching and/or assistance. ? social work consult to assess pt's ability to cont to care for himself (safety).\n\nDispo: remains on CPAP (? extubate this AM), ECHO ordered for today, Cardiac enzymes and other labs @ 1000, PICC eval ordered, ? transfer to CCU vs. call out to cardiac floor if stable after extubation, cont med regimen and icu care @ this time.\n" }, { "category": "Nursing/other", "chartdate": "2183-01-06 00:00:00.000", "description": "Report", "row_id": 1379712, "text": "Respiratory Care:\n\nPt received from EW with respiratory failure with PMHx of CHF & CP, orally intubated & sedated on full ventilatory support, breathing over set rate. We were able to transition to minimal spontaneous ventilation; PSV, See Careview. RSBI done ~47. Bs are coarse cracles and occ fine wheezes l>R. We are sxtn for small amt of thick tan to blaood tinged, active cough. Plan: wean to elective extubation.and Continye present ICu monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2183-01-06 00:00:00.000", "description": "Report", "row_id": 1379713, "text": "Respiratory Care Note\nPt received on PSV 5/5 and placed on SBT 5/0 at start of shift. BS are clear with good aeration throughout. Pt tolerated SBT well with VT in 500's and RR 20-25. Subglottic suctioning done prior to extubation. Pt suctioned for small amt thick, bloody secretions. Pt has a positive cuff leak test. Pt extubated to cool aerosol without incident.\n" }, { "category": "Nursing/other", "chartdate": "2183-01-06 00:00:00.000", "description": "Report", "row_id": 1379714, "text": "NPN\n\nROS:\nNeuro: Pt dozing on and off, easily arousable oriented X 3. Following commands. MAE. OOB to chair w/ 2 assist..tolerated well. C/o sore throat to ET tube ...given ice chips.\n\nResp: Pt extubated at 9am. Initially placed on cool neb @ 50% w/ O2 sats of 100%. Currently on RA w/ sats 96-100%. RRR. Gag/cough (non-productive) intact. LS clear w/ some fine crackles to RLL.\n\nCV: Bp 90s-140s/40s-60s. HR 80s-100s w/ 15 beat runs of NSVT X2 this am...coreg dose increased w/ good effect. Pt with RBBB. Pt started on coreg, isorbide, , , lisinopril, and zocor. Trending CEs. Troponin elevated from 0.03-> 0.24. EKG and echo done this am. Pt waiting pacemaker placement this month.\n\nGI/GU: Abd soft. BS present. Pt advanced from clear lix to regular diet...tolerating well. No BM this shift. Foley draining 100-400cc/hr of clear yellow urine.\n\nID: Afebrile. WBC 5.5. No antbx. Skin intact.\n\nAccess: X2 (R and L wrist). PICC line placed at bedside this afternoon. CXR confirmed placement.\n\nSocial: Pt lives alone. Son lives nearby- involved in father's care. Son called this afternoon and updated on POC and pt's status. Pt states he does receive VNA services at home. ? if need more help w/ med compliance.\n\nPlan:\nContinue to monitor CEs and lytes.\nDiurese as needed.\nSocial work consult.\n? Pacemaker placement.\nTransfer to cardiac floor.\n" }, { "category": "Nursing/other", "chartdate": "2183-01-07 00:00:00.000", "description": "Report", "row_id": 1379715, "text": "19:00-00:00\n\nPT IS ORIENTED X3,MAE,NO C/O PAIN EXCEPT SORE THROAT FROM ET TUBE.LS COARSE/CLEAR.ON RA SATING FINE.IN NSR WITH RARE ECTOPY.NBP WITHIN LIMITS.AIMING FOR NEG BALANCE.PT IS CURRENTLY 2.3L NEG BALANCE.K WAS REPLETED.REPEAT K 4.1.CARDIAC ENZYMES TRENDING DOWN.\nPT TO 6.\n" }, { "category": "ECG", "chartdate": "2183-01-08 00:00:00.000", "description": "Report", "row_id": 289315, "text": "Sinus rhythm\nVentricular premature complex\nMarked left axis deviation\nLeft atrial abnormality\nRBBB with left anterior fascicular block\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2183-01-08 00:00:00.000", "description": "Report", "row_id": 289316, "text": "Sinus rhythm\nLeft axis deviation\nLeft atrial abnormality\nRBBB with left anterior fascicular block\nLateral T wave changes\nSince previous tracing of , QRS width longer at slower rate\n\n" }, { "category": "ECG", "chartdate": "2183-01-06 00:00:00.000", "description": "Report", "row_id": 289317, "text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. Left atrial abnormality. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing there is no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2183-01-05 00:00:00.000", "description": "Report", "row_id": 289318, "text": "Sinus tachycardia. Left axis deviation. Right bundle-branch block with\nleft anterior fascicular block. Diffuse non-specific ST-T wave changes.\nLeft atrial abnormality. Compared to the previous tracing the rate is faster.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2194-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1170945, "text": " 5:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infectious process\n Admitting Diagnosis: NON Q WAVE MYOCARDIAL INFARCTION\\CARDIAC CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with NSTEMI, now with new onset fever\n REASON FOR THIS EXAMINATION:\n please eval for infectious process\n ______________________________________________________________________________\n WET READ: NATg 6:26 PM\n Lungs clear, no effusion or pneumothorax. Heart size and pulmonary vasculature\n WNL.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:36 P.M. ON \n\n HISTORY: MI. New fever. Suspect pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are fully expanded and clear. There is no pleural abnormality. Heart\n size is normal. Mediastinal widening to the left of midline extending from\n the aortic knob which is partially obscured to the thoracic inlet is unchanged\n since , therefore unlikely due to malignancy or other active\n process. It could be a large fat collection or vascular anomaly, particularly\n left-sided SVC. I do not think this warrants additional imaging\n investigation.\n\n\n" }, { "category": "Echo", "chartdate": "2194-01-14 00:00:00.000", "description": "Report", "row_id": 86822, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 72\nWeight (lb): 266\nBSA (m2): 2.41 m2\nBP (mm Hg): 117/67\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 11:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo; basal inferolateral - akinetic; mid\ninferolateral - hypo; inferior apex - hypo;\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction with inferior/inferolateral\nhypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. The left ventricular inflow pattern suggests impaired\nrelaxation. The estimated pulmonary artery systolic pressure is normal. There\nis no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular systolic function is probably similar or slightly\nmore impaired (inferolateral hypokinesis noted in the current study).\n\n\n" }, { "category": "ECG", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 222978, "text": "Artifact is present. Sinus rhythm. There are Q waves in the inferior\nleads consistent with prior myocardial infarction. There is an early\ntransition consitent with posterior extension of the myocardial infarction.\nCompared to the previous tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2194-01-15 00:00:00.000", "description": "Report", "row_id": 222979, "text": "Artifact is present. Sinus rhythm. There are Q waves in the inferior leads\nconsistent with prior myocardial infarction. There is an early transition\nconsistent with posterior extension of the myocardial infarction. Compared to\nthe previous tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2194-01-14 00:00:00.000", "description": "Report", "row_id": 222980, "text": "Sinus rhythm. Inferior wall myocardial infarction. Early R wave progression.\nConsider posterior involvement. Minor ST-T wave abnormalities. Compared to the\nprevious tracing there is less artifact.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2194-01-14 00:00:00.000", "description": "Report", "row_id": 222981, "text": "Baseline artifact. Sinus rhythm. Inferior wall myocardial infarction. Since the\nprevious tracing there is no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 222982, "text": "Sinus rhythm. Inferior wall myocardial infarction. Early R wave progression.\nCompared to the previous tracing the rate is slower. Otherwise, findings are\nunchanged.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 222983, "text": "Sinus rhythm. Probable inferior myocardial infarction of indeterminate age.\nEarly R wave progression. Since the previous tracing of the rate is\nfaster. ST-T wave abnormalities may be more prominent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 222977, "text": "Sinus rhythm. There are Q waves in the inferior leads consisent with\nprior myocardial infarction. There is an early transition consistent with\nposterior extension. Compared to the previous tracing of there is no\nsignificant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2139-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949554, "text": " 6:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval hypoxia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with h/o ITP, DM2, cirrhosis, s/p variceal banding\n yesterday, now w/ hemoptysis.\n REASON FOR THIS EXAMINATION:\n eval hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old woman with history of diabetes, cirrhosis, status\n post variceal banding yesterday, now hemoptysis and hypoxia.\n\n AP UPRIGHT CHEST: In comparison to the portable film of ,\n there is no significant interval change. There are slightly lower lung\n volumes. Again seen are basilar streaky opacities likely representing\n atelectasis, although consolidation cannot be excluded. The exam is\n technically extremely limited due to patient positioning, body habitus and\n motion. The heart size is difficult to assess but appears grossly stable.\n\n IMPRESSION: Technically extremely limited exam offers little diagnostic\n information. Consider repeat film. Low lung volumes and bilateral basilar\n opacities which may represent atelectasis and/or effusions/consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949590, "text": " 11:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for infiltrate, effusions, chf, vascular con\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with h/o ITP, DM2, s/p rhogam with hypotension and fevers\n and hypoxia\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate, effusions, chf, vascular congestion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 11:36 P.M., .\n\n INDICATION: Multiple medical problems as above. Now with hypoxia.\n\n FINDINGS: Compared with 6:14 p.m. earlier the same day, as well as studies\n back to , there appears to be chronic underlying interstitial disease.\n\n There are bilateral foci of atelectasis and/or infiltrates, right greater than\n left, superimposing the chronic changes.\n\n The azygos vein is enlarged at this time indicating some increase in right\n ventricular pressures. No overt effusions seen on this AP study.\n\n" }, { "category": "Radiology", "chartdate": "2139-02-12 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 949899, "text": " 3:40 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o interstitial lung disease.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with severe as, mr, cirrhosis, heart failure, presents s/p\n winrho infusion w/ rigors and hypotension. Will undergo AVR and MVR during this\n stay.\n REASON FOR THIS EXAMINATION:\n r/o interstitial lung disease.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe AS, MR, cirrhosis and heart failure. Presents with rigors\n and hypertension. Evaluate for interstitial lung disease.\n\n COMPARISON: Chest radiograph, .\n\n TECHNIQUE: MDCT-acquired axial images of the chest were obtained without IV\n contrast with high resolution technique. Images were obtained in inspiration\n and expiration. 1.25 mm thin section and coronally reformatted images were\n also displayed.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: There is evidence of septal thickening,\n with scattered areas of ground glass opacity as well as bronchial wall\n thickening. Trace right pleural effusion also seen. These findings suggest\n CHF with interstitial pulmonary edema. No focal consolidations are seen\n within the lungs. Several tiny calcified granulomas are seen within the\n lungs. At least four sub 5-mm noncalcified nodular densities are seen within\n the right lung (series 3, images 31, 32, 35, 37). Moderate air trapping noted\n on expiratory images.\n\n 1.4-cm right lower paratracheal lymph node is noted (2:35). No other\n pathologically enlarged mediastinal, hilar, or axillary lymphadenopathy is\n identified. Coronary calcifications as well as atherosclerotic calcification\n of the aorta are also noted. Calcification seen at the mitral annulus. There\n is enlargement of the left atrium. Main pulmonary artery also appears\n dilated, measuring 4.2 cm, suggesting pulmonary artery hypertension.\n\n Airways appear patent to the subsegmental level.\n\n Small hiatal hernia is noted. Imaged portions of the upper abdomen\n demonstrate mild-to-moderate amount of ascites. The liver contour appears\n nodular, suggesting cirrhosis. There is splenomegaly. Gallstones are noted\n within the gallbladder. Diffuse stranding seen within the subcutaneous fat\n suggest anasarca. There is persistent elevation of the right hemidiaphragm,\n unchanged in comparison to the plain film from .\n\n IMPRESSION:\n\n 1. Smoothly thickened septal lines and ground glass opacities are most\n (Over)\n\n 3:40 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o interstitial lung disease.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with hydrostatic pulmonary edema, especially in the setting of a\n right pleural effusion and known cardiac disease. However, this process could\n potentially obscure underlying chronic interstitial disease, and if clinically\n indicated, repeat scanning following diuresis could be performed.\n\n 2. Several scattered noncalcified sub 5-mm nodular opacities within the right\n lung, possibly representing noncalcified granulomas given the presence of\n other calcified granulomas. However, followup CT in three months is\n recommended to document stability and to exclude a neoplastic etiology.\n\n 3. Pulmonary arterial hypertension.\n\n 4. Cirrhotic-appearing liver, with moderate amount of ascites and\n splenomegaly.\n\n 5. Cholelithiasis.\n\n 6. 1.4-cm mediastinal lymph node, which is nonspecific but may related to\n CHF.\n\n 7. Coronary artery calcifications.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2139-02-17 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 950632, "text": " 1:27 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: eval for evidence of carotid stenosis\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with CAD, AS, MR, CHF, renal failure, ITP, being evaluated\n for valve replacement. Please eval for evidence of carotid stenosis.\n REASON FOR THIS EXAMINATION:\n eval for evidence of carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID ULTRASOUND EXAMINATION\n\n INDICATION: A 68-year-old woman with coronary artery disease, being evaluated\n for valve replacement.\n\n FINDINGS: Carotid ultrasound examination was performed bilaterally.\n\n RIGHT SIDE: There is a mild plaque at the origin of the internal and external\n carotid arteries with respective peak systolic velocities 72 cm/sec and 97\n cm/sec. The peak systolic velocity in the common carotid artery 54 cm/sec.\n ICA/CCA ratio is 0.74. The flow in the vertebral artery is in antegrade\n direction.\n\n LEFT SIDE: There is a mild plaque at the origin of the internal carotid\n artery. The internal carotid artery is somewhat tortuous in its course. The\n peak systolic velocity in the internal carotid artery 85 cm/sec, common\n carotid artery 92 cm/sec and external carotid artery 86 cm/sec. ICA/CCA ratio\n is 0.92. The flow in the vertebral artery is in antegrade direction.\n\n IMPRESSION: Less than 40% stenosis of the proximal internal carotid arteries\n bilaterally. This is a baseline examination at the .\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2139-02-11 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 949694, "text": " 1:17 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: please evaluate for ascites and mark spot if possible; pleas\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with cirrhosis, chf, fevers\n REASON FOR THIS EXAMINATION:\n please evaluate for ascites and mark spot if possible; please evaluate RUQ for\n biliary process, GB wall edema, liver lesion.Please also do dopplers to\n evaluate flow\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 68-year-old female with cirrhosis, CHF, fevers. Please\n evaluate for ascites and mark spot if possible. Evaluate right upper quadrant\n for biliary process, gallbladder wall edema and liver lesion.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: Limited ultrasound of the abdomen secondary to\n technical difficulties. The liver demonstrates coarsened echotexture\n consistent with chronic liver disease. No focal masses evident within the\n liver. There is no evidence of intra- or extra-hepatic biliary dilatation.\n There is a contracted gallbladder containing multiple stones. No gallbladder\n wall edema is apparent. There is moderate amount of ascites. The right\n kidney measures 11.6 cm. The left kidney measures 11.5 cm. There is no\n hydronephrosis or stones. The portal vein is patent with normal hepatopetal\n flow. Doppler evaluation of the hepatic veins and arteries demonstrate normal\n waveforms. The pancreas is not well visualized. The spleen is enlarged and\n measures 17.6 cm.\n\n IMPRESSION:\n 1. The liver shows coarsened echotexture with nodular architecture consistent\n with chronic liver disease. No focal mass is seen within the liver.\n 2. There is a contracted gallbladder containing multiple stones. There is no\n gallbladder wall edema or evidence of cholecystitis.\n 3. Moderate amount of ascites. The right lower quadrant was marked for\n paracentesis by clinical team.\n 4. Splenomegaly.\n 5. Doppler evaluation of the hepatic vessels show normal hepatopetal flow\n within the portal vein. The hepatic vein and arteries demonstrate normal\n waveforms.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-10 00:00:00.000", "description": "Report", "row_id": 1545551, "text": "ADMIT NOTE\n68 Y/O FEMALE ADMITTED TO MICU FROM ER FOR FURTHER MONITORING AND CPAP. PT. HAS A PMH OF ITP, ADVANCED CHF, LIVER DISEASE. SHE WAS SEEN IN CLINIC TODAY FOR INFUSION OF WINRHO TO GET HER PLTS. HIGHER FOR ANTICIPATION OF UPCOMING VALVAULAR SURGERY. 45 MINUTES INTO INFUSION PT. STARTED TO HAVE RIGORS AND BECAME HYPOTENSIVE WAS GIVEN SOLUMEDROL, TYLENOL AND BENADRYL IN CLINIC PRIOR TO TRANSFERRING TO ED. WILL BE CONTINUED TO BE MONITORED HERE IN THE MICU AND SHE WILL BE PLACED ON CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-11 00:00:00.000", "description": "Report", "row_id": 1545552, "text": "npn 11p-7a (see also carevue flownotes for objective data)\n\n68 yo female w/ PMHx severe AS, MR, ITP, DM II, revcently admitted /07 for variceal banding and pna, s/p 7d levo/flagyl;\n was at clinic receiving Winrho (Rhogam) for ITP, trying to prep pt for heart valve replacemements; 45 minutes after receivin Winrho, became symptomatic for rxn--rigors, hypotension, hypoxia; ABG 7.44/44/54/33; received solumedrol, benedryl, tylenol, 20 IV lasix, and sent to ED;\n in ED found to have ST depressions in V4-6, RR 30's; cxr c/w CHF, given additional 40 IV lasix placed on bi-pap for 35 minutes /w improvement of oxygenation and and SOB; also had T 102.2, bld cx's sent;\n\narrove 4 approx 22:30; has been on nc O2 at 4 L with good O2 sats over night mid 90's to hi 90's;\n\ncardiac rhythm NSR/NSR, no ectopy, rate 99-low 100's; hx CMP;\nlungs w/ CR left post base, Rt post base\n\na/o x3, pleasant, able to verbalize concerns/needs/questions;\n\nNPO for ice chips at this time; received 1/2 dose hs glargine d/t NPO before pt ordered for Solumedrol; ordered for Solumedrol later; pt also is on RISS w/ q 6 hr FS'; no stool this night;\n\nlab called, stated qns in FDP (navy top) tube, MD aware, will re-order w/ next set of labs, likely to be drawn at approx 10:00;\n\nurine output dark amber, cloudy, volume increased very slightly over the night, though still is low;\n\na.m. labs show continued hyponatremia, yet with significant increase in BUN in relation to stable Creatinine, suggesting pt intravascularly dry;\n\nLFT's expectedly elevated d/t liver dz;\n\n covering MD re a.m. labs, stated appears possibly hemolytic rxn to Winrho (rhogam) received in clinic yesterday;\n\npt jaundiced, skin and sclera, amber/ urine; no skin breakdown;\n\npt's daughter is closest living relative, was present at admission last eve, called this morning for update;\n\nPLAN:\n1) goal sbp >85\n2) cont current plan of care\n3) further plans per a.m. rounds\n4) FS w/ SSI coverage, and hs glargine\n5) carafate for GI protection, as well as IV Pepcid\n6) try to obtain cardiac chair (recliner) for pt d/t her SOB;\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-11 00:00:00.000", "description": "Report", "row_id": 1545553, "text": "npn 0700-1900;\nabdomenal ultrasound to mark poss sites,for paracentisis.\ns/b renal and heme teams .\nfb for low bp and urine output with min response bolused with lasix then started on lasix drip to attempt to maintain a u/o of 100mls/hr.\nros;\nneuro; aox3 mae to command very pleasant and cooperative with care perla 4mm.sitting on edge of bed fro most of day.asking appropriate questions.\n\nresp; lungs clear upper with crackles way up on both sides.maintaining sats 96-100% rr 35-24. has unproductive couch which pt states is not new,.? cardiac cough.\n\ncvs; tmax 99.8 ax bp 62/27-113/40pt runs with low bp norm.80-95/40.\npt mentates dispite low bp. seems to be lower when pt lying flat on back pt dangles on side of bed witih bp 72-85/43. rr and hr decrease when sitting on side encouraged to lie on sides when lying down. min improvement of bp with fluid bolus.\n\ngu; aiming for u/o of 100 mls/hr. goal equal or slighly neg. given lasix 80 mgs x2 with min response then started on lasix drip tcurrently at 6mgs/hr. urine icteric in colour.with red cell debris and sediment.\n\ngi; belly obese heavy with ascitis., pos bs no stool no flatus refused bowel regime as had diarrhoea in ed yesterday. taking ice chips c/o of feeling dry, and hungry . now able to eat and awaiting tray. bs covered with humalog riss. glargine due at bedtime.renal feel that pt is not intravascularly dry.\n\nskin with ecchymotic areas,from blood draws.bone marrow site intact.\nskin remains jaundiced with icteric sclera,\n\nheme;prbcx1 transfused fro hct of 24.8 not released until 1300 as pt difficult to crossmatch.hct of 23.8 does not reflect prbcx1. increased inr no signs of bleeding.\n\na/p labile s/p acute intervascular hemolytic reaction from winro.\nplan to tolerate sbp of greater than 70. renal rec k will probably be released in blood an no more fluid as pt has persistent rales and high jvp.\ncontinue to monitor labs q6 to monitor progression of hemolysis.\nfollow urine output. k not repleted as k released from cell down and prbc,magesium repleted.\ncardiac enzymes show poss leak.continue to follow.\ncontinue with glargine and humalog cover. steroids and benadryl and antibiotics discontinued as felt that fevers due to hemolysis.please see renal and heme note.\ncontinue to monitor u/o closely. next labs due at 8 pm.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-13 00:00:00.000", "description": "Report", "row_id": 1545556, "text": "NPN Overnight 1900-0700\nNeuro: A&O x3, MAE, OOB to toilet X1 w/ assist. Some difficulty moving ascities. Afebrile.\nCV: HR in 90's , NSR w/ no ectopy noted. Pt exhibits chronic low BP's, ranging 79-100/37-55 this shift, medical team well aware. Denies CP/palps/dizziness. Easily audible systolic murmur mitral regurg. 3+ edema in LE's b/l but + pp's, ascites. On lasix gtt @ 1.5 cc/hr, titrated down from 6cc/hr @ beginning of shift. 1800 Na+ 126, Dr aware. AM labs pending\nResp: Pt remains on 3L NC w/ occasional c/o SOB but RR in low 20's and sats maintained >96%. LS clear in upper lobes but fine crackles auscultated in LL's b/l\nGI/Endo: Pt on cardiac/HH/DB/CC well tol. Small, formed BM x2. FS 247, 269. Abd remains grossly distended ascites\nGU: Patent foley draining dark yellow urine w/ occasional rust colored sediment @ >45cc/hr. Titrating Lasix drip to maintain output @ 60-80 cc/hr\nSkin: Multiple bruises on UE's and sacral area. Skin @ L groin red/irritated friction during movement b/c ascites. Aloe Vesta liberally applied.\nLine: New PIV placed on in L ant forearm. Patent\nSocial: Daughter telephoned\n: Monitor and support hemodynamic status\n Monitor u/o, titrating Lasix to maintain u/o 60-80cc/hr\n RISS\n C/O to to cardiac service\n Skin care @ groin area\n Encourage turn/deep breathe\n Emotional support\n" }, { "category": "Nursing/other", "chartdate": "2139-02-12 00:00:00.000", "description": "Report", "row_id": 1545554, "text": "Neuro: alert and oriented, cooperative with care, denies any pain. OOB to chair and dangle legs at edge of bed intermittently; gait steady with minimum assist.\n\nCV: 71-96/44-61 MAP 50-70, patient mentating well even with low BP, denies dizziness baseline SBP 80-90mmHg; acceptable BP for patient > 70mmHg; ST 100-105 without ectopy; pedal pulses weakly palpable, +2 edema of bilateral lower extremities\n\nRespi: denies shortness of breath, lung sounds clear, fine crackes at bases; occasional non-productive cough noted; sats > 95% at 4lpm\n\nGI/GU: tolerating diet, bowel sounds present, no BM tonight refused her bowel regimen. continues on Lasix drip at 10mg/hr with urine output 60-70cc/hr; + 1400 for 260 cc for 24 hrs; urine still icteric with sediments\n\nHeme: hct post BT 25.8, no transfusion this shift; patient lost approx. 20-30cc of blood, IV tubing cap fell off, hct check post blood loss, result pending.\n\nEndo: received 30u of glargine at bedtime, FS 219 on humalog sliding scale, coverage given at 2200\n\nSocial: patient's daughter called for update last night, aware ofplan of care. patient would want ot asign daughter as her HCP, -up docs in am.\n\nplan:\n\nmonitor hct and lytes q6hrs for hemolysis; transfuse platelets and PRBC if needed; continue lasix to maintain UO goal 60-80 cc/hr; transfer out to cardiology once off lasix drip; maintain BP > 70mmHg; monitor for signs of bleeding;\n" }, { "category": "Nursing/other", "chartdate": "2139-02-12 00:00:00.000", "description": "Report", "row_id": 1545555, "text": "Nursing Note: 0700-1900\n\nNeuro: pt 3, cooperative, denies pain, ambulates well out OOB to chair with assisstance, steady ambulation.\n\nCV: pt has low baseline BP, NBP 75-100/40-60, pt mentating well with BP, no dizziness sitting up or ambulating, afebrile, HR 80-90 SR no ectopy, pos systolic murmur, weak distal pulses, pos lower extremity edema. transferring west to cardiology floor, ? mitral valve replacement.\n\nResp: pts sats 96-99 on 3L NC, SOB noted with exertion, lungs clear upper with crackles lower, . chest CT done this afternoon.\n\nGI/GU: pt has cardiac diet, good appetite, pos bowel sounds aceities, refused carafate x2, lasix drip at 6mg/hr titrating to UO= 60-100cc/hr, UO 40-120cc/hr.\n\nIV: 18g PIV's left and right arms.\n\nSkin: skin fragile and multiple bruising, no active breakdown noted.\n\nSocial: pts daughter in to visit pt today.\n\nPlan: pt c/o to cardiology floor, titrate lasix drip r/t UO, continue to monitor vitals, resp status, labs. assessment ongoing.\n\n\n" }, { "category": "Echo", "chartdate": "2139-02-17 00:00:00.000", "description": "Report", "row_id": 71010, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment. BUBBLE STUDY. evaluate for PFO.\nHeight: (in) 64\nWeight (lb): 219\nBSA (m2): 2.03 m2\nBP (mm Hg): 98/52\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 15:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color Doppler or saline\ncontrast with maneuvers.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. TDI E/e' >15,\nsuggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral\nannular calcification. Moderate thickening of mitral valve chordae. Mild MS\n(MVA 1.5-2.0cm2). Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Dilated main PA.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\nBilateral pleural effusions.\n\nConclusions:\nThe left atrium is markedly dilated. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. There is\nmild symmetric left ventricular hypertrophy with normal cavity size and\nsystolic function (LVEF>55%). Regional left ventricular wall motion is normal.\nTissue Doppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). The right ventricular cavity is mildly dilated, with mild\nglobal free wall hypokinesis. There are three thickened/deformed aortic valve\nleaflets. There is at least moderate aortic stenosis, but accurate\nquantification of its severity was technically limited. Trace aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is severe mitral annular calcification and moderate thickening of the\nmitral valve chordae. There is mild mitral stenosis (area 1.5-2.0cm2).\nModerate to severe (3+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is moderate pulmonary artery systolic\nhypertension. The main pulmonary artery is dilated. There is no pericardial\neffusion.\n\nIMPRESSION: No patent foramen ovale seen. Left ventricular hypertrophy with\npreserved global and regional systolic function. Dilated right ventricle with\nmild systolic dysfunction. At least moderate aortic stenosis. Mild mitral\nstenosis. Moderate to severe mitral regurgitation. Moderate pulmonary\nhypertension.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "ECG", "chartdate": "2139-02-10 00:00:00.000", "description": "Report", "row_id": 150916, "text": "Sinus tachycardia\nLeft atrial abnormality\nNonspecific ST-T wave changes\nSince previous tracing of , ventricular rate slower and further ST-T\nwave changes present\n\n" }, { "category": "ECG", "chartdate": "2139-02-10 00:00:00.000", "description": "Report", "row_id": 150917, "text": "Baseline artifact\nRegular narrow complex tachycardia mechanism uncertain - could be sinus\ntachycardia but consider also atrial flutter with 2:1 response\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , ventricular rate faster and further ST-T\nwave changes present\n\n" } ]

[ { "category": "General", "chartdate": "2198-06-30 00:00:00.000", "description": "ICU Event Note", "row_id": 462412, "text": "Clinician: Attending\n right femoral triple lumen placement supervised using sterile technique\n with assistance of ultrasound, no complications\n Total time spent: 25 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2198-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462421, "text": "S/p unwitnessed fall at home, wife found patient unresponsive. EMS\n arrived and pt was in PEA arrest. Intubated and CPR/Epi, Atropine done\n in field, brought to , C1burst fracture and C2 dens\n fracture with posterior displacement. Head CT was negative. TX to\n , pt. was rescanned here.\n PMH: HTN, high cholesterol, colon CA with colectomy in , arthritis.\n NKDA\n Cervical fracture (with Spinal Cord Injury)\n Assessment:\n Opens eyes spontaneously, pupils are equal and reactive. On last exam\n corneal were absent but pt appears to be blinking at change of shift.\n No movement in bilateral upper extremities, bilateral lower extremities\n with triple flexion when nail bed pressure applied. No cough or gag\n reflexes present . Labs pending. Large indentation in chest with\n crepitus on exam.\n Action:\n Hard collar changed to J. Dopamine gtt weaned off and Levophed\n gtt titrated up for MAP >65. HR 40-120s. Femoral triple lumen and\n arterial line placed.\n Response:\n Labile vital signs\n Plan:\n MRI of head and c spine. Discuss POC with family.\n" }, { "category": "General", "chartdate": "2198-06-30 00:00:00.000", "description": "Generic Note", "row_id": 462407, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains on ac rr increased for goal co2 of 35\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: plan to continue on current support ? MRI\n Reason for continuing current ventilatory support:\n" }, { "category": "Physician ", "chartdate": "2198-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 462471, "text": "TSICU\n HPI:\n 80 yo M who reportedly had mech fall down ~ 3 stairs outside, who was\n found in PEA arrest upon EMS arrival. CPR initiated by Fire dept, no\n shocks, but reportedly ROSC with epinephrine, chest compressions, and\n intubation in the field. Was xferred from OSH () on dopamine,\n paperwork states pt \"clutched his chest\" but wife states the fall was\n unwitnessed. Apparently pt was leaning over a railing to trim ,\n and possibly fell over the railing landing on his neck/head, approx 3\n foot fall from porch. He was then \"found down\" not breathing by his\n wife approx 5 minutes after he went outside. Unclear circumstances, but\n ? resp arrest due to high cervical cord injury, then cardiac arrest.\n Presents here on dopamine, no sedation, no movement.\n PMHx:\n PMH: HTN, elev chol, pectus excavatum, arthritis, colon ca\n PSH: hernia repair, colorectal resection\n Current medications:\n 1. 2. 3. 1000 mL LR 4. 1000 mL LR 5. Calcium Gluconate 6. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 7. Cortroysn 8. DOPamine 9. Fentanyl Citrate 10. Hydrocortisone Placebo\n 11. Insulin 12. Magnesium Sulfate\n 13. Norepinephrine 14. Pantoprazole 15. Pneumococcal Vac Polyvalent 16.\n Potassium Chloride 17. Potassium Phosphate\n 18. Sodium Chloride 0.9% Flush 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:00 PM\n MULTI LUMEN - START 06:58 PM\n ARTERIAL LINE - START 08:00 PM\n MAGNETIC RESONANCE IMAGING - At 09:15 PM\n Admit to TSICU. R femoral CVL and R radial a-line placed. d/w\n family severity of injury based on CT scans and exam. MRI brain/cspine\n PENDING, further d/w neurosurg/trauma pending MRI, pt is currently FULL\n CODE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Dopamine - 4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:54 PM\n Other medications:\n Flowsheet Data as of 05:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 33.5\nC (92.3\n T current: 32.9\nC (91.2\n HR: 43 (29 - 94) bpm\n BP: 94/42(60) {67/38(49) - 139/83(104)} mmHg\n RR: 18 (14 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 66.5 kg (admission): 66 kg\n Total In:\n 647 mL\n 1,072 mL\n PO:\n Tube feeding:\n IV Fluid:\n 647 mL\n 1,072 mL\n Blood products:\n Total out:\n 2,240 mL\n 80 mL\n Urine:\n 840 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,593 mL\n 992 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 47.2 cmH2O/mL\n SPO2: 98%\n ABG: 7.42/34/146/21/-1\n Ve: 9.1 L/min\n PaO2 / FiO2: 365\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Click )\n Abdominal: Soft, Non-distended\n Left Extremities: (Temperature: Cool)\n Right Extremities: (Temperature: Cool)\n Neurologic: No(t) Follows simple commands, (Responds to: Unresponsive),\n No(t) Moves all extremities, (RUE: No movement), (LUE: No movement),\n intermittenly moves \n Labs / Radiology\n 277 K/uL\n 11.8 g/dL\n 168 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 33.7 %\n 14.5 K/uL\n [image002.jpg]\n 03:01 PM\n 06:05 PM\n 09:07 PM\n 11:24 PM\n 11:45 PM\n 03:59 AM\n 04:13 AM\n WBC\n 17.5\n 16.4\n 14.5\n Hct\n 38.5\n 35.6\n 33.7\n Plt\n 280\n 303\n 277\n Creatinine\n 1.0\n 0.9\n Troponin T\n 0.09\n 0.07\n TCO2\n 25\n 22\n 22\n 23\n Glucose\n 205\n 168\n Other labs: PT / PTT / INR:13.1/27.8/1.1, CK / CK-MB / Troponin\n T:219/12/0.07, ALT / AST:66/76, Alk-Phos / T bili:64/0.7, Lactic\n Acid:1.8 mmol/L, Albumin:4.3 g/dL, LDH:263 IU/L, Ca:9.0 mg/dL, Mg:1.4\n mg/dL, PO4:1.6 mg/dL\n Imaging: CT Head: (our rads read of OSH CT) no ICH, edema or mass\n effect.\n CT CSpine: WET READ- C1 burst fracture. Odontoid fracture with 9\n mm posterior distplacement of the superior fracture fragment. severe\n multilevel degenerative change with moderate canal and neural foraminal\n stenosis predisposes to cord injury. There is posterior subluxation of\n C1 and odontoid on the C2 body as seen by C1-2 facet malalignement on\n parasagittal reformats.\n CT Torso: WET READ- Bilateral posterior consolidation in the upper\n and lower lobes, could represent contusion vs aspiration. no effusion,\n hemothorax, or pneumothorax. no aortic injury or mediastinal hematoma.\n NG and ETT in adequate position. In abdomen/pelvis, there is no\n evidence of solid organ injury. No\n hemoperitoneum or free air. Non-specific perinephric stranding is\n present bilaterally. Aortic atherosclerosis with ectasia of the\n infrarenal aorta measuring up to 2.3 cm. No fractures are identified.\n Degeneative changes in the T/L spine. Mild anterolisthesis at L4-5 is\n likely degenerative.\n . MRI Brain: WET READ- No acute abnormality. No acute hemorrhage.\n No acute infarct. No shift.\n . MRI CSpine: WET READ- Fx c2, with tilting of the cranial portion\n of the fracture fragment, namely the dens, posteriorly. This indents\n the cord. There is cervical cord edema from the craniocervical junction\n to approximately the C3 level. There is a 5-mm focus of abnormal signal\n within the cervical cord at the C2 level, most likely representing a\n cord hemorrhage.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), CERVICAL FRACTURE (WITH\n SPINAL CORD INJURY)\n Assessment and Plan: 80 M s/p fall s/p PEA arrest with C1 burst and\n displaced dens fracture, with possible anoxic brain injury and\n quadraplegia vs. other cord injury.\n Neurologic: Neuro checks Q: 1hr. Pain: fentanyl prn. Hard C-Collar at\n all times, MRI Brain and C-Spine pending to further eval injury.\n Cardiac arrest team consulted as below, cooling for goal temp 33 C, p02\n 35-40 for neuro protection. not currently requiring sedation. After\n return from MRI, pt noted to spontaneously move his , pt is\n intermittently blinking, otherwise neuro exam similar to prior.\n Cardiovascular: s/p PEA arrest. No STE or obvious ischemia on EKG.\n Levophed for MAP > 65, sbp > 120 per neurosurg. Cardiac arrest\n team/cardiology consult involved, recommend aspirin pending eval for\n cord hematoma. Consider Echo in am. Trend CE.\n Pulmonary: Intubated, likely will require ventilatory support given\n level of likely cord injury. pCO2 35-40 for neuro protection.\n Gastrointestinal / Abdomen: npo\n Nutrition: NPO\n Renal: follow lytes, currently with good UOP.\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no current issues\n Lines / Tubes / Drains: ETT, OGT, Foley, R femoral CVL, R radial a-line\n Imaging: CXR today\n Fluids: LR\n Consults: Neuro surgery, Trauma surgery, Cardiology\n Billing Diagnosis: Cardiac arrest, (Shock: Unspecified), Vertebral\n fracture\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 06:58 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2198-07-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 462457, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Copious\n Comments: from oropharynx\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Not triggering\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 MRI\n 2100\n MRI head and neck. On versamed vent for whole study. No complications.\n" }, { "category": "Physician ", "chartdate": "2198-07-01 00:00:00.000", "description": "Intensivist Note", "row_id": 462458, "text": "TSICU\n HPI:\n 80 yo M who reportedly had mech fall down ~ 3 stairs outside, who was\n found in PEA arrest upon EMS arrival. CPR initiated by Fire dept, no\n shocks, but reportedly ROSC with epinephrine, chest compressions, and\n intubation in the field. Was xferred from OSH () on dopamine,\n paperwork states pt \"clutched his chest\" but wife states the fall was\n unwitnessed. Apparently pt was leaning over a railing to trim ,\n and possibly fell over the railing landing on his neck/head, approx 3\n foot fall from porch. He was then \"found down\" not breathing by his\n wife approx 5 minutes after he went outside. Unclear circumstances, but\n ? resp arrest due to high cervical cord injury, then cardiac arrest.\n Presents here on dopamine, no sedation, no movement.\n Chief complaint:\n PMHx:\n PMH: HTN, elev chol, pectus excavatum, arthritis, colon ca\n PSH: hernia repair, colorectal resection\n Current medications:\n 1. 2. 3. 1000 mL LR 4. 1000 mL LR 5. Calcium Gluconate 6. Chlorhexidine\n Gluconate 0.12% Oral Rinse\n 7. Cortroysn 8. DOPamine 9. Fentanyl Citrate 10. Hydrocortisone Placebo\n 11. Insulin 12. Magnesium Sulfate\n 13. Norepinephrine 14. Pantoprazole 15. Pneumococcal Vac Polyvalent 16.\n Potassium Chloride 17. Potassium Phosphate\n 18. Sodium Chloride 0.9% Flush 19. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:00 PM\n MULTI LUMEN - START 06:58 PM\n ARTERIAL LINE - START 08:00 PM\n MAGNETIC RESONANCE IMAGING - At 09:15 PM\n Admit to TSICU. R femoral CVL and R radial a-line placed. d/w\n family severity of injury based on CT scans and exam. MRI brain/cspine\n PENDING, further d/w neurosurg/trauma pending MRI, pt is currently FULL\n CODE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Dopamine - 4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:54 PM\n Other medications:\n Flowsheet Data as of 05:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 33.5\nC (92.3\n T current: 32.9\nC (91.2\n HR: 43 (29 - 94) bpm\n BP: 94/42(60) {67/38(49) - 139/83(104)} mmHg\n RR: 18 (14 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 66.5 kg (admission): 66 kg\n Total In:\n 647 mL\n 1,072 mL\n PO:\n Tube feeding:\n IV Fluid:\n 647 mL\n 1,072 mL\n Blood products:\n Total out:\n 2,240 mL\n 80 mL\n Urine:\n 840 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,593 mL\n 992 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 47.2 cmH2O/mL\n SPO2: 98%\n ABG: 7.42/34/146/21/-1\n Ve: 9.1 L/min\n PaO2 / FiO2: 365\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Click )\n Abdominal: Soft, Non-distended\n Left Extremities: (Temperature: Cool)\n Right Extremities: (Temperature: Cool)\n Neurologic: No(t) Follows simple commands, (Responds to: Unresponsive),\n No(t) Moves all extremities, (RUE: No movement), (LUE: No movement),\n intermittenly moves \n Labs / Radiology\n 277 K/uL\n 11.8 g/dL\n 168 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 33.7 %\n 14.5 K/uL\n [image002.jpg]\n 03:01 PM\n 06:05 PM\n 09:07 PM\n 11:24 PM\n 11:45 PM\n 03:59 AM\n 04:13 AM\n WBC\n 17.5\n 16.4\n 14.5\n Hct\n 38.5\n 35.6\n 33.7\n Plt\n 280\n 303\n 277\n Creatinine\n 1.0\n 0.9\n Troponin T\n 0.09\n 0.07\n TCO2\n 25\n 22\n 22\n 23\n Glucose\n 205\n 168\n Other labs: PT / PTT / INR:13.1/27.8/1.1, CK / CK-MB / Troponin\n T:219/12/0.07, ALT / AST:66/76, Alk-Phos / T bili:64/0.7, Lactic\n Acid:1.8 mmol/L, Albumin:4.3 g/dL, LDH:263 IU/L, Ca:9.0 mg/dL, Mg:1.4\n mg/dL, PO4:1.6 mg/dL\n Imaging: CT Head: (our rads read of OSH CT) no ICH, edema or mass\n effect.\n CT CSpine: WET READ- C1 burst fracture. Odontoid fracture with 9\n mm posterior distplacement of the superior fracture fragment. severe\n multilevel degenerative change with moderate canal and neural foraminal\n stenosis predisposes to cord injury. There is posterior subluxation of\n C1 and odontoid on the C2 body as seen by C1-2 facet malalignement on\n parasagittal reformats.\n CT Torso: WET READ- Bilateral posterior consolidation in the upper\n and lower lobes, could represent contusion vs aspiration. no effusion,\n hemothorax, or pneumothorax. no aortic injury or mediastinal hematoma.\n NG and ETT in adequate position. In abdomen/pelvis, there is no\n evidence of solid organ injury. No\n hemoperitoneum or free air. Non-specific perinephric stranding is\n present bilaterally. Aortic atherosclerosis with ectasia of the\n infrarenal aorta measuring up to 2.3 cm. No fractures are identified.\n Degeneative changes in the T/L spine. Mild anterolisthesis at L4-5 is\n likely degenerative.\n .\n MRI Brain: WET READ- No acute abnormality. No acute hemorrhage. No\n acute infarct. No shift.\n .\n MRI CSpine: WET READ- Fx c2, with tilting of the cranial portion\n of the fracture fragment, namely the dens, posteriorly. This indents\n the cord. There is cervical cord edema from the craniocervical junction\n to approximately the C3 level. There is a 5-mm focus of abnormal signal\n within the cervical cord at the C2 level, most likely representing a\n cord hemorrhage.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), CERVICAL FRACTURE (WITH\n SPINAL CORD INJURY)\n Assessment and Plan: 80 M s/p fall s/p PEA arrest with C1 burst and\n displaced dens fracture, with possible anoxic brain injury and\n quadraplegia vs. other cord injury.\n Neurologic: Neuro checks Q: 1hr. Pain: fentanyl prn. Hard C-Collar at\n all times, MRI Brain and C-Spine pending to further eval injury.\n Cardiac arrest team consulted as below, cooling for goal temp 33 C, p02\n 35-40 for neuro protection. not currently requiring sedation. After\n return from MRI, pt noted to spontaneously move his , pt is\n intermittently blinking, otherwise neuro exam similar to prior.\n Cardiovascular: s/p PEA arrest. No STE or obvious ischemia on EKG.\n Levophed for MAP > 65, sbp > 120 per neurosurg. Cardiac arrest\n team/cardiology consult involved, recommend aspirin pending eval for\n cord hematoma. Consider Echo in am. Trend CE.\n Pulmonary: Intubated, likely will require ventilatory support given\n level of likely cord injury. pCO2 35-40 for neuro protection.\n Gastrointestinal / Abdomen: npo\n Nutrition: NPO\n Renal: follow lytes, currently with good UOP.\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no current issues\n Lines / Tubes / Drains: ETT, OGT, Foley, R femoral CVL, R radial a-line\n Wounds:\n Imaging: CXR today\n Fluids: LR\n Consults: Neuro surgery, Trauma surgery, Cardiology\n Billing Diagnosis: Cardiac arrest, (Shock: Unspecified), Vertebral\n fracture\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 06:58 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2198-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462473, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n No spontaneous breathing, requiring ventilation\n Action:\n Cmv 40% 500x18 w/ peep of 5, suctioned q3h for no secretions, 0530 pt\n dropped spo2 to 88% suctioned thick plug,. PIPS=30\n Response:\n Spo2 back to baseline 98-100%, PIPS=22\n Plan:\n Continue logroll and s-s positioning, suction q3h and prn, monitor\n pulm. See NCP\n Cervical fracture (with Spinal Cord Injury)\n Assessment:\n Alteration in neuro vs and bradycardia with st elevation, varying pr\n intervals. Withdraws lower extremities to stimulation, no movement of\n upper extremities. Labile sbp on levo titration, becoming progressively\n bradycardic to 28,\n Action:\n dopamine started at 3.5mcg/kg/min, levo weaned off, lytes repleted,\n fluid bolus given for episode hypotention\n maintained temp 33C with cooling blanket. Pt placed on cardiac arrest\n team study of steroids post arrest. Fentanyl given for grimacing with\n suctioning.\n Response:\n Good response to dopamine, maintaining map 70\ns-80\n Plan:\n Monitor nvs and hemodynamics per routine, maintain map ~65, maintain\n temp ~33C for 24hrs ending at 1000. monitor uo, continue steroid study\n as ordered. Assess for pain and medicate as ordered. Maintain logroll\n precautions. Continue to monitor for spinal shock.\n Ineffective Coping\n Assessment:\n Family appropriately grieving, and very supportive of each other\n Action:\n Pt\ns condition and test results explained to family by MD ,\n Family asking approp questions . also spoke with cardiac arrest team.\n Response:\n Family seemed pleased with response to questions and concerns, went\n home for the night.\n Plan:\n Support family, encourage visitation, provide information as needed.\n" }, { "category": "Nursing", "chartdate": "2198-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462470, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n No spontaneous breathing, requiring ventilation\n Action:\n Cmv 40% 500x18 w/ peep of 5, suctioned q3h for no secretions, 0530 pt\n dropped spo2 to 88% suctioned thick plug,. PIPS=30\n Response:\n Spo2 back to baseline 98-100%, PIPS=22\n Plan:\n Continue logroll and s-s positioning, suction q3h and prn, monitor\n pulm. See NCP\n Cervical fracture (with Spinal Cord Injury)\n Assessment:\n Alteration in neuro vs and bradycardia with st elevation, varying pr\n intervals. Withdraws lower extremities to stimulation, no movement of\n upper extremities. Labile sbp on levo titration, becoming progressively\n bradycardic to 28,\n Action:\n dopamine started at 3.5mcg/kg/min, levo weaned off, lytes repleted,\n fluid bolus given for episode hypotention\n maintained temp 33C with cooling blanket. Pt placed on cardiac arrest\n team study of steroids post arrest. Fentanyl given for grimacing with\n suctioning.\n Response:\n Good response to dopamine, maintaining map 70\ns-80\n Plan:\n Monitor nvs and hemodynamics per routine, maintain map ~65, maintain\n temp ~33C for 24hrs ending at 1000. monitor uo, continue steroid study\n as ordered. Assess for pain and medicate as ordered. Maintain logroll\n precautions.\n" }, { "category": "Nursing", "chartdate": "2198-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462538, "text": "Ineffective Coping\n Assessment:\n Family coping appropriately. Family meeting this morning with TSICU\n team and neuro surgery team to discuss code status. Patient was made a\n DNR until all family members could be present.\n Action:\n At 1345 patient was made a CMO. Morphine gtt started and epi gtt was\n shut off, patient was extubated.\n Response:\n No spontaneous respirations.\n Plan:\n Time of death 1416. NEOB notified and trauma team to do paperwork.\n Cervical fracture (with Spinal Cord Injury)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2198-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462539, "text": "Ineffective Coping\n Assessment:\n Family coping appropriately. Family meeting this morning with TSICU\n team and neuro surgery team to discuss code status. Patient was made a\n DNR until all family members could be present.\n Action:\n At 1345 patient was made a CMO. Morphine gtt started and epi gtt was\n shut off, patient was extubated.\n Response:\n No spontaneous respirations.\n Plan:\n Time of death 1416. NEOB notified and trauma team to do paperwork.\n Cervical fracture (with Spinal Cord Injury)\n Assessment:\n Hemodynamiclly unstable this morning, Hr in the 20\ns, SPB down to 60,\n see flowsheet for specifics. Eventually patient was made a DNR then\n later a CMO.\n Action:\n Epi gtt and IVP atropine for hypotension and bradycardia.\n Response:\n VS more stable on epi gtt.\n Plan:\n Respiratory and cardiac arrest after planned extubation as CMO status.\n" }, { "category": "General", "chartdate": "2198-07-01 00:00:00.000", "description": "Generic Note", "row_id": 462442, "text": "TITLE:\n Cardiac Arrest Consult Note\n 80 year old male who suffered an unwitnessed arrest at home with an\n unknown total downtime\n wife found unresponsive after an apparent fall\n and EMS was called. Initial rhythm was PEA and he was intubated and\n given epi/atropine/cpr with resultant ROSC. Brought to OSH where found\n to have C1 burst fracture, C2 dens fracture and transferred here.\n Patient has remained hypotensive requiring dopamine initially that has\n now been converted to levophed. On exam, he is currently hypothermic\n (33 degrees), bradycardiac (50s), and hypotensive (110/70 on levophed).\n He does withdraw his legs but no movement of the arms. He opens and\n closes his eyes but no to command. No myoclonus observed.\n A:\n 1) Arrest\n unclear etiology and not clear if trauma\n caused or was resultant from event\n 2) C1 burst fracture, C2 dens fracture\n 3) Central Cord Syndrome (I suspect this clinically as withdraws\n lower extremities, not upper, and has the abrasion on forehead\n indicating mechanism)\n P:\n 1) Maintain hypothermia for 24 hours which would be until 9 AM\n 2) Sedate for shivering, paralyze for refractory shivering\n 3) Minimize intracranial pressure elevation\n a. HOB elevated\n b. Maintain pCO2 between 35-40\n 4) EEG when possible to evaluate for seizures. Order as cardiac\n arrest protocol\n 5) Restoration of hemodynamics/perfusion per ICU team\n note that\n if shock is from arrest itself, the hemodynamic profile may be\n cardiogenic, distributive, or both\n" }, { "category": "Physician ", "chartdate": "2198-07-01 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 462436, "text": "Chief Complaint: s/p fall, s/p cardiac arrest\n HPI:\n 80 yo M who reportedly had mech fall down ~ 3 stairs outside, who was\n found in PEA arrest upon EMS arrival. CPR initiated by Fire dept, no\n shocks, but reportedly ROSC with epinephrine, chest compressions, and\n intubation in the field. Was xferred from OSH () on dopamine,\n paperwork states pt \"clutched his chest\" but wife states the fall was\n unwitnessed. Apparently pt was leaning over a railing to trim ,\n and possibly fell over the railing landing on his neck/head, approx 3\n foot fall from porch. He was then \"found down\" not breathing by his\n wife approx 5 minutes after he went outside. Unclear circumstances, but\n ? resp arrest due to high cervical cord injury, then cardiac arrest.\n Presents here on dopamine, no sedation, no movement.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:54 PM\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: HTN, elev chol, pectus excavatum, arthritis, colon ca\n PSH: hernia repair, colorectal resection\n : valsartan 320', lipitor 10', hydrochlorothiazide 12.5', omeprazole\n 20', ASA 81', Tylenol, MVI\n married, family at bedside\n Flowsheet Data as of 04:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 33.5\nC (92.3\n Tcurrent: 33.1\nC (91.6\n HR: 45 (45 - 94) bpm\n BP: 119/54(77) {86/47(61) - 139/83(104)} mmHg\n RR: 18 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 66.5 kg (admission): 66 kg\n Total In:\n 647 mL\n 402 mL\n PO:\n TF:\n IVF:\n 647 mL\n 402 mL\n Blood products:\n Total out:\n 2,240 mL\n 80 mL\n Urine:\n 840 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,593 mL\n 322 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 16 cmH2O\n Compliance: 47.2 cmH2O/mL\n SpO2: 99%\n ABG: 7.44/32/156/21/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 390\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, No(t) Oriented (to): , Movement:\n No spontaneous movement, Sedated, Tone: Not assessed\n Labs / Radiology\n 303 K/uL\n 12.5 g/dL\n 168 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 139 mEq/L\n 35.6 %\n 16.4 K/uL\n [image002.jpg]\n 03:01 PM\n 06:05 PM\n 09:07 PM\n 11:24 PM\n 11:45 PM\n WBC\n 17.5\n 16.4\n Hct\n 38.5\n 35.6\n Plt\n 280\n 303\n Cr\n 1.0\n 0.9\n TropT\n 0.09\n 0.07\n TCO2\n 25\n 22\n 22\n Glucose\n 205\n 168\n Other labs: PT / PTT / INR:13.6/29.7/1.2, CK / CKMB /\n Troponin-T:219/12/0.07, ALT / AST:66/76, Alk Phos / T Bili:64/0.7,\n Lactic Acid:1.6 mmol/L, Albumin:4.3 g/dL, LDH:263 IU/L, Ca++:9.0 mg/dL,\n Mg++:1.4 mg/dL, PO4:1.6 mg/dL\n Imaging: CT Head: (our rads read of OSH CT) no ICH, edema or mass\n effect.\n CT CSpine: WET READ- C1 burst fracture. Odontoid fracture with 9\n mm posterior distplacement of the superior fracture fragment. severe\n multilevel degenerative change with moderate canal and neural foraminal\n stenosis predisposes to cord injury. There is posterior subluxation of\n C1 and odontoid on the C2 body as seen by C1-2 facet malalignement on\n parasagittal reformats.\n CT Torso: WET READ- Bilateral posterior consolidation in the upper\n and lower lobes, could represent contusion vs aspiration. no effusion,\n hemothorax, or pneumothorax. no aortic injury or mediastinal hematoma.\n NG and ETT in adequate position. In abdomen/pelvis, there is no\n evidence of solid organ injury. No\n hemoperitoneum or free air. Non-specific perinephric stranding is\n present bilaterally. Aortic atherosclerosis with ectasia of the\n infrarenal aorta measuring up to 2.3 cm. No fractures are identified.\n Degeneative changes in the T/L spine. Mild anterolisthesis at L4-5 is\n likely degenerative.\n .\n MRI Brain: WET READ- No acute abnormality. No acute hemorrhage. No\n acute infarct. No shift.\n .\n MRI CSpine: WET READ- Fx c2, with tilting of the cranial portion\n of the fracture fragment, namely the dens, posteriorly. This indents\n the cord. There is cervical cord edema from the craniocervical junction\n to approximately the C3 level. There is a 5-mm focus of abnormal signal\n within the cervical cord at the C2 level, most likely representing a\n cord hemorrhage.\n ECG: SBrady, no STE or obvious ischemia.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n CERVICAL FRACTURE (WITH SPINAL CORD INJURY)\n Assessment And Plan: 80 M s/p fall s/p PEA arrest with C1 burst and\n displaced dens fracture, with possible anoxic brain injury and\n quadraplegia vs. other cord injury\n Neurologic: Neuro checks Q: 1hr. Pain: fentanyl prn. Hard C-Collar at\n all times, MRI Brain and C-Spine pending to further eval injury.\n Cardiac arrest team consulted as below, cooling for goal temp 33 C, p02\n 35-40 for neuro protection. not currently requiring sedation. After\n return from MRI, pt noted to spontaneously move his , pt is\n intermittently blinking, otherwise neuro exam similar to prior.\n Cardiovascular: s/p PEA arrest. No STE or obvious ischemia on EKG.\n Levophed for MAP > 65, sbp > 120 per neurosurg. Cardiac arrest\n team/cardiology consult involved, recommend aspirin pending eval for\n cord hematoma. Consider Echo in am. Trend CE.\n Pulmonary: Intubated, likely will require ventilatory support given\n level of likely cord injury. pCO2 35-40 for neuro protection.\n Gastrointestinal: npo\n Renal: follow lytes, currently with good UOP\n Hematology: hct stable\n Infectious Disease: no current issues. Afebrile\n Endocrine: RISS\n Fluids: LR at 80cc/hr\n Electrolytes: stable, replace aggressively\n Nutrition: npo for now\n General: TLD: ETT, OGT, Foley, R femoral CVL, R radial a-line\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 06:58 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1081094, "text": " 1:47 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: Trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n Trauma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old male status post fall.\n\n COMPARISON None available\n\n PORTABLE SUPINE CHEST RADIOGRAPH: The study is limited due to underlying\n trauma board, overlying medical devices, and portable supine technique. The\n ET tube terminates 5.0 cm above the carina, projecting between the clavicles.\n An NG tube is seen coiled within the upper stomach. Allowing for technique,\n the cardiomediastinal contours are likely normal. Slightly leftward position\n of the cardiac contour may be due to mild S-shaped curvature of the upper to\n mid thoracic spine. The lungs are moderately well inflated. An airspace\n opacity in the left upper lung is concerning for contusion or aspiration. More\n streaky left retrocardiac opacity could represent atelectasis. No supine\n evidence for large pneumothorax or pleural effusion is seen. Degenerative\n changes are noted in the spine. No displaced acute fracture is seen.\n\n IMPRESSION: Airspace opacity in the left upper lung is concerning for\n contusion or aspiration in the setting of trauma. Similar streaking, likely\n atelectasis is noted in the left lung base.\n\n" }, { "category": "Radiology", "chartdate": "2198-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081165, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change, pulm edema\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n eval for interval change, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Cardiac arrest, assess for interval change.\n\n One portable view. Comparison with . There is streaky density at the\n lung bases consistent with subsegmental atelectasis and this finding has\n improved on the left. The heart and mediastinal structures are unchanged. An\n endotracheal tube and nasogastric tube remain in place. There is no interval\n change.\n\n IMPRESSION: Interval improvement in subsegmental atelectasis on the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1081100, "text": " 2:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p fall w/ known C1/C2 fx\n REASON FOR THIS EXAMINATION:\n Trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy SAT 3:05 PM\n Bilateral posterior consolidation in the upper and lower lobes, could\n represent contusion vs aspiration. no effusion, hemothorax, or pneumothorax.\n no aortic injury or mediastinal hematoma. NG and ETT in adequate position.\n In abdomen/pelvis, there is no evidence of solid organ injury. No\n hemoperitoneum or free air. Non-specific perinephric stranding is present\n bilaterally. Aortic atherosclerosis with ectasia of the infrarenal aorta\n measuring up to 2.3 cm. No fractures are identified. Degeneative changes in\n the T/L spine. Mild anterolisthesis at L4-5 is likely degenerative.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male status post fall with known C1/C2 fracture.\n Evaluate for thoracic or abdominal trauma.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen,\n and pelvis following the administration of 130 cc of Optiray intravenous\n contrast material. Multiplanar reformats were prepared and reviewed.\n\n CT CHEST: There are bilateral posterior consolidations in both the right and\n left lungs, upper and lower lobes. This most likely represents contusion,\n although aspiration is also a consideration. There is no effusion. There is\n no pneumothorax. There is no hemothorax. Within the limits of respiratory\n motion, there are no lung nodules or masses identified.\n\n The heart is displaced to the left by a large pectus excavatum. There is no\n pericardial effusion. The aorta and great vessels are normal in caliber,\n contour, and configuration, with no evidence for acute aortic injury. There\n is atherosclerotic calcification of the aortic arch. Pulmonary artery is\n normal in caliber. There is no large central pulmonary embolus. The trachea\n and central airways are patent to the subsegmental level, with no\n endobronchial lesions identified. Endotracheal tube terminates above the\n carina. NG tube coursing through the mediastinum below the diaphragm. There\n is no mediastinal hematoma. There is no pathologic mediastinal or hilar\n adenopathy. The thyroid enhances normally.\n\n CT ABDOMEN: There is no free fluid or hemoperitoneum. There is no free air.\n The liver is homogeneous with no focal lesions identified. The spleen,\n pancreas, and adrenal glands are normal in appearance. There is bilateral\n nonspecific perinephric stranding. Within both kidneys, there are rounded\n low-attenuation lesions, most compatible with renal cysts. Kidneys\n (Over)\n\n 2:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrate symmetric parenchymal enhancement and contrast excretion. There\n is no hydronephrosis. Left renal artery is relatively diminutive.\n\n The stomach, duodenum, and intra-abdominal loops of small and large bowel are\n unremarkable. There is a surgical suture line identified in the ileocecal\n region at the right lower quadrant. There is no mesenteric fluid. There is\n no bowel wall thickening. There is no bowel distension.\n\n There is atherosclerotic disease of the abdominal aorta, with ectatic\n dilatation of the infrarenal section just proximal to the bifurcation, with\n maximal dimension of 2.3 cm. The major mesenteric vessels appear patent at\n their origins. There is no pathologic retroperitoneal or mesenteric\n adenopathy.\n\n CT PELVIS: Urine opacifies the bladder. There is no extraluminal contrast\n identified. There is a Foley in the bladder, as well as a small focus of air\n in the dome, consistent with Foley placement. The rectum and sigmoid colon\n are unremarkable. There are scattered diverticula but no evidence for\n diverticulitis. There is no pelvic fluid. There is no pelvic adenopathy.\n Prostate is unremarkable. Postsurgical changes from bilateral inguinal\n herniorrhaphy are identified.\n\n BONE WINDOWS: There are no fractures. Degenerative changes are noted in the\n thoracolumbar spine with mild grade 1 anterolisthesis of L4 on L5, which is\n likely degenerative. There are no suspicious lytic or sclerotic osseous\n lesions. Marked left-convex focal scoliosis of the thoracic spine noted, with\n apex at T3-4. Changes at the shoulders suggest chronic rotator cuff disease.\n\n IMPRESSION:\n 1. Bilateral posterior consolidations in the right and left upper and lower\n lobes, most consistent with contusion, although aspiration is also in the\n differential.\n\n 2. No hemothorax, pneumothorax, or effusions.\n\n 3. Pronounced pectus excavatum causing displacement of the mediastinal\n structures to the left.\n\n 4. No solid abdominal organ injury. No free air or hemoperitoneum.\n\n 5. Bilateral nonspecific perinephric stranding.\n\n 6. Post-surgical changes from bilateral hernia repairs, as well as a suture\n line identified in the small bowel in the right lower quadrant.\n\n 7. Degenerative changes in the lumbar spine, with grade 1 anterolisthesis of\n (Over)\n\n 2:09 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n L4 on L5, which is likely degenerative.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1081101, "text": " 2:10 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with fall and known c1-c2 fx\n REASON FOR THIS EXAMINATION:\n Trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy SAT 2:46 PM\n C1 burst fracture. Odontoid fracture with 9 mm posterior distplacement of the\n superior fracture fragment. severe multilevel degenerative change with\n moderate canal and neural foraminal stenosis predisposes to cord injury. MRI\n recommended for evaluation of cord injury.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old male status post fall off a railing.\n\n COMPARISON: CT of the cervical spine performed at outside hospital at 11:19\n a.m. on the same day.\n\n TECHNIQUE: Contiguous axial images were obtained through the cervical spine,\n with preparation and review of multiplanar reformatted images.\n\n FINDINGS: There is a fracture of the C1 ring, fractures, midline anteriorly\n as well as bilateral posterior elements. Additionally, there is a transverse\n fracture of the odontoid process, with approximately 9-mm posterior\n displacement of the superior fracture fragment. Compared to the study\n performed earlier on the same day, the degree of posterior displacement has\n increased, it previously measured approximately 3 mm. There are no other\n fractures identified.\n\n There is extensive change in cervical spine, narrowing of intervertebral disc\n heights at all levels, with associated endplate sclerosis and osteophyte\n formation. This causes moderate multilevel canal stenosis and neural\n foraminal narrowing, which predisposes the patient to cord injury.\n\n There is no large epidural hematoma identified, although MRI is more\n sensitive. Prevertebral soft tissue swelling is seen anterior to the\n aforementioned fractures.\n\n Visualized soft tissues of the neck are unremarkable. There are no soft\n tissue masses or abnormal lymph nodes. NG tube and endotracheal tube are seen\n in expected position. Lung apices, there are posterior consolidations, better\n characterized on concurrent CT torso, likely representing contusions versus\n aspiration.\n\n IMPRESSION:\n\n 1. C1 burst fracture.\n\n 2. Odontoid fracture, with 9-mm posterior displacement of the superior\n (Over)\n\n 2:10 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fracture fragment, which is increased compared to degree of displacement seen\n on study performed earlier the same day.\n\n 3. Multilevel degenerative change with moderate canal to neural foraminal\n stenosis, which predisposes the patient to cord injury.\n\n MRI is recommended for further evaluation of cord contusion and ligamentous\n injury.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n\n ATTENDING NOTE: There is posterior subluxation of C1 and odontoid on the C2\n body as seen by C1-2 facet malalignement on parasagittal reformats. This\n finding has increased from previous CT as described.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-07-01 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2-3 VIEWS", "row_id": 1081180, "text": " 7:59 AM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: please assess posterior aspect of the dens in a lateral view\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with C1 burst fx\n REASON FOR THIS EXAMINATION:\n please assess posterior aspect of the dens in a lateral view with pillow placed\n under head.\n ______________________________________________________________________________\n FINAL REPORT\n LATERAL C-SPINE\n\n HISTORY: Assess posterior aspect of dens on lateral view.\n\n A single lateral view of the upper cervical spine down to the C5 level. Lower\n levels are obscured by the patient's shoulders. Comparison is made with CT\n examination done at 2:13 p.m. There is a transverse fracture of the\n odontoid process of C2 with posterior displacement of C1 and the odontoid\n process of C2. Comparison with the CT examination is difficult due to change\n of technique. The degree of displacement and orientation of C1 and C2 appear\n similar. There is disc space narrowing and degenerative arthritic change\n throughout the visualized portions of the cervical spine. No osteolytic or\n osteoblastic lesion is identified.\n\n IMPRESSION: Limited study as described, demonstrating fracture of the\n odontoid process with significant posterior displacement of the odontoid\n process and C1. Comparison with CT is difficult.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1081098, "text": " 1:59 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: ct headassess for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with fall over railings with head injury and PEA arrest, and by\n report dens fracture\n REASON FOR THIS EXAMINATION:\n ct headassess for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy SAT 2:47 PM\n outside study. no hemorrhage edema or mass effect. C-spine fracture better\n vizualized on concurrent CT c-spine.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male status post fall over railings with head injury\n and PEA arrest. Dens fractures reported outside hospital.\n\n COMPARISON: None available.\n\n TECHNIQUE: Non-contrast head CT performed at outside hospital at 11:18 a.m.\n was submitted for review.\n\n FINDINGS: There is no hemorrhage, edema, mass effect, or acute large vascular\n territorial infarction. The -white matter differentiation is preserved.\n There is no shift of normally midline structures. The ventricles, sulci, and\n cisterns are mildly prominent, appropriate for the patient's age. Dense\n calcification of the intracranial circulation. The calvarium demonstrates no\n fractures. Upper cervical spine fractures are noted, better visualized on\n concurrent CT of the cervical spine. Surrounding soft tissues, including\n globes and orbits are unremarkable.\n\n IMPRESSION:\n\n 1. No acute intracranial process.\n\n 2. Upper cervical spine fractures, better visualized concurrent cervical\n spine CT.\n\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1081131, "text": " 8:50 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: r/o spinal cord injury\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p fall down stairs who is non responsive and has a C2 and C1\n Fracture\n REASON FOR THIS EXAMINATION:\n r/o spinal cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD SUN 12:19 AM\n PRELIMINARY REPORT EU CRITICAL MR # IMAGES:224 A known fracture\n of C2 is identified. There is tilting of the cranial portion of the fracture\n fragment, namely the dens, posteriorly. This indents the cord. There is\n cervical cord edema from the craniocervical junction to approximately the C3\n level. There is a 5-mm focus of abnormal signal within the cervical cord at\n the C2 level, most likely representing a cord hemorrhage. For detailed\n description of fractures please refer to the concurrent CT scan. MD\n \n ______________________________________________________________________________\n FINAL REPORT\n MR CERVICAL SPINE\n\n INDICATION: 80-year-old man status post fall downstairs, non-responsive with\n C1 and C2 fracture.\n\n COMPARISON: NECT of the cervical spine dated .\n\n TECHNIQUE: Sagittal T1, T2, STIR, axial gradient echo and T2-weighted images\n of the cervical spine were obtained.\n\n FINDINGS: Again demonstrated is C1-C2 fracture-dislocation, with complete\n atlanto-axial dissociation and posterior displacement of the lateral masses of\n C1 on those of C2.\n\n There is a 3.3 cm long fusiform zone of edema within the spinal cord centered\n at the level of C1-C2, with relatively thin linear traversing\n virtually the entire AP dimension of the cord at the C1-2 level, splaying to\n an approximately 1.5mm gap, posteriorly, consistent with frank cervical spinal\n cord transection. The multifocal \"blooming\" susceptibility artifact on GRE\n sequence, at the site of transection indicates presence of hemorrhage.\n\n There no epidural hematoma and only minimal prevertebral hematoma.\n The tectorial membrane is intact.\n\n Multilevel degenerative changes are noted, causing moderate multilevel canal\n stenosis and neural foraminal narrowing.\n\n\n IMPRESSION: C1-C2 fracture-dislocation with complete C1-C2 dissociation\n resulting in frank cord transection, hemorrhage and edema at this level.\n (Over)\n\n 8:50 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: r/o spinal cord injury\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1081132, "text": " 8:50 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: rule out anoxic brain injury. Found to be PEA in the field.\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p fall down stairs who is non responsive and has a C2 and C1\n Fracture\n REASON FOR THIS EXAMINATION:\n rule out anoxic brain injury. Found to be PEA in the field.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD SUN 12:16 AM\n PRELIMINARY REPORT EU CRITICAL MRI BRAIN (C-) # IMAGES:199 No acute\n abnormality. No acute hemorrhage. No acute infarct. No shift. MD\n \n ______________________________________________________________________________\n FINAL REPORT\n MR EXAMINATION OF THE BRAIN WITHOUT CONTRAST ON .\n\n HISTORY: 80-year-old man, status post fall down stairs with PEA \"in the\n field,\" known C1 and C2 fractures and unresponsive; rule out anoxic brain\n injury.\n\n TECHNIQUE: Routine unenhanced MR examination of the brain was\n performed. The sagittal T1-weighted sequence demonstrates a dramatic\n abnormality at the craniocervical junction with atlanto-axial dissociation\n related to the completely displaced fracture of the odontoid process with\n related dorsal dislocation of C1 on C2, further characterized on concurrent\n dedicated cervical spine MR study. Of note, no significant associated upper\n cervical spinal epidural hematoma is identified on this sequence.\n\n As on the OSH NECT of roughly 10 hours earlier, there is no intra- or extra-\n axial hemorrhage, the midline structures are in the midline and the ventricles\n and cisterns are normal in size and in contour, for age. The FLAIR sequence\n is notable only for relatively mild periventricular white matter\n hyperintensity, suggestive of chronic microvascular infarction in a patient of\n this age. Of note, there is no evidence of cerebral edema, and both the GRE\n and DWI sequences are unremarkable with no finding to suggest diffuse axonal\n injury. The major intracranial vascular flow-voids are preserved. Noted is\n layering fluid within the nasal cavity and nasopharynx, as well as the\n sphenoid sinuses with opacified ethmoidal air cells, likely related to\n intubation and supine positioning.\n\n IMPRESSION:\n\n 1. No acute intracranial abnormality; specifically, there is no evidence of\n hemorrhage, edema or infarction.\n\n 2. No finding to specifically suggest hypoxic or diffuse axonal injury.\n\n 3. Atlanto-axial dissociation with significant associated injury to the upper\n cervical spinal cord, better evaluated on the concurrent dedicated cervical\n (Over)\n\n 8:50 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: rule out anoxic brain injury. Found to be PEA in the field.\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n spine MR.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081115, "text": " 5:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ETT position\n Admitting Diagnosis: CERVICAL FRACTURE, TRAUMATIC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with ETT, s/p transfer\n REASON FOR THIS EXAMINATION:\n eval for ETT position\n ______________________________________________________________________________\n WET READ: AGLc SAT 11:14 PM\n ETT 5.9 cm above carina, projecting between upper aspect of clavicles. OGT\n unchanged. LLL atelectasis. posterior lung consolidations better seen on\n CT.\n WET READ VERSION #1 AGLc SAT 11:13 PM\n ETT 5.9 cm above carina, projecting between upper aspect of clavicles. OGT\n unchanged. LLL atelectasis. Patchy airspace opacities better seen on CT.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: ET tube placement.\n\n One portable view. Comparison with the previous study done . There is\n streaky density at the lung bases, more pronounced on the left consistent with\n subsegmental atelectasis as before. The left chest is not entirely included\n on the image. The heart and mediastinal structures are unchanged. An\n endotracheal tube remains in place, terminating at the thoracic inlet. A\n nasogastric tube is present as before, coiled in the region of the stomach.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "ECG", "chartdate": "2198-06-30 00:00:00.000", "description": "Report", "row_id": 240814, "text": "Sinus bradycardia with sinus arrhythmia and atrial premature beats.\nFirst degree A-V block. Q-T interval is prolonged for rate raising\nthe possiblity of drug effect or metablic abnormality. Suggest clinical\ncorrelation. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2182-10-18 00:00:00.000", "description": "Report", "row_id": 1325043, "text": "Respiratory: Pt rec'd on FFV cpap 7/ps0/100%. BS auscultated reveal ^ aeration on RS with diminished LS. VT's 500's/VE 12/RR 21. 02 sats @ 98%. Pt removed mask once noc and wob increased immediately. Will continue pt on FFV and monitor.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-18 00:00:00.000", "description": "Report", "row_id": 1325044, "text": " \"B\" Nsg Progress Note;\n\nCVS: Afebrile. HR=83-100 SR with very rare PVC. Only one burst of RAF which was brief and self-limiting. IV Amiodarone drip at 1mg/min.\nSBP=117-168.\n\nSkin: Left knee reddened today. No open areas noted. Edema slightly better in extremities.\n\nGI: NPO, +BS no stools.\n\nGU: U/O=18-115cc/h blood-tinged urine at times.\n\nResp: Tolerated CPAP mask all night, sats=95-98% mostly. Strong cough but no sputum expectorated. Left lung sounds severely diminished.\n\nNeuro: More awake and oriented this am. No ativan required last night. Pt slept most of night. MAE,pupils=+. Speech clear and appropriate. Pt does still pull off O2 mask at times so wrist restraints loosely applied to remind pt not to touch O2 mask. Pt agrees with this plan.\n\nPlan: Hopefully start some nutrition today, Wean O2 on CPAP mask if possible. Also, Wean IV Amiodarone back to po.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-18 00:00:00.000", "description": "Report", "row_id": 1325045, "text": "NPN 0700-1900\nNeuro: A&O x3, calm and cooperative, but becomes anxious when turning and cleaning mouth. Pt slept most of shift. Pt denies pain. Pupils 3mm/3mm, PERRLA. Tolerating mask well.\n\nCV: HR 85-100, BP 156-131/55-81, NSR with occasional PVCs, x2 episodes of rapid A-fib resolving spontaneously, BP remained stable. IV amiodarone remains at 1mg/min. Pedal pulses palpable. Plt. 36 after recieving 1 unit of Plts at 1000. Transfuse for Plt <25. Goal to keep I/Os even, pt's I/O's (+), but he is not recieving lasix d/t insensible losses. Started on D5 and 1/2 NS at 75 cc/hr. L PICC line patent.\n\nResp: Lung sounds diminished on L lung fields, Coarse on R. Pt desats quickly when mask is removed but recovers in seconds when reapplied. Chest PT provided x2 with good effect, O2sats up to 99%. Vent settings changed to CPAP with 5 of PS, 90%/7/28/700s. ABG: pH 7.34, PaCO2 66, HCO3 37, Base excess 7 and PO2 110, valuse do not reflect current vent settings. Sx'd sticky secretions from oral cavity, tongue dark purple lesions with crustation to right upper hard palate. pt requested area sx'd however, due to low Plt. count did not attempt dislodging mass until seen by HO. Wife is aware.\n\nID: afebrile, Tmax 96.5. Continues ., vanco., ambisone, acyclovir and hydrocortisone. Pt on neutropenic percautions.\n\nEndo: FBS 187, SSI started.\n\nGI: NPO, +BS, abd soft and non distended. No BM. Discussed TPN however due to risk of infection team started pt on IV fluids.\n\nGU: Foley intact, draining light pink, cloudy urine at 35-160cc/hr.\n\nSkin: Diaphoretic at times. and dark purple abrasions on toes with scabs, open to air. Slight irritation at bridge of nose from vent mask. Applied folded gauze against skin as barrier.\n\nSocial: Wife is very involved in care. Many requests, wife requesting that FBS blood draws be taken from PICC, whe was educated that blood will not be drawn from PICC line for Q6H glucose blood checks due to risk of infection. Will continue FBS as before. Also, requests that nurse and student nurse pt care be done o/s of room. Nurse explained to wife that she will attempt to limit interaction and do some documentation to o/s of room.\n\nPlan: Provide mouth care and monitor crustation. Ween O2 on CPAP mask if possible. Ween IV amiodarone to PO. Check PM labs. Maintain neurtropenic precations. Provide chest PT.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-18 00:00:00.000", "description": "Report", "row_id": 1325046, "text": "Respiratory Care Note\nPt received on mask ventilation as noted. Pt taken off briefly for medications and mouth care - pt desats into high 80's, but not as quickly in the afternoon as in the morning. FiO2 weaned slowly and PS of 5 added according to ABG's. BS clear with good aeration throughout R side: essentially absent on L side with LUL crackles. Plan to remain on mask ventilation at this time - wean FiO2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-19 00:00:00.000", "description": "Report", "row_id": 1325047, "text": "NPN 7P-7A:\n\nNEURO: PT IS A/OX2. COOP W/ CARE. HE DENIES PAIN. HE IS TOLERATION MASK VENT WELL.\n\nRESP: LS RONCHI BILAT. HE IS ON MASK WENT . RR 20-26. ABG PH 7.41/PCO254/PO288/HCO3 35. NOW SETTINGS ARE .\n\nGI/GU: ON HIS TONGUE HE HAS A DARK PURPLE LESION. HE IS ABLE TO SWALLOW HIS PILLS WHOLE. + BS NO BM. FOLEY WITH DARK PINK URINE 40- 50CCHR.\n\nCV: AT THE START OF THE SHIFT HIS HR WAS 80. HE HAS A HX OF SWT AND AF. HIS HR WENT UP TO 130-170. NS BOLUS 750CC GIVEN, WITHOUT EFFECT NOTED. HE IS ON AAMIODARONE GTT 1MG. ALSO AMIODARONE 150MG BOLUS GIVEN. MORPHINE 2MG GIVEN HIS HR 130'S THROUGHT THE NIGHT.\n\n\nENDO: SSI WAS INCREASED.\n\nPOC: RESP DISTRESS: ,AMBISOME,VANCO. MASK VENT. PT IS FULL CODE. TACHYCARDIA: AFIB ON AMIODARONE GTT. TX PLT >25.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-19 00:00:00.000", "description": "Report", "row_id": 1325048, "text": "Resp: Pt rec'd on FFV PSV 5/7/90%. Bs auscultated reveal noted aeration with LS diminished in bases. Pt remained on FFV until 5:00 then placed on NRB with 02 sats 96-99%. Will continue to monitor and place back on PSV when needed.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-17 00:00:00.000", "description": "Report", "row_id": 1325039, "text": " \"B\" Nsg Progress Note:\n\nCVS: Afebrile. HR=RAF up to 160's with short bursts of NSR, then placed on IV Amiodarone drip at 1.0mg/min for 6hrs. Converted to NSR with rare PVC for most of night,until 5:30AM back to RAF 160's. EKG done. SBP=116-170. Received 1 unit PRBC's today and HCT=29 after. Also, received 1 pack of platelets for plt ct=10,repeat plt ct=33.\n\nResp: Lung sounds diminished on left side, coarse on rt. Using CPAP but very restless on it and needed Ativan to keep on mask ventilation. Sats=89-96%.\n\nGI: NPO except meds. +BS. No stools.\n\nGU: U/O=22-165cc/hr amber to blood-tinged when pt pulls on foley.\n\nSkin: Edema noted, 1+. No open areas.\n\nNeuro: Pt was slightly confused at times but became increasingly confused during the night. Pulling off clothes, waving arms around and picking at the air, trying to pull off O2 constantly. MAE, Pupils+=. Follows commands when someone is sitting with him.\n\nPlan: Continue to try CPAP ventilation,IV Amiodarone for RAF,Monitor CXR,ABG's,Blood products as needed. Pt is very neutropenic, he only drinks bottled water with meds.\n\nAccess: PICC line rt.\n\nSocial: Wife, , very involved with care, does not want pt intubated unless she is called. Will be in today at 8AM.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-17 00:00:00.000", "description": "Report", "row_id": 1325040, "text": "Respiratory Care:\n\nPatient started on Mask ventilation for increased WOB, RR 40's. O2 sats 89-93% on NRM with 6lpm nasal prongs. Pt. put on Cpap 7cm with Fio2 100%. Spont vols 700-800's. RR decreasing to mid to high 20's.\nBs coarse R lung and decreased L Lung. Periods of agitation. Pt. pulling mask off at times. O2 sats increasing to 96% on above settings. No further changes made. Continue with NIPPV as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-17 00:00:00.000", "description": "Report", "row_id": 1325041, "text": "Resp Care\n\nPt currently on NIPPV CPAP 7 PS 0 well thus far with Vt around 600-650cc and RR in the mid to upper 20s increasing to the mid 30s with agitation and stimulation. SPo2 stable in the mid to low 90s on FiO2 1.0. Unable to wean fio2 due to periods od desaturation. Will cont with current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-17 00:00:00.000", "description": "Report", "row_id": 1325042, "text": "NPN\n\nNeuro: Pt has been sleeping for most of the shift, periodically waking. He was groggy this morning, his afternoon, he was oriented x3, denied any pain and tolerating the mask.\n\nCV: He has been in NSR for most of the shift, she had a 10 min period of rapid afin to the 150s-170s, her amnio was increased to 1 mg/min from .5. Again this afternoon she went into rapid afib; pt to be rebolused with amnio. her BP has tolerated this increased rate. He needs an echo for a murmer\n\nResp: He has been on mask ventilation all day, tried once this morning with a NRB and NC but his SATs were 80% and not increasing. An ABG was sent but the team feels that it was venous they will try again though he is a difficult stick. His mental status has been orented while on the mask. He has very decreased breath sounds on the L and they are coarse on the R, he occationally has a cough but is not bringing anything up - he needs a sputum if he does.\n\nGI: ABD is soft, pos bowel sounds, he remains NPO and nutrition needs to be decided very soon, since he is mask ventilated he may need TPN and therefore a new IV.\n\nGU: U/O ~ 30cc/hr, his urine is brownish, creat .7.\n\nSoc: His wife was in today, concerned, remains involved in his care.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-16 00:00:00.000", "description": "Report", "row_id": 1325036, "text": "NPN 1900 -0700\n\nADMIT NOTE:\nPT IS AML/MDS WHO IS SEEN IN CLINIC FOR ROUTINE BLOOD TRANSFUSIONS,WAS FOUND TO HAVE A SAT OF 60% ON RA .C/O BEING INCREASINGLY SOB OVER THE PAST FEW DAYS. WAS FOUND TO HAVE A LOW GRADE FEVER, SATS ROSE TO 90% ON 10 L, OF NC. CXR SHOWED LLL COLLAPSE W/ MEDIASTINAL SHIFT.TO RIGHT W/ MULTI FOCAL CAVITY LESIONS.WAS ADMITTED TO 11 R.RESP STATUS CONT TO DETERIORATE TO SATS DOWN TO 89%ON 10 LITERS ,TACHY TO 180-200.PT TO M/SICU FRO FURTHER TREATMENT.\n\nNEURO: AXOX3, DENIES PAIN ,BUT STATES HE HAS CHRONIC PAIN THAT HE TAKES OXYCODONE FOR.\n\nRESP: DYSPNEA AT REST, L SIDE VERY DIMINISHED ,R SIDE COARSE.ON 100% NRB.\n\nC/V: ST IN 1TEENS,NO ECTOPY. BP STABLE .\n\nF/E/N: NPO AT THIS TIME, VOIDS IN URINAL.\n\nPLAN: CONT TO MONITER HEMODYNAMICS, AB TX ,EMOTIONAL SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-10-16 00:00:00.000", "description": "Report", "row_id": 1325037, "text": "ADDENDUM : PT HR CLIMBED UP TO 180-200. RECIEVED LOPRESSOR 15 MG AND DILT 10 MG W/ MIN EFFECT. HO ATTEMPTED CAROTID MASSAGE W/ NO EFFECT.WILL GIVE 10MG MORE OF DILT.RECIEVED 1 LITER NSS ON SECOND LITER\n" }, { "category": "Nursing/other", "chartdate": "2182-10-19 00:00:00.000", "description": "Report", "row_id": 1325049, "text": "NPN 0700-1900\nFull Code\nContact Precautions for hx VRE.\n\nNeuro: Alert and Oriented x 2, c/o pain only with respositioning, follows commands, no distress noted.\n\nResp: Lungs Coarse to RUL and RLL, diminished lung sounds to L chest, continue on 100% NRB, RR 15-22, o2 sats 93-96%, pt put on CPAP x 1 today for 2hrs. d/t increased RR and resp. effort, then placed back on NRB with further episodes.\n\nCV: HR 84-93 NSR no ectopy, BP's 146-160/70's, amiodarone gtt dc'd at 1540 after being given Amiodarone 400mg po. Team will tx further expisodes of Rapid Afib with Metoprolol IV. Pt still awaiting ECHO for ?Pericardial Friction Rub.\n\nHeme: Plt 16 this am, given 1u platlets IV, plt increased to 37 (goal plt >25).\n\nID: Continue Ambisone, Vanco., Meropenum, Hydrocortisone.\n\nEndocrine: FBS at 1200 was 361, given 18u Reg Insulin, will cont. to follow.\n\nGI: BS (+), cont. NPO, Nutrition consulted to start TPN.\n\nGU: Foley cath intact draining amber bld. tinged urine.\n\nSkin: +2 general edema, (+)periorbital edema, redenned area to post lower R chest with red/purple area, duroderm applied.\n\nPlan: Continue to monitor Resp Status, wean O2 as tolerated, monitor HR, follow FBS ac and hs, adm insulin as ordered. Follow Plt count.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-19 00:00:00.000", "description": "Report", "row_id": 1325050, "text": "Respiratory Care Note\nPt received on 100% Non-rebreather with sats in mid 90's. Pt placed on Bipap at 11:30a for increased work of breathing. Pt taken off Bipap and placed on 100% NRB at 2pm. Plan to continue alternating between Bipap and NRB as needed.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-20 00:00:00.000", "description": "Report", "row_id": 1325051, "text": "micu/sicu nsg note: 19:00-7:00\nthis is a 55 y.o. man adm with aml and previous pulm aspergillus presenting with hypoxia in requiring periods of mask ventilation alternating on 100% nrb with stable sp02. also has hx afib 4 months ago and has been this adm started on amnio gtt and now on standing dose amnio po. 10mg metoprolol iv required x1 this shift for hr up to 150s currently in 80s-90s sr.\n\nneuro: a&ox2 to person and place, not time or date. follows commands, appears uncomfortable with repositioning but denies pain other than foley uncomfortable with repositioning. feels fine at rest.\n\ncv: hr ranging 80s-90s sr with occas pvcs and up to 150s around 12am responding to 10mg iv metoprolol. bp ranging 130s-170/60s-110. + generalized edema. ext. elevated on pillows. +pp. +csm.\n\nresp: lungs cta on r side, crackles in lul but diminished in lll. alternating with mask ventilation and 100% nrb (see care vue) with sats stable on both settings ranging 93-98%. occas with rr up to 30s when found 02 mask pulled off by pt not realizing he did it. pt reoriented and bilateral wrist restraints placed to maintain adequate oxygenation. pt enc. to cough and deep breathe but with nonproductive cough. frequent mouth care done with palate lesion unchanged with dry, tan/blk/red protrusion from r hard palate.\n\ngi/gu: abd soft,nt, +bs, maintained npo except sips with meds. tolerating pills well. denies n/v. no bm, foley patent draining adequate amts clear amber urine approx even over last 24hours and 3.5 liters + los.\n\nid: t max 97.3 ax. continues on iv meropenem, vanco, ambisone, acyclovir and hydrocortisone.\n\nskin: reddish and dk purple abrasions on toes with scabs, ota. mult small bruised areas on ext.\n\nlines: l brachial dl picc sl sluggish when flushed with no blood return. attempted x3 to obtain peripheral stick and unsuccessful. md notified and md dr. 1cc tpa instilled in each port and dwelled for 1 hour from 5-6am. will addendum results of tpa.\n\nsocial: no contact from family this shift.\n\nplan: continue to attempt to wean 02 if possible and alternate 100% nrb with mask ventilation as ordered. monitor picc and will addendum results of tpa. will need am labs and will send if tpa successful-team aware. frequent mouth care and monitor mouth lesion. continue abx.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-20 00:00:00.000", "description": "Report", "row_id": 1325052, "text": "Resp: Pt rec'd on psv 8/8/70%. BS are clear on RS with crackles on LS. NPC. RR ^ to 30's at times. Alternating NRB with PSV. (see careview) Will continue to place on psv when tired.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-20 00:00:00.000", "description": "Report", "row_id": 1325053, "text": "MICU A NSG 7A-7PM\naddendum--pt to receivie 1u pc's for hct 24.4. pt currently having aline placed at bedside, will send abg when line in. awaiting on cxr to confirm placement of ogt. will d/c amiodarone gtt and start po meds and tube feeds.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-16 00:00:00.000", "description": "Report", "row_id": 1325038, "text": "NPN\n\nNeuro: Pt is alert and oriented x3 but is telling me that he is hallucinating - seeing people, told me that we were in a race that had something to do with oxygen. He has been cooperative, following commands.\n\nCV: He was in rapid afib this morning up to the 170s, he then spontaneously converted to SR in the 90s, he was started on PO amiodorone. This afternoon his HR has increased to the 1teens and he again has had periods of afib with rates into the 190s. These have been short in duration ~ 15 seconds and then converting back to SR.\n\nResp: LS coarse, diminished on the L. His 02 SATs have been decreasing through the day from the 94% range to the 90-91% range. RR in the 30s, he desats quickly to the 80s with any exertion and it has taken him longer to regain his saturation. Occational cough but he is not bringing anything up. CXR with whiteout on the L, pt to be started on ambisone; voriconazole, caspofungin to be d/ced. His wife is still considering if she wants him to be intubated.\n\nGI: NPO for possible intubation, he has had some RLQ abd pain - abd soft, pos bowel sounds, he was started on bowel meds.\n\nGU: His urine is icteric looking, he has been urinating ~ 100cc at a time, he is 2200cc pos since MN - to be given lasix with the plan for him to be 1000cc pos at MN, a foley will be placed.\n\nSoc: His wife has been in most of the day, concerned, involved with is care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-10-21 00:00:00.000", "description": "Report", "row_id": 1325059, "text": "NPN 0700-1900\nNeuro: Sedated on Fentanyl 100mcg/hr and midazolam 5mg/hr, arouses to turning and sx. Fentanyl (25mcg) and Versed (2mg)Bolus given with turning as pt grimacing and moving. Pupils 2mm/2mm, brisk, PERRL.\n\nCV: BP 100-141/43-70, HR 89-96 NS with occasional PVCs. Recieving amiodarone 400mg PO. Given lasix 40mg for goal of -1L, pt is currently +575ml. Hct was 23 and RBC 2.67, recieved 1unit PRBC's @ , draw pm labs. K was 3.7, recieved 60meq of KCl @1500. Plt. 58. Pedal pulses palpable bilateraly.\n\nResp: Crackles on RUL, RLL, & LUL. Diminished on LLL. Maintaining at O2sat of 95-100%. Removed crusted nasal secretions. Sx'd thick copious tan secretions per ETT. AC FiO2 70%, PEEP 12, TV 550, and RR 14. Team to obtain ABG this evening.\n\nID: T max 98.9 WBC 0.4. Pt recieving vanco, , acylovir, and ambisome.\n\nEndo: FS 197, received 7 units of regular insulin.\n\nGI: NGT, Receiving tube feedings of promote with fiber at 40cc/hr goal. PO meds given down NGT tube.\n\nGU: Foley cath intact draining clear yellow urine 120-600cc hr. BUN 47, CO2 33, Na 147, continues 200cc Free Water Boluses.\n\nSkin: Intact and diaphoretic at times. +1 edema. Toes have abrasions with purple/red scabs, open to air. L PICC patent.\n\nSocial: wife spoke with team and verbalizes u/s of plan of care.\n\nPlan: Continue to monitor HCT and Plt, monitor UO for goal of -1L, sx secretions prn.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-10-21 00:00:00.000", "description": "Report", "row_id": 1325060, "text": "Resp. Care Note\nPt received intubated and vented on settings as per resp flowsheet. FiO2 weaned over this shift from 70-50%, ABG done and with acceptable oxygenation. Sxn for thick tan secretions, large amount of oral secretions. cont current suppport.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-22 00:00:00.000", "description": "Report", "row_id": 1325061, "text": "NEURO: PT IS INTUBATED AND AGITATED. COUGHING. APPEARED TO BE IN PAIN. FACIAL GRIMACE. UNABLE TO FOLLOW COMMANDS. FENT WAS INCREASED SLOWLEY TO 140MCG AND VERSED UP TO 7MG. WITH GOOD EFFECT NOTED.\n\nRESP: VENT SETTINGS: AC 50%X550X14 W/ PEEP 12. SX Q2H FOR THICK CLEAR SPUTUM IN MOD AMOUNTS. LS RONCH AND DIMINSHED BILAT. LASIX 40MG GIVEN.\n\nCV: A FIB W/ PVC NOTED. HR 85-98. HE HAD ONE BURST OF RAF 150. WHICH RESOLVEN W/ THE INCREASE IN SEDATION MEDS. B/P 118/59(79).\n\nGI/GU: OG IN PLACE. PROMTE W/ FIBER @ GOAL 40. NO RESIDUAL . + BS. TWO SMALL MUSTARD COLORED STOOL. FOLEY CATH W/ GOOD OUTPUT NOTED.\n\nSKIN: HE HAS OLD BRUISEING NOTED ON ABD AND THIGHS.\n\nENDO: FINGER STICKS Q6H.\n\nPOC: VENT SUPPORT. GOAL IS NEG 500CC. IV ABX.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-22 00:00:00.000", "description": "Report", "row_id": 1325062, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings A/C 550 * 14 50% with 12 peep. Breathsounds are coarse. Suctioned for thick tan secretions and large amounts of clear oral secretions. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n\n" }, { "category": "Nursing/other", "chartdate": "2182-10-20 00:00:00.000", "description": "Report", "row_id": 1325054, "text": "MICU A NSG 7A-7PM\nRESP--PT WITH TENUOUS RESP STATUS, UNABLE TO BIPAP DUE TO AGITATION, AND PLACED ON 6L NC IN ADDITION TO NRB. PT AT ~1545 RECEIVED ETOMIDATE 20MG IV AND SUX 100MG IV FOR INDUCTION. PT Q 15 MIN SINCE FOR COPIOUS AMOUNTS THICK TAN BLOOD TINGED SECRETIONS. PLAN FOR BRONCOSCOPY TONIGHT. SPUTUM SPEC FOR GS AND CX SENT AFTER . ? WILL HAVE ALINE PLACED.\n\nCV--PT IN AND OUT OF AFIB THIS SHIFT, RECEIVED LOPRESSOR 10MG IV X2 WITH FAIR EFFECT. PT UNABLE TO TAKE PO MEDS AND RESTARTED ON IV AMIODARONE GTT AT 0.5MG/HR. OGT PLACED WITH INTUBATION, WILL RESTARTED PO MEDS WHEN TUBE PLACEMENT CONFIRMED. PT WITH (+) 2 GENERALIZED EDEMA IN EXTREMITES, LEFT ARM NOTED TO BE LARGER THAN RIGHT. RECEIVED 1U PLT'S, POST PLT COUNT PENDING.\n\nNEURO--PT X1-2 CONFUSED. MED WITH MORPHINE 2MG IV X2, AND ATIVAN 1MG IV WITH POOR EFFECT ON RESTLESSNESS AND AGITATION. PT WITH WITNESSED ASPIRATION WHILE TAKING AM PILLS, TEAM AWARE.\n\nGI--NPO AFTER APSIRATION. ORDERED FOR TF TO START WHEN OGT PLACEMENT CONFIRMED. TPN D/C'D. ABD SOFT NONTENDER, NO BM THIS SHIFT.\n\nGU--FOLEY CATH IN PLACE DRAINING AMBER TO PINK TINGED URINE, NS AT 100CC/HR , PT FLUID VOLUME APPROX EVEN, WITH U/O 80-100CC/HR.\n\nSOCIAL--WIFE IN TO VISIT, SPOKE WITH MICU TEAM AND DR FROM HEME ONC. AGREED TO INTUIBATION IF NEEDED. AWARE OF DAYS EVENTS.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-20 00:00:00.000", "description": "Report", "row_id": 1325055, "text": "Respiratory Care Note\nPt received on 100% NRB and placed on mask ventilation at start of shift for increased HR and increased WOB. Pt electively intubated at 3:30pm without incident. ETCO2 positive color change. Pt suctioned copious amts of thick, blood tinged secretions. BS are coarse, but equal after intubation. Pt placed on AC as noted. Bronchoscopy done - BAL sent to lab. Plan to remain on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-21 00:00:00.000", "description": "Report", "row_id": 1325056, "text": "micu/sicu nsg note: 19:00-7:00\nthis is a 55 y.o. man adm with aml and prior pulm aspergillus wtih hypoxia requiring mask ventilation leading to intubation on . pt has remained to have moderate to copious secretions from ett and back of throat, weaned down fi02 to 70% with stable 02 sats.\n\nneuro: agitated with coughing and repositioning requiring propofol 2cc boluses with suctioning and turns. propofol dc'd and fentanyl and versed started. fentanyl now infusing at 100mcg/hr and versed at 5mg/hr with pt appearing comfortable at rest but arousing to suctioning and repositioning requiring 2cc versed bolus with nsg interventions. opens eyes to nsg interventions. doesn't follow commands. pupils brisk. bilateral wrist restraints maintained for safety.\n\ncv: hr ranging 80s-90s sr with occas pvcs with 2 episodes of hr up to 150s afib breaking back to sr to 90s within a few seconds to one minute without intervention. amiodarone gtt was dc/'d earlier in the shift and pt given standing dose of amiodarone po via ogt. bp ranging 100s-130s/40s-60s. pm k of 3.7 repleted with 20meq kcl. awaiting am k results for more repletion as pt received 1 unit prbc and 40mg iv lasix. 2+ hand edema with l arm larger than r arm which was noted last shift.\n\nresp: remains intubated on ac: fi02 weaned to 70%, tidal volume 550, rr 14 overbreathing in the 20s, peep inc. to 12 from 8. suctioned for copious amts clear secretions from mouth with oral airway in place as pt was attemtping to bite at tube. pt also with moderate amts tan/bld tinged/rusty colored sputum from ett. suctioned out a lg \"wad\" of phlegm from the r side of his mouth. frequent mouth care given. lungs coarse on r side, crackles at lul and diminished at lll. sp02 ranging 95-99% on present settings of vent.\n\ngi/gu: abd soft, distended, +bs, no bm, +flatus. given sennakot and colace. ogt placement confirmed with + placement via abd cxr. tf infusing now at 20cc/hr with 60cc residuals bilious material. ogt flushed with 100cc free h20 q6hours. foley patent draining adequate amt amber colored urine. brisk diuresis from 40mg iv lasix, now approx liter negative (was 1.5 liters + prior to lasix).\n\nheme: pm hct 24.4-transfused with 1 unit prbc without incident.\n\nskin: toes with abrasions ota. mult. bruising on ext.\n\nendo: fs in 120s requiring ssri.\n\nlines: l dl picc patent with + blood return from both ports.\n\nsocial: no contact from family this shift thus far. wife was updated on condition and plan of care on days and had visited yesterday with pt.\n\nplan: continue vent settings per team with adequate sedation, monitor hct and plt and transfuse for hct < 25, replete lytes prn, continue standing dose amiodarone, continue abx and antifungal, continue qid fs with ssri, continue tf as ordered, continue ivf-changed to d5 at 100cc/hr from ns at 100cc/hr as na level up to 146 with pm labs. awaiting am lab results with am vbg result.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-21 00:00:00.000", "description": "Report", "row_id": 1325057, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. Decreased FiO2 to 70% and increased Peep to 12. BLBS are coarse. Sxn for thick tan secretions early in shift and blood tinged secretions at end of shift. Plan to decrease FiO2 as tolerated.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2182-10-21 00:00:00.000", "description": "Report", "row_id": 1325058, "text": "micu/sicu nsg note addendum: 19:00-7:00\nam plt count=17-transfused with 1 unit plts. am k=3.7- repleted with 40 meq po kcl via ogt. tf promote with fiber increased to 30cc/hr with only 10cc residuals. am cxr done with results pending. pt given another 40mg iv lasix this am as pt only .5 liters negative with a goal of making pt 1 liter negative. please f/u with repeat plt count and repeat lytes. am abg done with no change with vent settings. (see care vue for details).\n" }, { "category": "Echo", "chartdate": "2182-10-21 00:00:00.000", "description": "Report", "row_id": 69507, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 107/57\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 10:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\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 aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n4. There is a small pericardial effusion with fibrin deposits on the surface\nof the heart. There are no echocardiographic signs of tamponade.\n5. Compared with the findings of the prior study (tape reviewed) of ,\nthe ejection fraction is probably similar but was probably underestimated on\nthe previous study due to the quality of the study. The pericardial effusion\nis new.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-10-22 00:00:00.000", "description": "Report", "row_id": 1325063, "text": "NPN 0700-1900\nNeutropenic Precautions\nContact Precautions for hx of VRE\n\nNeuro: Sedated on Fentanyl @140mcg/hr, and Versed at 7mg/hr. Opens eyes to pain when being turned, does not follow commands.\n\nResp: Lungs Coarse to RUL and RLL, L side diminished, sx'd tan thick copious secretions per ETT, ABG at 1500 7.49/56/51/44, vent settings changed to 50%/550/14/10 Peep, sats 93-99%.\n\nCV: HR 99-101 NSR-ST occasional PVC's, BP's 97-118/40-50's, x 2 episodes of Rapid A-fib resolving spontaneously, no Metoprolol given since 0620 today d/t low BP's.\n\nID: Tmax 100.3, continues on Vanco/Ambisone/Acyclovir/Meropenum/Bactrim. HSV cx pf upper palate sent today, ID is evaluating area for ?Mucor. C-diff sample sent today.\n\nEndo: FBS 165 at 1200, tx per SSI.\n\nGI: BS diminshed, abd obese, x1 BM, heme (-).\n\nGU: Foley cath intact draining clear yellow urine in adequate amts.\n\nSkin: Old bruising to abd and thighs, all toes have apprasions which are red/purple in color.\n\nSocial: wife aware of plan of care\n\nPlan: Continue to wean vent settings as tolerated, adm sedation, adm abx.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-23 00:00:00.000", "description": "Report", "row_id": 1325064, "text": "NEURO: PT INTUBATED AND SEDATED ON FENT 140MCG AND VERSED 7MG. AT TIMES HE WAS REQUIRED FENT BOLUS SECONDARY TO OVER BREATHING THE VENT.\nHE IS ABLE TO MOVE THE LEFT HAND, AND WIGGLE HIS TOES.\n\nRESP: HIS O2 SAT DROP TO 85%. HE WAS SX FOR THICK CLEAR SPUTUM IN MOD AMOUNTS. ABG WERE DONE ON AC 50%X550X14 W/ 10PEEP. 7.41/53/46/41/85%. HIS PEEP WAS INCREASED TO 14 AND FOR A BREEF TIME HIS FIO2 WAS INCREASED TO 60%. HIS O2 SAT DID GO UP >92%. A CXR WAS DONE. LASIX 40MG IV WAS GIVEN. HIS ET TUBE WAS ADVANCED TO 21@ THE THEETH.\n\nCV: NSR W/ PVC AND PAC HR89-100. NO SVT NOTED. HIS B/P WENT DOWN TO THE HIGH 80'S X2. AND THAN UP TO 104/50. HIS IS ON LOPRESSOR AND AMIODARONE.\n\nGI/GU: OG IN PLACE. PROMOTE W/ FIBER AT GOAL 40CC/HR. NO RESIDUAL NOTED. + BS. SMALL SOFT FORMED STOOL. FOLEY CATH WITH ADEQUATE OUTPUT.\n\nID: TEMP MAX 100.6 ORAL. BCX2 AND URINE CULTURES. HE IV AND PO ABX.\n\nSKIN: INTACT.\n\nPOC: WEAN VENT AS . FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-23 00:00:00.000", "description": "Report", "row_id": 1325065, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Many changes overnight for worsening oxygenation. BS's coarse throughout. Sxing small amts thick white secretions. ETT advanced 4cms, 25cm. without event. See flowsheet for vent changes and other pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-23 00:00:00.000", "description": "Report", "row_id": 1325066, "text": "ADDENDUM:\n\nPT B/P DROPED TO 84/36. LEVOPHED 0.08MCG/KG/MIN STARTED. NOW B/P 101.50. HE NEEDS PLT THIS AM FOR A PLT 15.\n" }, { "category": "Nursing/other", "chartdate": "2182-10-23 00:00:00.000", "description": "Report", "row_id": 1325067, "text": "d: plt ct=15 and pt was transfused with 1 u plts. pt sedated on fentanyl gtt 140 mgc/hr and versed gtt at 4 mg/hr. received pt on levophed gtt for bp support but was d/c'd. pt responsive to painful stimuli and did open eyes to pianful stimuli but did not follow simple commands. l brachila picc line reported by radiologist to be coiled and in down flow position. picc line was pulled back 5 cm and redressed. dr. and medical team spoke with pt's wife and decision was made to change pt's code status to measures only. once other family members arrived fentanyl gtt was changed to mso4 gtt. pt was extubated at 1300. family memebers remained at the bedside at 1355 pt became apneic and asystolic. pt was pronounced by dr. . no autopsy scheduled. pt transported to morgue.\n\n" }, { "category": "ECG", "chartdate": "2182-10-16 00:00:00.000", "description": "Report", "row_id": 164328, "text": "Atrial fibrillation with a rapid ventricular response. Intraventricular\nconduction defect. Anteroseptal ST segment elevation, consider acute myocardial\ninfarction. Since the previous tracing of atrial fibrillation is new\nand ST segment elevation is seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-10-16 00:00:00.000", "description": "Report", "row_id": 164329, "text": "Sinus tachycardia with supraventricular extrasystoles. Normal ECG, except for\nrate. Since the previous tracing of -5 no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2182-10-17 00:00:00.000", "description": "Report", "row_id": 164096, "text": "Baseline artifact\nSinus tachycardia\nDiffuse ST segment elevation - suggests pericarditis - clinical correlation is\nsuggested\nSince previous tracing of the same date, rapid atrial fibrillation now absent\n\n" }, { "category": "ECG", "chartdate": "2182-10-17 00:00:00.000", "description": "Report", "row_id": 164097, "text": "Atrial fibrillation with a rapid ventricular response, rate 150. ST segment\nelevation in leads I, aVL and V2-V6. Acute anterolateral myocardial infarction\nis in the differential, a focal pericardial process should also be considered.\nCompared to the previous tracing of no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2182-10-15 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 887546, "text": " 8:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for causes of LLL collapse\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS/AML, presenting w/LLL collapse on CXR and multifocal\n cavitary PNA.\n REASON FOR THIS EXAMINATION:\n eval for causes of LLL collapse\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Myelodysplastic syndrome/AML with left lower lobe collapse on\n chest x-ray and multifocal cavitary pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained through the chest without\n intravenous contrast. Additional thin section reformatted images are\n provided.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The aorta is normal in caliber, with\n mural calcifications consistent with atheromatous disease. The pulmonary\n arteries are normal in caliber. There are coronary artery calcifications. The\n heart and pericardium appear otherwise unremarkable. A left-sided venous\n access catheter (PICC) is in place terminating with tip in the SVC.\n\n Again, seen is mediastinal lymphadenopathy, with an enlarged prevascular node\n measuring 1.3 x 2.9 cm (previously 1.3 x 3.0 cm). Additional prominent nodes\n are seen within the pretracheal, paratracheal, precarinal, and subcarinal\n regions. There are bilateral fat containing axillary lymph nodes, which do\n not meet criteria for pathologic enlargement.\n\n The central airways appear patent. There is dense consolidation within the\n lungs bilaterally involving all lobes of the lung, but most prominent within\n the left upper and left lower lobes. There is no obstructing endobronchial\n lesion identified to suggest post-obstructive consolidation or atelectasis.\n\n There are prominent air bronchograms within the collapsed left upper lobe and\n anterior aspect of the left lower lobe. Several focal rounded, lucent areas\n are seen within the consolidated left upper lobe, including a 1.4 x 0.9 cm\n gas-containing structure consistent with a cavitary lesion (series 3 image\n 43).\n\n Additional areas of dense consolidation are seen within the right upper, right\n middle, and right lower lobes centrally. There are numerous foci of patchy\n and nodular opacities scattered throughout the remainder of the aerated\n portions of the lung.\n\n In comparison with CT of , the degree of pulmonary\n (Over)\n\n 8:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for causes of LLL collapse\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consolidation and nodular opacity has progressed. There is a moderate left\n pleural effusion, also progressed in the interval. There is no pneumothorax.\n\n Limited images of the upper abdomen demonstrate stable hyperdensity of the\n hepatic parenchyma as noted at the time of prior CT. A nonobstructing 2-mm\n stone is seen within the interpolar region of the left kidney. The visualized\n portions of the spleen, pancreas, and adrenal glands appear unremarkable.\n\n Limited images of the neck demonstrate numerous subcentimeter lymph nodes\n along the jugular chains bilaterally.\n\n BONE WINDOWS: Bone windows demonstrate degenerative changes of the thoracic\n spine without suspicious lytic or sclerotic osseous lesions identified.\n\n IMPRESSION:\n 1. Interval progression of extensive bilateral pulmonary consolidation, most\n prominent within the left upper and left lower lobe but also involving the\n remaining lobes centrally, consistent with worsening infectious process. There\n are several areas of cavitation in the left upper lobes.\n 2. Increase in moderate left pleural effusion.\n 3. Stable appearance of mediastinal lymphadenopathy. Additional numerous\n nodes within the neck, not meeting criteria for pathologic enlargement.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888183, "text": " 4:41 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: post-intubation, OG tube placement\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with aml, pna a/p intubation, og tube placment\n\n REASON FOR THIS EXAMINATION:\n post-intubation, OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:04 P.M.\n\n HISTORY: AML. Pneumonia. Intubated.\n\n IMPRESSION: AP chest compared to and earlier today:\n\n Endotracheal tube tip is difficult to separate from nasogastric feeding tube,\n which appears to be at the upper margin of the clavicles, while the feeding\n tube passes into the stomach.\n\n Extensive consolidation in the right lung is more pronounced than it was in\n while more severe consolidation in the left lung has minimally\n improved. Substantial left pleural effusion is present. Large cardiac\n silhouette due to cardiomegaly and/or pericardial effusion. If there is\n clinical concern of purulent pericarditis, an echocardiography should be\n performed. Left PIC catheter passes to the SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 888185, "text": " 5:07 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval position of OG tube\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS and L lung mass, s/p intubation and og tube placement\n REASON FOR THIS EXAMINATION:\n please eval position of OG tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old male with MDS and lung mass status post NG tube\n placement.\n\n TECHNIQUE: AP single view of the abdomen.\n\n FINDINGS: This radiograph is not of diagnostic quality due to motion. The\n subsequent radiograph was performed and demonstrated tube within the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2182-10-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 887476, "text": " 12:02 PM\n CHEST (PA & LAT); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: MDS evaluate for left sided rib pain\n ICD9 code from order: 238.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS/AML\n REASON FOR THIS EXAMINATION:\n MDS evaluate for left sided rib pain\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old man with MDS now with left-sided chest pain.\n\n TECHNIQUE: PA and lateral views of the chest are obtained.\n\n COMPARISON: PA and lateral views of the chest .\n\n FINDINGS: There is a left-sided PICC line with tip within the SVC. Since the\n prior study there has been interval collapse of the left\n lower lobe with associated elevation of the left hemidiaphragm. There has\n also been interval shift of the mediastinum to the right which is concerning\n for associated left pleural effusion or hemothorax. The opacification of the\n left upper lung zone has worsened in the interval. There also appears to be\n slight progression of consolidation within the right middle lung zone\n consistent with worsening multifocal pneumonia. Within these areas of\n consolidation there is associated cavitation suggestive of aspergillosis given\n the clinical history.\n\n IMPRESSION: 1. New left lower lobe collapse with associated shift of the\n mediastinum to the right concerning for associated left pleural effusion or\n hemothorax.\n\n 2. Worsening multifocal cavitary pneumonia, given the clinical history\n concerning for aspergillosis.\n\n 3. Left PICC line within the SVC.\n\n The results of the study were discussed with the nurse practitioner, \n .\n\n" }, { "category": "Radiology", "chartdate": "2182-10-15 00:00:00.000", "description": "RIB, UNILAT (NO CXR)", "row_id": 887477, "text": " 12:04 PM\n RIB, UNILAT (NO CXR) Clip # \n Reason: MDS evaluate for left sided rib pain\n ICD9 code from order: 238.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS/AML\n REASON FOR THIS EXAMINATION:\n MDS evaluate for left sided rib pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left-sided rib pain.\n\n LEFT RIBS: Two views were obtained. No definite fracture is seen. There is\n amorphous calcification adjacent to the anterior rib ends of the inferior left\n ribs, likely representing cartilage calcification. A left-sided PICC is seen.\n There is large opacity in the left lung, which has worsened from earlier chest\n x-ray of .\n\n IMPRESSION: Doubt acute rib fracture. Short term worsening left lung\n consoldation. Please refer to chest x-ray performed on the same day for full\n evaluation (clip ).\n\n" }, { "category": "Radiology", "chartdate": "2182-10-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 888190, "text": " 7:47 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: please do film to assess OG tube placement - unable to visua\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS, L sided pneumonia, now intubated - OG tube placed\n REASON FOR THIS EXAMINATION:\n please do film to assess OG tube placement - unable to visualize, need better\n film penetration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old male with MDS and left side pneumonia, now intubated.\n Status post OG tube placement.\n\n COMPARISON: No comparisons are available.\n\n TECHNIQUE: AP supine single view of the abdomen.\n\n FINDINGS: There is interval placement of an NG tube with the tip in the\n stomach. The small bowel gas pattern is otherwise nonspecific. Note that\n radiograph is limited for evaluation of other processes since did not include\n the entire abdomen and is limited by motion. There is again noted a left\n lower lobe extensive pneumonia as previously seen in the chest radiograph.\n\n IMPRESSION: NG tube tip is in the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887885, "text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval progression of PNA\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with aml, pna, lll collapse\n\n REASON FOR THIS EXAMINATION:\n please eval for interval progression of PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML and pneumonia\n\n PORTABLE AP CHEST: As compared to , there is persistent diffuse\n opacification of the left lung, consistent with extensive consolidation as\n well as component of pleural fluid. There is no associated mediastinal shift\n to indicate volume loss. Stable moderate pulmonary edema within the right mid\n lung as well as improving right basilar subsegmental atelectasis are noted.\n PICC catheter remains in stable position.\n\n IMPRESSION: No significant interval change in moderate pulmonary edema and\n extensive left lung consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2182-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888131, "text": " 5:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for improvement\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with aml, pna, lll collapse\n\n REASON FOR THIS EXAMINATION:\n assess for improvement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:19 A.M. ON .\n\n HISTORY: AML, pneumonia and left lower lobe collapse.\n\n IMPRESSION: AP chest compared to and :\n\n Pulmonary details obscured by marked respiratory motion. The left hemithorax\n remains almost entirely opacified although the mediastinum is not shifted to\n the right. This represents a combination of consolidation and atelectasis in\n the left lung and probable left pleural effusion without progression since\n . Moderately severe pulmonary edema in the right lung is probably\n unchanged. There is no indication of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888216, "text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for progression of infiltrate\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with aml, pna a/p intubation\n REASON FOR THIS EXAMINATION:\n please eval for progression of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:42 A.M., :\n\n HISTORY: AML and pneumonia.\n\n IMPRESSION: AP chest compared to and 6th:\n\n Although aeration in the left lung has improved substantially since , there are larger areas of consolidation in the left mid lung with central\n cavitation at the left lung base, as well as increasing region at the left\n apex. Right lung shows persistent pulmonary edema and a region of pneumonia\n at the apex. Endotracheal tube tip is at the thoracic inlet, in standard\n placement with the mandible extended. Mild cardiomegaly and small left\n pleural effusion unchanged. Tip of the left subclavian central venous line\n projects over the SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887582, "text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for worsening collapse, mediastinal shift, worsening in\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with aml, pna, lll collapse\n REASON FOR THIS EXAMINATION:\n eval for worsening collapse, mediastinal shift, worsening infiltr\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:40 A.M.\n\n HISTORY: AML. Pneumonia. Worsening collapse and mediastinal shift.\n\n IMPRESSION: AP chest compared to and , read in\n conjunction with a chest CT scan performed 9:00 P.M. on :\n\n Consolidation in the left lung, increased dramatically between \n and and again between and . Rightward\n mediastinal shift has also developed, arguing for aggressive pneumonia\n accompanied by a small-to-moderate left pleural effusion. Right lung shows\n worsening edema, bronchiectasis, and atelectasis, obscuring the pneumonia seen\n on CT scan.\n\n Tip of the left PIC catheter is at the superior cavoatrial junction. Low lung\n volumes and opacification of the left hemithorax distort and obscure the\n cardiac silhouette. No pneumothorax. The upper esophagus is distended with\n air. All these studies suggest either an obstruction or esophagitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888472, "text": " 10:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for worsening chf.\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS/AML and acute respiratory failure.\n REASON FOR THIS EXAMINATION:\n evaluate for worsening chf.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST, \n\n COMPARISON: .\n\n INDICATION: Acute respiratory failure.\n\n An endotracheal tube is present, terminating above the level of the thoracic\n inlet, roughly 8.5 cm above the carina. A nasogastric tube is present, but\n the tip is not well visualized radiographically, and if warranted, a dedicated\n abdominal radiograph could be obtained to determine the location. A left PICC\n line terminates in the region of the superior vena cava. The heart is upper\n limits of normal in size and is partially obscured by an area of consolidation\n within the lingula which extends superiorly to also involve the left upper\n lobe. Multifocal patchy areas of consolidation are present throughout the\n remainder of the lungs, with overall interval improved aeration, particularly\n in the left retrocardiac area compared to the prior study. Small bilateral\n pleural effusions are noted. Vascular engorgement and perihilar haziness is\n present, suggesting a component of pulmonary edema in addition to multilobar\n pneumonia.\n\n IMPRESSION:\n 1. Proximal location of endotracheal tube. Please note that at the time of\n this dictation, a repeat chest radiograph has been performed with\n repositioning of the tube. That radiograph is dictated separately.\n 2. Multilobar pneumonia with interval improvement, particularly in the left\n lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888475, "text": " 12:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for progression of pneumonia\n Admitting Diagnosis: LOW O2 SATURATION;ACUTE MYELOID LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with aml and pneumonia, s/p advancing ET tube 4 cm.\n\n REASON FOR THIS EXAMINATION:\n please evaluate placement of ET tube.\n ______________________________________________________________________________\n FINAL REPORT\n Portable supine chest \n\n COMPARISON: .\n\n INDICATION: Endotracheal tube assessment.\n\n An endotracheal tube has been advanced in the interval, now terminating at\n approximately the level of the thoracic inlet, about 5.5 cm above the carina.\n A left PICC line has been repositioned in the interval, and now makes an\n abrupt curve, with the distal tip projecting laterally towards the axilla.\n This may be within a distended left brachiocephalic vein or within a branch\n vessel. Cardiac and mediastinal contours are stable. Multifocal\n consolidation remains present bilaterally, affecting the left upper lobe and\n lingula to the greatest degree. There is some associated mild volume loss in\n the left upper lobe as well. Additionally, there is vascular engorgement and\n perihilar haziness suggesting a component of mild fluid overload. Bilateral\n small pleural effusions are noted, left greater than right.\n\n IMPRESSION: Interval advancement of endotracheal tube as described.\n\n Malpositioning of left PICC line, as communicated to the Clinical Service\n caring for the patient on the date of the study.\n\n" }, { "category": "Radiology", "chartdate": "2182-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 887460, "text": " 11:03 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: 55 yr old man with MDS, with pain left mid axillary, pain wi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with MDS/AML\n REASON FOR THIS EXAMINATION:\n 55 yr old man with MDS, with pain left mid axillary, pain with palpation of\n ribs + aspergillosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old man with MDS and left mid axillary chest pain.\n\n TECHNIQUE: A single AP portable upright chest radiograph was obtained.\n\n COMPARISON: PA and lateral views of the chest at 1203, PA\n and lateral views of the chest .\n\n FINDINGS: There is a left-sided PICC line with tip within the SVC. On this\n single frontal view of the chest there has been rapid interval opacification\n of the left hemithorax in comparison to prior study within the last hour\n concerning for worsening left lower lobe collapse. Also noted is interval\n greater shift of the mediastinum to the right concerning for underlying left\n pleural effusion or potentially hemothorax given the rapid time course of\n these changes. Also noted is slightly worsened consolidation in the right\n middle lung zone consistent with worsening multifocal pneumonia.\n\n IMPRESSION: 1. Rapid opacification of the left hemithorax consistent with\n left lower lobe collapse. Associated mediastinal shift to the right\n consistent with left pleural effusion or hemothorax.\n\n 2. Worsening multifocal pneumonia.\n\n 3. Left-sided PICC line within the SVC.\n\n The results of the study were discussed with nurse practitioner, \n .\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2166-08-24 00:00:00.000", "description": "Report", "row_id": 1536204, "text": "CCU Nursing Note \nS: Orally Intubated\n\nO: Please see careview flow for all vs and objective data.\n\n pt with vs per careview on Dopa 5mcgs, Levo 0.2mcgs and Neo 8mcgs with MAP 60. Orally intubated on 60%/500/AC20/5 peep. Propofol 20mcgs/. Attempt to wean off pressors inorder to safely transport pt to ct scan. With any attempt to wean, MAP is below 60. Husband and son visited and spoke at length with Dr. . Will plan on having CT scan despite low BP.\n1100- Dr reviewed am labs and noted WBC 52.9. At this point, presented further information to husband and son, and it was decided that pt is to be CMO and will withdraw BP meds once pt's brother arrives.\n1400 - Dr. with family and friends. Dopa weaned to off. Morphine 3mg IVP for comfort\n1600 - Levo and Neo weaned to off and Morphine gtt started for comfort. Family present\n1705 - Pt with no spontaneous respirations off ventilator, No pulse.\nDr. pronounced pt, and family refuses post mortum. Family in possession of pt belongings.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-23 00:00:00.000", "description": "Report", "row_id": 1536200, "text": "CCU Nursing Progress Note 7am-7pm\nS: I don't understand how this can happen\n\nO: Pt and husband asking appropriate questions re condition, and have spoken at length with Dr. both before and after swan placement\n\nID - WBC 22.1 Started on Abx Levofloxacin, Flagyl and 1x dose of Gent. Temp monitored core 100.4 max\n\nCV - Aline placed with great difficulty, in r brachial art. BP 90-100/50 Swan placed l femoral with PAP,opening pressures 58/38, CVP 26. Swan re leveled with subsequent PA 60/28, CVP 20-22, CO 6.6, CI 4.4, SVR 570. HR 120 ST with no vea, converted to afib at 430pm, with slight drop in BP to 85-90/50. No intervention at this time. Pt states that she has been in afib before.\n\nResp - pt is quite tachypnic with rr 26-40. She c/o sob with slightest movement and with speaking, although sats remain 98-100%. ls are diminished at bases.\n\nGU - Lasix gtt started at 5mg/hr after 40mg ivp, started at 5pm. no u/o after lasix gtt started.\n\nGI - +bs and is passing flatus, but no stool. Poor appetite.\n\nHeme - INR this am 18, further rx with 10mg Vit K sx with subsequent INR 6. Labs pnd at 6pm\n\nSocial - Husband throughout day, and is aware of plan and progress\n\nA: RV failure with sepsis and high INR\n\nP: cont monitor fluid status, diuresing as able. Abx for sepsis, turn and position for comfort, check pnd labs and correct as necessary, keep pt and husband informed\n" }, { "category": "Nursing/other", "chartdate": "2166-08-24 00:00:00.000", "description": "Report", "row_id": 1536201, "text": "CCU Nursing Progress Note 1900-0700:\nEVENTS: Pt becoming increasingly hemodynamically unstable throughout night. Intially with MAPs in the low 60s on Lasix drip at 5mg/hr with goal to diurese. Neo drip added with goal of keeping MAPs > 70. Pt gtt increased to 10mg/hr without bolus with no affect in PADs, CVPs, or UOs. BP stable on 2.5mcg/kg/min Neo and Lasix gtt at 10mg/hr. Pt recieved in Afib with HR 110-150s. HR sustaining into the 130-150s and Amiodorone drip then added and later bolused with 150mg of Amiodorone. Pt rate coming down to 100-110s but remaining in Afib with stable BPs in the mid 90s with MAPs int the mid 60s. While in Afib pt becoming increasing tachypenic with RR into the mid 30s to lower 40s. ABG with with good oxgentation but with compensated metabolic acidosis with low PCO2 into the 20s and HCO3 in the mid teens. Pt beginning to further \"tire.\" MSO4 given in 1mg divided doses totaling 2mg but unaffective in decreasing drive and later electively intubated. Post intubation pt further hemodynamically unstable with severe metabolic acidosis with PH 7.11 requiring 6amps of NaHCO3 IVP and later NaHCO3 drip, converting into junctional rhythmn with rate into the 60-80s prompting discontinuation of Amiodorone drip, unstable BPs requiring additional pressor support, and cold rihgt upper extremetie with loss of pulses distal to Aline requiring emergent bedside ultrasound.\n\nS-Sedated and intubated\n\nO-Sedated on Propofol at 20mcgs/kg/min recently started at 0300. When intubated recieving 16mg of Etomidate and 10mg of Vecoronium with long lasting affect. Pt currently repsonding to verbal commands and moving extremeties with very weak movements but nodding appropriately to questions. Pupil brisk and reactive to light.\n\nCV:HR 60-150s, Afib/junctional/accelerated junctional with no ventricular ectopy. BPs mid to upper 90s with MAPs in the low to mid 60s on 5.0mcg/kg/min of Dopamine, 0.2mcgs/kg/min of Levophed, and 8.0mcgs/kg/min of Neo with the the to wean of Dopa and Neo and to max Levophed. If requiring additional support please continue other pressor. PADs 22-28 and CVPs 20-24 with high COs and low SVRs. When in junctional rhtyhmn pt noted to have correlating PADs and CVPs. Pulses parodox(-) on exam, heart sounds present, and aline(-) for pulses alternans with no changes in BPs at time. Pt with palpable pulses/dopperable pulses intially. Later post pressors and acidemia losing pulses throughout with only dopplerable pulses in LUE. Bilater and cold. LUE pale and cold and RUE mottled and cold. U/S of RUE done with arterial flow to hand therefor brachial aline left in place. Pulses later dopplerable in RUE and DPs in bilateral post bair hugger. DPs in bilateral LEs remain undopplerable. Worsening K and pt currently hyperkalemic K of 5.8. Given 30mg of Kayexelate, Ca Gluc, Dextrose and Insulin. Awaiting repeat K.\n\nRESP:AC/500/20/60% 5 PEEP. Breath sounds with crackle and diminished at bases. Erratic O2Sat tracing with poor perfusion. Unable to obt\n" }, { "category": "Nursing/other", "chartdate": "2166-08-24 00:00:00.000", "description": "Report", "row_id": 1536202, "text": "CCU Nursing Progress Note 1900-0700:\n(Continued)\nain accurate O2Sat. PaO2s stable on ABGs. CXR post intubation with ETT in place and no change in bilateral effusions or pulmonary edema. ABGs with metabolic acidosis depsite NaHCO3 therapy.\n\nGU/GI:Anuric with foley in place. Urine sent for lytes and osmo. Renal function worsening with last Creat of 2.6 and BUN of 45. Renal to be consulted for this AM with possible trial of CVVHD. NaHCO3 drip at 100cc/hr times 1L infusing. Abd increasing distended this AM with hypoactive bowel sounds. OGT placed and confirmed by CXR. OGT apirated for a small amount of coffee grounds, heme (+) and started on Protonix IV. No stool noted.\n\nID:Low grade temps. Currently on triple abx, recent WBC 28 with AM pending.\n\nA/P: Severe septic and cardiogenic shock c/b RV failure, dysrythmmias, hypotension, renal and liver failure\n\nFollow labs closely\nContinue to follow hemodynamic closely\nAdminister Abx treatment as orderd\nRenal to consult this AM, possible CVVHD\nLarge bilateral pleural effusions, possible CT insertion\n\n" }, { "category": "Nursing/other", "chartdate": "2166-08-24 00:00:00.000", "description": "Report", "row_id": 1536203, "text": "RESP CARE: Pt intubated with ETT # lip. Pt remains on CMV 500/20/.60/5PEEP. ABGs consistent with met. acidosis.\n" }, { "category": "Nursing/other", "chartdate": "2166-08-23 00:00:00.000", "description": "Report", "row_id": 1536199, "text": "CCU Nursing Admission Note 1900-0700:\nHPI: 80 year-old frail appearing female who was recently discharge from post triscupid valve replacement on presented to ER with worsening SOB. In ER found to have severe DOE with RR into 30s but stable O2Sats on 3LsNP of 99-100%. In addition, hypotensive(70-100s) and treated with IVF with fair response. CXR prior to IVF (+) pulmonary edema and bilateral pleural effusions. Not treated with Lasix in ED secondart to BPs. Also pt with elevated INR of 11.\n\nSEE FHP FOR DETAILED ALLERGIES, HPI, AND PMH\n\nS-\"I just want to go to sleep!\"\n\nO-MS:Alert and oriented time three. Very pleasant and cooperative with care. C/o of being \"tired\" and only \"wanting to sleep.\" Becomes very anxious with SOB repsonds to positive re-inforcement. Sleeping well overnight.\n\nCV:HR HR 100-115s, ST with no ectopy. K elevated at 5.0 and Mg normal. SBP via NIBP 90-100s. Denies CP. Pale appearing on arrival and skin hot. Weak palpable pulses throughout.\n\nRESP:Breath sounds with crackles at bases. Very dypsenic with any activity ie., taking PO tempertures and movement in bed. Breathing pattern at rest noraml. O2Sats unchanged with dypsnea or at rest, 99-100& on 6Ls. Aline and ABG attempted but unsuccessful. CCU team to attempt this morning. Mucous membranes extremely dry.\n\nGU/GI:Foley placed in ED with minimal output. Pt remaining oliguric despite fluid bolues and later attempted diuresis(Lasix 10mg times one and later 20mg) and is currently 2Ls positive. BUN/Creat elevated.\nUA sent for BUN and Creathine. Abd softly-distended with (+) BS. Mid-line inciscion present. LFTs pending. Tolerating POs fair overnight, clear liqs given only. Ordered for heart healtht/low sodium diet.\n\nID:Tm 101.4 rectally. WBC 20 on admission. Started on IV Abx, Vanco and Ceftriaxone.\n\nHEME: HCT 32. PLTs elevated 500s. PT/INR 11.0 Clot in BB. Pt recieving 5mg of PO Vit K in ED.\n\nSKIN:Intact. Right groin with recent inciscion about 5cm in width, suspect in correlation with valve surgery. Area with hard nodule felt beneath and marked. U/S performed to r/o abcess of area and (-). Sternal inciscion CDI, small areas of granulation. Both areas open to air.\n\nA/P: 80 yo female s/p recent TVR surgery with DOE, elevated WBC and supertherapeutic INR who is currently stable.\n\nMonitor for signs/symptoms of bleeding\nAdminster FFP and Vit K as ordered\nFollow I/O and administer fluid cautiously\nDepsite elevated coagulations pls consider central access\nin near future\nContine to emotionally support\n\n" }, { "category": "Radiology", "chartdate": "2166-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832898, "text": " 6:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 80 yo femle s/p valve surgery now sob\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with sob s/p valve surgery days ago at \n REASON FOR THIS EXAMINATION:\n 80 yo femle s/p valve surgery now sob\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, S/P valve surgery day previously.\n\n COMPARISONS: None\n\n SINGLE VIEW CHEST, AP: There are moderate sized pleural effusions bilaterally\n with bilateral lower lobe atelectasis/collapse. The pulmonary vasculature is\n within normal limits. There is cardiomegaly. The patient is S/P median\n sternotomy. A prosthetic heart valve is not well appreciated. There is no\n pneumothorax.\n\n IMPRESSION: Moderate bilateral pleural effusions with reactive\n atelectasis/collapse.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-23 00:00:00.000", "description": "P US SIMPLE/SING ABSC/CYST DRAIN/INCISION PORT", "row_id": 832917, "text": " 12:12 AM\n US SIMPLE/SING ABSC/CYST DRAIN/INCISION PORT Clip # \n Reason: r/o abscess in right groin\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with leukocytosis, hypothermia, fatigue s/p tricuspid valve\n surgery at 2 weeks ago with large flucuant area in right groin area.\n please eval for abscess.\n REASON FOR THIS EXAMINATION:\n r/o abscess in right groin\n ______________________________________________________________________________\n WET READ: AZm SAT 1:58 AM\n Right groin fluid collection\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Large fluctuant area in the right groin.\n\n RIGHT GROIN ULTRASOUND: There is a 3.9 x 2.9 x 3.8 cm fluid collection in the\n right groin region, anterior to the femoral vessels. No obvious internal\n debris. There is no demonstrable doppler flow in this collection. The flow in\n the common femoral vein and artery is normal.\n\n IMPRESSION: Nonspecific fluid collection in the right groin.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-24 00:00:00.000", "description": "P UNILAT UP EXT VEINS US PORT", "row_id": 833003, "text": " 12:48 AM\n UNILAT UP EXT VEINS US PORT Clip # \n Reason: please eval for flow to right hand\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with sepsis and right upper extremity brachial line and now\n loss of pulse\n REASON FOR THIS EXAMINATION:\n please eval for flow to right hand\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis. Right brachial arterial line, now with pulse-less right\n hand. Evaluate for brachial arterial thrombosis.\n\n LIMITED RIGHT UPPER EXTREMITY ARTERIAL ULTRASOUND: Limited exam in the region\n of the patient's right brachial a-line was performed. Normal color flow is\n seen in both the brachial artery and vein above the level of the arterial\n line. Flow is seen around the line, as well as distal to the line, with\n normal appearing arterial waveforms.\n\n IMPRESSION: Limited exam. No evidence of brachial arterial thrombosis at the\n level of the brachial arterial line. This study cannot exclude distal\n embolization or occlusion.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832967, "text": " 2:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for swan placement\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with sob s/p valve surgery days ago at \n\n REASON FOR THIS EXAMINATION:\n please eval for swan placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF 15:23 ON COMPARED TO PREVIOUS STUDY OF ONE DAY\n EARLIER.\n\n CLINICAL INDICATION: Swan-Ganz catheter placement.\n\n A Swan-Ganz catheter has been placed via a femoral approach. The catheter\n coils within the right atrium before terminating within the right ventricle,\n directed towards the ventricular outflow tract. Cardiac and mediastinal\n contours are stable. Bilateral pleural effusions and bibasilar lung opacities\n are unchanged.\n\n IMPRESSION: Malpositioning of Swan-Ganz catheter. This finding is known to\n the Clinical house staff caring for the patient.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832999, "text": " 11:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt s/p intubation, location of tube.\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with sob, tachycardia, hypotension s/p valve surgery days\n\n REASON FOR THIS EXAMINATION:\n Pt s/p intubation, location of tube.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman with shortness of breath, status post intubation.\n evaluate location of the tube.\n\n FINDINGS: This study is compared to the previous examination of the same day\n earlier. Since the previous study, there has been placement of an ETT.\n The NG tube remains\n in place. Large bilateral pleural effusions are again noted. Continued\n application of the right femoral vein Swan-Ganz catheter, The tip remains in\n the right main pulmonary artery. There is no evidence of pneumothorax.\n\n IMPRESSION: Since the previous study, there has been placement of an ET tube.\n No other significant changes are noted.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833025, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for worsening pleural effusions and or infiltrat\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with sob s/p valve surgery days ago at \n REASON FOR THIS EXAMINATION:\n please eval for worsening pleural effusions and or infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n This is a re-dictation for a previously lost report.\n\n CHEST RADIOGRAPH: The cardiomegaly, left lower lobe consolidation and\n bilateral pleural effusions are unchanged. Again noted is the looping of the\n Swan-Ganz catheter within the right atrium. ETT is approximately 5 cm above\n the carina. The osseous structures are unremarkable.\n\n IMPRESSION:\n 1) Unchanged appearance of the bilateral pleural effusions, left lower lobe\n opacity.\n 2) The Swan-Ganz catheter is again looped within the right atrium, as\n previously communicated with the clinical staff.\n\n" }, { "category": "Echo", "chartdate": "2166-08-22 00:00:00.000", "description": "Report", "row_id": 72115, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Valvular heart disease.\nHeight: (in) 63\nWeight (lb): 110\nBSA (m2): 1.50 m2\nBP (mm Hg): 85/40\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 22:15\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is mildly\ndepressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is moderately dilated. There is\nsevere global right ventricular free wall hypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: A bileaflet mitral valve prosthesis is present. The mitral\nprosthesis appears well seated, with normal leaflet/disc motion and\ntransvalvular gradients. No mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: A tricuspid valve annuloplasty ring is present. Mild to\nmoderate [+] tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant pulmonic regurgitation is seen.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nOverall left ventricular systolic function is mildly depressed (ejection\nfraction 45%). The inferior septum, inferior and inferolateral walls are\nhypokinetic. The remaining walls contract well. The right ventricular cavity\nis moderately dilated. There is severe global right ventricular free wall\nhypokinesis. The aortic valve is trileaflet and mildly thickened. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen. A bileaflet\nmitral valve prosthesis is present. The mitral prosthesis appears well seated,\nwith normal leaflet/disc motion and transvalvular gradients. A tricuspid valve\nannuloplasty ring is present. Moderate tricuspid regurgitation is present.\nModerate pulmonic regurgitation is seen. At least moderate pulmonary\nhypertension is present with an estimated PA pressure of 46 mm Hg plus CVP.\nThere is a trivial/physiologic pericardial effusion. A large left pleural\neffusion is seen.\n\nConclusion: Moderate right ventricular dilation. Severe right ventricular\nsystolic dysfunction. Mildly reduced left ventricular systolic function with\nhypokinesis of the inferior septum, inferior and inferolateral walls.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832978, "text": " 4:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: location of swan through heart\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with sob s/p valve surgery days.\n REASON FOR THIS EXAMINATION:\n location of swan through heart\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST COMPARED TO PREVIOUS STUDY OF EARLIER THE SAME DAY.\n\n CLINICAL INDICATION: Swan-Ganz catheter position.\n\n A Swan-Ganz catheter is coiled within the right atrium before entering the\n right ventricle. The distal tip is in the distal right main pulmonary artery.\n With the exception of advancement of the catheter, there has been no\n significant change since the previous study performed approximately one hour\n earlier.\n\n IMPRESSION: Coiling of Swan-Ganz catheter within right atrium as communicated\n to Clinical Service caring for the patient.\n\n" }, { "category": "Radiology", "chartdate": "2166-08-23 00:00:00.000", "description": "CHEST FLUORO WITHOUT RADIOLOGIST", "row_id": 832970, "text": " 2:48 PM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: SWAN PLACEMENT\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n A chest fluoro was performed without a radiologist present. 2 minutes of\n fluoro was used. No films submitted.\n\n" }, { "category": "ECG", "chartdate": "2166-08-22 00:00:00.000", "description": "Report", "row_id": 158725, "text": "A-V dissociation with an and accelerated junctional rhythm atrial tachycardia\n\n" }, { "category": "ECG", "chartdate": "2166-08-23 00:00:00.000", "description": "Report", "row_id": 158726, "text": "A-V dissociation with atrial tachycardia and accelerated junctional rhythm\n\n" }, { "category": "ECG", "chartdate": "2166-08-23 00:00:00.000", "description": "Report", "row_id": 158727, "text": "Atrial fibrillation with rapid ventricular response\nExtensive ST-T changes may be due to myocardial infarction\n\n\n" }, { "category": "ECG", "chartdate": "2166-08-23 00:00:00.000", "description": "Report", "row_id": 158728, "text": "Sinus rhythm with first degree AV block\nIntraventricular conduction defect\nPossible inferior infarct - age undetermined\nAnt/septal+lateral ST-T changes suggest myocardial injury/ischemia, more\npronounced than previous - consider ischemia\n\n" }, { "category": "ECG", "chartdate": "2166-08-22 00:00:00.000", "description": "Report", "row_id": 158729, "text": "Sinus arrhythmia\nLateral ST-T wave changes may be due to myocardial ischemia\nInferior Q waves of doubtful significance\n\n" }, { "category": "ECG", "chartdate": "2166-08-24 00:00:00.000", "description": "Report", "row_id": 158730, "text": "Junctional rhythm with occasional sinus beats\nPossible right ventricular hypertrophy\nAnterolateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2101-10-29 00:00:00.000", "description": "Report", "row_id": 1554890, "text": "NSG ADM NOTE\n\nS:\" JUST LET ME GET UP AND OUT OF THIS BED!\"\n\nO: CV/SKIN: PT ARRIVED FROM CATH LAB. C-CLAMP ON L GROIN. PT WANTING TO GET OOB. TO PT NEED TO STAY ON BR AND KEEP L LEG STRAIGHT. SBP 160-170 WITH RESTLESSNESS. DR AND FELLOW INTO ASSESS PT. HR 80-85 NSR WITH RARE PVC NOTED. PT HAD #1 U PRBC HANGING ON ARRIVAL. L GROIN NO BLEED,BUT SOFT LG HEMATOMA/ECCHYMOTIC AREA NOTED. PULSES ON R FT PALP,L FOOT PULSES DOPPLER DP/PT FT COOL. C-CLAMP PRESSURE MAINTAINED X2/HR WITH NO BLEED. CLAMP REMOVED BY FELLOW,HOMEOSTASIS MAINTAINED. U/S STUDY COMPLETED WHICH WAS NL. POST-TRANSFUSION HCT 37.4,38.\n\nNEURO: PT ALERT AND ORIENTED TO PERSON,TIME STATES SHE IS IN THE HOSPITAL BUT DOES NOT KNOW THE NAME. SHE HAS PERIODS OF CONFUSION, SEVERAL ATTEMPTS MADE TO GET OOB. AGITATED @ TIMES. ATIVAN 0.5MG IV GIVEN BUT SEEMED TO MAKE PT MORE CONFUSED AND LESS COOPERATIVE. HALDOL AND ZYPREXA GIVEN WITH VERY GOOD EFFECT. VSS POST SEDATION. PT SLEEPING SOUNDLY THEREAFTER. SITTER OBTAINED. PT'S DAUGHTER IN ROOM MOST OF NOC\n\nIV: POOR ACCESS. IV ON L HAND LEAKING. SEVERAL ATTEMPTS MADE TO DRAW BLOOD AND INSERT IV BUT FAILED. R IJ TRIPLE LUMEN INSERTED BY TEAM. CXR CONFIRMING PLACMENT.\n\nRESP: O2 SATS STABLE ON 5L NP%. BS DIMINISHED THRU-OUT. RR-16-20.\n\nGI: NPO + BS ABD OBESE HYPOACTIVE BS. DENIES N/V NO STOOL\n\nGU: U/O > 60CC/HR BUN 20 CREAT 1.1\n\nID: AFEBRILE. WBC 10.1\n\nLABS: HCT 38 CLOTT SENT TO BB COMPLETED #1 U PRBC TOL WELL BY PT.\n K+ 4.6\n\nSOCIAL: PT'S CHILDREN IN. SPOKE WITH NURSING AND HOUSE STAFF REGARDING POC AND CURRENT STATUS. PT HAS HEALTH CARE PROXY WHICH IS HER DAUGHTER.\n\nA/P: 75 YR OLD FEMALE S/P CC WITH SIGN. LCX DX. S/P STENT LCX. AGGRESSIVE BLEED OF L GROIN REQUIERING C-CLAMP PLACMENT AND BLOOD TRANSFUSION. CON'T TO CHECK HCT,VS. MONITOR GROIN ? F/U U/S IN AM\n\n" }, { "category": "Nursing/other", "chartdate": "2101-10-29 00:00:00.000", "description": "Report", "row_id": 1554891, "text": "CCU Nursing Progress Note 7am-7pm\nS/O: CV - HR 80-100 NSR with rare pvc and occ pac. Lopressor xl cont. BP 95-150/50-60. Rec'd lisinopril 10mg po this am. L groin hematoma unchanged and soft. Pulses +1/+3 bilaterally with good csm. L foot cooler than r. Hct is stable 33.3-33.5\n\nResp - LS have crackles at l base with O2 on 2ln/p with sat 98-100%\n\nGI - Appetite fair for meals today, +BS, no stool\n\nID - Afebrile\n\nNeuro - Pt sleepy throughout day, oriented x2 (not place), but children states that this is normal. Pt is cooperative\n\nSocial - children vss off/on throughout day, and have spoken with MD's\n\nA: Stable HCT, groin s/p stent\n\nP: Cont HCT q6hrs tonight, then tomorrow, Monitor groins and pulses for change, Turn and position for comfort, sitter tonight\n" }, { "category": "Nursing/other", "chartdate": "2101-10-30 00:00:00.000", "description": "Report", "row_id": 1554892, "text": "ccu npn 7p-7a\nS: \"I'm in the hospital, but I dont know the name of it.\"\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable with HR 70-90's NSR/ST, rare APC, PVC noted. BP ranges 90's-140's/50-70. Left groin remains with large ecchymotic area, soft hematoma. Distal pulses palp. Hct remains stable at 2300 at 32.5.\n\nResp; Sats 95-98% on 2L n/c. Lungs clear with fine rales in right base dependently. RR 16-22.\n\nID: Tmax 99.9 po, checked rectally 100.6, CCU team aware. Given tylenol 650mg po x1 with temp down TO 98.8\n\nGI:GU: Taking pos, no N/V. Ate toast in eve. Abdomen soft, obese with active bowel sounds, no stool this shift. Foley to drainage with clear yellow urine, amber this am. U/O 20-30cc/hour. I/O approx. even at MN.\n\nNeuro: Pt. awake and alert to person, place, disoriented to time, stated it was , reoriented to time. Pt. conversing easily with children. Daughter from Fla. spent the night. No sitter required. Pt. slept well most of shift, easily arousable. Frequent observations.\n\nAccess: RIJ TLC, patent and intact. One peripheral in right hand.\n\nA: Hemodynamically stable with stable Hcts s/p large groin bleed.\n\nP: Cont to monitor hemodynamics, follow up with am labs. Monitor for increase in temp. Assess u/o, encourage pos in am. Continue to monitor mental status, frequent observations and safety measures. Comfort and emotional support to Pt. and family\n\n\n" }, { "category": "Radiology", "chartdate": "2101-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841398, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with metastatic breast ca admitted to CCU with groin bleed.\n Now with cough and low grade fever.Q\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 75-year-old woman with metastatic breast cancer admitted to CCU\n with groin bleed, now with cough and low-grade fever. Please evaluate for\n infiltrate.\n\n AP UPRIGHT PORTABLE CHEST AT 1:40 P.M.: Comparison is made to prior\n portable film two days ago. There is increasing opacity at the left base with\n blunting of the left CP angle. This is consistent with pleural effusion, but\n infiltrate and atelectasis cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841270, "text": " 9:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate right IJ central line placement\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with metastatic breast ca admitted to CCU with groin bleed.\n Central line placed.\n REASON FOR THIS EXAMINATION:\n evaluate right IJ central line placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of metastatic breast CA, status-post right line\n placement.\n\n PORTABLE CHEST: A single AP supine view of the chest is submitted.\n\n There is suboptimal inspiratory effort. A right-sided central venous catheter\n is identified. Its tip is difficult to assess due to technique, but appears\n to terminate at the level of the SVC. There is aortic calcification. Cardiac\n size cannot be evaluated due to technique. No focal pulmonary consolidation\n or pneumothorax are appreciated. There is blunting of the right costophrenic\n sulcus.\n\n IMPRESSION\n\n 1. Limited examination.\n\n 2. The tip of the right central venous catheter appears to overlay the SVC,\n however, a PA and lateral examination of the chest is recommended to\n confirm positioning.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-10-28 00:00:00.000", "description": "LP FEMORAL VASCULAR US LEFT PORT", "row_id": 841277, "text": " 10:07 PM\n FEMORAL VASCULAR US LEFT PORT Clip # \n Reason: Evaluate for AV fistula, pseudoaneurysm\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman admitted to CCU with groin bleed from failed perclosure\n device.\n REASON FOR THIS EXAMINATION:\n Evaluate for AV fistula, pseudoaneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Failure of Perclose device. Groin hematoma. Evaluate for AV\n fistula and pseudoaneurysm.\n\n Doppler son of the bilateral groin vessels demonstrates normal vascular\n wave forms without evidence of arteriovenous fistula or pseudoaneurysm.\n\n IMPRESSION: No AV fistula or pseudoaneurysm detected.\n\n" }, { "category": "Radiology", "chartdate": "2101-11-01 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 841619, "text": " 12:28 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: evaluate left foot for evid of fx, arthritis\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with left foot pain, swollen metatarsal\n REASON FOR THIS EXAMINATION:\n evaluate left foot for evid of fx, arthritis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swollen metatarsal and pain.\n\n\n THREE VIEWS LEFT FOOT:\n\n There is metatarsus varus at the first MTP of approximately 50 degrees. No\n fracture is identified. There are extension deformities at the second through\n fifth PIPs with flexion at the second through fifth DIPs. However, this is not\n a standing film. There is no ankle joint effusion. There are no destructive\n lesions.\n\n IMPRESSION: No fracture. No radiographic evidence of osteomyelitis.\n\n" }, { "category": "Radiology", "chartdate": "2101-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841478, "text": " 10:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chf?\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with metastatic breast ca admitted to CCU with groin\n bleed. Now with labored breathing and afib with RVR\n REASON FOR THIS EXAMINATION:\n chf?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with metastatic breast cancer who is admitted\n with groin bleed, now with labored breathing.\n\n COMPARISON: .\n\n FINDINGS: An AP portable upright chest radiograph demonstrates an improved,\n but still persistent, left pleural effusion. There is linear opacity in the\n left base consistent with atelectasis. There is no evidence of failure or\n pneumonia. The heart and mediastinal contours are unchanged. The right\n central venous line has been removed. There is no evidence of a right\n effusion.\n\n IMPRESSION:\n\n Left pleural effusion with adjacent linear atelectasis. No evidence of\n definitive pneumonia or failure.\n\n" }, { "category": "ECG", "chartdate": "2101-10-27 00:00:00.000", "description": "Report", "row_id": 183712, "text": "Atrial fibrillation with rapid ventricular response\nInferior/lateral ST-T changes are nonspecific\n\n" }, { "category": "ECG", "chartdate": "2101-11-01 00:00:00.000", "description": "Report", "row_id": 183706, "text": "Sinus rhythm\nSupraventricular extrasystoles\nLong QTc interval\nSince last ECG, atrial fibrillation is gone\n\n" }, { "category": "ECG", "chartdate": "2101-10-31 00:00:00.000", "description": "Report", "row_id": 183707, "text": "Atrial fibrillation with rapid ventricular response\nInferior/lateral ST-T changes\nSince last ECG, atrial fibrillation is new\n\n" }, { "category": "ECG", "chartdate": "2101-10-29 00:00:00.000", "description": "Report", "row_id": 183708, "text": "Normal sinus rhythm. Compared to the previous tracing of no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-10-28 00:00:00.000", "description": "Report", "row_id": 183709, "text": "Normal sinus rhythm. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of no diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-10-28 00:00:00.000", "description": "Report", "row_id": 183710, "text": "Sinus rhythm\nLateral T wave changes are nonspecific\nSince pervious tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-10-27 00:00:00.000", "description": "Report", "row_id": 183711, "text": "Sinus rhythm\nLateral ST-T changes are nonspecific\nSince previous tracing, atrial fibrillation is gone\n\n" } ]

[ { "category": "Echo", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 70147, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. EV Myocardial infarction.\nStatus: Inpatient\nDate/Time: at 12:31\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 and cavity size are normal.\nOverall left ventricular systolic function is moderately depressed. There is\nmoderate regional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - hypokinetic; mid anterior -\nhypokinetic; mid anteroseptal - hypokinetic; anterior apex - hypokinetic;\nseptal apex - hypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: There is moderate pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Overall left ventricular systolic function is\nmoderately depressed. There is moderate regional left ventricular systolic\ndysfunction. Resting regional wall motion abnormalities include severe\nhypokinesis of the apex, septum and anterior wall. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\nCompared to the echo from , LV function has improved slightly.\n\n\n" }, { "category": "Echo", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 70148, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nAcute pulmonary edema.\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 133/62\nStatus: Inpatient\nDate/Time: at 11:35\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nA catheter is noted in the right side of the heart.\nLEFT ATRIUM: The left 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 severely depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild to moderate\n[+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality. The patient was on a ventilator.\nThe echocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\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 with akinesis of most of the septum,\nanterior wall and apical half of the left ventricle. The basal\ninferoposterolateral wall is normal. Right ventricular systolic function\ncannot be adequately assessed. The aortic leaflets are mildly thickened. No\naortic regurgitation is detected on limited aortic valve Doppler. The mitral\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen.\nThere is moderate pulmonary hypertension.\n\nIMPRESSION: Study c/w an extensive anteroseptal and apical myocardial\ninfarction.\n\n\n" }, { "category": "ECG", "chartdate": "2109-09-15 00:00:00.000", "description": "Report", "row_id": 158270, "text": "Sinus rhythm. Borderline low limb lead voltage. Compared to the previous\ntracing of there are new T wave inversions in leads VI-V4 consistent\nwith an acute anterolateral ischemic process. Rule out infarction. Followup and\nclinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 158271, "text": "Sinus rhythm, rate 69\nNonspecific anterior T abnormalities\nSince last ECG, no significant change\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 158272, "text": "Normal sinus rhythm, rate 71\nPoor R wave progression\nNonspecific anterolateral T abnormalities\nMinimal ST segment elevation, inferior leads\nSince last ECG, no significant change\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 158273, "text": "Normal sinus rhythm, rate 72\nChronic pulmonary disease pattern\nPoor R wave progression\nNonspecific Anterior T waves abnormalities\nCannot exclude ischemia\nLow voltage\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2109-09-01 00:00:00.000", "description": "Report", "row_id": 158274, "text": "Sinus rhythm. Low limb lead voltage. Variation in precordial lead placement\ncompared to the previous tracing of , without diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2109-08-29 00:00:00.000", "description": "Report", "row_id": 158275, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740504, "text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: FEMALE S/P AMI WITH ARF; PLEASE EVALUATE FOR OVERLOAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p leg BPG,\n s/p cath ptca\n REASON FOR THIS EXAMINATION:\n FEMALE S/P AMI WITH ARF; PLEASE EVALUATE FOR OVERLOAD\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n INDICATION: 51 y/o woman post leg bypass graft and AMI with acute renal\n failure.\n\n AP supine view of the chest compared with comparable study from 2 days before.\n ETT is 5.9 cm above the carina. NG tube extends well into the stomach. The\n left subclavian PA catheter tip is in the proximal left pulmonary artery in\n satisfactory position. No pneumothorax. The heart is not enlarged. There is a\n mixed interstitial and alveolar pattern throughout the lung fields slightly\n improved from exam 2 days before. No new superimposed air space process\n demonstrated.\n\n IMPRESSION: Modest improvement in mixed interstitial and alveolar air space\n process consistent with history of acute failure/volume overload. Otherwise\n unchanged exam from 2 days before.\n\n" }, { "category": "Radiology", "chartdate": "2109-08-29 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 740198, "text": " 1:45 PM\n ART EXT (REST ONLY) Clip # \n Reason: LEFT HEEL ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with dm1, lt. heel ulcer\n REASON FOR THIS EXAMINATION:\n ?? pvd\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: Noninvasive lower extremity arterial evaluation demonstrates\n triphasic Doppler tracings overlying the right femoral and popliteal arteries\n with a monophasic Doppler tracing overlying the right posterior tibial and\n right dorsalis pedis arteries. Along the left lower extremity there is a\n triphasic Doppler tracing overlying the left femoral artery and a monophasic\n Doppler tracing overlying the left popliteal, posterior tibial and dorsalis\n pedis arteries. Resting right ankle-brachial index measures 1.69 and the\n resting left ankle-brachial index measures 0.96. Pulse volume recordings are\n remarkable for flat line tracing at the left metatarsal level with amplitude\n measuring 2 mm at the left metatarsal and 10 mm at the right metatarsal.\n\n CONCLUSION:\n 1. Significant right tibial arterial disease.\n 2. Significant left superficial femoral arterial disease with probable\n additional left tibial arterial disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740369, "text": " 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: swan adjustment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p leg BPG, now w/ low UOP, low sats\n s/p cath ptca and stent s/p swan adjustment\n REASON FOR THIS EXAMINATION:\n swan adjustment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check Swan-Ganz catheter.\n\n COMPARISON: at 22:48.\n\n PORTABLE SUPINE CHEST AT 6:20: The endotracheal tube remains in satisfactory\n position. The NG tube extends into the stomach. There is a left subclavian\n Swan Ganz catheter with tip in the main pulmonary artery. Again seen are\n multifocal patchy opacities, bilaterally, not significantly changed since the\n previous examination. No pneumothorax.\n\n IMPRESSION: Swan-Ganz catheter tip in main pulmonary artery. No change in\n multifocal bilateral pulmonary opacities, which may represent diffuse\n pneumonia vs. ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-08-29 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 740189, "text": " 9:03 AM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: ?? foregin body\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with lt. heel ulcer and dm1 w neuropathy\n REASON FOR THIS EXAMINATION:\n ?? foregin body\n ______________________________________________________________________________\n FINAL REPORT\n FOOT 3 VIEWS:\n\n INDICATION: Left heel ulcer with neuropathy, assess for foreign body or\n osteomyelitis.\n\n COMPARISON: No old films available for comparison.\n\n 3 VIEWS OF LEFT FOOT: Bones are diffusely osteopenic. Old healing fracture mid\n shaft 4th metatarsal. Vascular calcification. No definite osteomyelitis or\n erosions are related to the area of ulcer specifically the calcaneus.\n\n CONCLUSION: Osteoporosis. No definite evidence of osteomyelitis or foreign\n body.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740594, "text": " 9:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ett tube placement, ? chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p mi\n REASON FOR THIS EXAMINATION:\n ? ett tube placement\n ? chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MI. Assess ET tube placement. ? CHF.\n\n AP BEDSIDE CHEST: The heart is normal in size with satisfactorily positioned\n ET and NG tubes. SG catheter introduced via left subclavian vein approach has\n tip in main pulmonary artery. There are diffuse increased interstitial\n markings in both lungs, with no focal consolidations. I cannot exclude the\n presence of small effusions layering in semi-erect position. No ptx. Overall\n appearances are unchanged from exam two days previously.\n\n IMPRESSION: No change. Presumed acute CHF/fluid overload without\n cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740320, "text": " 3:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PA cath placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p leg BPG, now w/ low UOP, low sats\n REASON FOR THIS EXAMINATION:\n PA cath placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST: Comparison with the prior study from .\n\n INDICATION: S/P catheter placement.\n\n FINDINGS: A Swan-Ganz catheter has been placed through the left subclavian\n vein, the tip is somewhat distal in the descending right pulmonary artery.\n There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2109-08-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 740188, "text": " 9:03 AM\n CHEST (PA & LAT) Clip # \n Reason: hx cad, preop\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with htn,hypothyroidism,dm1 lt. heel ulcer\n REASON FOR THIS EXAMINATION:\n hx cad, preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op for vascular surgery.\n\n CHEST, TWO VIEWS: The lungs are clear with normal pulmonary vascularity.\n Heart size, mediastinal silhouette and osseous structures are normal.\n\n IMPRESSION:\n No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740361, "text": " 10:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p mi pao2 of 58 low urine output\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p leg BPG, now w/ low UOP, low sats\n s/p cath ptca and stent with pao2 of 58\n REASON FOR THIS EXAMINATION:\n s/p mi pao2 of 58 low urine output\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia.\n\n COMPARISON: at 3:16.\n\n PORTABLE SUPINE CHEST AT 22:48: The ETT is approximately 5.1 cm above the\n carina. There is a left subclavian Swan-Ganz catheter with tip in the\n descending right pulmonary artery. No pneumothorax. There has been marked\n interval development of bilateral multifocal patchy opacities, which are new\n since the previous examination. No pleural effusions are seen. No\n pneumothorax.\n\n IMPRESSION: Left subclavian Swan-Ganz catheter tip in slightly distal\n location in the descending right pulmonary artery. No pneumothorax. Interval\n development of multifocal patchy opacities bilaterally, which may represent\n diffuse pneumonia vs. ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740416, "text": " 6:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 51 yo POD4 s/p fem-distal with postop MI/CHF s/p cath with P\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p leg BPG, now w/ low UOP, low sats\n s/p cath ptca and stent s/p swan adjustment\n REASON FOR THIS EXAMINATION:\n 51 yo POD4 s/p fem-distal with postop MI/CHF s/p cath with PTCA/STENT of LAD\n . Intubated with low grade temps, with rising WBC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low grade fever, rising WBC.\n\n COMPARISON: at 6:25.\n\n PORTABLE SUPINE CHEST AT 6:55: The ETT is 5.1 cm above the carina.\n There is an NGT within the stomach. There is a left subclavian Swan-Ganz\n catheter with tip in the main pulmonary artery. No pneumothorax. The heart\n and mediastinal contours are stable. There are diffuse bilateral air space\n opacities, which are unchanged since the previous exam.\n\n IMPRESSION: No change in diffuse bilateral air space opacities, which may\n reflect diffuse pneumonia vs. ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740732, "text": " 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Re-evaluate progression of CHF...\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p acute mi following fem- bypass currently intubated and\n mobilizing extravascular fluid with good urine output.\n REASON FOR THIS EXAMINATION:\n Re-evaluate progression of CHF...\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Assess for congestive heart failure in patient status\n post myocardial infarction.\n\n An endotracheal tube, nasogastric tube, and central venous catheter remain in\n place, in satisfactory position. Cardiac and mediastinal contours are stable.\n There remains a diffuse bilateral pattern of alveolar opacification involving\n both lungs diffusely. Compared to the recent study of one day earlier, there\n has been minimal improvement, with slightly better aeration in the left lung\n base.\n\n IMPRESSION: Very slight improvement in diffuse bilateral alveolar pattern,\n likely due to diffuse pulmonary edema. Lines and tubes remain in satisfactory\n position.\n\n" }, { "category": "Radiology", "chartdate": "2109-08-30 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 740217, "text": " 3:14 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: Patient is going to need a BPG on her right lower extremity.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with DM, PVD\n REASON FOR THIS EXAMINATION:\n Patient is going to need a BPG on her right lower extremity. We would like to\n know what veins we could use for conduit.\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: Duplex evaluation demonstrates the left greater saphenous vein to\n be patent from the saphenofemoral junction to the ankle level with diameters\n measuring between 0.18 and 0.48 cm. The left lesser saphenous vein is patent\n with diameter measuring between 0.26 and 0.32 cm. The right lesser saphenous\n vein is patent with diameter measuring between 0.20 and 0.26 cm. The right\n greater saphenous vein is patent only to the knee level with diameter\n measuring 0.23 cm at the saphenofemoral junction and 0.15 cm at the knee\n level.\n\n CONCLUSION:\n 1. Patent left greater saphenous, left lesser saphenous, and right lesser\n saphenous veins with diameters as noted in the body of this report.\n 2. Patent right greater saphenous vein from the saphenofemoral junction to\n the knee level with diameter as noted in the body of this report.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740625, "text": " 3:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax s/p ij central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p acute mi and fem- bypass\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax s/p ij central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51 year old woman status post acute MI, central line placement.\n\n Comparison to prior study from at 9:16 AM.\n\n PORTABLE CHEST: A right IJ central line has been placed terminating in the\n SVC. The endotracheal tube is in satisfactory position approximately 6 cm\n above the carina. The pulmonary artery catheter terminates in the right main\n pulmonary artery. The nasogastric tube terminates near the antrum. Heart\n size and mediastinal and hilar contours are stable. Again seen are diffuse\n bilateral air space opacities. There is no pneumothorax.\n\n IMPRESSION:\n 1. Satisfactory position of right IJ line with no pneumothorax.\n 2. Persistent diffuse bilateral air space opacities likely representing CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740652, "text": " 9:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate pulmonary edema progression\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p acute mi and fem- bypass\n REASON FOR THIS EXAMINATION:\n evaluate pulmonary edema progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n Comparison with prior study from .\n\n HISTORY: Evaluate for progression of pulmonary edema.\n\n FINDINGS: Support lines and tubes remain adequately positioned. There has\n been no change in the bilateral pulmonary opacities suggesting no change in\n the patient's cardiopulmonary status. There has been interval removal of the\n Swan-Ganz catheter.\n\n CONCLUSION: 1) Interval removal of Swan-Ganz catheter. 2) No change in the\n extent or degree of pulmonary opacities bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2109-08-29 00:00:00.000", "description": "INTRO AORTA FEM/AXIL", "row_id": 740201, "text": " 2:49 PM\n UNI-LAT FEMORAL Clip # \n Reason: Patient has a left heel ulcer that is not healing.\n Contrast: OPTIRAY Amt: 160\n ********************************* CPT Codes ********************************\n * INTRO AORTA FEM/AXIL ABDOMINAL A-GRAM *\n * EXT UNILAT A-GRAM NON-IONIC 150 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with DM, HTN, CAD, anemia and hypothyroidism who presents\n with left heel ulcer.\n REASON FOR THIS EXAMINATION:\n Patient has a left heel ulcer that is not healing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with diabetes, hypertension, coronary artery\n disease and nonhealing left heel ulcer.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. ; Dr. , the\n staff radiologist, present throughout the entire procedure.\n\n PROCEDURE/TECHNIQUE: Informed written consent was obtained. The patient was\n placed supine on the angiography table. The left groin was prepped and draped\n in the usual sterile fashion. Through an anesthetized skin approach and\n utilizing fluoroscopic guidance a 19 gauge single wall puncture needle was\n inserted into the femoral artery. wire was advanced into the\n abdominal aorta. The needle was then exchanged for a 4 French straight\n multisidehole catheter. An abdominal aortogram was performed. After reviewing\n the images the catheter was pulled back to the distal abdominal aorta and a\n pelvic aortogram was performed. Pressure measurements were then obtained from\n the distal abdominal aorta to the external iliac artery and no significant\n hemodynamic gradient was appreciated. At this time a left lower extremity\n arteriorgram was performed. After reviewing the images the catheter was\n removed and pressure was applied until hemostasis was achieved.\n\n CONTRAST/MEDICATIONS: 150 cc of Optiray contrast. 1 mg of Versed and 50 mcg of\n Fentanyl. These were given in intervals conscious sedation while continuous\n hemodynamic monitoring was being performed. Local anesthetic. This consisted\n of 1% Lidocaine.\n\n FINDINGS\n\n ABDOMINAL AORTOGRAM: The superior mesenteric artery and celiac axis are widely\n patent. Dual right-sided renal arteries are seen. A single left renal artery\n is appreciated. No significant aorta or iliac disease is present. Bilateral\n external iliac arteries are without disease. The left internal iliac artery\n does demonstrate some moderate disease.\n\n LEFT LOWER EXTREMITY ARTERIOGRAM: The common femoral, profunda femoral\n arteries are without significant disease. The superficial femoral artery\n demonstrates moderate disease distally. The popliteal artery occludes at the\n knee joint level. The above-the-knee popliteal is diseased. There is\n (Over)\n\n 2:49 PM\n UNI-LAT FEMORAL Clip # \n Reason: Patient has a left heel ulcer that is not healing.\n Contrast: OPTIRAY Amt: 160\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n reconstitution of a short segment of the balloon in the popliteal anterior\n tibial artery occludes proximally and is reconstituted but is attenuated as it\n procedes distally. The posterior tibial artery is dominant and also is\n occluded proximally. It is contiguous with a good caliber plantar artery. The\n anterior tibial artery occludes at the ankle joint. Noted is hyperemia in the\n region of the nonhealing left foot ulcer.\n\n COMPLICATIONS: None.\n\n IMPRESSION:\n 1) Moderately diseased distal superficial femoral artrery with occlusion of a\n moderately-to-severely diseased popliteal artery at the knee joint. The\n dominant runoff artery is the popliteal artery which is occluded proximally is\n of good caliber after reconstitution and contiguous with a good caliber\n plantar artery. Hyperemia is noted in the region of the nonhealing left foot\n ulcer. The anterior tibial artery is also occluded proximally and is\n attenuated as it procedes distally and the dorsalis pedis artery is occluded.\n the peroneal artery is occluded.\n 2) Dual right-sided renal arterial supply.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 740785, "text": " 1:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVALUATE PULMONARY EDEMA ON THIS INTUBATED PATIENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p acute mi following fem- bypass currently intubated and\n mobilizing extravascular fluid with good urine output.\n REASON FOR THIS EXAMINATION:\n EVALUATE PULMONARY EDEMA ON THIS INTUBATED PATIENT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate pulmonary edema.\n\n There is an endotracheal tube positioned 6 cm above the carina. There is a\n right internal jugular central venous catheter with its tip in the mid SVC.\n There is no pneumothorax. There is an orogastric tube extending below the\n level of the diaphragm, off the film. The cardiac and mediastinal silhouettes\n are stable. There are no pleural effusions. The diffuse alveolar infiltrates\n are slightly improved. Soft-tissue and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1) Slightly improved appearance of bilateral alveolar opacities.\n\n 2) Tubes and lines in appropriate position.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 1446613, "text": "RESPIRATORY CARE: PT. INTUBATED FOR HYPOXEMIC\nRESPIRATORY FAILURE WITH 7.0 ORAL ETT AT 20 LIP.\nINTUBATED WITHOUT INCIDENT. PLACED ON MECHANICAL\nVENTILATION CURRENTLY PS 20/.60/10 PEEP. ABG PENDING.\nSEDATED WITH DILAUDID AND PROPOFOL BY RN.\n\n , RRT\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 1446620, "text": "STATUS\nD: LABILE BP..WHEN HR DROPS <80 SAT'S DROP LOW 90'S\nA: BP DOWN 70/'S CUFF PRESSURE PT'S HIGHER..GIVEN 500CC N/S & 1U PC..DOPA GTT TO 10mcg & STARTED ON LEVO GTT UP TO 4mcg..LASIX GTT DC'D ..CORTISOL LEVEL SENT & GIVEN 100mgm SOLU CORTEF..BP IMPROVED & ABLE TO SLOWLY WEAN OFF LEVO & DOPA DOWN TO 3.4mcg..NO URINE X 3H NOW MIN AMT'S..HO AWARE\nR: IMPROVED HEMODYNAMICS AFTER SOLU CORTEF\nP: ? CVVH IN AM FOR WORSENING RENAL STATUS\n" }, { "category": "Nursing/other", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 1446614, "text": "ADMISSION NOTE / CONDITION UPDATE\nPT TX FROM VICU ~ 7:30 AM SECONDARY TO OLIGURIA, WORSENING RESP STATUS, POOR ABG'S.\n\nA/A: TEMP MAX 100.6\n\nNEURO: PT ARRIVED VERY TIRED, A+OX3, DENIES PAIN IN CHEST OF LLE. ABLE TO MAE. PT CURRENTLY SEDATED ON PROPOFOL GTT, DILAUDID GTT.\n\nCV: PLEASE SEE CAREVIEW FOR ALL VS'S/ HEMODYNAMIC MONITORING. HR 80'S-90'S NSR, ABP 90'S-150'S/60'S. EKG DONE IN AM SHOWING CARDIAC CHANGES, NTG GTT STARTED TO KEEP SBP <150. LOPRESSOR X2 IVP BY DR. TO KEEP HR < 80. CURRENT GOAL IS FOR SBP ~ 120, HR GOAL REMAINS < / ~ 80. PT CURRENTLY OFF NTG GTT. CARDIAC ECHO DONE AT THE BEDSIDE. PT IS RULING IN FOR MI.\n\nRESP: PT ON AND 8L/M NC WITH WORSENING O2 SATS AND ABG'S AS AM PROGRESSED. PLEASE SEE CAREVIEW FOR SPECIFIC ABG NUMBERS. PT WAS SEDATED AND INTUBATED. VENT SETTINGS HAVE BEEN CHANGED, PLEASE SEE CAREVIEW FOR CURRENT SETTINGS. GOAL IS TO WEAN OFF PROPOFOL GTT AND UTILIZE DILAUDID GTT FOR SEDATION WHILE INTUBATED. PT NOW O2 SAT ~ 97%, RESP PATTERN REGULAR, CRACKLES REMAIN BILAT BASES AND LUL.\n\nGI: NPO. IVF @ KVO.\n\nGU: PT HAS 60MG AND 100MG LASIX BOLUS'S WITH U/O 40-100 CC/HR.\n\nENDO: PT CURRENTLY ON INSULIN GTT, FOLLOWING GLUCOSE LEVELS CAREFULLY.\n\nR: LOW GRADE TEMP, VS NOW STABLE, RESP STATUS IMPROVING NOW INTUBATED, U/O REMAINS MARGINAL, RULING IN FOR MI.\n\nP: CONTINUE WITH CURRENT MANAGEMENT, TITRATE NTG, DILAUDID, AND PROPOFOL GTTS WITH GOAL OF WEANING OFF PROPOFOL GTT. TO CATH LAB THIS AFTERNOON. CONTINUE WITH INSULIN GTT TO KEEP GLUCOSE LEVEL < 200.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1446618, "text": "FOCUS-CONDITION UPDATE\nDATA-PT SEDATED THIS AM ON DILAUDID/PROPOFOL GTT-WEANING PROPOFOL GTT,\n PT HAVING OF ATTEMPTING TO SIT UP IN BED. BP LABILE THIS\n AM WITH DROPS TO 80'S, O2 SATS DROPPED TO 88-90% ON 50%/ A/C 12\n AND PEEP 10. PT SUCTIONED FOR SCANT TAN SECRETIONS. MINIMAL U/O\n THIS AM-RECEIVED LASIX 200MG IV AT 08:00. HR IN THE 70'S THIS AM.\n BS >200 THIS AM.\nACTION-PROPOFOL GTT WEANED TO OFF, PT STARTED ON ATIVAN GTT AT 1MG/HR.\n DILAUDID GTT INCREASED TO 2.5MG/HR. LEVOPHED GTT ON FOR SHORT\n PEROID-THEN CHANGED TO DOPAMINE GTT UP TO 6MCG/KG/MIN. ZAROXLYN 5MG\n VIA OGT GIVEN. PT STARTED ON LASIX GTT. DIURIL 400MG IV GIVEN X1.\n MULT VENT CHANGES DONE. PT RESPONDED WELL TO INCREASED TIDAL VOLUME.\n PT RESTARTED ON INSULIN GTT THIS AM.\n 1 UNIT OF PACKED CELLS GIVEN THIS PM.\n SERIAL CK'S SENT.\n FAMILY AT BEDSIDE MOST OF DAY-KEPT UPDATED THRUOUT THE DAY.\nRESPONSE-PT TOLERATING ATIVAN GTT, OPENS EYES WITH STIMULI.\n DOPAMINE TITRATED FOR BP AND TO KEEP HR 80-90. U/O 20-45CC/HR\n AFTER ABOVE DIURETICS. PT CONTINUES WITH OCCAS SPON DROPS IN O2 SATS\nACTION-HEPARIN GTT STARTED THIS PM.\n FIO2 INCREASED TO 60% FOR DROP IN PO2 TO 46.\n DOPAMINE INCREASED TO 6.5MCG/KG/MIN.\n REPEAT CHEMISTRIES SENT\nPLAN-CONTINUE TO MONITOR CLOSELY.\n CHECK PTT AT 22:00.\n WILL CONTINUE TO MONITOR/ASSESS NEED FOR DIALYSIS.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 1446619, "text": "CONDITION UPDATE\nD.7P-7A FOR APPROX 5 HRS PT WAS STABLE WITH HR 80-97,O2 SAT 95-99,SBP 120-140 ON 5.5 MCQ DOPAMINE PER DR. . HUO INCREASED STEADILY DURING THIS TIME AS HIGH AS 100ML ON LASIX 15MG/HR. PT APPEARED COMFORTABLE WITH MINIMAL SPONTANEOUS MOVEMENT. PT WAS ON LESS AMTS OF DILAUDID AND ATIVAN WHICH WAS DECREASED EARLY IN THIS SHIFT DUE TO DROP IN SBP WHICH DID RESPOND TO MENTIONED INTERVENTION. PIP'S ON VENT 35-38 DURING THIS STABLE PERIOD.\n AS OF 0500 O2 SAT FIRST SPONTANEOUSLY DECREASED AND THEN HR DECREASED TO 69. SHORTLY THERAFTER SBP DECREASED TO 100..HUO DECREASED TO 40 AT THIS TIME. PIP'S SL UP TO 40 ,DR. AWARE. PT ALSO APPEARS LIGHTER WITH SPONTANEOUS MOVEMENT..? VAGAL RESPOSE TO RESISTANCE TO VENTILATED BREATHS WITH PIPS SL HIGHER AT THIS TIME. PO2 INCREASE AGAIN TO 60% FROM 50% PER DR. .\n BS TREATED WITH SLIDING SCALE REG INSULIN,CALCIUM REPLACED.\n A. PT WAS STARTED ON DIGOXIN X4 DOSES . MAINTAIN SBP > 100 DR. AWARE THAT CUFF BP SIGNIFICANTLY HIGHER AT TIMES THAN A-LINE. DR. ALSO AWARE MOST DIFFICULT TO OBTAIN GOOD O2 SAT WAVEFORM ON ANY DIGIT AND ON FOREHEAD.\nR.HR DECREASED SPONTANEOUSLY PRIOR TO STARTING DIGOXIN.. PT IS HEMODYNAMICALLY LABILE.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 1446615, "text": "HEMODYNAMIC\nD: PT TO CATH LAB @ 1300..REMAINS ON DILAUDID/INSULIN/PROPOFOL GTT'S\nA: RETURNED FROM CATH LAB @ 1715..REMAINS INTUBATED ON INSULIN/DILAUDID/PROPOFOL GTT'S.. ON ARRIVAL DROPPED BP 70/'S & SAT'S 80'S PLACED ON 100% FIO2 & DOPA STARTED UP TO 5mcg BUT HR UP & CO 3.5 CI 1.8 SVR 1100..DOPA DC'D & LEVO STARTED WITH INCREASE IN CO/CI >2.0 BP BACK UP & LEVO WEANED OFF BY 2100..BS ON ARRIVAL 87 INSULIN GTT DC'D..K+/ICA REPLETED..SUCTIONED FOR MOD AMT FROTHY WHITE..ORAL NG DRAINING BILIOUS..HUO'S GOOD..RT GROIN SHEATH DC'D..SITE CLEAN NO HEMATOMA..BIL DOPP PULSES..LF LEG INCISION OOZING MOD AMT SS..DSD APPLIED..LGE HEMATOMA INNER THIGH..2 JP'S DRAINING MIN SS\nR: STABLE AT PRESENT\nP: WEAN PROPOFOL IN AM ATTEMPT TO EXTUBATE IN AM\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1446616, "text": "Respiratory Care 7P>7A:\n7.0 OET patent/secure. B/S with course crackles throughout>>ETS for red tinged secretions. ABG's were showing persistent hypoxia with fully compensated metabolic acidosis>>Changed to volume ventilation, and this, with a higher mean airway pressure, showed improved ABG's. ABG's now showing improving oxygenation with overcompensated metabolic acidosis>>weaning FIO2 and rate as tolerated. Pt. currently off pressors, remains sedated and synchronous with current level of support. Will continue to wean FIO2 and Peep as oxygenation improves, and wean rate/? change back to spontaneous ventilation as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1446617, "text": "CONDITION UPDATE\nD.11P-6A LOW GRADE TEMP AND NOW AFEBRILE,SR 80'S WHICH DECREASED TO 70 2 HRS AFTER LOPRESSOR DOSE,MAP 90-65.INITIALLY DILAUDID AND PROPOFOL WERE INCREASED WHEN PT MOVING SPONTANEOUSLY IN BED AND SBP ROSE TO 140.AS PROGRESSED PT NOT ACTIVELY MOVING AND SBP DOWN TO 100 REQUIRING PROPOFOL TO BE WEANED DOWN.. SBP RESPONDED TO LESS PROPOFOL.\n PAD REMAINED 22-23 WITH PCWP 16-17 DESPITE MINOR DIURESIS FROM LASIX.CI REMAINS>2.0.\n DR. NOTIFIED OF LOW PO2 AT 2300 AND LOW STV ON C-PAP WITH IPS.MINIMAL SECRETIONS DESPITE LAVAGING.\nA. VENT MODE CHANGED TO A/C WITH 10 PEEP .\nR. FIO2 WEANED DOWN TO 60% BY 0500.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1446621, "text": "STATUS UPDATE\nCV/HEMODYNAMICS\n HYPOTENSIVE EPISODES WITH SBP AS LOW AS 74, LEVO GTTS RESTARTED. DOPAMINE WEANED TO OFF AND MAINTAINED ON LEVO GTTS. DROPPED CO-3.48, CI-1.8, WITH SVR . DOBUTAMINE AND NTG GTTS STARTED WITH GOOD EFFECT. CO-7.56, CI-3.92, SVR 836, THOUGH UNABLE TO KEEP MAP @ GOAL<80. HO NOTIFIED OF PERSISTANT MAP OF 90'S, CONTINUING WEAN DOWN OF DOBUTAMINE AND MAX ADMINISTRATION OF NTG GTTS.\n URINE OUTPUT 15CC/H @ 1900, FLUID CHALLENGE ADMINISTERED. NS 250CC BOLUS X2. CO2 DOWN TO 14, 1LD5W&3AMPS HC03 @ KVO AND BOLUS 250CC X2, CO2 UP TO 18 THIS AM. HUO IMPROVED TO 200CC @ 0600.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1446622, "text": "Respiratory Therapy\npt. continues to be ventilated with 7.0ett 20 lip\nvent settings: AC 700x16 40%O2 7.5peep\nvs: temp 96.8, hr 70, bp 137/69, bs coarse\nplan: continue current settings\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1446623, "text": "FOCUS-CONDITION UPDATE\nDATA-PT SEDATED ON DILAUDID/ATIVAN GTTS. PT AFEBRILE, PT ON NTG GTT\n THIS AM, MAP 72-86. PT ON DOBUTAMINE GTT WITH C.I 3.2 THIS AM.\n PT CONTINUES ON INSULIN GTT-DROP IN BS THIS AFTERNOON <70.\n PT REMAINS VENTED ON 40%/A/C RATE 16/PEEP 10. PT SUCTIONED FOR\n SM AMTS WHITE/TAN SECRETIONS. O2 SATS THIS AM 98-100%.\n URINE OUTPUT THRUOUT THE DAY 300-400CC/HR. HCT 27 THIS AM.\nACTION-PT TRANSFUSED WITH 1 UNIT PACKED CELLS.\n NTG GTT WEANED AS TOL-STARTED ON HYDRALAZINE 10MG IV Q6 HRS.\n DILAUDID GTT WEANED SLOWLY AS TOL. PT STARTED ON D10W AT 50CC/HR\n WITH INSULIN GTT. PEEP DECREASED TO 7.5.\n DOBUTAMINE GTT OFF.\nRESPONSE-C.I 2.1 OFF DOBUTAMINE. SBP 120-140'S/-MIN RESPONSE FROM\n 1ST DOSE OF HYDRALAZINE. BS >100 WITH D10 INFUSING.\n PO2 88 WITH DECREASE IN PEEP. SL AGGITATION NOTED AFTER PT TURNED\n WITH DECREASE IN DILAUDID.\nACTION-ADDITIONAL DOSE OF HYDRALAZINE GIVEN, DOSE INCREASED TO 20MG\n Q6 HRS. PEEP DECREASED TO 5.\nPLAN-CONTINUE TO MONITOR CLOSELY. REPEAT ABG ON DECREASED PEEP.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-08 00:00:00.000", "description": "Report", "row_id": 1446624, "text": "NURSING UPDATE\nCV\n HYDRALAZINE DOSE INCREASED TO 30MG, ADMINISTERED @ 2200. PT RESPONDING VERY WELL TO MED, BP DIMINISHED AND MAINTAINED AROUND GOAL WITH SBP 90-110. ABLE TO WEAN OFF NTG GTTS BY 0100. HYDRALAZINE DOSE FURTHER INCREASED TO 40MG BY HO. HUO 100-500CC. HEPARIN CONTINUED @ 700U/H, AM PTT PENDING.\n\nRESP\n MAINTAINED ON ASSIST CONTROL 700X12, PEEP 5. FIO2 INCREASED FROM 40-50% @ 2300 DUE TO PAO2 66 @ 2200. FOLLOW UP PAO2 121. COUGHING @ TIMES, BS SLIGHTLY COARSE THROUGHOUT, BUT SXN FOR MINIMAL LOOSE WHITE SECRETIONS.\n\nCOMFORT\n CONT SEDATED ON ATIVAN GTTS @ 2MG/H. CALM MOST OF NOC, BRIEF EPISODES OF BREAKTHROUGH AGITATION DURING CARE/REPOSITIONING. DILAUDID GTTS WEANED TO OFF BY 2200 PER ORDER.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-12 00:00:00.000", "description": "Report", "row_id": 1446646, "text": "CCU NPN: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCARDIAC: BP 116-160/60-70'S WITH HR 80'S.\n\nVOLUME STATUS: LASIX DRIP INCREASED TO 10MG/HR TO MEET GOAL OF 300CC/HR. MAINTAINED MOST OF THE TIME LAST HR 220CC. NEGATIVE BY 1210 AT 6:30AM. LYTES SENT AT 6AM\n\nENDOCRINE: INSULIN DRIP AT 2U/HR WITH BS 142-165.\n\nGI: TF'S AT 40CC/HR. RESIDUALS ONLY 10CC AT 12AM AND THEN AT 6AM 120CC. RECEIVING REGLAN Q6. POSITIVE BS NO STOOL. CHECK RESIDUALS.\n\nID: T MAX 100.1 AT 4AM. CONT ON SAME ABX\n\nRESP: NO VENT CHANGES,PLAN TO TRY PSV AGAIN TODAY.SUCTIONED Q4 FOR SMALL AMOUNTS OF THICK YELLOW.\n\nNEURO: MOVING AROUND IN BED,DOES NOT FOLLOW COMMANDS,OCC OPENS EYES BUT DOES NOT TRACK.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-12 00:00:00.000", "description": "Report", "row_id": 1446647, "text": "CCU NSG Progress note\nCV: BP 140-160s through most of day (up to 170s when agitated). HR 70-80s SR. Lopressor increased to 50mg . Hydraline to be decreased. cont on Captopril. K+ 3.5 today - Given 60Meq KCL. Pt needs repeat K+ this evening. Pt cont on Lasix gtt - at 10mg/hr at 8am , gtt decreased to 5mg initially with good u/o (200-400cc/hr) This afternoon u/o dropped to 100cc/hr. Gtt titrated back to 10mg/hr with u/o 300cc/hr at present.\n\nRespiratory: Pt placed on pressure support 25 with RR 20s TV 500-600 O2sat >94%. Remained on pressure support for 2hrs until 1pm when pt noted to be increasinly agitated, attempting to pull at ETT, Pt c/o SOB and fatique. RR up to 36 with TV down to 300s. Pt placed back on AC with TV 650 (lowered from 700 to match pt's own TVs) FIO2 40%.\nPt suctioned mx times for small amt white secretions, Suctioned once for thick yellow plug - sputum sent for c%s.\n\nNeuro: Pt initially Propofol at 20mcg/kg/min. Pt opening eyes with turning/suctioning. No agitation noted. Propofol stopped when pt placed on pressure support. After 20min pt opening eyes spontaneously. Pt recognized her husband, was oriented to person and place and attempted to ask questions. Pt c/o discomfort from ETT (after coughing episode, otherwise nodded yes to ? \"are you comfortable?\" 1pm pt noted to becoming agitated, tachypneic, BP up to 170s. Pt placed back on AC and restarted on propofol at 20mcg. Agitation cont and Propofol titrated up to 30mcg with agitation controlled, BP down to 130s/\n\nGI: Minimal residuals today. TF increased to goal of 60cc/hr. Abdomen soft + BS, no stool today.\n\nID: Tmax 99.4 today. WBC down to 16. Sputum sent for culture\n\nEndo: BS up from 147 to 165 with increased TF. Insulin gtt increased from 2 to 3u/hr.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-09 00:00:00.000", "description": "Report", "row_id": 1446632, "text": "CCU NSG ACCEPTANCE NOTE\n51 Y.O. woman initially admitted to w/ L heel ulcer. Underwent fem- bipass.-> Anterior septal mi w/ ef 25%. Stented LAD. REnal Failure. Intubated. Now improving.\n\nPHX: DMI, HCS,hypothyroid, CAD, anemia, s/p appy, s/p c-section.\n\nALLERGIES: PCN, SULFA\n\nROS:\n\nCARDIAC: hr 70's nsr no vea. Attempting to convert hydralazine to captopril now that renal function has improved. b/p 130's-170's/ .Swan ganz inplace w/ pad 22, cvp 10-13.\n\nRESP: Remains intubated. Attempting to lighten sedation to change over to psv. If tol well will discuss extubation tomorrow.\n\nRENAL: dramatic improvement. bun 45, cr 1.5 today. Urine output >100cc/hr.\n\nGI: has not tolerated higher rates of tf. Today's residuals were 300cc on 30cc/hr. Currently on 10cc/hr w/ aspirates of 300cc one time (was all bile) but only 30cc bile noted later this eve. Seems to be absorbing meds. No stool noted.\n\nSKIN; has incision on L leg w/ serous weeping of proximal area. DSD, change prn. Has JP drain w/ minimal serousanguous dng. WET-DRY on L heel ulcer.\n\nNEURO: initially unresponsive. Lightening sedation. Ativan d/c earlier today. Cut back on propofol w/ lighter response.\nIncreased head movement, but won't respond to commands.\n\nID: afebrile. seratia L heel, xanthomonas L heel. On levo.\n\nFluid/Electrolytes: extravascular overload, diuresis very well now, requires frequent kcl replacement.On insulin gtt to keep glu < 200.\nOn d510 to balance insulin/glu.\n\nOn heparin gtt to maintain ptt 60-100. For ptt in am.\n\nFUll code\n\nAssess: stable. volume overload.\n\nPLAN; for weaning attempt tomorrow, d/c TF @ 4am.\n Plan to d/c swan in am.\n Discuss turning off propofol in am for weaning.\n or prn dsg changes.\n follow lytes.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-10 00:00:00.000", "description": "Report", "row_id": 1446633, "text": "CCU NPN:PLEASE SEE FLOWSHEET F0R OBJECTIVE DATA.\n\nCARDIAC: BP 140-160/60'S HR 80'S SR. CAPTOPRIL HAS BEEN INCREASED WITH NEXT DOSE AT 6AM 75 MG. REMAINS ON HYDRALAZINE 40MG QID.\nHEPARIN AT 1100U,PTT SENT THIS AM\n\nRESP: SUCTIONED X1 THICK WHITE SECRETIONS. TF'S TURNED OFF AT 4AM ANTICIPATING EXTUBATION TODAY. PROPOFOL CURRENTLY AT 15MCG/KG/MIN,TO BE DECREASED .NO VENT CHANGES.\n\nGU: UO ADEQUATE I&O'S EVEN.\n\nGI: HAD BEEN ON TF'S AT 10CC,RESIDUALS STILL GREATER THAN 120CC AT 12AM. CONTINUES ON REGLAN QID.NO STOOL,+ BS.\n\nENDOCRINE:REMAINS ON INSULIN AT 1U/HR AND D10W AT 50CC/HR. FS'S HAD BEEN 195 AND 196. AT 5AM 262,OFF TF'S. TO REPEAT FS AROUND 6AM. DR. NOTIFIED REGARDING INCREASED BLOOD SUGAR.\n\nNEURO: ON PROPOFOL TO BE WEANED OFF.DOES NOT OBEY COMMANDS. IS SQUIRMING AROUND IN THE BED.\n\nSKIN: STAPLE AREA ON UPPER THIGH CHANGED AT 5AM SEROUSANG DRAINAGE. LOWER STAPLES INTACT AND NOT DRAINING,JP DRAIN PUT OUT 50CC.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-15 00:00:00.000", "description": "Report", "row_id": 1446655, "text": "CCU NPN AND TRANSFER NOTE:PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nPLEASE SEE ADMISSION NOTE FROM .\n\nCCU COURSE:\n\nCARDIAC: STABLE HEMODYNAMICS MEDS HAVE BEEN TITRATED. CAPTOPRIL AT 100MG TID,LOPRESSOR 50MG ,ALDACTONE STARTED TODAY AT 25MG PO QD, AND NORVASC INCREASED TODAY TO 10MG PO QD. BP 126-140/60-80 HR 70-80'S.\n\nVOLUME:VOLUME OVERLOAD RESOLVED WITH SEVERAL DAYS OF LASIX DRIP,NEGATIVE BY 3L FOR SEVERAL DAYS. LASIX DRIP D/CED AT MIDNIGHT AND STARTED ON 40MG LASIX PO QD.FOLEY TO BE D/CED.\n\nRESP: AFTER VIGOROUS DIURESES EXTUBATED . NOW O2 SATS MID 90'S ON 3L NP,HAS PROD COUGH.\n\nRENAL/GU: HAD BRIEF ISSUE WITH ATN WHICH HAS RESOLVED.CREAT 1.2 AND BUN 47\n\nGI: STARTED EATING TODAY. +BS.LAST BM \n\nENDOCRINE: INSULIN DRIP D/CED . BLOOD SUGARS HAVE BEEN IN 250-350 RANGE. TODAY STARTED RECEIVING LENTE INSULIN,GIVEN 4U AT 11:30AM.ALSO COVERED BY SLIDING SCALE REG. PT HAS A CHART SHE USES TO MANAGE HER DIABETES.PT TO START TO PARTICIAPTE IN MANAGEMENT OF BLOOD SUGARS.\n\nID: AFEBRILE\n\nNEURO:ALERT AND ORIENTED X3.POST EXTUBATION HAS BEEN VERY EMOTIONAL,ANXIOUS AND DEPRESSED. LONG STANDING ISSUES WITH DEPRESSION ON PROZAC FOR YEARS. PT DOES MUCH BETTER WHEN FAMILY IS PRESENT.\n\nSOCIAL: MARRIED WITH ONE SON(LIVES IN )\n\nACCESS: RIGHT IJ TRIPLE LUMEN.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446642, "text": "CCU nsg progress note\nCV: BP 119-155/ HR 70-90 SR Pt cont on Hydralazine, Captopril. Lopressor increased to 25mg . Pt given Lasix 20mg IVP (placed on QID dosing) Pt responding slower than yesterday - only 500cc duiresed by 2pm. Dose increased to 40mg. K+ 3.3 - given 60meq KCL. Ca 1.1 - given 2amps Cagluconate.\n\nRespiratory: Pt tried on pressure support 20. RR initially 20s with TV 400s but after 15mins RR up to 40s and TV down to 300. Pt placed back on AC 10 TV 700 FIO2 40%. Lung sounds coarse throughout. Suctioned mx times for small amt thick white secretions. O2sats 94-97%\n\nGI: Minimal residuals today. TF advanced to 20cc/hr - tolerating so far. Abdomen soft +BS. No stool.\n\nNeuro: Remains sedated on Propofol. Dose decreased back to 15mcg/kg/min. Pt opening eyes when turned or suctioned, occationally to voice.\n\nEndo: BS 184 this morning. Insulin gtt restarted at 1u/hr but BS up to 222 - gtt increased to 2u/hr with BS 201. gtt increased to 3u/hr with BS 163 at present.\n\nID: Tmax 99.4 on Levo and Vanco. Line culture pending. Aline d/c'd today.\n\nSkin: L heel wound unchanged. Pediatry to be consulted re: debridement. Upper s/l on L leg cont to ooze serosang fluid. Dsg changed x2. JP draining serosanganous fluid - 30cc out this shift.\n\nPlan: Cont to duirese. Attempt Pressure support again tomorrow. Recheck K+ tonight. Follow temps, WBCs. Cont insulin gtt - do not d/c if BS drops - given pt D50.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446643, "text": "Resp.care note:\n Pt failed pressure support trial this am. Pt placed on pressure support 25cmh2o x1 hour. Pt desaturated and resp. rate was in mid-40s. Pt was switched back to AC700/10/40% +5. Plan is to continue to diuresis and try to wean again tomorrow. For further information refer to carevue charting.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-16 00:00:00.000", "description": "Report", "row_id": 1446656, "text": "CCU NPN 1900-0700\nS: \" I just want to go home \"\nO: afeb. pt. having difficulty sleeping again tonight, given ambien 10mg ~ 2200, sleeping for ~ 1 1/2 hours, then anxious, call light every 20-30min. weepy, responding some to TLC. also given xanax .25mg at 0230 and able to sleep on/off rest of night.\n\npt. also noted to have dry cough on and off during night. pt. reports that she had cough on ACE Inhibitors before.\n\n- BP down to 101/40 after captoril. otherwise 120-140/40's.\n- unable to void after trying bedpan x2. foley placed at 2300 with 200cc u/o. 50-75/hr since. HO aware\n- passing gas . no stool.\nFS 254 at , 314 at 2200-> given 6u SC. taking sips of water.\nA: anxiety r/t sleep difficulties, better with ambian and extra xanax.\nP: dangle today or OOB to chair. f/u on ? sensitivity to ACE. ? try foley out again today.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-09 00:00:00.000", "description": "Report", "row_id": 1446630, "text": "RESPIRATORY CARE: PT. REMAINS INTUBATED\nWITH 7.0 ORAL ETT AT 20 LIP. A/C 10/700/.40/5\nWITH STABLE ABG. SX. YELLOW PLUGS EARLIER.\nWILL REMAIN INTUBATED TODAY AND POSSIBLY\nGIVEN A TRIAL OF EXTUBATION TOMORROW AM.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446644, "text": "CCU NPN 3-11Pm\nCV: BP 130-160/50, HR 80-90's NSR. Increased Lopressor to 37.5, cont on Captopril 100mg tid, Hydralazine 20mg. Cont to diurese, given 40mg Lasix at 4PM, started Lasix gtt at 5 mg/hr at 9:30Pm, titrate to goal UO of 200cc/hr. Lytes sent at 22:00. Pt is 1800cc neg today.\n\nResp: remains on AC 40%, 700x10, 5 PEEP, 1-5spon resp. LS course. Suctioned for minimal white secretions.\n\nEndo: remains on Reg ins gtt .5-3U/hr, BS dropped to 68 this eve, given 1/4 amp D50. Last BS 188 , gtt at 3U/hr.(see flowsheet). Has Menses.\n\nNeuro: lighter, reaching for tubes, moving extremities but not following commands. Propofol increase to 20ug.\n\nGI: TF increased to 40cc/hr, residuals 5-20cc. No stool.\n\nID: T 100po, cont on vanco, levoflox.\n\nA/P: remains volume overloaded, continuing to diurese in preparation for extubation. Increasing Lopressor.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-12 00:00:00.000", "description": "Report", "row_id": 1446645, "text": "Respiratory care:\nPatient remians intubated and mechanically vented. Vent checked and alarms functioning. Settings A/C 700 *10 40% 5 peep. 7.0 Ett taped and secured at 20 cm. BS: Coarse. Patient synchronized with vent. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Will attempt ps wean this am.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-09 00:00:00.000", "description": "Report", "row_id": 1446631, "text": "CONDITION UPDATE\nA/A: T MAX 98.6\n\nNEURO: IN AM, PT RESTLESS, NOT FOLLOWING COMMANDS, MAE'S WITH EASE. SLOW WEAN OF ATIVAN WAS IN PROGRESS. PT CLEARLY UNCOMFORTABLE WITH ET TUBE. DR. MADE AWARE, ORDERED PROPOFOL GTT, SLOW WEAN OF ATIVAN. PT NOW ON PROPOFOL, OFF ATIVAN GTT, RESPONDING TO PAINFUL STIMULI OTHERWISE APPEARS COMFORTABLE, SEDATED.\n\nCV: HR 60'S-70'S, NSR PR= .12, QRS= .06, QT=.38. PA PRESSURES 40'S/20'S, LAST #'S @ 4AM: PCWP= 11 CO= 7.39, CI= 3.83, SVR 725, NO REQUESTS FROM TEAM TO REPEAT NUMBERS AT THIS TIME. LLE INCISION WITH SEROUS DRAINAGE, VASCULAR TEAM REMOVED DRESSING AND REQUESTED LOTA. GROIN AREA STILL WEAPING, DSD APPLIED. L HEEL NECROTIC AREA WITH ONE SMALL AREA OPEN, W-D DSG APPLIED. ALL PEDAL PULSES DOPPLERABLE. HEPARIN GTT REMAINS @ 1100 U/HR WITH X2 PTT'S IN THERAPEUTIC RANGE.\n\nRESP: LS SCATTERED RHONCHI, SX FOR SMALL AMOUNTS WHITE/YELLOW SECRETIONS. THRUSH NOTED ON TONGUE, NYSTATIN ORDERED. VENT SETTINGS: AC, PEEP 5, RR 10, FIO2 DECREASED TO 40%, TV'S 700. ABG'S 7.41, 33, 82.\n\nGI: ABDOMEN SOFT, HYPO BS, TUBE FEEDS ORDERED TO BE RESTARTED @ 10CC/HR. OG TUBE SECURED.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE 45-120 CC/HR.\n\nENDO: INSULIN GTT @ 1 U HR WITH LAST GLUCOSE LEVEL 103 @ 1500.\n\nR: AFEBRILE, HEMODYNAMICS STABALIZING, RESP STATUS IMPROVED, RENAL FUNCTION ALSO IMPROVING.\n\nP: CONTINUE WITH CURRENT MONITORING. COMPLETE K+ REPLETION, FOLLOW LABS AND TITRATE HEPARIN GTT AND INSULIN GTT ACCORDINGLY. CONTINUE WITH SEDATION OVERNIGHT, POSSIBLY WEAN IN AM FOR EXTUBATION.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446638, "text": "SYSTEM REVIEW:\nNEURO: INTUBATED, SEDATED WITH PROPOFOL; AROUSABLE, EYE FLUTTERING, SLIGHT MOVEMENT OF HANDS AND ARMS; GRIMACING WITH POSITION CHANGES.\n\nCV/HEMODYNAMICS; IN SR WITHOUT ECTOPY, ON HYDRALAZINE AND CAPTOPRIL; SEE FLOW SHET SECTION FOR CLINICAL INFORMATION.\n\nRESP: VENTED, ON 40%, SET RATE 10 WITH 10- 12 BREATHS TOTAL; SUCTIONED FOR SMALL AMOUNT THICK, WHITE SPUTUM; AM ABG PENDING.\n\nGU: ADDITIONAL 20 MG IV LASIX GIVEN TO PROMOTE CONTINUED DIURESIS;\n\nGI: TUBE FEEDINGS AT 10 CC/HR WITH MINIMAL RESIDUAL; ON REGLAN; SMALL OOZE STOOL.\n\nSKIN/WOUND: LEFT HEAL ULCER DRY WITH ESCHAR; LEFT UPPER THIGH WITH STAPLE SUTURES- DRAINING MODERATE AMOUNT SEROSANGUINOUS DRAINAGE; DRESSING CHANGED; INTACT- DRAINED 35 CC SANGUINOUS MATERIAL; LEFT AND RIGHT DP AND PT PULSES CONFIRMED WITH DOPPLER;\n\nENDOCRINE: BLOOD SUGAR RANGE RISING AGAIN -REQUIRING RESUMPTION OF INSULIN DRIP; CURRENTLY ON 3 UNITS/HR; SEE LAB SECTION FOR SERIAL FINGERSTICKS; AM CHEM 7 PENDING;\nFOR CORTISOL STIMULATION TEST THIS AM; BASELINE CORTISOL LEVEL DRAWN;\n\nPAIN/COMFORT: SEDATED ON PROPOFOL; APPEARS MODERATELY COMFORTABLE;\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446639, "text": "ALTERED ENDOCRINE STATUS R/T HYPERGLYCEMIA\nO: FINGERSTICK GLUCOSE RANGE TRENDING UP OVERNIGHT- REQUIRING RESUMPTION ON INSULIN DRIP; SEE FLOW SHEET SECTION FOR PRECISE VALUES;\nMAXIMUM RATE AT 3 UNITS/HR; AS BLOOD SUGAR RESPONDING, TAPERING OFF; ON TUBE FEEDINGS AT 10 CC/HR- ESSENTIALLY TOLERATING. A: AT TIMES HYPERGLYCEMIC. P: AWAIT AM CHEM 7; TAPER INSULIN DRIP TO OFF IF POSSIBLE; ADVANCE TUBE FEEDINGS IF NO PLANS FOR EXTUBATION THIS AM; CONTINUE FINGER STICK GLUCOSES Q1- Q2; OBSERVE FOR REBOUNDING.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446640, "text": "ALTERED CARDIAC STATUS R/T VOLUME OVERLOAD\nO: AFEBRILE, VS STABLE; IN SR WITHOUT ECTOPY; BP RANGE REFLECTING CAPTOPRIL AND HYDRALAZINE; LASIX FOR DIURESIS; A: NO CARDIAC DECOMPENSATION OVERNIGHT. P: FOR CONTINUED DIURESIS; REPLETE ELECTROLYTES PRN.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-14 00:00:00.000", "description": "Report", "row_id": 1446652, "text": "NPN 7P-7A\nNeuro: Sedated on propofol gtt, decreased propofol a bit, pt became more awake, nodding yes/no appropriately. Somewhat restless and agitated at times, then drifts back off to sleep.\n\nResp: has remained on AC overnight, sats in the high 90's on 40%. Suctioned q 3-4 for sm amt pale yellow thin secretions. LS course.\n\nCV: HR 60-70 on 50mg Lopressor, BP better controlled also at 110'-120's/. Was started on Norvasc last eve. Cont on Lasix gtt at 15mg/hr, was neg over 2L at MN, neg ~750cc so far today.\n\nEndo: BS 89-164 on 1-2U reg ins gtt.\n\nGI: TF FS peptomin increased to goal of 60cc/hr at 8PM, residual 180cc at MN, discarded, cont TF, residual at 4AM, 70cc, refed. Cont on Reglan. When awake denied belly pain. Abd soft, had sm formed stool, and then more liq brown stool, OB(-).\n\nID: afebrile, AB dc'd yest.\n\nSkin: Dry dressing over necrotic heel. Staples intact over leg wound. Open to air.\n\nA: Sats have improved since she has had several days of diuresis, becoming more responsive and appropriate when awakens from propofol.\n\nP: Attempt PS wean again today. Cont to follow BS on ins gtt. follow hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-14 00:00:00.000", "description": "Report", "row_id": 1446653, "text": "CCU NPN: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA\n\nCARDIAC: NO CHANGES IN MEDS TODAY. BP 120-140/60-70 WITH HR 70'S. NO VEA.ONE EPISODE OF CP AROUND 1PM-EKG TAKEN NO CHANGES,GIVEN 1 SL NTG WITH RELIEF\n\nRESP: EXTUBATED AT 11:15AM AND HAS BEEN DOING VERY WELL,FIRST ON CN VIA FACE TENT AND NOW 4LNP WITH SATS IN THE MID TO HIGH 90'S\n\nVOLUME/LYTES: LASIX DRIP DECREASED TO 10MG/HR AND IS CURRENTLY NEGATIVE BY 2500. K THIS AM 3.6 REPLETED WITH 40MEQ IV AND PLACED ON ORDER.REPEAT LYTES SENT AT 6PM\n\nNEURO: OFF PROPOFOL SINCE 9AM. ALERT AND ORIENTED X3. INTERACTING WITH STAFF AND FAMILY.\n\nID: AFEBRILE\n\nGI: TAKING PILLS AND SOME ICE CHIPS AND JELLO.\n\nSKIN: LEFT HEEL BLACK,WET TO DRY APPLIED AND MULTI PODUS BOOT PLACED.STAPLES INTACT,SLIGHT OOZING AT UPPER THIGH.\n\nENDOCRINE: OFF INSULIN DRIP NOW ON SSI, LAST FS AT 6PM-318 GIVEN 6U REG INSULIN SQ.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-15 00:00:00.000", "description": "Report", "row_id": 1446654, "text": "ALT. IN CARDIAC STATUS S/P MI\nNEURO: APPEARS DEPRESSED. ASKING TO SEE PSYCHIATRIST. PT. STATING SHE \"WOULD RATHER BE DEAD, IT WOULD BE ALOT EASIER\" PT. STATES SHE IS AFRAID TO BE ALONE FEARING SHE IS GOING TO HAVE ANOTHER \"HEART ATTACK\". CONTINUALLY REASSURING PT. OF HER CONDITION. SHE HAS DIFFICULTY SLEEPING DESPITE GIVEN SERAX 30 MG ( IN DIVIDED DOSES) AND XANAX 0.25 MG PO. PT. IS VERY FATIGUED. ABLE TO MOVE ARMS AND LEGS AND NEEDS MUCH ENCOURAGEMENT TO START DOING SMALL TASKS FOR HERSELF, IE USING TISSUES, CALL BELL. SHE IS ALERT AND ORIENTED X3.\n\nRESP: LUNGS CLEAR IN UPPER AIRWAYS DIMINISHED AT BASES. O2 4L NC. O2 SATS 98%. ENCOURAGED TO USE INCENTIVE WHEN AWAKE. COUGHING AND RAISING THICK WHITE SPUTUM.\n\nCV: BP STABLE SEE FLOWSHEET FOR OBJECTIVE DATA. C/O 1 EPISODE OF MIDSTERNAL CHEST PAIN RELIEVED WITH 1 SL NTG.\n\nGU: FOLEY TO GRAVITY. DRAINING CLEAR YELLOW URINE. LASIX GTT D/C'D AT 0100. URINE OUTPUT 30-35 CC/HR SINCE LASIX GTT OFF.\n\nGI: + BOWEL SOUNDS TAKING SIPS OF WATER WITHOUT DIFFICULTY. NO BM OVERNIGHT.\n\nENDO: BS COVERED WITH SLIDING SCALE REG. INSULIN. GIVEN 2 UNITS REG INSULIN AT 2230 FOR BS 210. AM SUGAR PENDING.\n\nSKIN: HEEL ULCERATION REMAINS SAME. BLACKENED WOUND. CLEANSED WITH NS AND W-D DSD APPLIED. DOPPLERABLE PULSES. FOOT WARM TO TOUCH. LEFT LEG INCISION LINE C&D, STAPLES INTACT.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446641, "text": "ALTERED RESPIRATORY STATUS\nO: REMAINS VENTED AND SEDATED; FIO2 40%; SET RR 10 WITH 10 - 12 TOTAL BREATHS; SUCTIONED FOR SMALL AMOUNTS WHITE, THICK SPUTUM; AM ABG IMPROVED. A: NO RESPIRATORY DETERIORATION OVERNIGHT. P: FOR CONSERVATIVE WEAN FROM VENT.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-12 00:00:00.000", "description": "Report", "row_id": 1446648, "text": "Respiratory note:\nCurrently pt remains sedated and intubated, mechaniclly ventilated on a/c 650x10, 40%Fio2, 5peep. Pt was weaned off propofol to see her tol on pressure support ventilation, tol psv/peep 25/5 well for 2H with spont vt 450-600, RR 14-21, Spo2 96-98%. At the end of 2H pt start to become agitated and techypenic rr 35 and so propofol started and pt was placed on a/c settings.sx'd fair amt of tan sec. BS coarse.\nPlan to attempt psv wean tomorrow as tol.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-13 00:00:00.000", "description": "Report", "row_id": 1446649, "text": "CCU NPN 1900-0700\nO: TM 100po. tylenol x1, down to 97.7po. continue on levoquin and vanco.\n\nHR 60's-70's SR. AM K+ 3.1 repleted with 40KCL IV. BP 157-137/50-60.\nlasix gtt at 15mg/hr. u/o max 300/hr, with average 160-250/hr u/o. (-) 3.6l for and currently (-) 700cc at 0600.\n- LS course throughout in eve, distinct crackles at bases with course upper in AM. sats 94-96% on settings of .40/650x10/5/5. RR 10-16. suctioned for only small thin secretions. dry oral sec.\n-\ninsulin gtt at .5u/hr initially in eve for FS low 108. then FS climbing to 277 with insulin gtt titrated to 3u/hr. 0600 FS 124-> no change in gtt, however TF increased 30-50cc/hr.\n- high TF residual in eve of 300cc. TF held and restarted at 10cc/hr, gradually increased to 50cc/hr at 0600 per above note. no stool. continues reglan po. abd soft, (+) BS.\n\n-in eve, pt. very awake, eyes open restless, moving about and straining at restaints. not responding to commands or to name but continued restless. propofol increased to 30mcq with good effect.\n\nA: good diuresis on 15mg lasix\n rest on AC overnight\n required increase in insulin gtt.\n restless\nP: follow u/o, diuresis. follow plan for vent wean today. follow Q1-2 FS and titrate insulin gtt as needed. increase TF to goal 60cc/hr as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-13 00:00:00.000", "description": "Report", "row_id": 1446650, "text": "WEANED 2 HR CPAP ,LESS RESTLESS DURING WEAN THAN YESTERDAY BUT BECAME TIRED ,PLACED ON AC. AFTER RETURN TO AC PT ,RESTLESS ,PUTTING LEGS OUTSIDE OF BED TONGUEING AT TUBE,PROPOFOL INCREASED C GOOD EFFECT.\n\nLASIX GTT CONTINUES 15 MG, HUO 200CC OR BETTER. K 4.0 REPLETED C 40 MEQ .\n\nTOL 50 CC TF /HR .D/C WHILE WEANING IN ANTICIPATION OF EXTUBATION BS 77 TO 350 HR. INSULIN GTT INCREASED ACCORDINGLY . DULCOLAX SUPP S RESULTS\n\nVSS STABLE\n\nL LEG INCISION C/D ,MIN SANG DRAIN.L HEEL ULCER BLACK,DRY, MULTIPODIS SPLINT IN PLACE\n\nREST OVERNIGHT, WEAN IN AM\nFOLLOW BS,K\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-13 00:00:00.000", "description": "Report", "row_id": 1446651, "text": "RESP CARE\nPT. DIURESED T/O NOC. THIS MORNING TRIED PSV WEAN. PT. TOLERATED TRIAL FOR ABOUT 3 HRS. PSV LOWERED TO , HOWEVER PT. BECAME TACHYPNIC DRAWING IN VT'S OF 300-400, RR >30 TOWARDS END OF TRIAL. PLACED BACK ON A/C 650X10/5/40% AND SEDATED. WILL FOLLOW\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-08 00:00:00.000", "description": "Report", "row_id": 1446625, "text": "Respiratory care:\nPateint remains intubated and mechanically vented. Vent checked and alarms functioning. Settings A/C tidal volume of 700 Respiratory rate of 12 decreased from 16 as patient was noted on vent check to have a respiratory alkalosis. Fio2 increased to 50% from 40% because of a pao2 of 66. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-10 00:00:00.000", "description": "Report", "row_id": 1446634, "text": "CCU NSG progress note\nCV: BP 140-150/50-60s HR 80s SR Pt started on Lopressor, Captopril increased to 100 TID and Hydralazine decreased to 20mg QID. No change noted in BP, HR now down to 70s. PA 47-49/18-20 CVP 10-12 PCWP 15. Pt CO 7.17. Pt given Lasix 20mg IVP with 1L duiresed. PCWP down to 13, now back to 15 - Pt to receive additional 20mg Lasix. Heparin gtt d/c'd and pt started on Heparin SQ.\n\nRespiratory: Pt tried on PSV 25 but RR up to 30s TV down to 300. ABG 62/38/7.42 O2 sats 94%. Pt placed back on AC 10x700 FIO240%. O2sats 96-98% throughout afternoon. Pt suctioned for small amts thick white secretions.\n\nGI: ABdomen soft BS hypoactive. 200cc residual TF/meds removed from OGT this morning. No aspirates this afternoon. No stool.\n\nGU: BUN 36 Creat 1.1 Foley draining large amt clear yellow urine\n\nID: WBC 19 afebrile today. HO will place new TL Levoquin dose increased due to pt's improved renal status.\n\nNeuro: Pt cont on Propofol for sedation. Pt opening eyes to painful stimuli, withdraws to pain.\n\nEndo: BS 234 on Insulin gtt at 1u/hr and D10 at 50cc/hr. D10 d/c'd with BS 203. Insulin gtt increased to 1.5u/hr with BS 173 at present.\n\nSkin: Staples intact to L leg wound, upper suture line draining small amt serosang fluid, no drainage from low leg. DSD changed x2. w-d dsg to Left heal ulcer\n\nPlan: Increase lopressor as tolerated, cont to diurese. D/C swan after TL placed. Attempt wean to PSV again tomorrow. Restart TF at 10cc/hr - advance as tolerated. TPN tomorrow if residuals remain high.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-08 00:00:00.000", "description": "Report", "row_id": 1446626, "text": "Resp. Care:\n Pt. remains intubated and on vent support: A/C 700 x 12 40% 5P. Sedation being weaned slowly. Pt. occas. biting down on ETT. Please see flow sheet for data. Will wean as pt. becomes more alert.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-08 00:00:00.000", "description": "Report", "row_id": 1446627, "text": "FOCUS-CONDITION UPDATE\nDATA-PT SEDATED ON ATIVAN GTT AT 2MG/HR THIS AM, PT OPENS EYES TO\n TACTILE STIMULI, SL AGGITATED AFTER TURNING. PT AFEBRILE, SBP\n 111-133/, C.I. 2.7. PT ON INSULIN GTT AND D10W GTT THIS AM.\n U/O >100CC/HR. PT ON 50%/A/C RATE 12/PEEP THIS AM-SUCTIONED FRO\n SM AMTS WHITE SECRETIONS, O2 SATS 94-98%.\nACTION-HYDRALZINE DOSE BACK UP TO 40MG IV Q6 HRS.\n PT STARTED ON TF THIS AM-PEPTAMIN AT 10CC/HR. D10W GTT DC'D THIS\n AM PER SERVICE. FIO2 DECREASED TO 40%.\n ATIVAN GTT DECREASED TO 1.5MG/HR.\nRESPONSE-O2 SATS 94-96% WITH DECREASED FIO2.\n BS DROPPED WITH D10W OFF.\n PT TOLERATING TF.\nACTION-INSULIN GTT OFF SHORT WHILE-D10W GTT RESUMED AT 50CC/HR.\n TF INCREASED Q6 HRS AS TOL.\nPLAN-CONTINUE TO MONITOR CLOSELY.\n CHECK LABS THIS PM AS ORDERED.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-09 00:00:00.000", "description": "Report", "row_id": 1446628, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Initial Settings: A/C 700 * 12 40% 5 peep. Fio2 increased to 50% this am as patients sats fell to high 80's. Patient noted to be very agitated at this time. Patients rate was decreased from 12 to 10. BS Coarse. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Patients WBC are climbing. Monitor sats closely. Patient with several episodes of agitation. ? IF patient is ready for weaning.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-09 00:00:00.000", "description": "Report", "row_id": 1446629, "text": "NURSING UPDATE\nCV/HEMODYNAMICS\n AFEBRILE THOUGH WCC BACK UP TO 19,000 THIS AM. HR 70-89 NSR. SBP 110-127, MAPS 63-77. CO/CI CONTINUE TO IMPROVE TO 7.39/3.83 WITH SVR 725 @ 0400. PCWP 10-11.\n PTT @ 2200 50.1, PER PROTOCOL ORDER BY DR , HEPARIN 1800U BOLUS GIVEN @ 0100 AND GTTS RATE INCREASED TO 1100U/H. WILL REPEAT PTT @ 0700.\n K+ 3.3 @ 2200, KCL 60MEQ GIVEN OVER 6H, K+ REMAINED 3.3 @ 0400, DR AWARE. HYDRALAZINE INCREASED TO 50MG QID. HUO 80-120CC.\n INCISION DRAINING MOD AMOUNT OF SEROSANG FLUID, STAPLES INTACT. JP DRAINED 60CC SEROSANG FLUID ALSO. PEDAL PULSES PALPABLE EXCEPT LEFT DP, BUT ALL STRONG ON DOPPLER.\n\nRESPIRATORY\n BREATH SOUNDS CLEAR TO COARSE WITH SATS 94-95% MOST OF NOC ON ASSIST CONTROL, 40% FIO2, 700X10. OVERBREATHING VENT @ RATE 13-17.\n AT 0500 PT DESATURATED TO 89%, BREATH SOUNDS RHONCHOROUS THROUGHOUT, SXN WITH LAVAGE AND AMBU ON 100% FIO2, OBTAINED MOD AMOUNT OF SMALL YELLOW PLUGS. SATS 93-95% SINCE. VENT FIO2 INCREASED TO 50% BY RT. FOLLOW-UP ABG PENDING.\n\nNUTRITION\n TUBE FEED ADMINISTERED @ 30CC/H UNTIL 2200, GASTRIC RESIDUAL AT THAT TIME 350CC BILE STAINED TUBE FEED. OGT RECONNECTED TO LWS, DR AWARE.\n CONT IV D10W @ 50CC/H. INSULIN GTTS TITRATED 2-3U/H ACCORDING TO BLOOD GLUCOSE.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-10 00:00:00.000", "description": "Report", "row_id": 1446635, "text": "resp. care note: pt received intubated with a #7.o ett secured 20cm at the lip, pt also mech. ventilated current settings:ac 700 x 10 peep 5 and fio2 of 40%. pt had two failed wean attempts on psv of 25, and peep of 5, rr immediately increased to a rate in the thirties, and never came down. pt then placed back on current settings and will remain on them for remainder of the night . all is wll at tis time. rrt\n" }, { "category": "Nursing/other", "chartdate": "2109-09-10 00:00:00.000", "description": "Report", "row_id": 1446636, "text": "CCU NPN 3-11PM\nCV: HR 70-80's NSR, no ectopy. BP 140-150/50's on Lopressor12.5 , Captopril 100mg tid. Cont to diurese well to Lasix given earlier. Is 2L neg so far today. Swan and cortis dc'd, swan tip sent for culture.\n\nResp: on AC 700x10, 40% spon rr 0-4. ABG: 84/36/7.46/26/1. LS course throughout, suctioned x2 for scant white secretions.\n\nID: afebrile, on levo, adding Vanco for coverage of leg wound per ID recommendations. Thigh incision draining yellow serous drainage, ABD's changed.\n\nNeuro: sedated on 20ug of propofol. Yawning.\n\nGI: sm smear of stool. Peptomen TF restarted at 10cc/hr. On reglan, residuals only 5cc. (+) BS. Abdomen soft.\n\nSoc: Husband called and updated.\n\nA/P: diuresing well, oxygenation improved from earlier today. Will attempt to lighten and extubate within next couple days after further diuresis.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-11 00:00:00.000", "description": "Report", "row_id": 1446637, "text": "Respiratory Care:\n\nPatient intubated with 7.0 ETT. Vent settings Vt 700, A/C 10, Fio2 40% and peep 5. PAP/Plateau 33/26. Bs slightly coarse bilaterally. Sx'd/lavaged for sm amount of thin white sputum. O2 sats 99%. Pt. sedated with propofol and appears comfortable through the shift. No further changes made. See Carevue for Abg's. Continue with mechanical support.\n" } ]

[ { "category": "Radiology", "chartdate": "2124-05-31 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1022818, "text": " 8:19 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old female with trauma. Evaluate.\n\n COMPARISON: None.\n\n AP BEDSIDE RADIOGRAPH OF THE CHEST: The patient is intubated with the ET tube\n terminating 3.6 cm above the carina. NG tube is extending into the stomach\n and out of the field of view.\n\n Lung volumes are low. There is no pleural effusion or pneumothorax.\n Cardiomediastinal silhouette is slightly widened due to low lung volumes. The\n aortic contour is well defined. There is no pulmonary edema. There are no\n displaced rib fractures.\n\n IMPRESSION: No traumatic injury to the imaged chest. ET tube in standard\n location.\n\n" }, { "category": "Radiology", "chartdate": "2124-05-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1022819, "text": " 8:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? strok, bleed, progression\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with stroke L frontal parietal and ? uncal herniation\n REASON FOR THIS EXAMINATION:\n ? strok, bleed, progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb WED 8:49 PM\n large left cerrebral intraparenchymal hemorrhage with large perihemorrhagic\n edema and signifcant mass effect worse than prior outisde study, there is\n subfalcine, uncal and beginning downward transtentorial herniation with\n effacement of quadrigeminal plate cisterns.\n\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT PERFORMED ON \n\n CLINICAL HISTORY: 74-year-old woman with large left cerebral hemorrhage,\n transferred from outside hospital. Evaluate for interval change.\n\n Comparison is made with outside hospital head CT performed today at 5:47 p.m.\n (three hours ago).\n\n FINDINGS: Non-contrast head CT. A large acute left cerebral intraparenchymal\n hemorrhage is again noted measuring approximately 5.7 x 4.5 cm. This is\n similar to that seen previously; however, there is increased surrounding edema\n which causes effacement of the left lateral ventricle and subfalcine\n herniation of approximately 10 mm. There is diffuse effacement of the left\n cerebral sulci. There is partial (left) effacement of the suprasellar cistern\n and the quadrigeminal cistern which is worrisome for impending downward\n transtentorial herniation. There is no evidence of ventricular obstruction.\n Osseous structures appear grossly intact. Vascular calcifications are noted.\n Sinuses appear essentially clear.\n\n IMPRESSION:\n\n Large left cerebral parenchymal hemorrhage with surrounding edema and\n increasing mass effect causing 1-cm rightward subfalcine herniation and mild\n effacement of the suprasellar and quadrigeminal cisterns on the left worrisome\n for early downward transtentorial herniation.\n\n These findings were discussed with Dr. at approximately 8:35 p.m. on\n .\n SESHa\n\n" }, { "category": "Nursing/other", "chartdate": "2124-06-01 00:00:00.000", "description": "Report", "row_id": 1665432, "text": "Respiratory Care:\n\nPt received from EW, for L ICH bleed. She is orally intubted on full ventilary support, until we placed on spontaneous ventilation, tol so far. BS are clear bil. We are sxtn minimal secretions. Plan: Continue present ICU monitoring. See Careview for further details.\n" }, { "category": "Nursing/other", "chartdate": "2124-06-01 00:00:00.000", "description": "Report", "row_id": 1665433, "text": "Respiratory care\nPt remains intubated no vent changes this shift. Suctioned for small amts of clear secrections. Plan to continue support as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2124-06-01 00:00:00.000", "description": "Report", "row_id": 1665434, "text": "0700-1900\n\nShift Events: Mental status remains unchanged. Pt transfered to neurology service, as no surgical interventions being pursued at this time. Family meeting with Dr. and Dr.. Daughter , -in-law and common law partner present for meeting. Son was listening on family cell phone speaker phone. After meeting, family expressed that this is not the quality of life the patient would want and have asked that patient be extubated and made CMO. Mannitol and head CT D/C'd.\n\nNeuro: PERRL/Brisk/3mm. W/D right side to pain. Lifts and holds on left; attempts to reach for ETT and uses left are purposefully. Intermittently will squeeze left and hand and release on command. Head CT D/C'd and mannitol stopped as family has decided for CMO; orders have not been written. Waiting for Neuro attending. Pt does not appear to be in any pain.\n\nCV: HR 70-80's/NSR/no ectopy. BP 120-140; Labetalol PRN for SBP >160; given once @1600. Has remained hemodynamically stable.\n\nResp: Lungs diminished @ bases. Minimal secretions. PSV 10/5/.4. No tachypnia. SATs 98%\n\nGI/GU: Abd/SNT. +BS. +Flatus. No BM. NGT-LWS; minimal bilious output. Foley patent. UOP 25-50cc/hour.\n\nSkin: Intact\n\nID: Afebrile.\n\nEndo: RISS; no coverage.\n\nSocial: Waiting for Neurology to make CMO. Pt is currently still intubated and ordered as DNR. Family wishes to extubate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-06-01 00:00:00.000", "description": "Report", "row_id": 1665435, "text": "0700-1900\n\nShift events: No improvements in mental status. FFP x1 given for INR 1.6; tolerated transfusion. NGT placed in right nare w/o complication. TF started at 1700 @ 10cc/hour. Mannitol held for elevated Na+/Osm.\nFamily at bedside all day; updated by SICU team and Neuro- attending. No current plans for new CT.\n\nNeuro: PERRL. Opens eyes to stimuli intermittently. Rarely follows commands. Had to re-apply restaints d/t reaching for NGT and foley catheter. MAE. Speech remains garbled and patient is confused.\n\nCV: HR 80-100's/ Afib w/ occ PVC/PAC. Lopressor increased from Q6hour to Q4hour; tolerates well. BP 120-140. Has remained hemodynamically stable.\n\nResp: Lungs diminished @ bases. SAT's 94-98% on 2liters NC. RR 20-30. No secretions.\n\nGI/GU: Abd/SNT w/ hypoactive BS+. TF started; advance to goal per orders. NGT confirmed by CXR. Foley patent; UOP 30-60cc/hour. IVF @ 80cc/hour.\n\nID: TM 100.8; no culture data or anbx.\n\nSkin: Abraision to back of head; no drainage. Otherwise intact.\n\nEndo: RISS; last FSBS 170; covered w/ 4units regular insulin.\n\nSocial: Family at bedside and updated.\n\nPLAN: ICU overnight to monitor neuro status Q1hour. Continue to check Na+ and Osm; tx with mannitol if indicated.\n" }, { "category": "Nursing/other", "chartdate": "2124-06-01 00:00:00.000", "description": "Report", "row_id": 1665431, "text": "SICU A NPN:\nPt. 74 y/o with CAD s/p CABG, hyperlipidemia and L MCA stroke in setting of cardiac cath two weeks ago who is transferred here for large L ICH.\nNEURO: Q1hr neuro checks. No sedation given. Opens eyes to voice and spontaneously, no following of commands. Primary language spanish but apparently understands some English per family. PERL 3mm and brisk. +cough and corneals. Weak gag. Purposeful movement with LUE and LLE. No movement on R side. Weakly withdrawing to pain on L side. Doesn't withdraw on R side. Mannitol 12.5mg q6hrs as ordered. CT shows large ICH into area of prior L MCA infarct. Pt. to receive repeat head CT this am. Discuss with family regarding medical mgmt. vs. crainotomy if she shows evidence of impending uncal herniation.\nCV: Afeb. HR 80s-100s SR/ST, no ectopy noted. Goal SBP <160 and goal map <120. Labetalol prn ordered. Skin warm and dry with palp. pedal pulses bilat.\nRESP: Placed on PS 10 peep 5 FiO2 40% and tolerating well. LS clear and diminished. Minimal secretions.\nGI/GU: Abd. soft with positive bowel sounds. No BM. NGT to LWS with scant drainage. Foley draining clear yellow urine >30cc/hr.\nSKIN: Intact. Three peripheral ivs intact.\nOTHER: Family into visit last pm and updated on pt's condition. Numbers written on board. Daugher is main spokesperson. Pt. has significant other but he doesn't speak english.\n" }, { "category": "ECG", "chartdate": "2124-05-31 00:00:00.000", "description": "Report", "row_id": 222533, "text": "Sinus rhythm\nLeft atrial abnormality\nEarly precordial QRS transition - is nonspecific\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2120-10-08 00:00:00.000", "description": "Report", "row_id": 1552234, "text": "CCU NPN 1900-0700\n\nS/O:\nPT ARRIVED TO CCU AT , A&O X3 FROM IR.\nON ARRIVAL, 2 SHEATHS PLACED RIGHT ARM AV FISTULA, ONE IN ART, AND ONE IN VEIN. CATHETERS PLACED IN BOTH SHEATHS, BOTH INFUSING TPA AT A RATE OF 1MG/HR X'S 2HRS THEN DROPPED TO .5MG/HR AT 2100. SHEATHS PLACED ON HEPARINIZED PRESSURE TUBING TO MAINTAIN PATENTCY.\nRIGHT ARM ON SHORT ARM BOARD, ++OOZE FROM PUNCTURE SITE (?ACCESS ATTEMPT) COVERED W/ PATCH, WRAPPED W/ KERLEX FOR STABILTY OVER ARM BOARD.\nRIGHT IJ DIALYSIS LINE W/ THIRD LUMEN OOZING AROUND SITE, REINFORCED W/ 4X4'S.\nPT BLIND, CONVERSIVE, ORIENTED X3.\n\nCV: HR SR W/ FREQUENTY VENT. BIGEMINY & TRIGEMINY.\nBP 109-138/56-60 LAST EVE, COREG GIVEN PER PARAMETERS. SBP DROPPING TO 90'S THIS AM. SERIAL COAGS AND FIBRINOGEN CHECKED Q 3HRS. VALUES STABLE & WITHIN LIMITS. SEE CARREVUE.\nAM LABS W/ HCT PENDING.\nHD TU/TH/SAT. LAST ON SUNDAY REMOVED 3.4LITERS.\n\nRESP: O2 SAT 100% ON 4LNC. LS CLEAR UPPER, RALES AT BASES. NO SOB.\n\nGI/GU: CLEAR LIQS. DRINKING GINGERALE. HD TODAY ? TIME.\nSKIN: DUODERM INTACT OVER L&R GLUT. SMALL OPEN SORES ON LOWER EXTREMITIES.\nSOCIAL: MOTHER DIED AT 1630 YESTERDAY PM. PT LIVES AT REHAB, WOULD LIKE TO MAKE SERVICES FOR MOTHER ON WEDNESDAY/THURSDAY.\n\nA/P: COAGS & FIBRIN STABLE ON TPA, NO SIGNS OF SEVERE BLEEDING. SHEATHS AND CATHETERS TO AV FISTULA PATENT.\nRETURN TO IR TODAY. HD TODAY. ? PLANS FOR THOMBECTOMY IN OR AS WELL. PT CURRENTLY NOT CONSENTING TO OR.\nDNR/DNI.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-10-08 00:00:00.000", "description": "Report", "row_id": 1552235, "text": "CCU NURSING PROGRESS NOTE: AM'S\nS. \"I NEED SOME GINGERALE - I DON'T CARE IF I MIGHT NEED SURGERY!\"\n\nO. PT IS A 45YO MAN W/DIABETES, MULTIPLE COMPLICATIONS INCLUDING ESRD, BLINDNESS, CAD, PERIPHERAL NEUROPATHY, PVD, ADMITTED TO WITH CLOTTED AV FISTULA/ TRANSFERRED TO CCU AFTER IR PROCEDURE FOR THROMBOSED FISTULA.\nVASCULAR: SHEATHS IN PLACE L ARM A+V FISTULA BOTH A AND V PORTS UNDER PRESSURE WITH HEPARINIZED SALINE AND TPA INFUSING INTO EACH SITE 1MG/HR INITIALLY THEN .5MG/HR CONTINUOUSLY, 1430 PT RETURNED TO IR TO REEVALUATE FISTULA; PULSES + PALPABLE L HAND WARM; PT/PTT/INR/FIBRINOGEN FOLLOWED Q 3HRS - FIBRINOGEN 302-307, PT 14.7-13.9, INR 1.3-1.2, PTT 32.3-30.3 DURING DAY TODAY\n\nCV: HR 80-90'S SR W/FREQUENT PVC'S, VENT BIGEMINY, W/O TREAT PER TEAM ON ROUNDS THIS AM; BP 80-130'S/50-80; CARVEDILOL HELD THIS AM IN ANTICIPATION OF DIALYSIS\n\nRESP: LUNGS BASILAR RALES, SATTING 95-100% ON 4L NC, OS DECREASED BUT THE INCREASED TO 4L AGAIN AS PT C/O SOB W/< 4L O2, RR 18-22\n\nGI: NPO EXCEPT ICE CHIPS, PT FREQUENTLY ASKING FOR GINGERALE, RECEIVED GINGERALE W/AM MEDS AT 0800, THEN 90CC AT 1030 AFTER SPEAKING TO IR ABOUT TIMING OF PROCEDURE IN LATE AFTERNOON, NOTHING BUT ICE CHIPS SINCE 1030; NO STOOL\n\nRENAL: AM BUN/CR 44/4.7 - DIALYZED IN AM FOR 5 LITERS VIA RSC QUINTON CATH, SITE C+D, SLLIGHT OOZE W/SM SKIN TEAR BELOW SITE WHICH IS ALSO OOZING DSD IN PLACE; EPO GIVEN DURING DIALYSIS RUN\n\nENDOCRINE: PT NPO, FINGERSTICKS 70-89 - NO INSULIN COVERAGE PER SS\n\nSKIN: DUODERMS INTACT ON R+L GLUTEAL DECUBITI, LEFT IN PLACE THIS AM, SKIN CARE RN UP TO EVALUATE PT WHO WAS ON WAY TO IR - WILL F/U AT ANOTHER TIME; PT ALSO WITH MULTIPLE SM LESIONS ON EXTREMITIES - OPEN TO AIR, SCROTAL AREA SWOLLEN - ELEVATED\n\nALT COMFORT: PT HAS GENERALIZED NEUROPATHY PAIN IN ALL EXTREMITIES, PT C/O LEG PAIN IN AM - RECEIVED OXYCODOONE 10MG PO AT 0800 - NONE SINCE, C/O PAIN UPON TRANSFER TO IR\n\nSOCIAL: MOTHER PASSED AWAY YESTERDAY, WANTS TO BE D/C'D IN AM TO GET TO SERVICES, FUNERAL ON THURSDAY, PT LIVES AT ; PT CALLED AND SPOKE WITH HIS FATHER THIS AM, OTHERWISE NO VISITORS THIS SHIFT\n\nA. PT IN ICU FOR MONITORING OF FISTULA/TPA INFUSION - PRESENTLY IN IR\nTO ATTEMPT DE-CLOTTING ; TOLERATED DIALYSIS RUN TODAY\n\nP: AWAITING RESULTS OF IR PROCEDURE, ? CALL OUT OF UNIT IF FISTULA IS CLEARED, ? TO OR FOR OPEN THROMBECTOMY IF FISTULA REMAINS CLOTTED; EMOTIONAL SUPPORT, EVALUATE PAIN - PAIN MEDS AS ORDERED,PRN; PLAN TO PREPARE PT FOR DISCHARGE TOMORROW IF POSSIBLE PER PT'S WISHES; PT REMAINS DNR.\n" }, { "category": "Nursing/other", "chartdate": "2120-10-08 00:00:00.000", "description": "Report", "row_id": 1552236, "text": "CCU NURSING ADDENDUM\nPT RETURNED FROM IR AT 1700; RE-LOOK SHOWED BOTH A+V SIDES OF FISTULA PATENT; TPA D/C'D - RETURNED TO CCU - ACT AT 1800 128 - A+V CATHETERS\nD/C'D SITE C+D, PALPABLE PULSES, PT RESUMED DIET - CALLED OUT OF UNIT - NO BEDS AT PRESENT TIME, PT REMAINS DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2120-10-09 00:00:00.000", "description": "Report", "row_id": 1552237, "text": "Nursing Note 7p-7a\nS:\"I want ice cream. You need to feed me\".\nO: See careview for complete data.\nNeuro- A+Ox3, cooperative but very needy. Pt is legally blind. Given PRN oxycodone for general neuropathy pain & ambien for sleep.\nCV- Tele SR w/occ PVCs, rare bigeminy. NBPs 92-115/50s. Gave coreg dose, hold morning dose d/t poss HD tx. L UE warm, radial/ulner pulses by doppler. Serial coags d/c'd.\nResp- LS +rales in bases, cont on 4L nc w/sats 94-99%.\nGI/GU- On renal diet. Obese +bs, no stool. Anuric.\nSkin- 3+ LE edema, duoderms to L/R buttock intact, scrotal area elevated.\nSocial- Several phone calls to family members regarding mothers funeral on thursday.\nA/P: 45yo male DNR/DNI p/w clotted off AV fistula. TPA used to successfully clear both A & V sides. Thrombectomy plans d/c'd, HD prob again today. Call out when bed comes available.\n" }, { "category": "Nursing/other", "chartdate": "2120-10-09 00:00:00.000", "description": "Report", "row_id": 1552238, "text": "CCU Progress Note: (MICU border)\n\ndialysis done today- 1u PRBC's infused without incident- renal access cath D/C'd by IR- dsg D&I- discharge paperwork completed- Pt anxious to return to his rehab facility- vss- taking Po well- no BM today- ambulance to transfer Pt to Rehab @ 1530- see discharge summary & page 2 for more info.\n" }, { "category": "Echo", "chartdate": "2120-10-08 00:00:00.000", "description": "Report", "row_id": 82054, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 72\nWeight (lb): 270\nBSA (m2): 2.42 m2\nBP (mm Hg): 113/53\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Trivial 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: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal. Due\nto suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. Trivial mitral regurgitation is seen. The left ventricular\ninflow pattern suggests impaired relaxation. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2120-10-07 00:00:00.000", "description": "Report", "row_id": 208486, "text": "Sinus rhythm. Low limb lead voltage. Early R wave progression. ST-T wave\nabnormalities. Since the previous tracing of precordial voltage has\ndiminished.\n\n" }, { "category": "ECG", "chartdate": "2120-10-06 00:00:00.000", "description": "Report", "row_id": 208487, "text": "Sinus rhythm\nIndeterminate axis\nInferior ST-T changes are nonspecific\nLow QRS voltages in limb leads\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2120-10-09 00:00:00.000", "description": "TUNNELED CENTRAL W/O PORT", "row_id": 934952, "text": " 10:05 AM\n DIALYSIS REMOVE Clip # \n Reason: please REMOVE HD catheter placed by IR on (line is in R\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * TUNNELED CENTRAL W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with CRF admitted with clotted AV fistula, s/p successful TPA\n clearance, who had temp HD line placed now to go home, needs line removed\n REASON FOR THIS EXAMINATION:\n please REMOVE HD catheter placed by IR on (line is in Rt. Subclavian vein)\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n INDICATION: 45-year-old man who presented with a clotted AV fistula status\n post successful TPA clearance by IR. Has a right subclavian temporary\n hemodialysis line in place which needs to be removed.\n\n RADIOLOGIST: (radiology resident), (radiology\n attending).\n\n TECHNIQUE/FINDINGS: The procedure was done at the bedside in the CCU. The\n patient's temporary hemodialysis catheter was identified. A preprocedure\n timeout was performed. The patient was brought to a 90 degree seated position.\n The dressing covering the entry site was removed. Using standard sterile\n technique, the sutures anchoring the catheter to the skin were cut. The\n catheter was removed in a continuous motion. Pressure over the right\n subclavian venous entry site was held for approximately 20 minutes. Hemostasis\n was achieved. The site was covered with a small sterile dressing and a\n Tegaderm. There were no immediate post-procedure complications. A note was\n left in the chart.\n\n IMPRESSION: Successful removal of a right subclavian temporary hemodialysis\n catheter at the bedside.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-10-06 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 934589, "text": " 7:23 PM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: evaluate liver, vasculature, amount of ascites. If signific\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESRD on HD, DM, ascites\n REASON FOR THIS EXAMINATION:\n evaluate liver, vasculature, amount of ascites. If significant ascites, please\n mark spot for tap\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease with severe diabetes. Ascites.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: Liver is normal in echogenicity with no focal liver\n lesions seen. There is a small right pleural effusion. Small ascites is\n present. There is no intra- or extra-hepatic biliary ductal dilatation. The\n common duct measures 4.5 mm. The gallbladder is surgically removed. Midline\n images were inattainable due to shadowing from overlying bowel gas. Native\n atrophic kidneys are seen bilaterally. The spleen measures 14 mm and is\n enlarged.\n\n LIVER DOPPLER: The hepatic veins are patent with appropriate directionality\n of flow and demonstrated triphasic waveforms. The portal veins are patent\n with hepatopetal flow. The hepatic arteries are also patent.\n\n IMPRESSION:\n 1. Patent hepatic vasculature with appropriate directionality of flow.\n 2. Small ascites. No appropriate spot for tap was identified.\n 3. Small right pleural effusion.\n 4. Atrophic bilateral native kidneys.\n 5. Mild splenomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-10-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934513, "text": " 1:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema, pericardial effusion, pleural effu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with ESRD on HD now with clotted-off HD shunt, hyperkalemia,\n low voltage on ECG.\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema, pericardial effusion, pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old man with end-stage renal disease on hemodialysis, now\n with clotted hemodialysis shunt, hyperkalemia, low voltage on EKG.\n\n CHEST AP: The cardiac silhouette is mildly enlarged. There is an arc-like\n calcification overlying the right and inferior heart borders. The central\n pulmonary arteries appear somewhat dilated. There is a moderate-sized right\n pleural effusion. Associated linear opacities may represent atelectasis. The\n left lung is clear. Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION:\n\n 1. Moderate right pleural effusion.\n\n 2. Rim of calcification overlying the right and inferior heart borders. This\n likely represents pericardial calcification and can be seen in pericarditis.\n Less likely, this could represent ventricular or pleural calcification.\n\n" }, { "category": "Radiology", "chartdate": "2120-10-06 00:00:00.000", "description": "NON-TUNNELED", "row_id": 934532, "text": " 9:10 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place trialysis catheter (extra port for access)\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS MOD SEDATION, FIRST 30 MIN. *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with clot in HD shunt - needs HD catheter placed.\n\n REASON FOR THIS EXAMINATION:\n Please place trialysis catheter (extra port for access)\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE:\n\n 1. 12 French Arrow-, triple-lumen, right internal jugular approach\n temporary hemodialysis catheter; ultrasound-guided venipuncture.\n\n 2. Moderate intravenous sedoanalgesia.\n\n OPERATORS:\n , M.D. (IR fellow).\n , M.D. (supervising IR staff, present and attending throughout\n the course of the procedure).\n\n DIAGNOSIS: AV fistula malfunction. Dialysis access required. Phlebotomy\n access required.\n\n DESCRIPTION OF PROCEDURE: After appropriate timeout and informed consent were\n obtained, the patient was positioned on a special procedures/angiography\n table. The lower right-side of the neck and right upper anterior chest wall\n were prepped and draped in usual sterile fashion. Ultrasound was employed to\n assess the right internal jugular vein for patency. The right internal\n jugular vein was noted to be widely patent and compressible. The skin and\n anticipated subcutaneous needle tract were infiltrated with approximately 5 cc\n of buffered 1% Xylocaine for local anesthesia. Under ultrasound guidance,\n uneventful one-wall, micropuncture venipuncture of the low right internal\n jugular vein was obtained using a left anterolateral approach. (Static\n son images both prior to and after the venipuncture were recorded and\n placed in the patient's record.)\n\n The tract was then serially dilated over a guidewire. Using fluoroscopic\n guidance, a 12 French x 20 cm length Arrow- central venous catheter was\n delivered over a stiff guidewire with final tip position in the right atrium.\n The guidewire was removed. The three lumens of the catheter were flushed,\n heparin locked, and hubbed. The patient tolerated the procedure well without\n immediate complication. The catheter was secured to the skin using 2, 2-0\n silk retention sutures.\n (Over)\n\n 9:10 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place trialysis catheter (extra port for access)\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n A final post-procedural digital spot radiograph demonstrates a moderate-sized\n right pleural effusion. Pericardial calcifications are also evident. No\n pneumothorax line is seen.\n\n All guidewires were removed, inventoried, and accounted for subsequent to the\n procedure.\n\n MEDICATIONS: Moderate intravenous sedoanalgesia was provided by administering\n doses of fentanyl and Versed throughout the total intraservice time of 30\n minutes. During this time, the patient's hemodynamic parameters were\n continuously monitored by the special procedures nurse. Fentanyl was given in\n one dose for a total dosage of 25 mcg IV. Versed was given in a total of one\n dose for 0.5 mg IV.\n\n IMPRESSION:\n\n Successful placement of triple-lumen Arrow-, 12 French x 20 cm central\n venous catheter. Final tip position is the right atrium. The catheter is\n ready to employ.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-10-07 00:00:00.000", "description": "THROMBOCTMY, PERC AVF", "row_id": 934649, "text": " 10:13 AM\n AV FISTULOGRAM SCH Clip # \n Reason: eval/treat\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * THROMBOCTMY, PERC AVF PTA VENOUS *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATHETER INFUSION FOR LYS *\n * -59 DISTINCT PROCEDURAL SERVICE INTRO DIALYSIS FISTULA *\n * -51 MULTI-PROCEDURE SAME DAY INTRO DIALYSIS FISTULA *\n * -59 DISTINCT PROCEDURAL SERVICE ART VENEOUS SHUNT *\n * -59 DISTINCT PROCEDURAL SERVICE PTA VENOUS *\n * TRANSCATHETER INFUSION CATH, TRANSLUM ANGIO NONLASER *\n * CATHETER, THROMBOECTMY/EMBOECTMY CATHETER, THROMBOECTMY/EMBOECTMY *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1887 CATHETER GUIDING INF/PERF C1887 CATHETER GUIDING INF/PERF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with occluded L fistula\n REASON FOR THIS EXAMINATION:\n eval/treat\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: AV fistulography with AngioJet thrombectomy, percutaneous\n transluminal angioplasty, and cross catheter technique TPA thrombolysis\n infusion.\n\n CLINICAL HISTORY: 45-year-old man with occluded left arteriovenous graft.\n\n OPERATORS: , M.D. (supervising staff, present and attending\n throughout the course of the procedure).\n , M.D. (IR fellow).\n , M.D. (radiology resident).\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient.\n Specifically discussed were the indications for the procedure(s) as well as\n the attendant risks, potential complications including, but not limited to\n that of bleeding, infection, embolism, thrombosis, and failure to rescue the\n arteriovenous graft. The patient agreed to have the procedure(s) performed\n and provided verbal consent which was witnessed by the special\n procedures/angiography nurse. The patient was unable to provide written\n consent due to the medical condition.\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition,\n and appropriate informed consent. Once the above were verified, the patient\n was positioned in supine fashion on a special procedures/angiography table.\n The left arm was abducted, prepped and draped from the shoulder to the forearm\n level. The dialysis graft was accessed using both palpable, fluoroscopic,\n and/or songraphic guidance. The graft was initially punctured with a one-wall\n 21- gauge needle at the arterial end of the graft, directed towards the venous\n (Over)\n\n 10:13 AM\n AV FISTULOGRAM SCH Clip # \n Reason: eval/treat\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n end of the graft. A 0.018-inch guidewire was then threaded through the needle\n and advanced through the intraluminal graft thrombus. After the guidewire was\n placed into the graft, a 0.035-inch angled Glidewire was introduced via the 4-\n French sheath of the micropuncture set. A 5-French vascular sheath was then\n placed over the guidewire and secured in place. Subsequently, the venous\n anastomosis was crossed with a 0.035-inch angled Glidewire - 5-French glide\n catheter combination. Similarly, a second puncture was then made in the venous\n end of the graft with a guidewire - 5 Fr vascular sheath directed towards the\n arterial end. Initially, an attempt was made to perform AngioJet thrombectomy\n throughout the thrombosed graft. Several passes were made, with suboptimal\n result. Further attempt was made to macerate the clot using a 6 mm x 3 cm\n angioplasty balloon throughout the course, with unsuccessful result. At this\n stage, a decision was made to pursue thrombolytic therapy. The length of both\n occluded segments were then determined and 2, 5- French - \n catheters selected and placed via the respective 5 Fr sheath accesses with the\n lengths of the sidehole segments corresponding to the length of the occlusions\n respectively. The prograde - infusion catheter was then bolused\n with 3 mg of TPA solution. The retrograde catheter placed was then bolused\n with 2 mg of TPA solution. Subsequently, both catheters were then connected to\n TPA infusion at the rate of 1 mg/hour times two hours and then subsequently\n 0.5 mg/hour overnight. Heparin was infused via the side arm of both sheath at\n the rate of 100 units per hour to maintain patency. Three thousand units\n bolus of heparin was administered intravenously upon initiation of the\n thrombolytic procedure.\n\n MODERATE SEDATION was provided by administering divided doses of 75 mcg of\n Fentanyl and 1 mg of Versed throughout the intraservice time of 3 hours and 15\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n COMPLICATIONS: None immediately.\n\n EBL: Minimal.\n\n IMPRESSION:\n 1. Suboptimal recanalization of AV dialysis graft with attempts at AngioJet\n thrombectomy and percutaneous angioplasty.\n 2. Status post initiation of TPA thrombolysis for recanalization of\n thrombosed arteriovenous graft left upper extremity. A follow-up TPA catheter\n and AV graft check will be performed ensuingly on the next date ()\n 3. Post-procedural orders written.\n\n\n (Over)\n\n 10:13 AM\n AV FISTULOGRAM SCH Clip # \n Reason: eval/treat\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2120-10-08 00:00:00.000", "description": "F/U STATUS INFUSION/EMBO", "row_id": 934861, "text": " 2:35 PM\n TPA CATH CHECK Clip # \n Reason: Please assess success of thrombolysis initiated on .\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: OPTIRAY Amt: 115\n ********************************* CPT Codes ********************************\n * F/U STATUS INFUSION/EMBO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with occluded L AV graft s/p TPA\n\n REASON FOR THIS EXAMINATION:\n Please assess success of thrombolysis initiated on .\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Left upper extremity arteriovenous graft venography via 5 Fr\n retrograde sheath, TPA catheter check, discontinuation of crossed -\n TPA infusion catheters, discontinuation of TPA infusion and heparin\n infusion.\n\n OPERATORS: , M.D. (supervising staff, present and attending\n throughout the course of the procedure).\n , M.D. (IR fellow).\n\n DIAGNOSIS: Arteriovenous graft thrombosis. End-stage renal disease.\n\n DESCRIPTION OF PROCEDURE: After appropriate timeout and informed consent were\n verified, the patient was positioned in supine fashion with the left arm\n abducted, externally rotated and prepped and draped from the axilla to the\n forearm. The more cephalad, i.e., retrograde 5-French vascular sheath was\n accessed via its side arm. Slow hand injection of contrast was performed\n under fluoroscopy which depicts the AV graft to be widely patent.\n Subsequently, serial power injections were made by the same access with\n imaging back to the central circulation. Specifically, no arterial, or venous\n anastomotic strictures observed. No central stenosing or obstructing lesions\n observed. The runoff to the central circulation is widely patent. No\n extravasation of contrast is noted. A power final injection was made with a\n tourniquet applied to the left upper arm to visualize the arterial\n anastamosis, which too is widely patent.\n\n Subsequent to imaging above, both 5-French vascular sheaths were removed.\n Pursestring technique using 2-0 prolene was employed for hemostasis. One hour\n later the pursestring sutures were removed. Both access wounds were dressed\n with Syvel patches and overlying Tegaderm patches. No residula bleeding,\n hematoma, or distal pulse deficit was encountered.\n\n ESTIMATED BLOOD LOSS: Less than 20 cc total.\n\n COMPLICATIONS: None immediately.\n\n IMPRESSION:\n 1. Successful course of the thrombolytic therapy for treatment of left AV\n (Over)\n\n 2:35 PM\n TPA CATH CHECK Clip # \n Reason: Please assess success of thrombolysis initiated on .\n Admitting Diagnosis: HYPERKALEMIA\n Contrast: OPTIRAY Amt: 115\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n graft thrombosis with a residual left AV graft which is widely patent.\n 2. No central stenosing lesions seen.\n 3. No anastomotic or perianastomotic lesion observed.\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2106-03-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 782132, "text": " 1:57 PM\n CHEST (PA & LAT) Clip # \n Reason: 52 yr old male s/p cranial biopsy now with fever please r/o\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with\n REASON FOR THIS EXAMINATION:\n 52 yr old male s/p cranial biopsy now with fever please r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cranium biopsy, now with fever, evaluate for\n pulmonary infiltrates or other causes.\n\n FINDINGS: The heart size is within normal limits. The thoracic aorta is\n moderately widened and slightly elongated but without evidence of calcium\n deposits in the wall. No mediastinal abnormalities are present. The\n pulmonary vasculature is normal. No signs of acute or chronic parenchymal\n infiltrates are found, and the pleural spaces are free. Bony structures\n grossly within normal limits.\n\n There exists a previous chest examination in our records dated , but\n these films are not available for direct comparison. The report did not\n mention abnormalities at that time.\n\n IMPRESSION: No evidence of CHF or acute parenchymal infiltrates.\n\n" }, { "category": "Radiology", "chartdate": "2106-03-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 782062, "text": " 5:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: SUDDEN CONFUSION APHAGIA S/P CRANI FOR BIOPSY OF LESION\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD AT 17:12.\n\n INDICATION: Confusion, aphasia, status post brain biopsy.\n\n TECHNIQUE: Routine noncontrast head CT.\n\n COMPARISON: Multiple CT and MRI studies from .\n\n FINDINGS: There is hemorrhage in the left temporal lobe, which corresponds to\n the previously identified low attenuation structure seen previously. This\n presumably relates to recent brain biopsy in this location. There is some\n surrounding hypodensity in this location. There is no shift of normally\n midline structures. The basal cisterns are not effaced. There is intracranial\n air identified anteriorly on the left, presumably from the brain biopsy. There\n is also air and edema in the subcutaneous tissues overlying the frontotemporal\n region. There is mucosal thickening of the ethmoid air cells as well as the\n sphenoid sinus on the left.\n\n IMPRESSION: Small area of intracranial hemorrhage at the site of the brain\n biopsy. No shift of normally midline structures.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2106-03-09 00:00:00.000", "description": "Report", "row_id": 130508, "text": "Normal sinus rhythm. Within normal limits. Compared to the previous tracing\nof no change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2189-09-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 982834, "text": " 8:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for intracranial pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with agitation, altered mental status at dialysis\n REASON FOR THIS EXAMINATION:\n Evaluate for intracranial pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JVg TUE 10:01 PM\n Negative\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old male agitated with altered mental status at dialysis.\n Evaluate for intracranial pathology.\n\n COMPARISON: head CT.\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, or\n shift of normally midline structures. -white matter differentiation is\n preserved. The ventricles are normal in size and symmetric. There is\n moderate cavernous carotid athersclerotic calcifications. The visualized\n paranasal sinuses and mastoid air cells are clear. There is congenital\n nonfusion of the C1 vertebral body.\n\n IMPRESSION: No evidence of intracranial hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2189-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982906, "text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with endotracheal tube for severe AMS/agitation\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: AMS and agitation with intubation.\n\n Tip of Endotracheal tube is 6 cm above carina and located at the thoracic\n inlet. Lungs are grossly clear. Probable left ventricular enlargement. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-02 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 982908, "text": " 10:20 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunnelled line for HD\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with ESRD without access for HD\n REASON FOR THIS EXAMINATION:\n please place tunnelled line for HD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with end-stage renal disease needing dialysis\n treatment.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. ,\n Dr. , the attending radiologist was present and supervising throughout\n the procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiographic table and the right neck and chest were prepped and\n draped in the standard sterile fashion. A preprocedure timeout was performed.\n Using son guidance, access was gained into the right internal jugular\n vein with a 21-gauge needle and a 0.018 guidewire was advanced through the\n needle up to the level of the distal SVC under fluoroscopic guidance. Hard\n copy ultrasound images were obtained before and after venous access\n documenting vessel patency. The needle was then exchanged for a 4.5 French\n micropuncture sheath. Attention was directed to construction of the tunnel\n that was performed using blunt dissection after 10 mL of 1% lidocaine with\n epinephrine. The double-lumen dialysis catheter was tunneled and the access\n tract into the vein was progressively dilated with 8, 12, and 14 French\n dilators. A 14 French peel-away sheath was then placed and the inner dilator\n and wire were removed. The line was placed into the right atrium and the\n peel-away sheath was removed. The line was secured to the skin with Prolene\n sutures and the neck incision was closed with Dermabond. Dressing was\n applied, both lumens were flushed and heplocked. A final fluoroscopic image\n of the chest demonstrates the tip of the catheter to be located in the right\n atrium. The patient tolerated the procedure well without immediate\n complications.\n\n IMPRESSION: Successful placement of a double lumen 14.5 French tunneled\n hemodialysis catheter. Line is ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-02 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 982947, "text": " 1:43 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: MRI head with DWI imaging to evaluate for any evidence ofpos\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with acute onset of agitation, MS changes and elev BP to 230s.\n r/o PRESS, CVA, HSV encephalitis\n REASON FOR THIS EXAMINATION:\n MRI head with DWI imaging to evaluate for any evidence ofposterior\n leukoencephalopathy, any temporal lobe changes c/w HSV encephalitis, or any\n evidence of stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 52-year-old man with acute onset of agitation and mental status\n changes with hypertension.\n\n COMPARISONS: Limited comparison to a head CT from the prior day.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were\n performed. An MR angiogram of the circle of was also obtained with 3D\n time-of-flight images, including reconstruction of multiplanar maximum\n intensity projection reconstructions.\n\n MRI OF THE BRAIN: Faint foci of hyperintensity in the vertex parietal sulci\n on the FLAIR images show a bilateral symmetric distribution. These may be\n artifactual or could be explained by propofol administration or\n hyperoxygenation. No signal abnormalities are demonstrated within the basal\n cisterns.\n\n There is no mass effect, hydrocephalus, or shift of the normally midline\n structures. A mild extent of scattered punctate foci of T2 hyperintensity in\n the deep, subcortical, and periventricular white matter of the cerebral\n hemispheres is most suggestive of chronic small vessel infarcts. However,\n there is no area of restricted diffusion to suggest a recent infarct. No\n susceptibility artifacts are present.\n\n A small amount of fluid and/or mucosal thickening is present in the sphenoid\n sinus, as well as mucosal thickening in the ethmoid sinuses, an appearance\n that can be seen in intubation. The frontal and maxillary sinuses, as well as\n mastoid air cells are clear, aside from a tiny area of mucosal thickening\n along the medial wall of the left maxillary sinus, likely inflammatory in\n origin.\n\n MR ANGIOGRAM: A 4-mm aneurysm is present along the anterior communicating\n artery without a well-defined neck. The A1 segment of the left anterior\n cerebral artery is small. Blood supply to each anterior cerebral artery\n predominantly stems from the right A1 segment. The right posterior\n communicating artery is either very small or absent. There is no evidence of\n stenosis or arteriovascular malformation.\n\n IMPRESSION:\n (Over)\n\n 1:43 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: MRI head with DWI imaging to evaluate for any evidence ofpos\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Evidence of chronic small vessel infarction in the cerebral white matter,\n but no evidence of recent infarction, encephalitis, or other acute\n intracranial process.\n\n 2. Small anterior communicating artery aneurysm of 4 mm in diameter.\n Neurosurgical evaluation is recommended. The findings were discussed with Dr.\n on .\n\n\n" }, { "category": "Radiology", "chartdate": "2189-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982982, "text": " 5:50 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess OGT placement.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with endotracheal tube for severe AMS/agitation\n\n REASON FOR THIS EXAMINATION:\n assess OGT placement.\n ______________________________________________________________________________\n WET READ: KCLd WED 7:11 PM\n new ogt seen with tip projecting over stomach, most proximal side port\n projects over region of ge junction. . this should be advanced several cm's\n so most proximal side port is within stomach. otherwise no significant change\n from prior. d/w dr. 7:10pm \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube placement.\n\n ET tube is in standard position. NG tube tip is in the stomach with proximal\n side port projecting at the GE junction. Left lower lobe retrocardiac\n atelectasis has improved. Mild cardiomegaly is unchanged. Right IJ catheter\n is in standard position. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2189-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982830, "text": " 8:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with new endotracheal tube for severe AMS/agitation\n REASON FOR THIS EXAMINATION:\n Evaluate tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endotracheal intubation due to altered mental status and agitation.\n\n Comparison is made to prior radiographs dated and .\n\n SUPINE PORTABLE CHEST RADIOGRAPH: The lungs are clear. Cardiomediastinal\n silhouette and hilar contours are within normal limits given portable supine\n technique, and there are unchanged calcifications within the intrathoracic\n aorta. No evidence of pneumothorax, pulmonary edema, or large effusions.\n Endotracheal tube terminates approximately 5.8 cm from the carina and is just\n below the thoracic inlet.\n\n IMPRESSION: No acute cardiopulmonary process. Endotracheal tube terminates\n approximately 5.8 cm from the carina. Consider mild advancement.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-02 00:00:00.000", "description": "Report", "row_id": 1384484, "text": "2300-0230 NPN\nPt. admitted through the ER from HD where he became highly agitated and combative requiring leather restraint and intubation. CT head was neg.\n\nNEURO: Pt. is intubated and sedated. propofol at 40 mcq/kg. wt at 65 kgm. he withdraws to pain all ext. however there notable less movement on left than right. pt. had rhythmic twitch, with rotation of lower ext to core and release with some rigidity briefly. does not follow commands, sternal rub no opening of eyes. pupil on right is surgical, left is pinpoint.\n\nCV: Hypertensive with sbp in 220 on arrival. gave diltiazam 10 mgm then started a gtt titrating to current rate of 15. propofol is currently at 60 mcq. no urine out but renal HD pat. skin dry\n\nRESP: arrived intubated, AC 15, TV 500 p5 100%. no secretions. unsure if ETT is in correctly. 100%\n\nGU/GI: no BT , abd soft foley urine none\n\nENDO: BS wnl\n\nACCESS: 3 PIV with good return\n\nID: Ceft./vanco in er\n\nSOCIAL: no family avail for consent.\n\nPLAN: to or for repair of fistula aneurysm\n" }, { "category": "Nursing/other", "chartdate": "2189-09-02 00:00:00.000", "description": "Report", "row_id": 1384485, "text": "Respiratory Care:\nPatient received from ED with fistula aneurysm on A/C ventilatory support. To OR for repair of aneurysm. Received back from OR and is back on ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-02 00:00:00.000", "description": "Report", "row_id": 1384486, "text": "POST OP note\nPT returnsfrom the OR for recovery in the MICU. ebl 100 cc, right arm drsg serous, distal pulse strong, cms intact, jp to bulb suction for sm serous.\n\nNEURO: unresponsive from anesth, pupils unchanged from preop exam, does not follow commands\n\nCV: sbp 170-180, hr 91, sinus no ectopy\n\npt returns on propofol 40 mcq/kgk/min, received isoformin, fentanyl 250 mgm in or, 400cc crystloid, no urine output.\n\nreport to oncoming rn given. venous access 3 piv, no central line.\n\nPLAN: recover from OR, sed/analgesia/ vent support, ensure cms intact, reeval neuro status once off sed. , follow labs, insert ogt,\n" }, { "category": "Nursing/other", "chartdate": "2189-09-04 00:00:00.000", "description": "Report", "row_id": 1384493, "text": "Nsg.notes 1900-0700hrs\n\nNeuro:alert and oriented x 3.denies any pain.slept well throughout the shift.got up inbetween at midnight ,saying uncomfortable,and agitated ,started on cool neb O2 for sometime and then switched to NC 2lit.called friend and spoke to her and then slept again.\n\nResp:LS clear,sats 98% on NC 2lit.no SOB noted.\n\nCVS:HR 80-90'S ,NSR.No ectopics noted.BP stable 110-140 sys.drain on Rt hand,draining minimally.serosanguinous.\n\nGU/GI:on oral diet,had dinner.no BM this shift.on foey cath,anuric,may be HD today.\n\nSocial:calm and co operative.full code.friend and daughter called early shift and updated.pt spoke to his girl friend midnight.\n\nPlan:may call out to floor today.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-09-04 00:00:00.000", "description": "Report", "row_id": 1384494, "text": "contd..nsg notes\n\nRU dressing changed,small ss drainage notes,all staples intact.c/o pain in penis,may be ?foley cath pulling as pt moving so much,not stay on a position.secured folry cath.slept again.no meds for pain.may need order.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-04 00:00:00.000", "description": "Report", "row_id": 1384495, "text": "MICU 7: RN Note 0700-1900\n\nEvents: Pt advocate; Medical spoke with pt re:surgery\n EEG;\n\nNeuro: AAO; Reports pain of RUE (surgical site). Declines pain med. MAE. OOB to toilet and chair. Bathed self. Becomes animated/angry w/discussion of surgery. Does not accept explanations re: surgery, sedation/intubation (due to extreme agitation). Pt only remembers falling asleep and awakening to \"being held down\".\nEEG done at noon.\n\nCV: SR/ST HR 80s (90-100s w/discussions). BP 170s-200/90-100 even after Lisinopril and . Hydralazine 10mg IVP trial effective with subsequent BP 140s-160/70s. Compression boots on. +DP/PT. #20PIV LFA; #18 PIV LUE. Tunnelled cath RSC for HD; Dssg changed. RUE incision-fistular aneurysm repair.\n\nResp: RR 18-22; Lungs clear, denies SOB/cough, sats 98-100 on RA.\n\nGI: Abd soft, n/t, +BS, +BM.\n\nGU: Anuric. HD . Due .\n\nSocial: FULL CODE. Children supportive. No family contact with RN today. Pt uses phone periodically. Pt advocate involved.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-05 00:00:00.000", "description": "Report", "row_id": 1384496, "text": "PT. REMAINS A CALL OUT TO THE FLOOR. TRANSFER NOTE WRITTEN.\n\nPT. IS A FULL CODE.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O AND HAS BEEN AWAKE ALL SHIFT. PT. FOLLOWS ALL COMMANDS AND DENIES ANY PAIN OR DISCOMFORT DURING THIS SHIFT. PT. IS AFEBRILE. PT. IS IN NSR 70-80'S WITH NO NOTED ECTOPY. B/P CONTINUES TO RANGE 120-170'S/80-114. B/P CUFF REMAINS ON THIGH. PT. HAS BEEN AMBULATING THROUGHOUT THE ROOM ALL NIGHT. PT. STARTED ON HYDRALAZONE 25MG PO TID. LUNG SOUNDS REMAINS CLEAR THROUGHOUT AND PT. IS 100% ON ROOM AIR. PT. HAS ADVANCED TO RENAL DIET AND TOLERATING THIS WELL. NO STOOL THIS SHIFT, BOWEL SOUNDS EASILY AUDIBLE. PT. IS ANURIC. AND RECEIVES HEMODAILYSIS M/W/F. SKIN EXHIBITS DRESSING TO RIGHT UPPER ARM, FROM FISTULA/ANUERSYM REPAIR. DRESSING CHANGED, DUE TO FALLING OFF. STAPLE ALL REMAIN INTACT, AND INCISION REMAINS WELL APPROXIMATED WITH NO DRAINAGE NOTED. ALL LINES REMAIN INTACT, SECURED, AND FUNCTIONING WELL. PLAN IS FOR CALL OUT AND CONTINUE TO MONITOR B/P FOR HTN.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-02 00:00:00.000", "description": "Report", "row_id": 1384487, "text": "Respiratory Therapy\n\nPt remains orally intubated, weaned to PSV after RSBI = 40. Continues on +5PSV/+5PEEP w/ ABGs WNL. SpO2 90s, suctioned for scan clear secretions. Travelled to IR for tunnel cath placement and to MRI for head scan after ? seizure activity during dialysis a couple days ago. Returned to MICU w/out incident. ETT retaped, remains secure/patent. See resp flowsheet for specific vent data.\n\nPlan: maintain support; ?extubate\n" }, { "category": "Nursing/other", "chartdate": "2189-09-02 00:00:00.000", "description": "Report", "row_id": 1384488, "text": "0700-1900\nneuro: sedated on fentanyl/propofol gtt, no response to command, grimacing to painful stimuli, perl\n\ncv: hr nsr, no ectopy, sbp 150-197, goal sbp 160-180, diltiazem gtt dc'd\n\nresp: placed on cpap today from AC, now on 40% cpap 5/ 10 ps, bs+ all lobes, clear, diminished to bases, sux sm loose white sputum, sat 99-100. no resp distress noted\n\ngi: npo, ogt placed this pm, cxr done, waiting for placement, no n/v or stool, iv protonix\n\ngu: foley in, no uo, to IR today for R sc tunnelled dialysis cath, to have hemo tommorrow\n\nother: sisters called & updated on pt'd condition, mri done, result pending, fentanyl gtt dc'd, to tx pain with iv fentanyl, ifv started @ 75/hr\n\nplan: continue with ventilatory support, wean to extubate tomorrow, diltiazem gtt as needed for goal sbp 160-180, hemo tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 1384489, "text": "1900-0700 NPN\nPT is pending extubation this am. decreasing ps to 5 at 0400 and titrating propofol to off.\n\nNEURO: on propofol, will not open eyes except to deep pain stim. does follow commands on all ext. left seems weaker than right.\n\nCV: sinus, diltizem to manage sbp between 160-180 principly off this most of shift. afebrile. no urine out\n\nRESP: on ps10/5 this night, changed to ps 5/5 at 0400. no secretions, mod oral clear secretions. lungs fields clear. sat 100%\n\nGU/GI: foley in no urine, prob dc today , abd soft bt present. right arm site drsg with , 25+ cc from JP. distal pulse on arm good. cms intact\n\nENDO: BS 101, remains npo with IVF this night for planned extubation this am\n\nPAIN: grimace and rises up from bed with body with pain stim . Fentanyl 100 mcq given x 1 with good relief. pt falls asleep easily when undisturbed\n\nACCESS: 3 piv and tunneled HD cath in place wnl\n\nSOCIAL: family here, took valuable envelope and pt clothes home with them. appear supportive and realistic about pt. aggressive behavior. they state pt. does not like hospital. may be aggressive and combative when sedation removed. He has demonstrated this behavior in past.\n\nPLAN: extubate this am. mobilize asap, nutrition consult, HD planned for today. add venodynes this am(done)\n\nPAIN: pain with movement of arm\n" }, { "category": "Nursing/other", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 1384490, "text": "Respiratory Care:\nPt remains intubated and vented. PS decreased to 5 this am, with RSBI = 47. Minimal secretions, sedation weaning. Plan to extubate this am as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 1384491, "text": "MICU 7: RN Note 0700-1900\n\nEvents: HD; Extubation; Drsg ; Post Extubation EEG planned\n\nNeuro/Pain: Received pt sedated w/Propofol. Lightly sedated, pt arousable to voice/gentle tactile. Periodic agitation r/t ET tube and oral secretions. Bolused w/Propofol w/good effect. Followed commands. Hand grasps and foot push/pull strong and equal. Pupils reactive-right pupil s/p cataract surgery. Reports mild pain at incision site RUE (fistula aneurysm)- pain level of acceptable to patient. Pt cooperative, AAO x3 after extubation.\n\nC-V: SR w/o ect; HR 80s; BP 160s-200/70-90s pre HD (goal SBP 160-180), 140s-160s/90s post HD; \u0014Afebrile; IV Diltiazem off since midnight. PO Lisinoprill and started at 1300. Access: #18 LUE patent, #20 LFA patent but difficult to flush, #18 Left foot. No IVF. +DP/PT bilat. +Radial and Ulner bilat. Compression boots on bilat.\n\nInteg: Right arm swollen; elevated on pillow. Circumference unchanged. RUE dssg changed by vascular surgeon. New dry sterile dressing applied at 1400. Small amount of drainage by 5pm. JP intact with very small amount of drainage throughout the day. Circumference of RUE unchanged throughout the day. Upper portion of RUE 35.5cm, Lower portion of RUE 34cm (see landmarks on skin). Area less firm this afternoon than this morning. Skin is otherwise intact with only a small calloused area w/o breakdown at coccyx-Aloevesta applied.\n\n\nResp: CPAP/PS until extubation at 2pm. Lungs course while intubated. LS clear with excellent aeration post extubation. Pt had scant to small amount thin secretions from ET; large to copious oral secrtions.\nRespiratory Therapist extubated patient at ~2:15pm. Placed on 40% cool mist face tent maintaining sats of 99-100%. Pt generally cooperative but removed face tent and maintained sats of 95-97%\n\n\nGI: Abdomen soft, n/t, +BS, No BM. NPO until supper- Renal diet ordered. Pt ordered a tuna fish , jello, juice. Pending.\n\nGU: Foley in place. Anuric. Unable to send urine for tox screen. HD at 0915-1300: 3L taken off. SBP was 180s prior to HD- climbed intitially then dropped as low as 120s. SBP 140s consistently after.\n\nSocial: FULL CODE, Family supportive-notes on board made patient smile when off sedation. No contact with family today.\n\nPlan: ICU tonight; Call-out tomorrow; Renal diet.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-03 00:00:00.000", "description": "Report", "row_id": 1384492, "text": "MICU 7: RN Addendum 0700-1900\n\nPt tolerated tunafish and juice.\nBedpan requested; no BM.\n" }, { "category": "Nursing/other", "chartdate": "2189-09-05 00:00:00.000", "description": "Report", "row_id": 1384497, "text": "NPN 7a-7p\nPlease see carevue and FHP for additional data.\nFUll Code\nNKDA\n\nNeuro: Aox3. Follows commands. Pleasant, cooperative with care. No c/o pain.\nResp: LS CTA. Sats 100% on RA. Occ. dry, non-productive cough.\nCV: NSR 80's. No ectopy noted. Sbp 170-210. Pt received one time dose of 25mg of PO Hydralazine for HTN 210. Cuff on thigh. HD today.\nGI/GU: Abd soft, non-distended, non-tender. +BS. Pt is anuric. Well tolerating renal diet. No stool.\nSkin: Rt. upper arm fistula, aneurysm repair site w/ dsd intact.\nID: afeb. Negative bld. cx.\nA/P: Cont. to monitor BP. On Hydral. Ace, and BB. Surgery following, f/u on when drain can be removed. Cont. providing supportive care.\n" }, { "category": "ECG", "chartdate": "2189-09-02 00:00:00.000", "description": "Report", "row_id": 276159, "text": "Sinus rhythm\nLeft ventricular hypertrophy\nInferior/lateral ST-T changes are probably due to ventricular hypertrophy\nSince previous tracing of , heart rate slower\n\n" }, { "category": "ECG", "chartdate": "2189-09-01 00:00:00.000", "description": "Report", "row_id": 276160, "text": "Sinus tachycardia\nLeft ventricular hypertrophy\nLateral ST changes are probably due to ventricular hypertrophy\nMild QT interval prolonged for rate\nSince previous tracing of , heart rate faster, Q-Tc interval less\n\n" } ]

[ { "category": "Radiology", "chartdate": "2187-11-21 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 770997, "text": " 10:35 AM\n MR CERVICAL SPINE Clip # \n Reason: clear c-spine of ligamentous injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n clear c-spine of ligamentous injury\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Head trauma, ?ligamentous injury.\n\n TECHNIQUE: Sagittal T1, T2 and inversion recovery images were obtained. Axial\n T2-weighted images were obtained from C2 through T1.\n\n FINDINGS: The posterior fossa and spinal cord are normal in intensity. There\n is no significant central canal stenosis or neural foraminal narrowing. On\n the STIR images, there is a subtle area of increased signal in the posterior\n elements at the level of C6, which may suggest ligamentous injury (although\n not of sufficient magnitude to be specific). There are multilevel\n degenerative changes of the cervical spine with anterior osteophyte formation.\n There is a compression deformity of the C6 vertebral body with no abnormal T2\n signal, suggesting a chronic process.\n There is increased T2 signal within the C5-6 disc space. There is significant\n prevertebral soft-tissue swelling with fluid posterior to the anterior\n longitudinal ligament. The ligament is displaced anteriorly.\n\n IMPRESSION:\n\n No malignment of the cervical spine. There is no central canal or neural\n foraminal narrowing.\n\n Extensive prevertebral soft tissue swelling identified which may include\n anterior longitudinal ligament damage. High T2 signal in the C5-6 disc is\n suspicious for disc injury as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-11-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 770998, "text": " 10:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with interval CT eval IPH\n REASON FOR THIS EXAMINATION:\n assess interval change\n CONTRAINDICATIONS for IV CONTRAST:\n head bleed\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT SCAN:\n\n HISTORY: Reevaluation for multiple intracranial hemorrhages.\n\n TECHNIQUE: Noncontrast head CT scan was obtained.\n\n FINDINGS: Comparison with the prior day's study redemonstrates the multiple\n intra-axial hemorrhages without a substantial alteration perceived, other than\n slightly increased thickness of the left frontal subdural hygroma. However,\n this latter collection remains exceedingly thin and exerts negligible mass\n effect upon the adjacent cerebral cortex. No change in ventricular size is\n appreciated. There remains hyperdense material within multiple paranasal\n sinuses, likely indicating hemorrhagic fluid contents.\n\n CONCLUSION: Continued demonstration of many brain hemorrhages as defined\n above.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 770739, "text": " 1:22 PM\n L-SPINE (AP & LAT) Clip # \n Reason: ped struck gcs 3 ro injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n ped struck gcs 3 ro injury\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pedestrian struck by car.\n\n FINDINGS: All five lumbar vertebrae are visualized. Five lumbar vertebrae\n are visualized. The vertebral body heights and disc spaces are preserved.\n There are anterior and a lateral osteophytes seen that are most prominent at\n the T12-L1 level, L2-3 level and the L4 and L5 level. There is normal bony\n alignment. There is facet hypertrophy at the L5-S1 level. There are no\n fractures or subluxations seen. There is contrast seen in the collecting\n system. The SI joints are symmetric.\n\n IMPRESSION: Degenerative changes. No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 770733, "text": " 12:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ped struck by car\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n ped struck by car\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DRS 1:44 PM\n w/ intravent hemorr\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHNIQUE: Non-contrast axial images were obtained from the skull base\n through the vertex.\n\n CT HEAD WITHOUT IV CONTRAST: There are several tiny foci of high attenuation\n within the left frontal lobe and at least two foci within the right frontal\n lobe consistent with axonal injury. There are rounded foci of increased\n attenuation suggestive of acute hemorrhage along the lateral right lateral\n ventricular wall and within the septum pellucidum. Acute hemorrhage is seen\n layering within the occipital of the left lateral ventricle. High\n attenuation material is also noted on series 5, image 5 layering along the\n left portion of the tentorium. The ventricles, basal cisterns and sulci are\n of normal size, without evidence of hydrocephalus or shift of the normally\n midline structures. Extensive high-attenuation material is seen within both\n maxillary sinuses along with opacification of the ethmoid sinuses. There is a\n large hematoma adjacent to the left orbit. Please see accompanying CT of the\n facial bones for full description of the facial bone fractures.\n\n IMPRESSION:\n\n 1) Multiple foci of acute hemorrhage consistent with diffuse axonal injury\n associated with hemorrhage within the occipital of the left lateral\n ventricle.\n\n 2) Please see accompanying CT of the facial bones for a description of facial\n bone fractures.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2 VIEWS", "row_id": 770740, "text": " 1:23 PM\n C-SPINE NON-TRAUMA 2 VIEWS Clip # \n Reason: R/O fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p pedestrian MVA\n REASON FOR THIS EXAMINATION:\n R/O fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is an 80__ year old man struck by car.\n\n FINDINGS: All seven cervical vertebrae are visualized. There is disc space\n narrowing seen at the C3-4, C4-5, C5-6 and C6-7 levels. At these levels there\n is associated anterior and posterior osteophyte formation and anterior\n longitudinal ligament calcification. Bony alignment is within normal limits.\n There is an endotracheal tube present with its tip at the clavicles. The\n prevertebral soft tissues cannot be evaluated. Posterior elements are intact.\n\n IMPRESSION: No fracture. Degenerative changes. However, the study is\n limited by the lack of an odontoid view.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 770782, "text": " 7:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Interval CT eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with interval CT eval L post heme.\n\n REASON FOR THIS EXAMINATION:\n Interval CT eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Follow-up study for intraventricular hemorrhage.\n\n TECHNIQUE: Non-contrast CT scan was obtained.\n\n FINDINGS: Comparison with prior study of , reveals apparent progression\n of multiple foci of hemorrhage, particularly with respect to both frontal\n lobes, as well as the body of the corpus callosum, to the left of midline.\n There is continued demonstration of intraventricular hemorrhage sedimenting in\n both occipital horns. A punctate area of hemorrhage is redemonstrated within\n the dorsal aspect of the pons to the right of midline. There is no\n hydrocephalus or shift of normally midline structures. There is a small\n amount of subarachnoid hemorrhage as well seen within the intrapeduncular\n cistern. There is extensive probable mixture of hemorrhage and mucosal\n thickening within the paranasal sinuses. The patient is intubated, which may\n also account for some of the paranasal sinus abnormalities.\n\n Finally, there is inadvertent lack of coverage of the outer table of the\n posterior aspect of the calvarium, representing a technical error in patient\n positioning.\n\n CONCLUSION: Progression of multiple hemorrhages within the brain, which are\n cosistent with shearing injuries.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771176, "text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: for position of the dopoff\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA\n\n REASON FOR THIS EXAMINATION:\n for position of the dopoff\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Assess feeding tube placement.\n\n A view of the lower thorax and abdomen was submitted for evaluation.\n\n FINDINGS: The Dobbhoff tube enters the stomach body and curls up into the\n fundus. The lower lung fields are exposed and appear unchanged in appearance\n as compared to the prior study dated . The visualized portions of\n the abdomen are unremarkable. Degenerative changes involving the lower\n thoracic and upper lumbar spine are observed.\n\n IMPRESSION: Satisfactory placement of feeding tube.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 770735, "text": " 12:55 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: mvc, unconscious, r/o facial fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n mvc, unconscious, r/o facial fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DRS 3:07 PM\n mult facial frx; see report\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained through\n the facial bones. Coronal reformatted images were performed.\n\n CT MAXILLOFACIAL BONES AND SINUSES: Multiple fractures involving the lateral,\n medial and inferior walls of the left orbit are noted. The right orbit\n appears uninvolved. There is extensive preseptal swelling along the left\n orbit, without evidence of retrobulbar extension. The optic nerves and\n extraocular muscles appear intact. There is near complete opacification of\n the left maxillary sinus associated with fractures through the medial and\n lateral walls. There is an air-fluid level in the right maxillary sinus\n associated with likely lateral wall fractures. The fluid in the maxillary\n sinuses is high attenuation material, conisitent with acute hemorrhage. There\n is near complete opacification of the ethmoid and sphenoid sinuses. A fracture\n through the anterior portion of the nasal bridge is noted. Mild mucosal\n thickening is noted in the frontal sinuses. There is a probable fracture\n through the base of the styloid process extending from the temporal bone.\n\n IMPRESSION: Multiple facial fractures, as described above. No evidence of\n retrobulbar involvement.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 770736, "text": " 12:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: mvc, unconscious, ro injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n mvc, unconscious, ro injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DRS 2:20 PM\n no acute injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis, with IV contrast only.\n\n CT ABDOMEN WITH IV CONTRAST: Atelectasis is noted at the posterior lung\n bases. The liver, gallbladder, pancreas, spleen, adrenal glands and kidneys\n are unremarkable. The visualized loops of bowel are unremarkable. There is\n no free air or ascites. No significant mesenteric or retroperitoneal\n lymphadenopathy.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bladder is unremarkable other than a\n Foley catheter. The rectum is normal. Scattered diverticula are noted along\n the sigmoid colon, without evidence of diverticulitis. There is no free\n pelvic fluid or deep pelvic lymphadenopathy. The prostate appears slightly\n enlarged measuring up to 5.4 cm. A fat-containing right inguinal hernia is\n noted.\n\n Extensive degenerative changes are noted along the lumbar spine.\n\n IMPRESSION: No evidence of acute traumatic injury to the abdomen or pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "CT C-SPINE W/CONTRAST", "row_id": 770737, "text": " 12:56 PM\n CT C-SPINE W/CONTRAST Clip # \n Reason: mvc, head injury, unconscious, ro injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n mvc, head injury, unconscious, ro injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DRS 2:37 PM\n djd, no frx/mal-align\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma and head injury.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n skull base through the thoracic inlet. Both coronal and sagittal reformatted\n images were performed.\n\n CT CERVICAL SPINE WITHOUT IV CONTRAST: The patient is status post intubation.\n No definite prevertebral soft-tissue swelling is noted. Extensive\n degenerative changes including narrowing of the disc spaces at C3-4, C4-5,\n C5-6, C6-7 and C7-T1 are noted in association with large anterior osteophyte\n formation. No malalignment or fracture is detected. The dens and lateral\n masses are unremarkable. There is a single focus of gas density along the\n right lateral transverse process of T1. This may be associated with the\n adjacent joint space. Soft-tissue swelling is seen adjacent to the left\n sterno-clido-mastoid muscle.\n\n IMPRESSION: No evidence of fracture or malalignment. Extensive degenerative\n changes, as described above.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "T-SPINE", "row_id": 770738, "text": " 1:21 PM\n T-SPINE Clip # \n Reason: ped struck, gcs 3, ro injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n ped struck, gcs 3, ro injury\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Struck by car.\n\n FINDINGS: All twelve thoracic vertebrae are visualized. The vertebral body\n heights and disc spaces are preserved. There are diffuse degenerative changes\n seen throughout the thoracic spine. The paraspinal soft-tissue line is within\n normal limits. The posterior elements are intact.\n\n IMPRESSION: Degenerative changes and no fracture.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-19 00:00:00.000", "description": "RP AP WRIST & HAND RIGHT PORT", "row_id": 770785, "text": " 9:11 AM\n AP WRIST & HAND RIGHT PORT; ELBOW (AP, LAT & OBLIQUE) LEFT PORT Clip # \n Reason: Asses for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p MVA\n REASON FOR THIS EXAMINATION:\n Asses for fx\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Trauma.\n\n RIGHT HAND, THREE VIEWS: There is degenerative joint disease, with joint space\n narrowing of the interphalangeal joints. Exam is slightly limited by patient's\n positioning and pulse oximeter artifact. There is no evidence of fracture.\n\n LEFT ELBOW, THREE VIEWS: There is an extremely subtle cortical irregularity of\n the radial head, but no joint effusion. No other evidence of fx is\n identified.\n\n IMPRESSION:\n\n Limited right hand exam, without fracture.\n\n Minimal cortical irregularity of radial head, without joint effusion. Doubt\n fracture, but is sx persist, then repeat short term f/u xray could help to\n assess for a subtle radial head fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 770752, "text": " 5:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ETT pos. Eval L clavicle ( L clavicle deformity)\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA\n REASON FOR THIS EXAMINATION:\n Eval ETT pos. Eval L clavicle ( L clavicle deformity)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma and intubation.\n\n The endotracheal tube is 7 cm above carina. Allowing for technique, size is\n within normal limits. There is tortuosity of the thoracic aorta. The right\n CPA region is not included on the film. No pneumothorax or pulmonary\n consolidation. Probable atelectasis at the left base and blunting of the left\n costophrenic angle.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-18 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 770732, "text": " 12:37 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: ped struck by car\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n ped struck by car\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80__ year old man struck by car.\n\n CHEST X-RAY: There is an endotracheal tube in place with its tip at the level\n of the clavicles. The lung volumes are low. There is crowding of the\n pulmonary vasculature. Cardiac, hilar and mediastinal silhouettes are within\n normal limits. The costophrenic angles are sharp. The visualized bones are\n unremarkable except for mild degenerative changes seen along the thoracic\n spine.\n\n IMPRESSION: Low lung volumes.\n\n PELVIS: Both hips are seated. There are no fractures seen. The joint spaces\n are preserved. There are mild degenerative changes seen. There are no\n unusual lytic or sclerotic lesions.\n\n IMPRESSION: No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-29 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 771705, "text": " 1:05 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: DVT B/L LOWER EXT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n DVT B/L LOWER EXT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73 year old man with history of head trauma. On bed rest.\n\n BILATERAL VENOUS DUPLEX ULTRASOUND STUDY:\n\n FINDINGS: The common femoral, superficial femoral, and popliteal veins were\n imaged bilaterally. There is normal compressibility, augmentation, and\n respiratory variation. No evidence of venous thrombosis.\n\n IMPRESSION: No evidence of venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 770899, "text": " 9:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change for ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with interval CT eval L post heme.\n\n REASON FOR THIS EXAMINATION:\n interval change for ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n\n HISTORY: Evaluate for progression/regression of known intracranial\n hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan was obtained.\n\n FINDINGS: Comparison with prior study of , reveals negligible\n alteration in the extent of multiple hemorrhages which are present both within\n the brain parenchyma, subarachnoid space and ventricular system. There has\n been no change in ventricular size. No shift of normally midline structures\n were observed. The present study observes near complete loss of aeration of\n the left maxillary sinus, with an air fluid level seen within the right\n maxillary antrum. There is prominent opacification of the ethmoid sinuses,\n total opacification of the left sphenoid air cell and mild right sphenoid air\n cell mucosal thickening. The sinus abnormalities likely relate to intubation.\n\n CONCLUSION: No evidence of significant change in appearance of multiple\n intracranial hemorrhages.\n\n COMMENT: There is mild left parietal scalp soft tissue swelling.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772913, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval resolving PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo s/p struck by car SAH, reintubated for sepsis/pneumonia\n\n REASON FOR THIS EXAMINATION:\n eval resolving PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Struck by car, subarachnoid hemorrhage, re-intubated for\n sepsis/pneumonia.\n\n COMPARISONS: AP chest radiograph from .\n\n FINDINGS: Again demonstrated is a left sided subclavian central venous line\n which is unchanged in appearance. The heart size, mediastinal contours, and\n pulmonary vasculature are stable. There are patchy areas of increased opacity\n at the lung bases bilaterally which likely represent aspiration or\n atelectasis. No definite pleural effusions are present. The osseous structures\n are unchanged.\n\n IMPRESSION: Patchy areas of bibasilar aspiration or atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-16 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 773202, "text": " 1:18 PM\n UNILAT UP EXT VEINS US Clip # \n Reason: r/o clot in presence of L arm edema in setting of long stand\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p ped vs. car MVC\n REASON FOR THIS EXAMINATION:\n r/o clot in presence of L arm edema in setting of long standing line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left arm swelling in the setting of longstanding CVL. R/O DVT.\n\n COMPARISONS: None.\n\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND: -scale and Doppler son of\n the left internal jugular, subclavian, axillary, brachial, basilic and\n cephalic veins were performed. There is normal flow, compressibility and\n augmentation. There is a central venous line in the subclavian vein.\n\n IMPRESSION: No evidence of DVT of left upper extremity.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-02 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 771961, "text": " 2:45 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: CTA: r/o PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with trauma and acute respiratory embarassment\n REASON FOR THIS EXAMINATION:\n CTA: r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute respiratory distress status post trauma.\n\n TECHNIQUE: Chest CT was performed according to pulmonary angiogram protocol.\n\n CONTRAST: 100 cc of Optiray was administered due to the rapid rate of bolus\n injection required for this study.\n\n CHEST CT: The heart size is normal. There is one 9 mm left paratracheal\n lymph node. There are several other smaller lymph nodes in the left\n paratracheal region. There is no significant hilar or axillary\n lymphadenopathy. The great vessels are unremarkable. There is no evidence\n for a pulmonary embolism. There is near-complete consolidation of the right\n and left lower lobes. There are patchy air space opacities within the right\n middle lobe posteriorly. The upper lobes are almost completely clear. There\n are no pleural effusions. No pericardial effusion. The osseous structures\n are unremarkable.\n\n IMPRESSION: No evidence of pulmonary embolism. Bilateral lower lobe\n consolidations consistent with pneumonia or aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772723, "text": " 7:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: resolving PNA eval please?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo s/p struck by car SAH, reintubated for sepsis/pneumonia\n\n REASON FOR THIS EXAMINATION:\n resolving PNA eval please?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Subarachnoid hemorrhage following car collision. Re-intubated\n for sepsis or pneumonia. Check for possible resolving pneumonia.\n\n FINDINGS: A single AP semi-upright chest image is provided. Comparison study\n dated . The lungs are slightly less well inflated than before.\n However, there appears to be have been slight resolution of the ill defined\n infiltrates in the right lower lobe and in the left lower lobe inferiorly. No\n new pulmonary infiltrates are detected. No definite pleural effusions are\n identified.\n\n IMPRESSION: Allowing for differences in inspiration, there has been some\n significant resolution of the bibasilar pulmonary infiltrates demonstrated\n previously.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 771960, "text": " 2:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with trauma\n REASON FOR THIS EXAMINATION:\n assess CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess CVA status post trauma.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There has been further evolution of the multiple intraparenchymal\n hemorrhages. The hemorrhages within the right hemisphere are nearly\n imperceptible demonstrating hypodensity on this examination. The large left\n frontal hemorrhage is somewhat less dense on this examination. There is still\n a moderate degree of hypodensity surrounding the area of acute hemorrhage\n consistent with edema. The ventricles are not dilated. There is no shift of\n normally midline structures. The left frontal subdural hygroma is unchanged.\n There are no new parenchymal attenuation abnormalities. There is persistent\n blood within the paranasal sinuses.\n\n IMPRESSION: There has been further evolution of the multiple intracranial\n hemorrhages. No new intracranial hemorrhage is identified. There is no\n hydrocephalus.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2187-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772003, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval the infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo s/p struck by car SAH, reintubated for sepsis/pneumonia\n REASON FOR THIS EXAMINATION:\n eval the infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident with subarachnoid hemorrhage, intubated for\n sepsis/pneumonia.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: ETT remains in satisfactory position. The Swan-Ganz\n catheter has been advanced, the tip now in a right descending intralobar\n artery. Bilateral diffuse air space opacities have improved. The\n cardiomediastinal silhouette is stable.\n\n IMPRESSION: Resolving aspiration/asymmetric edema.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771947, "text": " 12:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p swan\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA acute sat drops/p swan\n\n REASON FOR THIS EXAMINATION:\n s/p swan\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n IMPRESSION: The tip of the left subclavian Swan-Ganz catheter in the right\n main PA. Continued patchy opacities in both lower lobes indicating aspiration\n pneumonia. No pneumothorax.\n\n COMMENT: Portable AP view of the chest is reviewed, and compared with the\n previous study of 10:12 a.m.\n\n The tip of the ETT is identified at thoracic inlet. There is new left\n subclavian Swan-Ganz catheter terminating in the right main PA. No\n pneumothorax is identified.\n\n There is continued patchy opacity in both lower lobes indicating aspiration\n pneumonia.\n\n The heart is normal in size.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772044, "text": " 12:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: DOBOFF PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo s/p struck by car SAH, reintubated for sepsis/pneumonia\n\n REASON FOR THIS EXAMINATION:\n DOBOFF PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident with subarachnoid hemorrhage, re-intubated\n for sepsis/pneumonia. New feeding tube.\n\n PORTABLE AP CHEST RADIOGRAPH 12:26 P.M. is compared with a portable AP\n radiograph of the chest from 7:37 a.m. of the same day. The ETT is withdrawn\n slightly, now with tip 8 cm above the carina. A weighted tip feeding tube has\n been placed with tip just below the junction. The Swan-Ganz catheter remains\n with tip in a right descending interlobar branch. Cardiomediastinal silhouette\n is stable. Bilateral diffuse air space opacities are stable.\n\n IMPRESSION: 1) Feeding tube tip just below GE junction. This should be\n advanced.\n\n 2) ETT withdrawn with tip now 8 cm above the carina.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772091, "text": " 9:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of central line\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo s/p struck by car SAH, reintubated for sepsis/pneumonia\n\n REASON FOR THIS EXAMINATION:\n placement of central line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 73 y/o struck by car with subarachnoid hemorrhage. Patient\n reintubated for sepsis/pneumonia, please evaluate placement of central line.\n\n FINDINGS: Comparison is made to previous films from .\n\n There is an endotracheal tube in good position. There is a left sided\n subclavian catheter in place with its distal tip in the SVC. There is a\n feeding tube in place which passes beneath the diaphragm. THe distal tip of\n this feeding tube is not completely visualized. The heart size, mediastinal\n contours are stable. There is patchy bilateral consolidation at the bases\n which is slightly more prominent on the right. This finding is concerning for\n aspiration versus pneumonia. The costophrenic angles are excluded from this\n study. There is no pneumothorax. The pulmonary vascularity cannot be assessed\n with the patient in a supine position.\n\n IMPRESSION: Patchy consolidation concerning for aspiration or pneumonia\n which is slightly worse on today's study in comparison to .\n\n\n" }, { "category": "Radiology", "chartdate": "2187-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 772505, "text": " 11:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: resolving PNA?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo s/p struck by car SAH, reintubated for sepsis/pneumonia\n\n REASON FOR THIS EXAMINATION:\n resolving PNA?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Struck by car, intubated, evaluate for pneumonia.\n\n There has been some clearing of the right lower lobe infiltrate since the\n previous chest X-ray of . No new infiltrates is seen. A small amount of\n atelectasis at the left base is present.\n\n IMPRESSION: Clearing infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771935, "text": " 9:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA acute sat drop\n\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: MVA.\n\n IMPRESSION: New patchy opacities in both lower lobes, right greater than left\n indicating aspiration pneumonia.\n\n COMMENT: Portable AP radiograph of the chest is reviewed, and compared to the\n patient's study of .\n\n The patient has been extubated and feeding tube has been removed. There are\n new opacities in both lower lobes, right greater than left, which are\n indicating aspiration pneumonia. The heart and mediastinum are within normal\n limits. There is no evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2187-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771939, "text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation film\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA acute sat drop\n\n REASON FOR THIS EXAMINATION:\n post intubation film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P intubation.\n\n IMPRESSION: The tip of the endotracheal tube at the thoracic inlet. No\n pneumothorax. Worsening opacity in both lower lobes probably indicating\n aspiration pneumonia.\n\n COMMENT: Portable AP radiograph of the chest is reviewed and compared with\n the previous study of 9:56 a.m.\n\n The tip of the new endotracheal tube is identified at the thoracic inlet. No\n pneumothorax is seen.\n\n There is increase in patchy opacities in both lower lobes, which most likely\n represents massive aspiration. The heart and mediastinum are within normal\n limits.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771240, "text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVA, pedestrian.\n\n CHEST, SINGLE AP VIEW: An NG tube is present, with tip approximately 6 cm\n above the carina, at the lower level of the clavicles. An NG tube is present,\n radiopaque tip curled in the fundus. There is bibasilar atelectasis with\n minimal blunting of the left costophrenic angle. Upper zone redistribution is\n noted, but may relate to supine technique.\n\n IMPRESSION: NG tube tip curled in fundus. Bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771277, "text": " 5:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLACEMENT OF DOPOFF, SPIKING FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA\n\n REASON FOR THIS EXAMINATION:\n PLACEMENT OF DOPOFF, SPIKING FEVER\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pedestrian MVA status post Dobhoff now spiking fever.\n\n Single AP view of the chest, portable. Centered in low chest for Dobhoff\n placement. The tip of the Dobhoff lies in the region of the GE junction, and\n should be advanced. The lung apices are not included on this film. There is\n left lower lobe collapse and/or consolidation. The remaining visualized\n portions of the lungs are grossly clear.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771704, "text": " 1:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: POSITION OF DOBOFF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA\n\n REASON FOR THIS EXAMINATION:\n POSITION OF DOBOFF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate position of Dobbhoff tube.\n\n Portable AP chest dated is compared to the prior study dated\n .\n\n FINDINGS: In the interval, the patient has been extubated. The Dobbhoff tube\n remains in position just beyond the distal end of the cardia. The cardiac and\n mediastinal contours appear stable. The pulmonary vasculature is\n unremarkable. There is atelectasis involving the retrocardiac portion of the\n left lower lobe. In addition, left apical pleural thickening is seen.\n The lungs otherwise appear grossly clear. The visualized osseous structures\n and soft tissues are unremarkable, with no evidence of fracture.\n\n IMPRESSION: Stable position of Dobbhoff tube just beyond the distal end of\n the cardia.\n\n" }, { "category": "Radiology", "chartdate": "2187-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771397, "text": " 12:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: dopoff placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p pedestrian MVA\n\n REASON FOR THIS EXAMINATION:\n dopoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evalute Dophoff tube placement.\n\n Portable AP chest is compared to the prior image dated .\n\n FINDINGS: The ET tube is positioned approximately 7 cm above the level of the\n carina. In the interval, the feeding tube has been advanced slightly so that\n it now terminates at the gastric fundus. The cardiac and mediastinal contours\n appear stable. The pulmonary vascularity is within normal limits. There is\n persistent left lower lobe atelectasis, not significantly changed in the\n interval. The lungs otherwise appear clear, with no acute infiltrates. There\n are no pleural effusions. The visualized osseous structures and soft tissues\n are unremarkable.\n\n IMPRESSION: Slight advancement of the Dophoff tube past the level of the GE\n junction, so that it now terminates in the gastric fundus.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-11-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 771488, "text": " 10:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change s/p ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with interval CT eval IPH\n\n REASON FOR THIS EXAMINATION:\n interval change s/p ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma with significant intracranial pathology follow up.\n\n NON-CONTRAST HEAD CT\n\n FINDINGS:\n\n There is no appreciable change in the size of the ventricles. There is\n evolution of the multiple intracranial hemorrhages. The left frontal subdural\n hydroma is unchanged. There are no new parenchymal attenuation\n abnormalities.\n\n There is persistent blood within the paranasal sinuses.\n\n IMPRESSION: Stable appearnce of the brain and ventricles.\n\n\n\n" }, { "category": "ECG", "chartdate": "2187-12-02 00:00:00.000", "description": "Report", "row_id": 171007, "text": "Sinus tachycardia\nDiffuse ST-T abnormalities - cannot exclude ischemia - clinical correlation is\nsuggested\nP-R interval 0.16\nSince previous tracing of : ST-T wave abnormalities present\n\n" }, { "category": "ECG", "chartdate": "2187-11-18 00:00:00.000", "description": "Report", "row_id": 171008, "text": "Baseline artifact\nSinus rhythm\n- borderline first degree A-V block\nOtherwise probably normal ECG\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-25 00:00:00.000", "description": "Report", "row_id": 1452533, "text": "NEURO:PT OPENING EYES SPONT. MAE'S R>L, PERLA, NOT FOLLOWING COMMANDS. APPEARS TO HAVE SL IMPROVEMENT IN NEURO STATUS PER TEAM. J ON.\n\nRESP:REMAINS SETTINGS NOTED. ABG DRAWN, WNL. PT W/ SPONT BREATHS 17-23. LS DOCUMENTED. NO RESP DISTRESS NOTED. O2 SATS 97-99% THROUGHOUT DAY. MOUTH CARE DONE W/ MUCH DIFF SECONDARY TO PT BITING ON TUBE. LG AMTS OF ORAL OLD BLOODY SECRETIONS CONTINUE.\n\nCV:SBP VIA L RADIAL ART LINE 130-150'S/70-80'S HR 90-100'S PT W/ IV LOPRESSOR Q6HR 5MG ALL DOSES GIVEN. RARE PVC'S NOTED. TRACE EDEMA NOTED, PULSES PALP W/O DIFF.\n\nGI/GU:FOLEY TO GRAVITY, QS UOP, YELLOW W/ SEDIMENT. PT ON LEVOFLOXACIN IV FOR UTI. IMPACT W/FIBER AT GOAL OF 95CC/HR, NO BM TODAY.\n\nSKIN:SWELLING IMPROVED TO L EYE, ECCYMOSIS REMAINS. NO BREAKDOWN NOTED ON BACKSIDE.\n\nTMAX 102.1 ON LEVOFLOXACIN IV, FAMILY AT BEDSIDE THROUGHOUT DAY, CLERGY IN TO VISIT PER FAMILY REQUEST. CONT TO CHANGES IN NEURO STATUS, PLAN FOR FAMILY MEETING ASAP TO DISCUSS POSSIBLE TRACH PLACEMENT. PROVIDE EMOTIONAL SUPPORT PRN.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-25 00:00:00.000", "description": "Report", "row_id": 1452534, "text": "RESP. CARE NOTE\nPT REMAINS AND VENTED ON PSV 5 PEEP 5 40%. NO VENT CHANGES AMDE THIS SHIFT. TV 400 RANGE, GOOD ABG'S. SXN FOR THIN TANNISH SECRETIONS FROM ET AND OLD BLOODY ORAL SECRETIONS. CONT CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-26 00:00:00.000", "description": "Report", "row_id": 1452535, "text": "npn\ns=.\no=neuro exam essentially unchanged. right upper and lower extremities in almost constant motion except when asleep. some movement of left hand. occasionally moves left leg, but difficult to hold in position in bed. unable to show two fingers of right hand, but reflexively grasps.\ncv=monitor pattern nsr. no ectopy noted. hr occasonally increases to 100's. bp as noted on careview. ivf at kvo. continues on lopressor, but doses held after defervescence when bp is 90's systolically.\npulm=vent. settings unchanged. breath sounds clear upper, decreased lower bilaterally. suctioned for thick tan secretions. sats=100%. continues to have slightly blood=tinged oral secretions. oral airway placed to assist in suctioning since pt. clenches jaws making it difficult to et or orally suction.\ngi=continues on tube feeds at goal 95cc/hr. small stool during bath. abdomen soft, non-distended. passing flatus.\ngu=urine continues cloudy with sediment much of time.\nskin=no changes\nendo=glucoses covered with reg. insulin as per sliding scale.\nsocial=family member with pt. during night.\na=unchanged.\np=continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-26 00:00:00.000", "description": "Report", "row_id": 1452536, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds rhonchi clearing somewhat with suct for mod th yellow sput. No vent changes made overnoc. Cont PSV.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-23 00:00:00.000", "description": "Report", "row_id": 1452527, "text": "T-SICU Nsg note\nNeuro - opens eyes spont & sometimes to stimulation. Does not follow commands. Localizes with R arm - reaches toward mouth during mouth care, when R arm not restrained, reaches toward ET tube. Spont movement of feet, withdraws from touch. PERRL. Strong cough, impaired gag.\nCV - back to 5mg Metoprolol q 4 hrs, BP higher today, no doses of lopressor held today. No hydralazine. NSR to ST up to 110.\nResp - Remains on 5cm PSV above 5cm PEEP, 40% FIO2. Vt 400-600cc, usually in 400's. Less sputum, still tan, thin to thick. Lung sounds clear.\nGU - adequate U/O. IV down to 30cc/hr.\nGI - sump removed, Dubhoff feeding placed via R nare. Tube feedings increased to 80cc at 17:00, goal 95cc/hr. Residuals only 5-10c. Smear of stool this am. Abd softly distended, bowel sounds active.\nID - cultures pending. Spiked again this eve.\nSkin - back & buttocks intact. Skin under cervical collar intact. Bruises are resolving. Abrasions to knees & ankles dry & healing.\nEndo - BS 130-150, on sliding scale insulin.\nStill with very impaired gag, no swallowing motions noted. Oral secretions less, still with dk old blood.\nLifted OOB to chair for about an hour today - family pleased to see pt up.\nSocial - wife & children here most of day in shifts sitting with pt. Family's questions answered by nursing staff & Dr. .\nA: Stable neuro status. TF increasing toward goal. Supportive & involved family.\nP:Increase TF to goal. Continue to monitor. Informational & emotional support to pt & family. Monitor for slow neuro improvements.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-24 00:00:00.000", "description": "Report", "row_id": 1452528, "text": "NEURO-DOES NOT OPEN EYES TO STIMULATION, PERTA AT 3.0 MM, DOES NOT FOLLOW COMMANDS, MAE UNPURPOSEFULLY, RUE NORMAL MVMT, LUE MOVES MINIMALLY, BLE MOVE ON BED-LIFT AND FALL BACK\n\nCARDIAC- HR REGULAR RHYTHM, SR/ST WITH FEVER, BP GOOD- NO PRN HYDRALZINE REQUIRED, PULSES PALPABLE\n\nRESP- LUNGS WITH SCATTERED RHONCI BILATERALLY, 40%, PEEP 5, PS 5, TV 400'S, RR ~22, SECRETIONS HAVE DECREASED-HOWEVER SM-MOD THICK TAN SECRETIONS, SATS > 98%\n\nGI- ABDOMEN SOFT, BS PRESENT, NO BM'S\n\nGU- FOLEY, UOP GOOD- 70-100/HR, URINE CLEAR AND YELLOW\n\nENDO- FSBS HAVE 159-171, SS INSULIN GIVEN\n\nSKIN- BRUISING AND CONTUSIONS HEALING, LEFT EYE STILL SUTURED AND ECCHYMOTIC, STERNUM IS STILL BRUISED, BUT HEALING\n\nID- HAS HAS TEMP ALL SHIFT, AS HIGH AS 102.6- TYLENOL 650 MG GIVEN Q4, PAN CX, DIAPHORETIC, URINE CX FROM GREW E. COLI\n\nSUPPORT GIVEN TO FAMILY, WIFE AND CHILDREN VISITED, SON AT BEDSIDE MOST OF NIGHT, FAMILY MEETING PLANNED FOR MONDAY TO DISCUSS TRACHEOSTOMY\n" }, { "category": "Nursing/other", "chartdate": "2187-11-24 00:00:00.000", "description": "Report", "row_id": 1452529, "text": "NEURO:SL IMPROVEMENT TODAY, PT W/ PURPOSEFUL MOVMT. R >L OPENING EYES MORE, NOT FOLLOWING COMMANDS. PERLA.\n\nRESP:NO VENT CHANGES MADE, ABG WNL RR 15-20, DIFF SXNING DUE TO PT BITING TUBE.LS DOCUMENTED. CTA SCATTERED RHONCHI IN BASES. O2SATS 99%\n\nCV:HEMODYNAMICALLY STABLE, HYPERTENSIVE AT X'S CONT'S ON LOPRESSOR BP LABILE 120'S-70'S/70'S. NO ECTOPY NOTED. PULSES PALP NO EDEMA NOTED.\n\nGI/GU:DOBHOFF REPLACED BY MD TODAY FOR OCCLUSION AFTER ADM OF LEVOQUIN, AWAITING CXR TO CONFIRM PLACEMENT. RECEIVING IMPACT W/ FIBER AT GOAL. POSITIVE BOWEL SOUNDS. NO BM THIS SHIFT, ABD SOFT. FOLEY TO GRAVITY UOP QS.\n\nSKIN:L EYE HEALING, SUTURES INTACT, PT W/ SEVERAL ECCYMOTIC AREAS THROUGHOUT. C COLLAR REMAINS ON.\n\nI/D:TMAX 102.1 PT STARTED ON LEVOQUIN FOR UTI. PER SICU TEAM.\n\nACT:OOB TODAY W/O DIFF, FAMILY AT BEDSIDE, ALL QUESTIONS ENCOURAGED/ANSWERED. MUCH EMOTIONAL SUPPORT NEEDED/GIVEN.\n\nPLAN:CONT TO NEURO STATUS, PT FOR POSSIBLE TRACH. FAMILY MEETING FOR . WILL CONT TO .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-24 00:00:00.000", "description": "Report", "row_id": 1452530, "text": "PLACEMENT OF DOBHOFF CONFIRMED BY MD , READY FOR USE...WILL RESUME TUBE FEEDINGS.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-25 00:00:00.000", "description": "Report", "row_id": 1452531, "text": "RESP CARE NOTE:\n\nPt cont intub on mech vent as per Carevue. Lung sounds clear but dim suct sm th tan. No vent changes made overnoc. Cont mech vent PSV.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-25 00:00:00.000", "description": "Report", "row_id": 1452532, "text": "npn\ns=.\no=neuro=opens eyes spontaneously, but not always to commands. grasp on right seems more reflexive. no grasp on left. unable to hold two fingers on right when asked. almost constantly moving right leg, except when sleeping. occasional movement of left leg, but unable to hold on bed. positive bilateral pedal pulses. pupils equal and reactive.\ncv=monitor pattern=nsr--no ectopy noted. bp wnl, at times low 100's systolically. ivf at kvo.\npulm=vent. settings remain unchanged--pressure support5 and peep 5cm on 40%. breathing 16--24 breaths/min. breath sounds clear upper, decreased lower bilaterally. suctioned for thick tan secretions. tidal volumes=350--550. sats=100%.\ngi=tolerating tube feeds of impact with fiber at 95cc/hr. abdomen soft, non-distended. no stool this shift.\ngu=foley patent for slightly cloudy at times yellow urine. occas. sediment.\nendo=blood sugars covered per sliding scale.\nskin=no open areas. dressing to right lower extrremity replaced. ecchymosis at left eye area and left axillary area present.\nsocial=family member at bedside throughout night.\na=stable overnight.\np=continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-22 00:00:00.000", "description": "Report", "row_id": 1452525, "text": "SOCIAL WORK NOTE:\n\nFamily meeting held today with pt's wife, , their son, , and their , and . Drs. (T-SICU), (trauma), (T-SICU), NP (neurosurg), this SW, and RNs and were present. Family given medical update by team and had many questions answered about his condition and plan of care. Family wants to be here around the clock because they want to be here when pt \"wakes up\". This SW encouraged family to pace themselves due to pt's long expected recovery. wife lovingly described pt as a very intelligent and stubborn man who she feels must be very frustrated by this experience and process. She also described him as being very sensitive to noise. wife also said that they want to advocate for him and she seemed to feel that discussions of trach placement were an indication that team is \"giving up on him\". Team assured family that this is far from being the case. wife is struggling to balance her role as his wife with her knowledge as a nurse and we encouraged her to try to trust medical team as much as possible. She remains very detail-oriented and made specific suggestions for things like his bowel medications. Their children are involved and supportive. This SW remains available as needed. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-23 00:00:00.000", "description": "Report", "row_id": 1452526, "text": " PT DOES NOT OPEN EYES, PERTLA AT 4.0 MM, WILL LOCALIZE AND LIFT/HOLD RUE, LUE MOVES MINIMALLY, BLE CONSTANTLY MOVES ON BED, EMV 8T\n\nCARDIAC- HR REGULAR, SR, NO ECTOPY, BP GOOD-DID NOT REQUIRE PRN HYDRALZINE, PULSES EASILY PALPABLE\n\nRESP- LUNGS SOUND BETTER THAN AT BEGINNING OF SHIFT, 8.0 OETT-21 AT LIP, IMAPAIRED GAG RREFLEX, WEAK COUGH, 40% PS 5, RR 18/19, LUNGS WITH A FEW SCATTERED RHONCI BILATERALLY, SUCTIONING SMALL AMTS. OF THICK TAN SECRETIONS, LAVAGING Q2-4 HRS, SATS 100%\n\nGI- ABDOMEN SOFT, BOWEL SOUNDS PRESENT, NO BM'S\n\nGU- UOP GOOD, 100CC/HR, URINE CLEAR AND YELLOW\n\nENDO- FSBS 142 AND 153, SS INSULIN GIVEN\n\nSKIN- LEFT EYE SUTURED AND ECCHYMOTIC, CHEST WITH YELLOW/BROWN BRUISES, LLE SKIN ABRASION TO INSIDE ANKLE\n\nID- T-MAX 102.6, TYLENOL GIVEN PO, PAN CX SENT YESTERDAY FOR TEMP SPIKE 101.8\n\nDIET- TF-IMPACT WITH FIBER VIA OG TUBE, RESIDUALS , CONTINUE TO INCREASE BY 10 CC Q4 IF RESIDUALS OKAY- GOAL OF 95, MIVF NS PLUS 40 KCL\n\nSOCIAL- FAMILY VISITED AND CALLED LAST NIGHT, SON AT BEDSIDE MOST OF NIGHT, PT RESTED WELL OVERNIGHT\n" }, { "category": "Nursing/other", "chartdate": "2187-11-22 00:00:00.000", "description": "Report", "row_id": 1452524, "text": "T/SICU NPN 4:45pm (Shift 7A-7P)\n\nS/P pedestrian struck 73yo on .\n\nNeuro:\nPupils round, reactive and equal, and occasionally opens eyes with command and spontaneously. Continuosly moves bilateral lower extremities non-purposely, and removes to pain stimuli. Upper extremity movement is with purpose but remains inconstistant- right greater than left and moves both to pain stimuli. Neuro exams changed to every 2 hours.\n\nCV:\nSBP 130 to 150 while at rest, but at times 190's with procedures and movement. Lopressor changed to 10mg q4 hours, and hydralizine 10mg PRN. NSR with rare PVC's noted. k level at 2pm: 4.0 - no intervention. extremities warm and well perfused, easily palpable periph pulses; p-boots on 2 hours at a time per family request.\n\nRespir:\nLSCTA with decreased bases bilaterally. Tolerated vent wean settings, however remains for airway protection. Suctioned as needed for thick tan secretions small to moderate amounts. Oral sx for blood tinged sputum in moderate amounts.\nGI:\nAbdomen soft, positive BS. Tube feeds increased this AM, with a goal of 95cc per hour - currently at 30cc/hour. No bowel movement this shift.\n\nGU:\nFoley patent with clear yellow urine, WNL output.\n\nID:\nFrebile with Tmax 101.5, team aware and workup done - Bld Cx, UA, and sputum Cx sent.\n\nEndo:\nMonitoring FS q 6 hours, with RSSI coverage.\n\nSkin:\nMultiple abrasions, left eye ecchymotic and lac with sutures intact and OTA. No drainage noted. Large Hematoma to left upper arm.\n\nSocial:\nFamily meeting this afternoon, all immediate family present. Discussed peg and trach placement for futures needs, which family is against of at this time.\n\nPlan:\nContinue to monitor neuro status, trach needs with suction needs as appropriate. Will advance tube feeds per order. Monitor for pain, and give supportive care to patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-07 00:00:00.000", "description": "Report", "row_id": 1452573, "text": "SICU NURSING NOTE 7P-7A\nREVIEW OF SYSTEMS\n\nNEURO: LETHARGIC AT TIMES BUT RESPONDS TO VOICE. MAE WITH LEFT SIDED WEAKNESS NOTED ESPECIALLY IN UPPER EXTREMETY. INTERMITTENTLY FOLLOWING COMMANDS. WEAK COUGH AND NO GAG. C COLLAR INTACT.\n\nCV: HEMODYNAMICALLY STABLE. LOPRESSOR CONTS.\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. 40% FACEMASK WITH SATS 95-97%. NO NTS THIS SHIFT.\n\nGI: ABD SOFT WITH +BS. REMAINS NPO. CONTS TPN. BM X2 BROWN LIQUID.\n\nGU: U/O ADEQUATE. K REPLETED.\n\nHEME: HCT STABLE.\n\nENDO: BS RX'D PER SS.\n\nID: AFEBRILE. WBC 7. CONTS ON ZOSYN AND VANCOMYCIN.\n\nSKIN: NO ISSUES\n\nSOCIAL: WIFE CALLED THIS AM AND UPDATED ON EVENTS OVER NIGHT. WIFE ALSO AWARE OF PLAN TO TRANSFER PT TO FLOOR TODAY WHEN BED AVAILABLE.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-12-07 00:00:00.000", "description": "Report", "row_id": 1452574, "text": "T_sicu nsg prog note: days\nREmains stable , awaiting transfer to floor. Improving mental status.\nVSS\n\nROS:\n\nGI: npo, on TPN, for swallowing evaluation.\n\nNEURO: Opens eyes only on command. Will repeat \"hello\" but won't answer questions. Will respond with nodding to direct questions. Limited interaction w/ family, will follow commands consistently.\nMAE.\n\nCARDIAC: stable. On iv lopressor.\n\nRESP: Stable. Lungs clear w/ RUL bronchial sounds. SAts fgood on 50% neb. Did not require suctioning, has cough.\n\nRENAL; good u.o.\n\nSOCIAL: family with patient. They want to be notified when pt transfers to floor so they can come to sit with him.\n\nLINES: has a-line, 3-Lumen catheter that functions well.\n\nASSESS: stable, improving mental status.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-27 00:00:00.000", "description": "Report", "row_id": 1452544, "text": "nsg note 7 to 1 pm. back to bed at 830pm. tol well one lg soft brown stool tol tube feeds hemodynamically stable, nodding head yes and no , purposeful with rt arm.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-28 00:00:00.000", "description": "Report", "row_id": 1452545, "text": "npn\ns=orally .\no=opens eyes spontaneously, and at times on command. pupils equal and reactive. strong grasp right hand. holds up extended fingers when asked to show two fingers. frequent movement of right lower extremity. less movement of left upper and lower extremities. weaker grasp of left; does not hold left lower extremity in bended-knee position. bilateral positive pedal pulses. skin warm and dry.\ncv=monitor pattern nsr. no ectopy noted. ivf at kvo--site benign.\nbp wnl--see careview. 0200 dose lopressor held--bp 132. 0400 bp=123/61.\npulm=vent settings unchanged. sats=98%. tidal volumes=4460-490. breath sounds coarse bilaterally and decreased at right base. suctioned for thick tan secretions. continues to have copious tan oral secretions.\ngi=tube feeds continue-impact with fiber at goal rate 95cc/hr. abdomen soft, non-distended.\ngu=foley patent for yellow urine with sediment.\nskin=as previously. scrotal erythema==mycostatin powder to area.\nid=afebrile. continues on vancomycin and levoflox.\nsocial=family not staying at bedside.\na=stable overnight.\np=continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-28 00:00:00.000", "description": "Report", "row_id": 1452546, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse low pitched rhonchi clearing somewhat after suct for sm th tan sput. No vent changes made overnoc. Cont PSV ? trach soon.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-28 00:00:00.000", "description": "Report", "row_id": 1452547, "text": "NSG NOTE\nROS:\n\n CV;stable,art line out,t max 99,8.lopressor held at 10/2pm.\n\n resp:REMAINS ON PSV 5,NO CHANGE IN RR OR VT.SX FOR THICK TAN SECRETIONS.HOPEFULLY WILL BE TRACHED SOON.SICU ATTENDING SPOKE TO WIFE AGAIN TODAY.SHE SEEMS TO BE COMMING TO TERM REGARDING THE NEED FOR A TRACH.\n\n NEURO:PT MORE AWARE/ALERT,INTERACTING WITH FAMILY,OOB,ATTEMPTED TO GET PT TO STAND AND PIVOT BUT HE DIDN'T PUT ANY WEIGHT ON LEGS.\n\n GU:GOOD UO\n\n GI:ON GOAL TF,1 SOFT STOOL.\n\n ENDO:FS 162/176.RECEIVED INSULIN AS ORDERED.\n\n SOCIAL:WIFE,DAUGHTERS IN MOST OF THE DAY.BELIEVE THEY WILL BE TALKING WITH DR THIS PM RE:NEED FOR TRACH AND PEG AND THE BENEFITS TO THE PT.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-28 00:00:00.000", "description": "Report", "row_id": 1452548, "text": "SOCIAL WORK NOTE:\nFamily meeting held this evening with pt's wife, , and their , and . Dr. and this SW were present. Meeting held to readdress trach placement issue. wife is now amenable to this pending ENT consult. Trach will likely be placed tomorrow or Friday. There is contention among family around this issue and around some preexisting issues. This SW met privately with pt's wife after meeting at her request to discuss personal issues in her life and related to this incident. This SW remains available for continued family support and assistance. wife plans to research rehabilitation options. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-19 00:00:00.000", "description": "Report", "row_id": 1452512, "text": "SICU NPN\nPt is a 73 yr old man who was a pedestrian struck by a car yesterday. Pt remains intubated due to neuro status, however hemodynamically stable. Pt brought to head CT this AM, results pending. Pt's neuro exam waxes and wains, at times able to follow commands with all 4 extremities, other times requires painful stimuli to wake. Pt noted to have intact cough, but impaired gag. Pt also noted to have large ammts oral bleeding/old blood in back of throat. Hemodynamically stable, HR 70-90's without ectopy, BP 100-150's systolic. A-line placed this PM for close monitoring. Pt placed on T-piece X1 hour this AM, appeared to tolerate fairly well however extubation on hold due to neuro status. Pt remains NPO, abd softly distended with very hypoactive BS throughout. Boarderline u/o via foley catheter, team notified and aware. Low grade temps, 98.9-100 orally. Pt continues on clinda for oral fractures. Pt also underwent X-rays of R hand, L elbow, results pending. Waiting for optho to repeat exam on L eye, plastics re: orbital fractures. Family in all day, able to speak with dr. for updates.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-19 00:00:00.000", "description": "Report", "row_id": 1452513, "text": "T-SICU Nsg NOte\nNeuro - opens eyes spont at times - difficult for pt to open L eye due to edema. Opthamology dilated eyes about 16:30, still 7-8mm. Strong movement of all limbs, purposeful. Pt did not clearly follow commands for me, but does respond to touch. Does not nod to questions.\nCV - NSR to ST, no ectopy, BP up to 180 sys at times when moving, usually 130-150sys. Art line & NBP agree well.\nResp - on 5cm PSV above 5cm PEEP and 40% FIO2. Sats 98-100% Vt 380-450cc usually, occ up to 600cc Vt. Pt easy to bag. Strong cough. Suctioned occ for thick tan, occ blood tinged sputum. Continues with lots of dk bloody oral secretions (from sinus fx) Lung sounds diminished.\nGU - adequate u/o. IV of NS with KCl at 60cc/hr.\nGI - trophic TF started at 10cc/hr per oral sump into stomach. Abd softly distended, bowel sounds present, small stool smear this eve.\nHeme - Hct adequate per SICU team. Hct to be re-checked in am. INR stable at 1.2\nID - Temp 100 -100.6 F PO. Continues on clinda.\nEndo - sliding scale insulin started this eve. BS at 20:00 122.\nSkin - back & buttocks intact. Abrasions on knees & ankle very superficial, dry and healing well. Lac above L eye sutured, no drainage, antibiotic ointment applied. Bruising around L neck, shoulder & clavicle.\nSocial - Wife in most of day, being updated by nurses & Drs. tonight with daughter , plans to stay night here at hosptial.\nA:Not following commands, but very purposeful & strong. Stable.\nP: CT scan of head in am to follow up. Remains intubated to to greatly impaired gag and copious oral drainage. Continue to monitor pt & support family.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 1452560, "text": "NURSING PROGRESS NOTE\nS/O- REVIEW OF SYSTEMS\n PT MORE AWAKE, TAPPING ON SIDERAILS, FIDGETING, MORPHINE GIVEN 1MG X2 OVER 12H, PT INCONSISTENTLY FOLLOWING, PURPOSEFULLY MOVING SPONTANEOUSLY. PERL BRISKLY.WEAK COUGH AND NOT GAG NOTED.\n PT STABLE WITH NO FLUID REQUIREMENT ,IVF AT 40CC HR, WITH IMPROVED FILLING PRESSURES, PCW NOW AND CVP 8=9. CARDIAC INDEX GREATER THAN 5. EDVI= 110- 140. MVO2 72-75. PT IN NSR, 90-100. NO ECTOPI, LYTES REPLETED, HCT DOWN TO 27 THIS AM.LEVO WEANED TO .1MCG/KG.MIN.\n PT REMAINS ON IMV MODE , 450X12 WITH SPONT RATE OF , WITH 10 PEEP, FIO2 DECREASED THIS AM TO 505 WIH ADEQUATE SATS. PT Q2-3 FOR SM TO MOD AMTS OF TAN THIN SECRETIONS, BREATH SOUNDS DIMINISHED BILATERALLY. PT CONT TO HAVE LARGE AMTS OF ORAL SECRETIONS.\nABG IMPROVED.\n PT HAS MAINTAINED U/O OF 80-120CC HR , BUN AND CREAT WNL.\n PT RECEIVING CARAFATE Q6, MIN AMT OF CLEAR DRAINAGE FROM ORAL GASTRIC TUBE , ABD SOFT WITH BOWEL SOUNDS, PT X1 MOD AMT OF LIQUID BROWN STOOL.\nSKIN- ABRAISIONS HEALING, SKIN ON BACK AND BUTTUCKS INTACT.\n PT RECEIVING REG INSULIN PER SS 4U FOR BS OF 129 AND 133.\n PT TEMPT SLOWING DECREAED TO 99.4. WBC AT 20. XONT ON PIPERACILLIN AND VANCO.\nSOCIAL- FAMILY HOME TONIGHT, FEELING BADLY ABOUT SETBACK, DAUGHTER SUPPOSED TO GO HOME TODAY, SON FLEW IN LAST NIGHT.\nA/ PT STABILIZING, WEAN OF LEVO, IMPROVED FILLING PRESSURES. CONT TO MAINTAIN HIGH CI OF 5. FAMILY SHOULD HAVE SOCIAL SERVICE SEE THEM TODAY, DAUGHTER WOULD LIKE TO GO HOME, DOES NOT KNOW IF THIS IS A GOOD IDEA AT THIS TIME, THIA IS COMING BACK SOON AND SON FLEW IN LAST NIGHT . CONT WITH RESP CARE, DISCUSS NEED FOR TRACH AS PT STABILIZES. CONT WITH ANTIBIOIC THREAPY, SUPPORT HEMODYNAMICS AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 1452561, "text": "SOCIAL WORK NOTE:\nPt reintubated over the weekend. Met with pt and his wife, , today to offer continued support. Pt seems increasingly alert and aware. Their son, , has returned from CA. Dtr, , has gone back to and will be moving here within the next couple days. Dtr, , is returning to this evening. wife is hoping that intubation is a very temporary set-back and she remains hopeful that he will be able to go to rehab soon. She continues to explore these options. Family's Greek Orthodox priest just visited. This SW will remain involved. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 1452562, "text": "NSG NOTE\nROS:\n\n CV:\n\n ABLE TO WEAN LEVO TO .02MCG/KG BY 2PM.MAP MID 70'S.SEE FLOW SHEET FOR MVO2/CO/CI.T MAX 101.7,RX WITH TYLENOL AT 2PM.\n\n RESP:CPAP TRIAL THIS AM.ABGS AFTER 2 HRS ACCEPTABLE.SX FOR\nTHICK TAN SPUTUM.NOW ON PSV WITH 5 CPAP.NO PLAN TO EXTUBATE.\n\n NEURO:MORE AWARE,QUITE ACTIVE WITH HANDS ESP WITH NOXIOUS TREATMENTS.HATES ANYTHING AROUND HIS MOUTH.SEEMS AWARE,WORKED WITH PT.\nAPPAERS TIRED,DOZING WHEN LEFT ALONE.\n\n GU:GOOD UO,IVF AT 40CC HR.\n\n GI: PLACED,STARTED TROPHIC TF AT 10CC HR AT 1PM.OGT DC'D.\n\n ENDO:BS 117,NO NEED FOR INSULIN\n\n SOCIAL:WIFE AND CHILDREN IN,HAVE TALKED TO SOCIAL SERVICE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-26 00:00:00.000", "description": "Report", "row_id": 1452539, "text": "T-SICU Nsg update\n Neuro - opening eyes more & for longers periods of time. More movement of L arm & leg, more strength in L also. Continues purposeful in R arm movements, does not follow commands. DOes not nod head to questions. Still without gag reflex.\n GI - TF at full strength, Had mod size stool this eve, loose brown stool.\nFamily mtg today - see note from . See flow sheet for more details.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-27 00:00:00.000", "description": "Report", "row_id": 1452540, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct sm-mod th yellow. No venmt changes made overnoc. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-27 00:00:00.000", "description": "Report", "row_id": 1452541, "text": "T-SICU NSG NOTE:\nROS:\nNEURO- MOVES R>L SPONT NOT FOLLOWING COMMANDS, VERY PURPOSEFUL MOVEMENT W/ F HAND REPETEDLY TOSSING BALL AGAINST HIP USING PITCHER'S GRIP ON PALL. NO GAG, STRONG COUGH, OPENS EYES TO VOICE AND STIMULI.\n\nRESP- REMAINS ON PSV W/ GD ABG'S, SUX FOR SM AMT THICK TAN SECRETIONS. BS CTA, DIMINISHED IN BASES.SAO2 96-98%\n\nCVS- SBP 120'S AFTER LOPRESSOR WHICH WAS GIVEN IN DIVIDED DOSES OF 5MG IV. HR 70'S-80'S NSR NO ECTOPY, SBP 120'S-150'S SYS. TM 99.7 PO.\n\nGI- TF @ GOAL RATE OF 95, LG SOFT FORMED BM X2. ABD SOFT W/ NL BS.\n\nGU- ADEQ AMTS CLOUDY YELLOW URINE VIA FOLEY.\n\nSKIN- REDDENED SCROTUM W/ AREA OF EXCORIATION D/T STOOLING. VASELINE APPLIED\n\nA:STABLE \n\nP: MONITOR VS PER ROUTINE, MAINTAIN PULM HYGIENE, REPLETE LYTES PRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-27 00:00:00.000", "description": "Report", "row_id": 1452542, "text": "SOCIAL WORK NOTE:\nPt and his wife and their seen in room this evening for continued support. Pt seemed more aware and had his eyes open and glasses on. Family seemed pleased with today's events and remain hopeful. Trach issue is still pending. ICU Attending might meet with wife again soon to discuss further. This SW remains available. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-27 00:00:00.000", "description": "Report", "row_id": 1452543, "text": "SICU NURSING NOTE 7A-7P\nREVIEW OF SYSTEMS\n\nNEURO: PT LIGHTER TODAY THAN PREVIOUS. OPENS EYES TO VOICE AND SPONTANEOUSLY. INTERMITTENT FOLLOWING COMMANDS WITH RUE AND STICKS OUT TONGUE TO COMMANDS. MOVES LEFT SIDE LESS THEN RIGHT. MOVING LUE A LITTLE MORE BUT REMAINS WEAK ON LLE. PUPILS 3MM/BSK BILAT. IMPAIRED COUGH NOTED. NO GAG. C COLLAR INTACT. OOB TO CHAIR. HEAD CT NO CHANGE.\n\nCV: HEMODYNAMICALLY STABLE. LOPRESSOR DECREASED TO 5MG Q4. +PP WITH SKIN WARM AND DRY.\n\nRESP: L/S CLEAR TO COARSE IN UPPER LOBES AND DIMINISHED AT BASES. CONTS ON PS 5/5. REMAINS D/T NO GAG AND ALTERED NEURO STATUS.SX FOR THICK YELLOW SPUTUM.\n\nGI: ABD SOFTLY DISTENDED WITH +BS. TOL TUBEFEEDS VIA PEDITUBE. BMX2 LOOSE BROWN. COLACE HELD.\n\nGU: U/O ADEQUATE. LYTES WNL.\n\nHEME: HCT STABLE. AWAITING WORD ON WHETHER TO START HEPARIN SC FROM NEUROSURG.\n\nENDO: BS RX'D PER SS.\n\nID: LOW GRADE TEMPS 99'S. CONT ON IV LEVOQUIN FOR ECOLI IN URINE. BC X1 (PERIPHERAL STICK)+ FOR GRAM+COCCI IN PAIRS AND CLUSTERS. REPEAT SENT AND VANCOMYCIN STARTED.\n\nSKIN; NO CHANGES.\n\nSOCIAL: FAMILY INTO VISIT. WIFE REMAINS RESISTANT TO TRACH PLACEMENT. WILL CONT TO MONITOR. SICU ATTENDING SPOKE WITH DAUGHTERS TODAY AND ANSWERED THEIR QUESTIONS APPROPRIATELY.\n\nA: STABLE.\nP: CONT NEURO MONITORING AND TRACH PT AT END OF THE WEEK IF PT CONTS WITH NO GAG OR NEUROLOGICAL IMPROVEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-19 00:00:00.000", "description": "Report", "row_id": 1452510, "text": "NURSING PROGRESS NOTE\nS/O PT WAKES SOMETIMES TO PAIN AND OTHER TIMES TO STIMULI, EXAM WAXES AND WANES, SOMETIMES FOLLOWS WITH UPPER EXTREMITIES WITH STRONG GRASPS BILATERALLY AND OTHER TIMES DOES NOT FOLLOW AT ALL, LOWER EXTREMITIES HE MOVES SPONTANEOUSLY BUT RARELY TO COMMAND. PERL, BRISKLY REACTING, NOW AT 4.NO SEIZURE ACTIVITY NOTED , J COLLAR APPLIED. PT APPEARS LIGHTER THIS AM. TLS STILL NOT CLEARED.\n PT HEMODYNAMICALLY STABLE PT IN NSR RATE 90-110, DEPENDING IF PT IS AWAKE OR ASLEEP. B/P 120-150/60-80.HCT STABLE\nID-TMAX 100.2., REMAINS ON CLINDA\nRESP-VENT CHANGED FROM SIMV TO PRESSURE SUPPORT OF , PT TV ARE 500 WITH RATE OF 16-20, PT SATS 99%, NO GAS DRAWN. PT SUCTIONED FOR MOD AMT OF THICK BLOODY SECRETIONS.\n PT HAD ORAL GASTRIC TUBE PLACED, DRAINING YELLOW DRAINAGE, NO BOWEL SOUNDS HEARD, ABD IS SOFT. NO STOOL PASSED.\n PT ON IVF AT 60CC HR WITH U/O OF 40-60 CC HR. BUN AND CREAT PENDING\n PT LEFT EYE LAC SUTURED IS STILL OOZING A SMALL AMT OF BLOODY DRAINAGE, L EYE VERY ECCHYMOTIC. RT THUMB IS SWOLLEN AND BRUISED.\nL ELBOW SWOLLEN AND BRUISED. ABRAISIONS ON L AND AND RT LEGS. SKIN ON\n BACK AND BUTTUCKS INTACT.\n WIFE AND SON HERE TONIGHT, UNABLE TO SLEEP, STAYING TO SPEAK WITH NEUROSURG. ASKING APPROP QUESTIONS.\nA/ PT APPEARS LIGHTER THIS AM AND FOLLOWING MORE CONSISTANTLY, CV STATUS STABLE. WILL FOLLOW WITH CT SCAN TODAY AND DO XRAYS OF RT THUMB AND L ELBOW. QUESTION NEED FOR SLING FOR L CLAVICLE FX. TLS NEED TO BE CLEARED, EXTUBATE IF PT NEURO STATUS IMPROVES TO BE ABLE TO PROTECT AIRWAY.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-19 00:00:00.000", "description": "Report", "row_id": 1452511, "text": "SOCIAL WORK NOTE:\nNew trauma pt on T-SICU. Pt is a 73 year old married man who lives in with his wife, (home cell ). He is s/p pedestrian struck by a car. Pt is a professor and statistics at and a professor engineering at . Pt and his wife have three adult children: dtr, , son , and dtr , and two grandchildren. This SW met with pt's wife and dtr today to introduce self, gather information, and offer support. Family reports that pt has no psychiatric or substance abuse history and is a very healthy and active man. wife reports that she works as a nurse case manager and she was eager for this SW to call insurance company for pre-cert. I have referred this issue to RN Case . wife seems detail-oriented and has been persistent with staff about this and other issues. Family given contact information for this SW and I remain available as needed. Pt intubated at this time. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-12-01 00:00:00.000", "description": "Report", "row_id": 1452558, "text": "sicu nursing note 7a-7p\nREVIEW OF SYSTEMS\n\nNEURO: ALERT BUT REMAINS NONVERBAL D/T WEAKENED VOICE. FOLLOWING COMMANDS WITH ALL EXTREMETIES. LEFT SIDED WEAKNESS NOTED. PEARL. WEAK CONGESTED COUGH NOTED AND MINIMAL GAG. C COLLAR INTACT. OOB X2 TODAY FOR FEW HOURS AND TOL WELL.\n\nCV: HEMODYNAMICALLY STABLE. LOPRESSOR HELD D/T PARAMETERS. +PP WITH SKIN WARM AND DRY. PIV X1.\n\nRESP: L/S COARSE AND DIMINISHED AT BASES. RR 16-22. 50%FACE TENT INTACT WITH SATS 96-99%. NTS FOR MOD TO COPIOUS AMTS OF THICK TAN SPUTUM X3.\n\nGI: ABD SOFTLY DISTENDED WITH +BS. TUBEFEEDS RESTARTED AND ADVANCED TO GOAL. NO STOOL. +FLATUS.\n\nGU: U/O ADEQUATE. LYTES WNL.\n\nHEME; STABLE.\n\nENDO: RX'D PER SS.\n\nID: AFEBRILE. WBC WNL. LEVO D/C AND CONT VANCOMYCIN.\n\nSKIN; NO ISSUES.\n\nSOCIAL: FAMILY INTO VISIT.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-12-02 00:00:00.000", "description": "Report", "row_id": 1452559, "text": "SICU NURSING NOTE 10A-7P\nPT GET TO FLOOR LAST EVENING AND BECAME UNRESPONSIVE WITH LOW SATS THIS AM. REINTUBATED ON THE FLOOR AND BACK TO SICU.\n\nREVIEW OF SYSTEMS\n\nNEURO: PT MEDICATED WITH ETOMIDATE AND SUCCS ON FLOOR FOR INTUBATION AND THEN GIVEN 8MG MORPHINE ON ARRIVAL TO SICU D/T RR 50'S. PT LETHARGIC MOST OF SHIFT BUT NOW WITHDRAWS WITH ALL 4 EXTREMETIES. OPENS EYES TO VOICE AND STIMULATION. NOT FOLLOWING COMMANDS. HEAD CT DONE WHICH IS IMPROVED FROM LAST SCAN. C COLLAR INTACT.\n\nCV: HR 150'S ST WITH SBP 70-80 IN ARRIVAL. ALINE AND SWAN PLACED. PA 20/8-14. CVP 3-6 AND WEDGE . CO/CI WITH SEPSIS WITH CO AND INDEX 4. 6.5L FLUID GIVEN FOR LOW FILLING PRESSURES AND U/O WITH SOME EFFECT. LEVOPHED STARTED TO KEEP MAP>70. +PP WITH SKIN WARM AND DRY. 1ST CPK NEGATIVE. LOPRESSOR HELD.\n\nRESP: RR 50'S ON ARRIVAL MEDICATED WITH MORPHINE 4MG IV X2 FOR HIGH RR WITH EFFECT. PT PLACED ON IMV WITH FIO2 100% D/T SATS OF 81-82%. PT ABLE TO BE WEANED TO 60% WITH LAST PAO2 69. SX FOR THICK TAN SPUTUM WITH TUBEFEEDS IN IT. PEEP INCREASED TO 10.\n\nGI: ABD SOFTLY DISTENDED WITH +BS. OGT INSERTED DRAINING BILIOUS MATERIAL. REMAINS NPO. NO STOOL OR FLATUS. PEDITUBE REMOVED ON ARRIVAL TO SICU D/T IT WAS OUT A FAIR AMT.\n\nGU: U/O 10-20CC/HR ON ARRIVAL BUT HAS IMPROVED WITH FLUID TO 80CC/HR. K AND CALCIUM TO BE REPLETED.\n\nHEME: HCT STABLE 32. INR 1.3\n\nENDO: BS 129 RX'D PER SS.\n\nID: TMAX 102.8. PAN CX THEN CAME DOWN ON ITS OWN. ZOSYN AND VANCOMCYIN STARTED.\n\nSKIN: INTACT.\n\nSOCIAL: WIFE UPDATED BY DR. AND ALSO UPDATED ON SCAN RESULTS BY SICU HO. DAUGHTER INTO VISIT. BOTH OBVIOUSLY APPROPRIATELY UPSET BY SET BACK TODAY.\n\nA: S/P ASPIRATION.\nP: AGGRESSIVE PULMONARY TOILET, ANTIBIOTIC RX, AND CONT TO SUPPORT FAMILY.\n\n\nGU:\n" }, { "category": "Nursing/other", "chartdate": "2187-11-18 00:00:00.000", "description": "Report", "row_id": 1452508, "text": "Resp. Care:\n Pt. is s/p trauma (ped.vs.car), came into EU already intubated with a #7.5(21@lip). BS equal,clear bilat. in EU. Pt. transported to CT scan, then to X-RAY, back to EU, then finally to T-SICU-Placed on vent. SIMV 750 x 12 100% 5P 5PS. Alarms on and functioning. Will wean Fi02 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-18 00:00:00.000", "description": "Report", "row_id": 1452509, "text": "T/SICU NSG ADMISSION NOTE\n1600>>\n\nTHIS IS A 73 YO MALE W/O SIGNIFICANT PMH/PSH WHO WAS A PEDESTRIAN STANDING IN A CROSSWALK WHEN HE WAS HIT BY A CAR TODAY..ALLEGEDLY THROWN ~ 20FT AND FOUND ON LEFT SIDE WITH + LOC AND GCS OF 3. PT INTUBATED IN FIELD>>>. PT HAD FULL TRAUMA SERIES TO ASSESS INJURIES: LEFT ORBITAL FX,ETHMOID FX, LEFT NONDISPLACED CLAVICLE FX, LEFT EYEBROW LACERATION. AWAITING APPROVED CLEARANCE OF SPINE SERIES; PT ON LOG ROLL PRECAUTIONS WITH C-COLLAR IN PLACE. HEAD CT REPORTED AS 'DIFFUSE AXONAL INJURY'W/NO INTRAPARENCHYMAL BLEED BUT POSITIVE BLOOD IN VENTRICLE.\n\nOTHER INJURIES INVOLVE ABRAISIONS NOTED ON LEFT CHIN EDGE, BOTH KNEES, AND RIGHT INNER ANKLE. BRUISING NOTED ON CHIN AND LEFT NECK. LEFT EYE IS SWOLLEN SHUT WITH ECCHYMOSIS AND SUTURED LACERATION. LEFT CLAVICULAR AREA IS SWOLLEN FROM MID POINT EXTENDING UPWARD TO LEFT NECK AREA.\n\nALLERGY TO PER WIFE (40YRS PTA> HIVES)\nPRE-ADM MEDS: MULTIVITAMIN AND BABY ASA\nPMH: ARTHRITIS\nPSH: REMOVAL OF PILONIAL CYST 40 PTA.\nNO H/O ETOH, SMOKING, DRUG USE.\n\nPT IS A HEALTHY, ACTIVE 73 YO MAN WHO CONTINUES TO WORK AS A FULL TIME PROFESSOR U AND COLLEGE. WIFE REPORTS PT IS ACTIVE BY WALKING AND WATCHES HIS WEIGHT.\n\nROS-\nNEURO- PERRL AT 3MM WITH INTERMITTENT SLUGGISH REACTION ON LEFT. PT DOES NOT OPEN EYES TO STIMULATIN OR SPONTANEOUSLY. NOT FOLLOWING COMMANDS, BUT WILL MOVE RUE WITH PURPOSE TO STIMULATION; LE'S WILL BEND UP; AND LUE ONLY WITHDRAWS TO PAINFUL STIMULATION( NO SPONTANEOUS MOVEMENT) IMPAIRED COUGH & GAG. + GRIMACING WHEN INJURED AREAS ARE PROBBED.\n\nCVS- NSR IN 90'S W/O ECTOPY. BP 140-170/ 70'S\n IVF INFUSING WITH NS AT 60C//HR\n\nRESP- INTUBATED & VENTED ON S/IMV 40% 500 X14 WITH 5 PEEP. BREATH SOUNDS ARE CLEAR WITH DIMINISHED SOUNDS AT RIGHT BASE. SECRETIONS ARE MOD AMTS THICK BLOODY SPUTUM. SATS- 100%. OCC SPONTANEOUS BREATHS OVER VENT. STABLE ABG\n..ORALLY INTUBATED WITH BLOOD TINGED ORAL SECRETIONS NOTED- SMALL AMTS.\n\nRENAL- ADEQUATE HOURLY OUTPUT BY FOLEY..CLEAR\n BUN/CREAT WNL\n\nID- AFEBRILE..KEFZOL IN EW..CLINDAMYCIN FOR FACIAL FXS\n\nHEME- HCT 44 ON ADM>> 40 THIS EVE..WILL FOLLOW SERIAL HCT OVERNIGHT.\n COAGS WNL\n ACTIVE CLOT AVAILABLE\n\nGI- SOFT ABD W/O BOWEL SOUNDS\n NO GASTRIC TUBE.\n\nSKIN- ISSUES AS NOTED\n INITIALLY COOL AND PALE..NOW WARM WITH PALAPBLE PERIPHERAL PULSES; COLORING MPROVED.\n COMPRESSION BOOTS IN PLACE.\n NO SKIN ISUES NOTED ON BACK\n LOGROLL PRECAUTIONS.\n\n WIFE PRESENT AND IS BEING KEPT INFORMED OF STATUS/PLANS\n WIFE HAS OTHER APPROPRIATE FAMILY MEMBERS.\n WIFE IS SPOKESPERSON; NO HCP\n\nASSESS- PEDESTRIAN HIT BY CAR WITH FACIAL FX, LEFT CLAVILCE FX, AND AXONAL INJURY TO BRAIN; PT WITH ALTERED NEURO RESPONSEIVENESS; GCS ~ . REQUIRING VENTILATORY SUPPORT\n\nPLAN- CLEAR BACK/SPINE PER RADIOLOGY REPORTS- FINAL..PND\n ATTEMPT WEAN/EXTUBATION\n MONITOR NEURO EXAM AND CHANGES.\n INTERVENTIONS PER OPTHO AND PLASTICS CONSULT REGARDING ORBITAL/FACIAL FX.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-21 00:00:00.000", "description": "Report", "row_id": 1452521, "text": "NPN: Review of Systems\nNeuro: Pt opens eyes to voice, but has not followed commands. PERRL. (+) cough, (-) gag reflex. Pt periodically restless. MAES. Moves LEs the most: moving them up and down. Moves left arm to noxious stimuli only. No seizure activity observed. Head CT and cervical MRI done. Awaiting results. Recieved propofol while undergoing tests, but has not received anything else.\n\nResp: Continues on 5 ps and 5 peep. Breathing comfortably on vent w/ RR 17-19. ABG=7.43/40/172 and 27/+2. Sxning small amts of thick tan secretions.\n\nCV: SR. Occaional PVC. BP trending up over the course of the day w/ SBP 170s-180s now. Lopressor q6hrs to be started. K+ and Ca++ being repleted.\n\nGI: Impact w/ fiber infusing at 10cc/hr. Abdomen is soft and nondistended. (+) bowel sounds.\n\nGU: Foley to gravity. Please see flowsheet for UO>\n\nEndo: Maintaining glucose < 10 via sliding scale.\n\nSkin: Backside intact. Abrasions clean and dry.\n\nSocial: Wife and children by bedside. Spoke w/ social worker and a family meeting w/ trauma, neuro and SICU physicians planned for so that everyone has the same information. Family appears calm and is asking appropriate questions.\n\nA: No change in neuro exam. oes not appear that he could protect airway at this time given (-) gag reflex.\n\nP: F/U w/ MRI and CT results. Anticipate attending family meeting on .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-21 00:00:00.000", "description": "Report", "row_id": 1452522, "text": "S/P Trauma\n\nPt opens eyes to voice, MAE, grimaces, legs in constant motion, no sedation given-? if follows commands rarely. Cervical collar on.\n\nLopressor begun for increased BP with good effect. No ectopy. IVF@60cc/hr.\n\nSuctioned for thick tan sputum. Breath sounds clear. Sats 100%, no vent changes.\n\nUrine output good.\n\nTube feeds remain at 10cc/hr.\n\nPneumoboots on.\n\nFamily at bedside, they are very hopeful and believe every grimace is purposeful and that pt is smiling and laughing at their conversation.\n\nPlan: Continue to assess neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-22 00:00:00.000", "description": "Report", "row_id": 1452523, "text": "Nursing Progress Note\nS/O- neuro exam unchanged, inconsistantly follows commands with upper ext, lower extrem, moving constantly, moving uppers purposefully., arms remain restrained. pupils at 4 and reactive. opens eyes occas, but not always to command. pt not resting. MSO4 given .5mg given.MRI of neck needs to be read as well as yesterdays head CT\ncv- hypertension persists despite increasing Lopressor to 10 mg q6h. hr 75-80 NSR no ectopi. B/p only below 150 systolic if pt stops moving and rests.\nresp- pt remains on pressure support of 5 with 5 peep, with sats of 100% and good Abg, pt has mod amt of thick blood tinged tan sputum. Pt cont to have large amts of oral secretions\ngu- good u/o,\ngi- trphic feeds cont at 10cc hr of impact with fiber, no stool, abd soft.\nsocial- patients daughter spent the , encourage family to go home at night and get some restful sleep. family meeting to be held today.\na/p pt still not awake enough to protect airway for extubation. Plan of care will be discussed at family meeting. Cont to monitor and support.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-26 00:00:00.000", "description": "Report", "row_id": 1452537, "text": "SICU NURSING NOTE 7A-7PR\nREVIEW OF SYSTEMS\n\nNEURO: PT OPENS EYES SPONTANEOUSLY AND TO VOICE. MOVES R SIDE>LEFT SIDE. PUPILS 3MM/BSK BILAT. NO GAG AND STRONG COUGH NOTED. C COLLAR INTACT.\n\nCV: HEMODYNAMICALLY STABLE. 2P LOPRESSOR HELD. +PP WITH SKIN WARM AND DRY.\n\nRESP: L/S COARSE THROUGHOUT. CONTS ON CPAP 5/5. SX FOR THICK YELLOW SPUTUM. GRAM-RODS IN SPUTUM FROM .\n\nGI: ABD SOFT WITH +BS. CONTS ON IMPACT WITH FIBER AT 95CC/HR. LARGE BM X1.\n\nGU: U/O ADEQUATE. LYTES WNL.\n\nHEME: HCT STABLE.\n\nENDO: BS RX'D PER SS.\n\nID: TMAX 102.2. PAN CX. CONTS ON LEVOFLOXIN.\n\nSKIN: NO ISSUES\n\nSOCIAL: FAMILY MTG HELD WITH DR. TO DISCUSS TRACH PLACEMENT. SEE SOCIAL WORK NOTE FOR SPECIFICS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-30 00:00:00.000", "description": "Report", "row_id": 1452554, "text": "Tsicu NPN 11p-7a\nS/\n pt bright at times w/ spontaneous eye opening, PERL at 4mm, brisk corneals bilat. Pt following commands intermittantly, moving all extremities, right > left. Pt purposeful w/ movements. Cough intact yet still unable to elicit gag.\n\n pt hemodynamically stable , SR rate 80-90's, did get lopressor 5mg q 6hr. SBP 128-140's. Extremities warm and dry w/ easily palpable pulses. Hct stable at 32.4, lytes all WNL's this AM.\n\n pt remains on PSV 5 and 5 of PEEP w/ RR 18-22 nonlabored w/ TV's 400-550. Breath sounds slightly coarse in upper lobes yet diminished slightly at the bases bilateerally. Suctioned times two for small amt thick yellow secretions. Plan for trial extubation this AM.\n\n pt NPO for potensial extubation, Abd soft nondistended w/ active bowel sounds , no BM's on this shift.\n\nGU- maintaining good U/O on minimal fluids over . weight up slightly at 72.8. BUN and creat stable at .08 and 31.\n\nID- low grade temp overnoc, t max 100.7. Con't on vanco and levoflox. Vanco trough level pnd this AM. WBC's = 10.3 today, down from 12 yesterday.\n\nendo- BS stable off TF's , not requiring coverage at this time.\n\nSkin- abrasions and contusions healing, scrotum excorieated, ointment appllied w/ mycostatin powder where appropriate.\n\nS/O stable , plan for extubation today.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-30 00:00:00.000", "description": "Report", "row_id": 1452555, "text": "RN T/SICU Progress Note\nS/O:\nNeuro: Patient alert, following commands. MAE RUE with strong grasp other extremities move but are weaker.\n\nCV: HR remains 80-90's NSR BP on non-invasive 115's-130's/60's-70's. IV Lopressor 5mg Q4hrs held prn for BP<135 as ordered. Heparin Q8hrs SQ as ordered P-Boots on bilateral LE.\n\nResp: Patient this am on PEEP of 5 and PSV of 5. At 9am changed to CPAP of 5 for 2hours. Patient tolerated change well ABG's remain stable. Patient suctioned for moderate amount of thick tan secretions down ETT and orally. Patient extubated at 1200noon and placed in 70% face tent. Patient with strong productive cough and some gag reflex with mouth care. At 1300 decreased to 50% face tent. Mouth care done patient hard to suction orally due to patient biting down and not letting suction tube pass. Nasal suction for small amounts of thick secretions. Sats remain stable 98-100%.\n\nGU/GI: Abd soft +BS npo for extubation. +loose BM X3 today. Foley draining cloudy yellow urine QS\n\nEndo: FS Q6hrs 8am 132 given 3uR insulin 1400 blood glucose 119 no coverage needed.\n\nID: Remains on IV Vanco and Levo as ordered for + Blood cultures and + cath. tip\n\nSkin: Abrasions on BLE scabbed over with no drainage, contusion on L eye yellow and healing no drainage. Bottom and scrotum reddened mositure barrier cream applied.\n\nMobility: Remains with c-collar on at all times, collar care done. OOB to chair X2 for 2-3 hrs at a time slide board transfer. Patient tolerated well\n\nSocial: Wife and daughters in to visit all day and updated on care and progress. Wife and one daughter went to visit rehabs for future rehab stay. Met with social work and case management.\n\nA: This is a 73 year old man s/p ped vs auto extubated today with thick secretions needing oral and nasal suctioning. Mental status slowly improving following commands and moving appropriately.\n\nP: Continue to monitor respiratory status/pulmonary hygeine. Monitor VS, I&O's, skin care, nutrition, and IV Abx as ordered. Cont to monitor, support patient and family, and follow plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-30 00:00:00.000", "description": "Report", "row_id": 1452556, "text": "SOCIAL WORK NOTE:\nPt extubated today which family is excited about. wife continues to visit rehab options and is hopeful that pt will transfer early next week. This SW will remain involved. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-12-01 00:00:00.000", "description": "Report", "row_id": 1452557, "text": "T/SICU NPN: 1900-0700\nS/O: SYSTEM REVIEW:\nNEURO: AROUSABLE TO VOICE/NAME PERRL 4MM WITH BRISK REACTION\nINTACT CORNEALS OCCASIONAL MOAN/GROAN---NO WORDS YET INCONSISENTLY FOLLOWS COMMANDS MAE RIGHT STRONGER THAN LEFT C-COLLAR REMAINS ON\nCVS: HR 70-90'S NSR WITH NO VEA/AEA SBP 100-120'S LOPRESSOR HELD\nD/T SBP <135 STRONG PALPABLE PEDAL PULSES\nRESPIRATORY: REMAINS EXTUBATED ON 50% FT SAO2 > 96% RR 16-20\nLUNGS MOSTLY COARSE DECREASED AT BASES STRONG SPONTANEOUS COUGH\nALTHOUGH NONPRODUCTIVE NTS TWICE FOR INITIALLY LARGE TO NOW SMALL THICK BLOOD-TINGED TAN SECRETIONS OCCASIONAL ABLE TO SUCTION BACK OF MOUTH ALTHOUGH BITES DOWN AND FIGHTS IT CPT X1\nRENAL: FOLEY PATENT AND DRAINING YELLOW URINE WITH SEDIMENT\n30-70CC/HR K+ 4.0 BUN 28 CREAT .7\nGI: ABDOMEN SOFT WITH +BS NO BM REMAINS NPO IVF: NS AT 40CC/HR\nENDOCRINE: FS 131 3U REGULAR INSULIN SQ 0200 FS 104\nNO INSULIN REQUIRED\nHEME: HCT 32.2 ON HEPARIN SQ AND PNEUMOBOOTS\nID: TMAX 101 WBC 9.9 ON LEVOFLOXACIN AND VANCOMYCIN\nSKIN: BACK AND BUTTOCKS INTACT\nCOMFORT: NO SIGNS OF DISCOMFORT\nPSYCHOSOCIAL: WIFE AND DAUGHTERS IN FOR VISIT LAST EVENING AND PLAN TO COME IN EARLY TODAY TO AVOID TRAFFIC FROM REGATTA\nWIFE CALLED OVERNIGHT UPDATED ON CLINICAL SITUATION AND QUESTIONS ANSWERED\nA: DOING WELL S/P EXTUBATION--MAINTAINING SATURATIONS AND SECRETIONS\nLESSENING\nP: CONTINUE TO MONITOR ABOVE PARAMETERS\n" }, { "category": "Nursing/other", "chartdate": "2187-11-21 00:00:00.000", "description": "Report", "row_id": 1452518, "text": "T/SICU NSG PROGRESS NOTE\n11PM >>0700\n\nNEURO- PERRL/SLUGGISH>BRISK; PUPILS REMAIN DILATED FROM OPTHAL EXAM BUT ARE NOW 5-6MM; IMPAIRED CORNEALS. CONT TO MAE'S BUT DOES NOT FOLLOW. WILL OPEN RUGTH EYE TO VOICE BUT DOES NOT FOCUS OR ATTEMPT TO COMMUNICATE. LUE REMAINS LESS MOBILE/WEAK(D/T CLAVICLE FX/).\n..PT CONT WITH RESTLESSNESS WITH GRADUALLY ELEVATED VS'S..SEE CAREVIEW FLOWSHEET; PT UNABLE TO SLEEP; 1MG MSO4 IVP WITH BRIEF EFFECT.\n\nCVS- ELEVATED VS WITH NSG CARE, INTERVENTIONS; WITH SETTLING WHEN LET ALONE AND WITH SEDATION.\n\nRESP- REMAINS ON PSV/PEEP WITH RR 17-27. CLEAR DIMINISHED BREATH SOUNDS. SMALL TO MOD AMT THICK TAN SECRETIONS. FAIR COUGH; STILL WITH DIMINISHED/IMPAIRED GAG. ABG WNL.\n\nRENAL- ADEQUATE U/O\n IVF AT 60CC/HR\n ELECTROLYTES WNL\n\nID- AFEBRILE; CLINDAMYCIN HAS BEEN D/C'D\n WBC 10(11)\n\nGI- CONT ON TROPHIC TUBE FEEDS; SOFT ABD WITH ABSENT BOWEL SOUNDS; NO STOOL. PEPCID CONT.\n\nENDO- BLOOD SUGARS WNL..NO INSULIN REQUIRED\n\nSKIN- ABRAISIONS HEALING; LEFT EYE LESS SWOLLEN; LACERATION SUTURED: CLEAN & DRY; ECCHYMOSIS REMAINS.\n\nASSESS- ALTERED NEURO STATUS PERSISTS\n AIRWAY STATUS REMAINS QUESTIONABLE ? READINESS TO EXTUBATE AND PROTECT AIRWAY.\n\n\nPLAN- PER TRAUMA/SICU/NEURO TEAMS.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-21 00:00:00.000", "description": "Report", "row_id": 1452519, "text": "SOCIAL WORK NOTE:\nReceived telephone message from pt's wife, . She is eager to set up a family meeting because she wants to hear updates from the various teams at one time. Met with pt's wife and their , and , in pt's room. Family meeting arranged for 2pm tomorrow (Thursday). This SW spoke with Drs. , , and . Dr. will attend and Drs. and that they would have a representative from their teams, neurosurgery and trauma, respectively, available for the meeting. Family and RN informed of meeting time. This SW plans to attend. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-21 00:00:00.000", "description": "Report", "row_id": 1452520, "text": "the pt has been to CT and MRI.the transport went without any problems.\nthe pt remained on cpap 40% 5/5 .abg results:7.43/40/172.bs:clear.\nthe ct showed no changes.the mri is still pending.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-05 00:00:00.000", "description": "Report", "row_id": 1452566, "text": "NURSING PROGRESS NOTE\nS/O- UNCHANGED, PT BUT EASILY AROUSABLE, INCONSISTENTLY FOLLOWING COMMANDS, MOVING ALL EXTREMITIES PURPOSEFULLY, HAND UNRESTRAINED\n PT B/P UPT TO 170 SYSTOLIC, LOPRESSOR 5MG IV Q6 RESTARTED. B/P NOW 14- 150 SYSTOLIC. HR 80-90.\nID- AFEBRILE, REMAINS ON ZOSYN AND VANCO, VANCO LEVELS LOW.\n PT BS 143, 6U REG INSULIN GIVEN.\nNUTRUTION- TPN STARTED WITH LIPIDS. 1750CC \n PT NOT BEING TF AT THIS TIME, SWALLOW STUDY TO BE DONE IN AM, PT LIQUID BROWN STOOL\n PT ON LASIX GTT BEING TITRATED TO KEEP URINE OUTPUT 100CC HR GREATER THAN INTAKE, K BEING REPLETED\n PT REMAINS EXTUBATED ON 60 % FT WITH ADEQUATE SATS, REQUIRING NTS Q2 FOR THICK BLOOD TINGED SECRETIONS, NASAL TRUMPENT INSERTED FOR EASIER ACCESS AND LESS TRAUMA TO NARE RR 20-30.\nA/P- DOING WELL EXTUBATED WILL ASSESS SWALLOWING IN AM, TO BE OOB FOR STUDY. CONT WITH LASIX GTT, REPLETE LYTES AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-05 00:00:00.000", "description": "Report", "row_id": 1452569, "text": " 7p-11p\n\nNEURO: eyes open to speech, PERTL at 3.0mm, MAE with weakness except RUE has normal strength. No verbal.\n\nCV:NSR HR70-80s with no ectopy, SBP 140-150, pulses palpable, skin pink and warm. SCDs BLE for DVT prophylaxis.\n\nRESP: 50% face tent with sats 100%; lungs clear BUL and diminished BLL. Secretions managed with oral sxn q1hr.\n\nGI: NPO with normoactive bowel sounds all quads. TPN at 83cc/hr\nAbdomen is soft/nondistended.\n\nGU: Foley to straight drain, UOP clear/yellow in adequate amounts with a lasix gtt at 1.5mg/hr to keep -100/hr.\n\nSKIN: Warm,dry, intact\n\nLABS: K low, needs one more run of 20meq which is already in the room.\n\nPLAN: ENT came today and scoped after pt did not swallow for test. Found vocal cords intact, but due to inability to swallow, advised PEG placement. SVC discussed this with family and said they would wait a couple of days to see how he does and if no improvement will place a Jtube in the OR.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-06 00:00:00.000", "description": "Report", "row_id": 1452570, "text": "SICU NURSING NOTE 11P-7A\nREVIEW OF SYSTEMS\n\nNEURO: PT LETHARGIC AT TIMES. OPENS EYES TO VOICE AND STIMULI. INTERMITTENTLY FOLLOWING COMMANDS. MAE WITH LEFT SIDE WEAKER ESPECIALLY NOTED IN UPPER EXTREMETIES. PUPILS 3MM/BSK BILAT. WEAKENED CONGESTED COUGH NOTED. NO GAG NOTED. C COLLAR INTACT.\n\nCV: HEMODYNAMICALLY STABLE. LOPRESSOR GIVEN PER PARAMETERS AND WELL. +PP WITH SKIN WARM AND DRY.\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. RR 22-26. FACE TENT INTACT AT 50% WITH SATS 96-98%. 93-94% ON RA. CONGESTED COUGH NOTED. NTS X1 FOR THICK BLOOD TINGED SPUTUM.\n\nGI: REMAINS NPO. ABD SOFT +BS. NO STOOL +FLATUS.\n\nGU: U/O>100CC/HR. LASIX GTT CONTS AT 1.5MG/HR. K REPLETED AGGRESSIVELY\n\nHEME: HCT STABLE 33.1\n\nENDO: BS 129-144 RX'D WITH REGULAR INSULIN PER SS.\n\nID: AFEBRILE. WBC 6. CONTS ON ZOSYN AND VANCOMYCIN.\n\nSKIN: INTACT.\n\nSOCIAL: WIFE UPDATED VIA PHONE.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-06 00:00:00.000", "description": "Report", "row_id": 1452571, "text": "NURSING PROGRESS NOTE SEE CAREVIEW FOR DETAILS.\n\nNEURO:PUPILS 3MM AND BRISKLY REACT TO LIGHT.FOLLOWS SOME COMMANDS.LEFT SIDE APPEARS STRONGER THAN RIGHT SIDE.WAS ABLE TO STAND AND USE LEFT LEG TO PIVOT TO CHAIR.WRITES NOTES WITH RIGHT HAND.OCCASSIONALY WILL SPEAK AND ANSWER YES OR NO OR WILL NOD HEAD.IS NOT ALWAYS CONSISENT IN FOLLOWING COMMANDS.SOMETIMES APPEARS LETHARGIC ,MORE REACTIVE WHEN SITTING UP IN CHAIR AND INTERACTING WITH FAMILY.\n\nCV:REMAINS IN NSR WITHOUT ECTOPY.BP STABLE,TOLERATING LOPRESSOR.FEET WARM WITH BIL DP AND PT PULSES PRESENT.\n\nRESP:BREATH SOUNDS CLEAR BUT DIMINISHED BIBASILAR.WAS NT ONE TIME FOR BLOOD TINGED SECRETIONS.RESP RATE 20 TO 30 WITH SP02 95 TO 97%.\n\nGI:ABD SOFT WITH POSITIVE BOWEL SOUNDS PRESENT,REMAINS NPO.EVALUATED BY SPEECH AND SWALLOWING PT WAS LETHARGIC AT TIME AND WAS UNABLE TO EVALUATE.GAG IS ABSENT.\n\nGU:REMAINS ON LASIX GTT.URINE CLEAR .\n\nSOCIAL:VISITED BY DAUGHTER AND WIFE AND UPDATED ON CONDITION.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-06 00:00:00.000", "description": "Report", "row_id": 1452572, "text": "SOCIAL WORK NOTE:\nMet with pt's wife this afternoon to offer continued support. Their son, , is back from CA and dtr, , is back from NM. wife seems in good spirits and is hopeful about pt's continued progress. She is continuing to pursue temporary guardianship and will be going to court tomorrow. She continues to limit visitors to immediate family only as she believes that this would be in keeping with pt's wishes. This SW will remain involved. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-11-26 00:00:00.000", "description": "Report", "row_id": 1452538, "text": "SOCIAL WORK NOTE:\n\nFamily meeting held again this afternoon with pt's wife, , and their children, , and . This SW, RN and MD were present for meeting. Meeting was arranged to discuss trach placement for pt for comfort and health reasons. wife remains opposed to this at this time because she wants to \"give him a chance\" to recover without taking step of trach placement. Medical team expressed their opinion about why trach placement would lead to greater comfort for pt among other reasons. wife also seems concern that trach placement would rush rehab placement. Medical team has tried to assure her that this is not the case. wife and children had many questions about trach process which were answered. wife plans to talk with pt's PCP about this issue and seems open to further conversation about this after that conversation has happened. Wife was encouraged to refer PCP to Dr. for medical update if she wishes. Pt's children seem more in favor of trach placement than his wife does. This SW will remain involved. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-12-05 00:00:00.000", "description": "Report", "row_id": 1452567, "text": "npn\ns=responds verbally to questions.\no=pupils equal and reactive. moves all extremities. follows commands for the most part. speaking in quiet voice--seems to respond appropriately to questions.\ncv=monitor pattern nsr, no vea. bp 150's on lopressor 5mg iv. becomes hypertensive when nt or coughing. resolves quickly. ivf at kvo. lasix drip at 1.5mg tpn at 73. mg and kcl repleted.\npulm=shovel mask at 60%. stas=97-100%. breath sounds clear upper, diminished lower bilaterally. coughs well, but is unable to raise secretions to expectorate them. nt for mod. amts thick\nblood-tinged secretions, approx. q 2-3 hrs.\ngi=npo. positive bowel sounds. sm. smear stool. abdomen soft.\ngu=foley patent for copious amts yellow urine with sediment. lasix drip continues as above. plan to keep -100cc/hr.\nskin=intact.\nendo=glucoses covered as per sliding scale.\na=stable overnight with vigilant pulmonary toilet.\np=plan speech and swallow study. ot and pt to visit.\n\n\n\n\n\n\n\n\nblood-tinged secretions, approx. q 2-3 hrs/\n\n" }, { "category": "Nursing/other", "chartdate": "2187-12-05 00:00:00.000", "description": "Report", "row_id": 1452568, "text": "NSG NOTE\n\nROS:\n\n CV:HEMODYNAMICALLY STABLE,AFEBRILE.\n\n RESP:SX THIS AM BY NURSE FOR MOD AMT SECRETIONS.PT HAS STRONG PRODUCTIVE COUGH BUT CN'T RAISE AND SPIT SECRETIONS OUT.ABLE TO SX BACK OF THROAT FOR MOD AMT THIS PM WITHOUT NEED FOR NT SX.SAT 97 ON 50% FT.\n\n NEURO:NOT VERY RESPONSIVE THIS AM,? IF ON PURPOSE.SEEMED TO BE MORE ACTIVE AFTER UP IN CHAIR.QUITE PURPOSEFUL IN MOVEMENTS.TRIED TO PIVOT UP TO CHAIR AND BACK TO BED,PT DIDN'T PUT WEIGHT ON LEGS AT ALL,BUT IS QUITE ACTIVE IN BED.\n BY SPEECH AND SWALLOW AS WELL AS ENT TODAY(SEE CHART FOR NOTES)\n\n GU:ON LASIX QTT,EXCELLENT DIURESIS.\n\n GI:NPO,ON TPN\n\n SOCIAL:WIFE AND CHILDREN IN ALL DAY.THEY SPOKE TO SICU ATTENDING,SPEECH AND SWALLOW AND ENT SO THEY ARE UP TO DATE WITH ALL THOUGHTS.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-29 00:00:00.000", "description": "Report", "row_id": 1452552, "text": "T/Sicu NSg Progress Note\n0700>>1500\n\nEvents:\n ENT consult done\n Tube feeds held pnd possible extubation trial>> trial deferred until am because time of extubation today would be too late in the day.\n\nNeuro- calm; responds to voice quickly & easily. Following consistently today and appropriately but at times still slowly..needing encouragement. Continued to have left sided weakness..both upper and lower extremities.\n+ cough\nstill absent gag\n\ncvs- vss..see careview. lopressor held per parameter quidelines.\n\nresp- psv/peep 40% with adeqaute sao2. rr 20's with spontaneous tidal volumes 350>>500cc. No arterial line..no abg's done.\n..breath sounds are coarse with diminished bases. secretions are thick and tan and difficult to clear. cough fair with stimulatin of suctioning.\n\nrenal- adeqaute hourly urine via foley..clear.\n\nheme- no issues\n\nID- temp 99.5.. wbc 12 today(^);cont on levoquin and vancomycin(+GPC blood )\n\nGI- tube feeds at goal, stopped for ?? extubation today. Restart delayed d/t ?? tube placement when tube coiling noted in back of mouth. done to confirm placement...feeds restarted @ 1600.\n..abd soft; stool x1 loose brown.\n\nendo- q6/hr blood sugars; ssri per order; 9u given this am with 2pm value of 116.\n\nskin- healing abraisions/lacerations.\n palpable pulses; compression boots in use\n no issues on back/buttocks.\n\n c-collar in place\n nystain for oral thrush\n\nassess- cont slow waking with improving neuro responses; cont with left side weakness.\n rehab activities progresing\n airway protection issues\n\nplan- cont with current plan of care\n extubation trial in am; hold tube feeds at midnight for early am extubation. Pt to be monitored throughout day for resp distress/airway issues.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-29 00:00:00.000", "description": "Report", "row_id": 1452553, "text": "TRAUMA SICU NPN\nO:\nNEURO: NEURO STATUS SLOWLY IMPROVING. CONT W/ L SIDED WEAKNESS. MAE AND CONSISTENTLY FOLLOWS COMMANDS. GIVING THUMBS UP TO ANSWER YES/NO QUESTIONS.\n\nCV: STABLE HEMODYNAMICS. HR 90'S NSR, NO ECTOPY W/ BP 120-130/60-70.\nLOPRESSOR NOT GIVEN TODAY.\n\nRESP: COUGH STRONGER, GAG REMAINS ABSENT. SM - MOD ORAL SECRETIONS AND\nSXN FOR SM-MOD AMT SPUTUM. REMAINS ON PSV 5 W/ RR 20'S AND ADEQUATE TV. 02SATS 98%.\n\nRENAL: ADEQUATE U/O.\n\nGI: CONT ON TF AT GOAL TO BE HELD AFTER MN FOR EXTUBATION IN AM. ABD SOFT W BS PRESENT. LGE LOOSE BROWN STOOL TODAY.\n\nHEME: STABLE\n\nID: TMAX 100. REMAINS ON VANCO AND LEVOFLOX. VANCO LEVEL PND.\n\nSKIN: PERIRECTAL AREA RED AND EXCORIATED. UNABLE TO PLACE FECAL INCONTINENCE BAG. PROTECTIVE CREAM APPLIED. MICONAZOLE POWDER ALSO APPLIED. BACKSIDE INTACT. ABRASIONS AND CONTUSIONS ARE HEALING.\n\nACTIVITY: OOB-CHAIR FOR 5 HRS AND TOL WELL. NO WT BEARING, TOTAL LIFT.\n\nSOCIAL: FAMILY IN AND ANXIOUS FOR TRIAL OF EXTUBATION. WIFE AND DAUGHTER WILL BE IN TOMORROW AM.\n\nA: STABLE. COUGH STRONGER BUT GAG REMAINS ABSENT. IMPAIRED SKIN INTEGRITY. NVS SLOWLY IMPROVING.\n\nP: NPO AFTER MN. PULM TOILET OVERNOC AND EXTUBATE IN AM W/ CAREFUL MONITORING. RESUME LOPRESSOR AS BP INCREASES. CONT ABX. DILIGENT SKIN CARE, PROTECTIVE CREAM. FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-28 00:00:00.000", "description": "Report", "row_id": 1452549, "text": "NURSING PROGRESS NOTE\nS/O- STABLE EVENING, PT OOB UNTIL 6PM WHEN LIFTED BACK TO BED. PT HAS BEEN RESTING SINCE THAT TIME, BUT IS EASILY AROUSED AND IS NOW INTENTENTIONALLY CLICKING HIS O2 SAT MONITOR AGAINST THE BEDRAIL. HE IS MOSTLY CONSISTENT WITH FOLLOW COMMANDS RT STRONGER THAN LEFT. CV STATUS STABLE, LOPRESSOR HELD FOR B/P OF 130. RESP STATUS UNCHANGED. TF REMAIN AT GOAL.CONT TO REQUIRE INSULIN SC. PT PASSING LARGE AMT OF LOOSE STOOL. ABRAISIONS HEALING. ADEQUATE U/O.\nA/P PT STABLE, ENT CONSULT TO BE DONE PER REQUEST OF WIFE BEFORE TRACH AND PEG WHICH SHOULD BE DONE BY , PT NEEDS TO BE SCREENED BY REHAB.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-20 00:00:00.000", "description": "Report", "row_id": 1452514, "text": "npn\ns=orally intubated.\no=neuro=opens eyes at times on command, at times spontaneously, sometimes not to command. pupils remain somewhat dilated from previous eye exam. no corneal reflex on left. moves all extremities; inconsistently to command. strong grasp bilaterally when able to grasp on command. good strength in legs. positive bilateral pedal pulses. feet warm, color good. left eye wound with scant serosanguineous drainage.\ncv=monitor pattern--nsr to st; no ventricular ectopy noted. becomes quite hypertensive when disturbed, or when care is being rendered, but resolves quickly without intervention. ivf at 60cc/hr.\npulm=continues on pressure support 5 and peep 5cm and 40% fio2. resp. rate=17-21. tidal volumes=350--460 and as high as 600's when disturbed. breath sounds diminished bilaterally to bases. suctioned for scant amts. tan thick secretions. sats=100%.\ngi=positive bowel sounds. abdomen soft, non-distended. trophic tube feeds of impact with fiber at 10cc/hr with residuals 5cc or less. no flatus or stool this shift.\ngu=foley patent for clear yellow urine.\nendo=glucose covered as per sliding scale.\nid=low grade temp. 100.2 at start of shift; currently 99.5. wbc's 11. continues on clindamycin.\nsocial=son with pt. all night.\nskin=open areas on lower extremities unchanged.\na=stable overnight. no issues.\np=for repeat ct today. continue to monitor neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-20 00:00:00.000", "description": "Report", "row_id": 1452515, "text": "T/SICU NPN 7A->3PM:\n\nNEURO: PT - OFF SEDATION - LABILE NEURO EXAM: INCONSISTENTLY F/C'S TO OPEN EYES/MOVE EXTREMITIES. COUGH REFLEX INTACT/GAG IMPAIRED. PUPILS REMAIN DILATED S/P OPTHAMOLOGY STUDY : 6MM/SLUGGISH - (+)CORNEALS R>L. GIVEN MSO4 1MG X 2 FOR PAIN W/ (+) EFFECT - RESTING COMFORTABLY - SLEPT ON/OFF. REPEAT HEAD CT TODAY->UNCHANGED. CONTINUES IN C-COLLAR.\n\nCV: HR SR 70-80'S, SBP 130-140'S: PT HYPERDYNAMIC W/ STIMULATION/AGITATION. PULSES EASILY PALPABLE, SKIN WARM/DRY/PINK. LYTES REPLETED.\n\nRESP: LUNG SOUNDS DIMINISHED THROUGHOUT. VENT SETTINGS UNCHANGED. STRONG COUGH EFFORT - SXN FOR SM AMTS THICK/TAN SECTRETIONS. RR 16-22, SATS 98-100%. SEE CAREVIEW FOR ABG DATA. CONTINUES ON VENT UNTIL NEURO EXAM IMPROVES - UNABLE TO SELF MAINTAIN AIRWAY AT THIS TIME.\n\nGI: ABD SOFT, NT/ND W/(+)BS - NO BM. TROPHIC TF HELD FOR POTENTIAL EXTUBATION - (?) RESTART. NPO X MEDS. NGT TO LWCS DRIANING SM AMT BILIOUS FLUID.\n\nGU: FOLEY CATHETER PATENT DRAINING ADEQUATE HOURLY VOLUME OF CLEAR YELLOW URINE.\n\nENDO: GLUCOSE LEVELS <120 - NO SSRI COVERAGE REQUIRED.\n\nID: TMAX 100.0->99.8. CONTINUES ON CLINDAMYCIN.\n\nSKIN: FACIAL LAC'S INTACT - SUTURES SECURELY IN PLACE - BACITRACIN APPLIED. BACK/BUTTOCKS INTACT. SKIN ASSESSMENT UNCHANGED.\n\nSOCIAL: SPOUSE @ BEDSIDE MOST OF THIS SHIFT: REQUIRED REDIRECTION/LIMIT SETTING ON SEVERAL OCCASIONS BY VARIOUS STAFF MEMBERS->WIFE STATES SHE \"WAS A NURSE\" AND ASKS MULTIPLE SPECIFIC/DETAILED/STATISICAL QUESTIONS. FURTHER CONTINUES TO STIMULATE PT STATING \"OKAY, LET'S GO - ENOUGH SLEEP. IT'S TIME TO OPEN THOSE EYES\" AS WELL AS OFTEN REQUESTING PT TO MOVE EXTREMITIES TO COMMAND. WIFE FURTHER STATES THAT HER ACTIONS ARE AS HIS \"PATIENT ADVOCATE\" WITH REGARD TO THIS AND ANALGESIA ISSUES. WIFE REASSURED BY THIS RN THAT STAFF ADVOCATES FOR PT IN HER ABSENCE - ALSO ASKED TO LIMIT/MINIMALIZE ACTIVITY THAT SERVES TO ESCALATE/OVER STIMULATE PT. WIFE VERBALIZES UNDERSTANDING OF THESE REQUESTS. SW CLOSELY FOLLOWING PT/FAMILY.\n\nA/P: HEMODYNAMICALLY STABLE - LABILE NEURO EXAM. AWAITING PT TO F/C'S MORE CONSISTENTLY BEFORE EXTUBATING. CONTINUE PER PLAN OF CARE - FULL SUPPORT/COMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-20 00:00:00.000", "description": "Report", "row_id": 1452516, "text": "Respiratory Care Note:\n Patient remains and sedated on PSV of and 40% with tidal volumes of 450-550, RR=15-18, VE of app 8L. BS equal bilat, decreased LLL. Secretions less today, less blood from oropharynx. NIF -25. Patient less responsive today. Extubation held. Head CT repeated this am without significant change. Plan to leave until more awake. Sedation is off - received propofol 10am for CT scan.\n" }, { "category": "Nursing/other", "chartdate": "2187-11-20 00:00:00.000", "description": "Report", "row_id": 1452517, "text": "NURSING PROGRESS NOTE\nS/O- NEURO- EXAM UNCHANGED, WAXES AND WANES, INCONSISTANT, INITIALLY DIFFICULT TO AROUSE, AS NIGHT PROGRESSED PT MORE AWAKE, MOVING FEET CONSTANTLY, OCCASIONALLY FOLLOWING TO COMMAND, OPENING EYES SPONT. PUPILS REMAINS DILATED, AT 6 AND REACTIVE, COLLAR REMAINS ON, SKIN INTACT.\n PT CONT TO GET HYPERTENSICE WITH NURSING CARE AND NEURO ASSESSMENTS, B/P WILL COME DOWN ONCE PT IS LEFT ALONE,IVF CONT AT 60CC HR, K+3.8 20 MEQ GIVEN PO.\nID- T 99.3, PT CONT ON CLINDA.\n PT CONT TO BE , ON PSV OF WITH SATS OF 99-100% RR 13-16. TV 400-550. SUCTIONED FOR MOD AMTS OF THICK TAN SECRETIONS.\nPT CONT TO HAVE LARGE AMT OF THICK OLD BLOODY SECRETIONS ORALLY.\nGI- RESTARTED ON TROPHIC FEEDS AT 10CC HR OF IMPACT WITH FIBER , ABD SOFT, NO BOWEL SOUNDS AND NO STOOL.\nGU- ADEQUATE U/O.\n PT ON SS RECEIVED 2U REG INSULIN.\nSKIN- ABRAISIONS HEALING, NO DAINAGE FROM SUTURE ED LAC ON FOREHEAD. SKIN ON BACK AND BUTTUCKS INTACT\nSOCIAL- FAMILY IN TO VISIT MOST OF SHIFT, SON WILL STAY THE NIGHT.\nA/P- CONT TO KEEP UNTIL PT WAKENS MORE AND NEURO EXAM IS MORE AND PT CAN PROTECT AIRWAY, CONT TO MONITOR AND SUPPORT.\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-29 00:00:00.000", "description": "Report", "row_id": 1452550, "text": "NSG NOTE:11P-7A:\nNEURO: PT TO IMPROVE SLOWLY, FOLLOWING COMMANDS MOST OF THE TIME, MIN MOVMT FROM L SIDE. PERLA, WEAK GAG, STRONG COUGH. C COLLAR INTACT.\n\nRESP:NO VENT CHANGES MADE, REMAINS ON PULLING SUFFICIENT TIDAL VOLUMES. O2 SATS 99%PT W/ THRUSH IN MOUTH VERY RESISTANT TO MOUTH CARE, MOD AMTS ORAL SECRETIONS NOTED. AGGRESSIVE MOUTH CARE GIVEN. LS CTA BILAT.\n\nCV:HEMODYNAMICALLY STABLE. NIBP CUFF 120'S-30'S/70'S, NO ECTOPY NOTED NSR 80'S. PULSES PALP THROUGHOUT, NO EDEMA NOTED.\n\nGI/GU: NO BM X8HR, POSITIVE BS, IMPACT W/ FIBER AT 95CC/GOAL VIA DOBHOFF TO R NARE. FOLEY TO GRAVITY, QS UOP YE W/ SEDIMENT.\n\nTMAX 99.5, WBC UP TO 12.8 PT ON VANCO, ENT TO DISCUSS W/ WIFE PT NEED FOR TRACH PROVIDE EMOTIONAL SUPPORT PRN, CONT W/ POC\n\n\n" }, { "category": "Nursing/other", "chartdate": "2187-11-29 00:00:00.000", "description": "Report", "row_id": 1452551, "text": "SOCIAL WORK NOTE:\nMet with pt's this afternoon for emotional support. Pt might be able to be extubated tomorrow which has brought a great sense of relief to his wife with whom I also spoke this afternoon. She is busy visiting potential rehabilitation centers and today this SW connected her with for further discussion of this topic. This SW will remain involved. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2187-12-03 00:00:00.000", "description": "Report", "row_id": 1452563, "text": "TRAUMA SICU NPN\nO:\nNEURO: PT SL LESS RESPONSICVE TODAY. RECEIVED MS04 DURING THE DAY FOR FEEDING TUBE PLACEMENT. CONT TO MAE, RESTLESS WITH LEGS AND LOCALIZES W/ BUE R>L. NODDING RARELY TO QUESTIONS. NOT FOLLOWING COMMANDS.\nC-COLLAR REMAINS ON.\n\nCV: STABLE HEMODYNAMICS AND SWAN D/CED. TRIPLE LUMEN WIRED.\nHR 90'S NSR, BP 120/70.\n\nRESP: REMAINS ON 10PS/5PEEP. RR 16-20'S WITH ADEQUATE TV. STABLE ABG ON CPAP TRIAL. MODERATE AMT SECRETIONS. STRONG COUGH, NO GAG.\n\nRENAL: BRISK U/O. K=3.7. 20KCL INFUSING.\n\nGI: TROPHIC TF UNTIL 7PM. FEEDING TUBE CLOGGED AND UNABLE TO CLEAR. TF ON HOLD FOR EXTUBATION TOMORROW. NO STOOL TODAY. ABD SOFT.\n\nHEME: STABLE.\n\nID: CONT ON ZOSYN AND VANCO. TMAX 100.4. CX'S PND.\n\nSKIN: INTACT\n\nSH: WIFE AND SON IN VISITING. WIFE FEELING STRESSED ABT PT'S ILLNESS AND OTHER FAMILY STRESSORS. WILL BE IN TOMORROW.\n\nA: STABLE HEMODYNAMICS. LESS RESPONSIVE THIS EVE. STABLE ON PSV.\n\nP: PLAN IS TO HOLD TF AND EXTUBATE. ASSESS PT FOR IMPROVED ALERTNESS PRIOR TO EXTUBATION. CONT ABX. AWAIT CX'S. FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-04 00:00:00.000", "description": "Report", "row_id": 1452564, "text": "npn\ns=.\no=follows commands, opens eyes spontaneously, moves all extremities to command. pupils equal and reactive.\ncv=monitor pattern=nsr, no vea. bp maintained independently with map > 60 all shift. no pressors since 1900hr. ivf at 40cc/hr. kcl and mg repleted.\npulm=on pressure support 10-peep 5cm and 40 % all night. sats good, abg good, resp. rate 10-20's. tidal vol.=450-470. breath sounds clear upper, decreased lower bilaterally. for thin tan secretions. placed on in=line trach collar at 0600 by resp. therapy.\ngi=npo for planned extubation this a.m. incontinent of mod. amt dark brown thick liquid stool.\ngu=foley patent for yellow urine.\nid=afebrile.\nendo=glucoses wnl. no issues.\na=stable overnight.\np= plan extubation this a.m.\n" }, { "category": "Nursing/other", "chartdate": "2187-12-04 00:00:00.000", "description": "Report", "row_id": 1452565, "text": "T/SICU RN Progress Note\nResp: Extubated today at 1030am. Orally at that time for large amount of clear secretions. Sats remain stable 95-98% on Face Tent 60%. Lungs clear but decreased in bases. Chest PT done patient with productive cough.\n\nCV: HR 80-90's NSR, ABP 130-150's/60's-80's with MAP's 90-100's. P-Boots on Bilat. LE on Heaprin Q8hrs.\n\nGU/GI: Abd soft +BS feeding tube d/c'd per team to be started on TPN at 1800. Foley draing clear yellow urine >100cc/hr. Placed on Lasix gtt to keep net balance -100cc. Lasix gtt titrated. Speech and swallow eval ordered, await procedure.\n\nNeuro: Patient arouses to voice follows simple commands.\n\nHeme/Lytes: HCT 23.4 ordered 2UPRBC. K+ and Phos repleated\n\nID: Conts on Zosyn and Vanco. HO Boukman notified of subtherapeautic Vanco levels.\n\nMobility: PT to see today to get OOB to chair\n\nSocial: Wife in to visit updated on condition and plan of care.\n\nA/P: Cont to monitor resp. function I&O's titrate Lasix gtt, PT to see, await speech and swallow eval, cont to monitor, support patient and family, and cont to follow plan of care.\n" } ]

[ { "category": "Radiology", "chartdate": "2168-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991321, "text": " 12:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 44-year-old man with respiratory distress, evaluate for\n CHF.\n\n FINDINGS: Upright portable AP chest radiograph obtained. Right IJ central\n line is seen with its tip in the proximate location of the superior vena cava.\n The heart appears enlarged. Low lung volume somewhat limit evaluation, as\n does patient motion. There is, however prominence of pulmonary vasculature,\n with indistinct pulmonary hila. Findings are compatible with congestive heart\n failure. There may be right basilar atelectasis and small effusion. No\n pneumothorax. Mediastinal contour is unremarkable.\n\n IMPRESSION:\n\n Right IJ central line in acceptable position.\n\n Cardiomegaly, congestive heart failure.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-12-06 00:00:00.000", "description": "Report", "row_id": 1635726, "text": "addendum:\n\nGU: voided 90cc of clear yellow urine this 1800, 4th exchange started, draining at of this time. Dwelling for this exchange will be 4hrs.\n\nEndo: on RISS, coverage given for FS 204 and 151\n\nHeme: rpt CBC at 1400, hct 29.1 from 26.5 this am. continues on procrit 3x/week\n\nSkin: intact\n\nSocial: patient wife at bedside, updated with . For transfer to 717, transfer note faxed. Will call for report. Patient wished to be discharge to home , but team are not comfortable sending patient back home since he was on nitro drip upon admission and was off drip just this am.\n\nplan:\n\nfor transfer to 7, monitor hemodynamically. keep BP to goal 120-130's systolic, continue PD exchange q4hrs starting now. Goal > 500 cc drain per exchyange.\n" }, { "category": "Nursing/other", "chartdate": "2168-12-06 00:00:00.000", "description": "Report", "row_id": 1635724, "text": "Nursing Progress Note:\nNo events overnight; unable to perform peritoneal dialysis tonight as pt PD catheter Fresenius brand, and incompatible with Baxter brand, renal team in to see pt and aware unable to do PD, since pt not in resp distress, no SOB, will see pt in am and decide what to do with equipment\n\nNKDA\n\nFULL CODE\n\nUNIVERSAL PRECAUTIONS\n\nNEURO: pt alert and oriented x3, follows commands, moves all extremities; PERL, pupils 3mm and brisk bilaterally; c/o HA intermittantly throughout shift, given tylenol x1 and cold compress with some relief, team aware, no further intervention at this time, pt sleeping and appears comfortable presently\n\nCV: HR NSR with T wave inversion; EKG done, CE's drawn, tropinin from 0.10 to 0.14, team notified; lopressor ; continues on nitroglycerin gtt @ 1mg/kg/min; SBP 130's-110's, MAP >60; difficult to palpate pedal pulses; non-pitting edema lower extremities; restarted procrit tonight; am labs pending\n\nRESP: LS clear at apices, with crackles RLL, dim at LLL; weaned O2 to 2LNC, satting 92-96%; RR regular 25-13, denies SOB, no wheezing\n\nGI/GU: cardiac diet, good PO intake; abd soft obese; +BS, +flatus, no stools; on bowel regimen; PD cath intact; pt voided 50cc this shift, anuric at baseline; plan to do PD this am when correct equpment available\n\nSKIN: WNL\n\nACCESS: port-a-cath intact, PIV x1 WNL\n\nPOC: PD in am; wean nitro gtt with PD, to goal SBP 120-130; follow lytes, FS\n\n" }, { "category": "Nursing/other", "chartdate": "2168-12-06 00:00:00.000", "description": "Report", "row_id": 1635725, "text": "12 hrs events: Nitro drip dc' NP came and change PD catheter tubing. Peritoneal dialysis restarted, rapid exchange done q2hrs x 4, q4hrs thereafter.\n\nNeuro: oriented x 3, OOB to commode independently. Received tylenol 650 mgs x 1 for headache at around 0800, no complaints thereafter.\n\nCV: lopressor increased from 25mg to 37.5 mg TID after nitro drip was dc'd. Hemodynamically stable, SBP 130-150's, goal 120-130. SR-ST without ectopy. +2 edema of lower extremities, pedal pulses x4. cardiac echo done this am, result pending.\n\nrespi: off of O2 by 1000, sats > 95% at room air. lung sounds clear, dim at RLL. BNP >70K, CHF consistent per CXR. Occasional non-productive cough.\n\nGI: tolerating PO's, soft - loose BM x3 on bowel regimen. Will continue on bowel regimen to promote better emptying of PD, non-tender abdomen.\n\nGU: voided 100cc of clear yellow urine x 1, PD restarted 1st exchange no drainage, 2nd exchange 350cc, 3rd exchange 700cc - all clear yellow. Uneventful PD so far, patient remained stable the whole time dialysis is done. Next exhange due at 1800, dwellingtime will be 4 hrs per renal attending.\n" }, { "category": "Echo", "chartdate": "2168-12-06 00:00:00.000", "description": "Report", "row_id": 85618, "text": "PATIENT/TEST INFORMATION:\nIndication: Chemotherapy. Pulmonary embolus. Left ventricular function. Right ventricular function.\nHeight: (in) 71\nWeight (lb): 257\nBSA (m2): 2.35 m2\nBP (mm Hg): 143/110\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:04\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV\ncavity size. Moderate-severe global left ventricular hypokinesis. No LV\nmass/thrombus. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Mildly dilated aortic arch. No 2D or Doppler\nevidence 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.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is top normal/borderline dilated.\nThere is moderate to severe global left ventricular hypokinesis (LVEF = 25-30\n%). No masses or thrombi are seen in the left ventricle. Right ventricular\nchamber size and free wall motion are normal. The aortic root is mildly\ndilated at the sinus level. The aortic arch is mildly dilated. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\nIMPRESSION: Borderline left ventricular cavity dilation with moderate to\nsevere global hypokinesis c/w diffuse process (toxin, metabolic, cannot\nexclude multivessel CAD). Dilated thoracic 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": "ECG", "chartdate": "2168-12-05 00:00:00.000", "description": "Report", "row_id": 218618, "text": "Sinus rhythm. ST-T wave changes in leads I,II, aVL and V3-V6. Consider\nmyocardial ischemia. Clinical correlation is suggested. Compared to\ntracing #1 the rate is slower and there is less baseline artifact making\ninterpretation more clear.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2168-12-05 00:00:00.000", "description": "Report", "row_id": 218619, "text": "Sinus tachycardia. Baseline artifact. Diffuse non-specific ST-T wave changes.\nNo previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2147-05-05 00:00:00.000", "description": "Report", "row_id": 79569, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Murmur.\nHeight: (in) 67\nWeight (lb): 200\nBSA (m2): 2.02 m2\nBP (mm Hg): 120/53\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 11:45\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. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\n1.The left atrium is mildly dilated. The left atrium is elongated.\n2.There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). While the views are somewhat limited, no wall motion abmormalities\nseen.\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen.\n5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n6.Moderate [2+] tricuspid regurgitation is seen.\n7.There is moderate pulmonary artery systolic hypertension.\n8.There is no pericardial effusion.\n\nIMPRESSION:\nNo echocardiographic evidence of endocarditis.\n\n\n" }, { "category": "ECG", "chartdate": "2147-05-04 00:00:00.000", "description": "Report", "row_id": 209635, "text": "Sinus tachycardia. Diffuse low voltage. Compared to the previous tracing\nof evidence for prior inferior myocardial infarction is not apparent.\nThe voltage has diminished markedly. Followup and clinical correlation are\nsuggested.\n\n" }, { "category": "Radiology", "chartdate": "2147-05-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 908385, "text": " 2:20 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess cvl placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with fever, n/v, LIJ placed\n REASON FOR THIS EXAMINATION:\n assess cvl placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old female with fever, nausea and vomiting, status post\n left IJ placement. Evaluate.\n\n COMPARISON: None.\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A left internal jugular central venous\n catheter terminates within the mid SVC. There is no pneumothorax. The\n cardiac silhouette, mediastinal contours are normal. There is mild fullness\n of the right hilum, which may represent an early pneumonia. The left lung is\n clear, and there are no effusions bilaterally. The surrounding soft tissue\n and osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Left IJ catheter with tip in mid SVC.\n 2. No pneumothorax.\n 3. Mild opacification at right medial lung base may represent atelectasis\n versus pneumonia. Lateral film is recommended for further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-05-04 00:00:00.000", "description": "B CT LOW EXT W&W/O C BILAT", "row_id": 908417, "text": " 7:07 PM\n CT LOW EXT W&W/O C BILAT Clip # \n Reason: r/o osteomyelitis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with sepsis likely source foot ulcers.\n REASON FOR THIS EXAMINATION:\n r/o osteomyelitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old female with sepsis likely source of foot ulcers. Rule\n out osteomyelitis.\n\n CT lower extremity, left.\n\n TECHNIQUE: Axial images were obtained of the left and right foot with\n multiplanar reconstructions.\n\n FINDINGS:\n\n In the left foot, there are extensive destructive bony changes and bony\n fragmentation in the mid and hind foot consistent with neuropathic changes. At\n the first tarsometatarsal joint, there are lytic changes and a large soft\n tissue ulcer with gas extending to the underlying bone. These findings are\n concerning for osteomyelitis. There is extensive soft tissue swelling.\n\n Within the right foot, there are severe neuropathic changes particularly at\n the tarsometardal joints medially. There is soft tissue prominence adjacent\n to the 1st TMT joint. Bony fragmentation is also seen in this region. No\n large ulcerations are seen nor are any focal areas of gas. The patient is\n status post left second digit amputation at the base of the 2nd proximal\n phalanx.\n\n IMPRESSION:\n\n 1. New large medial plantar ulcer of the left foot adjacent to the 1st TMT\n joint with extension of gas down to bone. These findings are concerning for\n osteomyelitis. There are extensive neuropathic changes of the mid and hind\n foot.\n\n 2. Within the right foot, neuropathic changes are seen of the midfoot,\n however, no significant ulcer or gas formation is identified. If there is\n further clinical concern.\n\n These findings were discussed with Dr. at 10:40 a.m. on .\n\n\n\n\n\n\n (Over)\n\n 7:07 PM\n CT LOW EXT W&W/O C BILAT Clip # \n Reason: r/o osteomyelitis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Respiratory ", "chartdate": "2121-09-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597630, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: 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 Comments: Increase PS as needed with possible extubation tomorrow.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2121-09-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597736, "text": "Chief Complaint:\n 24 Hour Events:\n - trial of PSV and decreased PEEP - RSBI @ 28, hopeful trial of\n extubation tomorrow\n - medications switched to PO to help reduce fluid load\n - lasix drip weaned with continued large urine output\n - diamox added to help diurese and waiste bicarbonate to elevate\n respiratory drive in setting of metabolic alkalosis\n - picc line placed, a-line removed as non-invassive BP correlates\n - NG exchanged for OG tube for anticipated swallowing difficulties s/p\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:36 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.5\n HR: 57 (52 - 66) bpm\n BP: 121/43(62) {105/39(55) - 167/70(92)} mmHg\n RR: 10 (8 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 8 (8 - 9)mmHg\n Total In:\n 4,027 mL\n 642 mL\n PO:\n TF:\n 1,080 mL\n 149 mL\n IVF:\n 877 mL\n 192 mL\n Blood products:\n Total out:\n 5,000 mL\n 1,520 mL\n Urine:\n 4,000 mL\n 870 mL\n NG:\n Stool:\n 1,000 mL\n 650 mL\n Drains:\n Balance:\n -973 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 855 (453 - 855) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 9\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.43/55/95./37/9\n Ve: 6 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General: NAD, responsive to commands\n Lungs: soft crackles at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, no CC, mod. pitting edema, DP 2+\n Labs / Radiology\n 271 K/uL\n 8.1 g/dL\n 178 mg/dL\n 3.2 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 89 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 8.7 K/uL\n [image002.jpg]\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n WBC\n 7.5\n 9.9\n 9.4\n 8.7\n Hct\n 23.7\n 26.6\n 28.2\n 26.6\n 25.4\n Plt\n 71\n Cr\n 3.9\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n TCO2\n 35\n 37\n 38\n 38\n Glucose\n 241\n 138\n 184\n 153\n 188\n 178\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\ns, no organisms, NGTD\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n extent of ventilated has substantially increased in upper\n and lower lobes bilaterally, persistent retrocardiac atelectasis with\n sparse air bronchograms\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (5 of 14) and linezolid (5 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 20L for 1L overnight\n - f/u cultures and CXR\n - attempt SBT and trial of extubation\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - add Amlodipine 5 mg today and wean down PO hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - Na normalized, may decrease free water flushes\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - continue to trend daily HCT\ns with transfusion if HCT < 23\n will\n avoid transfusion immediately post-extubation to prevent volume\n overload and respiratory strain\n # Schizophrenia: will hold clozarin until linezolid course complete\n for risk of pancyotopenia\n #.Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Picc line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: ICU\n likely to the floor tomorrow\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2121-09-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597962, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continued thick secretions with high oxygen requirements\n - continued lasix gtt at 10 mcg, even yesterday and neg. 19,059 ml for\n LOS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 PM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 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: 78 (54 - 78) bpm\n BP: 124/50(68) {108/41(57) - 153/58(80)} mmHg\n RR: 22 (9 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,705 mL\n 758 mL\n PO:\n TF:\n 1,080 mL\n 315 mL\n IVF:\n 405 mL\n 98 mL\n Blood products:\n Total out:\n 2,670 mL\n 675 mL\n Urine:\n 2,370 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 35 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///36/\n Physical Examination\n General: NAD, wet cough\n Lungs: coarse cough and end-expiratory breath sounds\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: diffuse 2+ pitting edema, DP 2+\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 191 mg/dL\n 3.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 90 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.8 %\n 7.6 K/uL\n [image002.jpg]\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n Plt\n 247\n 284\n 271\n 298\n 316\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n TCO2\n 37\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.1 mg/dL\n Microbiology\n - none\n Imaging\n - none\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (8 of 14) and linezolid (8 of 14)\n - increase lasix gtt (titrated as low as possible) for continued\n diuresis as patient was positive yesterday + 19 for f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - continue to up-titrate Amlodipine and down titrate Hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.1 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and continue minimal lasix gtt to achieve -\n 1.5L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - contact family concerning baseline mental status and interactions\n - consider psychiatry consult\n # Urinary infection\n only urine Cx from positive for VRE,\n completed 7 day course of Linezolid. Most recent cultures from \n negative.\n - continue to follow with periodic surveillance cultures\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 in the\n setting of known PUD\n - re-guiac stool to r/o slow GIB\n - avoid transfusion if possible to avoid contributing to volume\n overload\n threshold is 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: PICC line\n # Code: FULL\n # Disposition: possible to floor in PM\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:19 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597303, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Admit with urosepsis VRE, now with gram neg rods in sputum, tx for\n pneumonia, pos balance > 20l\n remains pos balance > 20l for LOS , lasix titrated for net\n neg 50cc/hr\n fluid bolus increased to 300cc q4, for re-check NA/K this\n eve [ team considering D5W]\n team aware of B/P 150-160 systolic [ no action unless\n maintained in 170\n psych team reviewed ? to re-commence psycyh meds\n AC switched to PS with stable abg\n Hct trending down, new T/S sent\n Hypernatremia (high sodium)\n Assessment:\n NA at 1200hrs = 149/ K at 3.2\n Action:\n Free water increased to 300 q4h. received 60 po K\n Response:\n For pm lytes @ 1900hrs\n Plan:\n Trend Na ? for DW5 if no decrease in level\nfollow K level and replete\n as necessary\n Altered mental status (not Delirium)\n Assessment:\n Pt off sedation for >48 hours, pt easily rousable to voice, constantly\n following commands, movement noted of all 4 limbs, PERRL, denies pain.\n Soft wrist restraints for safety of lines/tubes\n Action:\n Mental status evaluated q4h, pt oriented to person nods head\n appropriately and denies pain, seen by psych team this pm\n Response:\n Pt\ns mental status continues to clear\n Plan:\n Continue to assess mental status frequently, question need for sedation\n for comfort if no plans for extubation any time soon. ? to re-commence\n psych meds soon\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute on chronic renal failure, pt\ns baseline Cr around 2.0,\n currently 4.4. UOP adequate on lasix drip, putting out >250cc q2h.but\n remains in grossly pos balance [ due to free water that is needed for\n NA level, b/p 140-160 but upto 170 systolic if stimulate, HR 58-65bpm\n SR [ patient is S/P NSTEMI on this admission]\n Action:\n Team have asked for net neg balance of 50cc/hr, therefore aim\n 170-200cc/hr\nno treatment with b/p unless maintained in 170s, HR stable\n at 58-65 SR\n Response:\n U/O maintained at this time and pm creat down to 4.1, overall exam\n improved\n Plan:\n Aim net neg 50cc/hr,trean lytes\nif fluid balance continues to be high\n pt will be consulted by renal for CRRT\n.follow b/p HR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV 50%/420/20/+10, pt rarely ove rbreathing vent, lung sounds\n rhonchorous throughout.\n Action:\n Suctioned for small amounts of thick, blood tinged secretions, chest\n PT done with excellent effects. Lasix drip for fluid overload and\n pulmonary edema. CXR not improved but able to switch patient to PS this\n am to \n Response:\n Stable abg on therefore lowered to TV @ 500 MV @ 6, SATS @\n 95%\n Plan:\n Continue pulmonary toilet, lasix drip, chest PT. , sats maintained >\n 94% on , trend sats/abgs\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597370, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG= 7.42-52-87,\n pt denies SOB when asked, Sats currently 96-97% . Hct this am = 23.7 (\n same value as yesterday)\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered, CXR completed and results pending\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated. Transfuse as\n ordered and prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with right radial Aline with good waveform---aline oozing blood and\n dressing changed x 3, BP= 130-150\ns/50-60\ns, BP occasionally\n 160-170\ns/60\ns with stimulation, no antihypertensives at this time as\n MICU team will accept BP <170, Foley draining clear yellow urine\n >100ml/hr, IV lasix gtt initially at 9 mg/hr and increased to 10mg/hr,\n good output but large input negating diuretic effect, K= 3.3---replaced\n with total of 40mEq IV KCL, Bun= Cr.= , pt remains positive >\n 20 liters for LOS\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldol as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Physician ", "chartdate": "2121-09-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597601, "text": "Chief Complaint: 74 yom with hypothyroidism presenting with septic\n shock, NSTEMI, hypothermia with suspected pulmonary vs. urine source.\n Patient initially grew out enterococcus from urine and GNR from sputum,\n now with MRSA and acinetobacter growing from sputum\n 24 Hour Events:\n TTE performed: Overall left ventricular systolic function is low normal\n (LVEF 50-55%). The right ventricular cavity is moderately dilated with\n normal free wall contractility. Wall motion abnormalities could not be\n excluded do to technique.\n Received 1 unit PRBC\ns for gradual drop in HCT to 23.7 with bump to\n 26.6\n now stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:00 PM\n Meropenem - 12:09 AM\n Infusions:\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 06:14 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: 36.5\nC (97.7\n HR: 57 (52 - 76) bpm\n BP: 164/59(88) {131/57(85) - 182/77(104)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 112 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 6 (2 - 10)mmHg\n Total In:\n 5,142 mL\n 798 mL\n PO:\n TF:\n 1,079 mL\n 280 mL\n IVF:\n 1,708 mL\n 218 mL\n Blood products:\n 375 mL\n Total out:\n 5,785 mL\n 1,055 mL\n Urine:\n 4,985 mL\n 1,055 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n -643 mL\n -257 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (583 - 848) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.45/51/73./35/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 146\n Physical Examination\n General: NAD, alert and able to respond to commands\n Lungs: soft crackles at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: NT, pitting edema, DP 2+\n Labs / Radiology\n 247 K/uL\n 9.2 g/dL\n 184 mg/dL\n 3.5 mg/dL\n 35 mEq/L\n 3.3 mEq/L\n 94 mg/dL\n 104 mEq/L\n 148 mEq/L\n 28.2 %\n 9.9 K/uL\n [image002.jpg]\n 12:06 PM\n 02:58 PM\n 05:30 PM\n 12:14 AM\n 12:31 AM\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n WBC\n 7.5\n 9.9\n Hct\n 23.7\n 26.6\n 28.2\n Plt\n 217\n 247\n Cr\n 4.1\n 3.9\n 3.6\n 3.5\n TCO2\n 32\n 34\n 32\n 34\n 35\n 37\n Glucose\n 132\n 241\n 138\n 184\n Other labs: PT / PTT / INR:12.2/44.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n worsened bilateral pleural effusions and diffuse lung\n consolidations with superimposed oulmonary edema on background of\n multifocal consolidation\n Assessment and Plan\n This is a 74 yom w/h/o paranoid schizophrenia, hypothyroidism,\n hypoadrenalism p/w septic shock, NSTEMI and hypothermia with initial\n suspected pulmonary vs. urine source.\n ##. Respiratory Failure/PNA: most recent cultures positive for\n Acinetobacter and MRSA with superimposed pulmonary edema.\n Sensitivities include Tobraicin and Imipneum (Acinetobacter) AND\n Vancomycin, Linezolid (MRSA). Echo showed severe dysfunction and\n pulmonary edema likely resulted from combination of ATN with fluid\n resuscitation. Barriers to extubation include underlying infectious\n process and fluid overload\n - continue meropenum (4 of 14) and linezolid (4 of 14)\n switch to PO\n Linezolid to reduce free water loads\n - lasix gtt for continued diuresis + 20.9 L for LOS, - 1 L overnight,\n attempt to titrate down drip as long as UOP remains stable\n - attempt to wean vent to with SBT if tolrates\n - follow up cultures, CXR\n # Hypertension\n patient with continued HTN in 160\ns but holding ACE-I\n for RF and BB for bradycardia. Patient recently started on hydralazine\n 10 mg TID with minimal response. Patient continues on Lasix gtt.\n - consider increasing dose of hydralazine for improved BP control\n will consider adding back CCB amlodipine while avoiding any nodal\n agents as h/o bradycardia\n # Urinary infection\n initial urine cultures grew VRE and patient was\n started on Linezolid per ID with most recent urine culture negative.\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.6 from peak of 4.6\n - continue to trend Cr and UOP\n - continue lasix gtt for diuresis with goal of -1.5 L negative per day\n titrate down gtt while maintain UOP\n #hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor and treat with free water flushes and IVF PRN\n # Anemia: patient is s/p 1 unit PRBC\ns for gradually dropping HCT,\n responding with appropriate HCT bump. Patient dose have history of\n PUD; however, negative guiac, normocytic anemia with high RDW and\n negative hemolysis workup likely representing\n - continue to monitor with daily HCT\ns with goal HCT > 25\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - will not restart clozarin until linezolid course complete for risk\n of pancyotopenia\n #. Bradycardia: patient with noted bradycardia requiring atropine in\n the field and episode of sinus bradycardia while in the CCU\n - consider cardiology consult if continued problems with HR to evaluate\n for SSS AND continue to hold nodal blocking agents\n #. Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n #COPD: continue atrovent and albuterol\n #Adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - continue hydrocortisone 25 mg q 12 today = to home dose of decadron,\n may switch to decadron today\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:02 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597681, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, vented, on CPAP, PSV 5 and peep 5\n and O2 50%. RR 10-20 and o2 sats 95-98%. Bilateral lung sounds\n rhonchorous and diminished bases, large pink frothy secretion with\n suction\n Action:\n No vent changes overnight, continue pul toilet and MDI\ns as ordered\n Response:\n Plan:\n NPO after 4am for possible extubation in AM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received patient with lasix drip 8mg/hr and diamox po for three\n doses.UO 100-200mls/hr\n Action:\n Lytes checked\n Response:\n AM labs\n Plan:\n Monitor labs, lytes repletion\n Impaired Skin Integrity\n Assessment:\n Mult\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597683, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, vented, on CPAP, PSV 5 and peep 5\n and O2 50%. RR 10-20 and o2 sats 95-98%. Bilateral lung sounds\n rhonchorous and diminished bases, large pink frothy secretion with\n suction\n Action:\n No vent changes overnight, continue pul toilet and MDI\ns as ordered\n Response:\n Plan:\n NPO after 4am for possible extubation in AM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received patient with lasix drip 8mg/hr and diamox po for three\n doses.UO 100-200mls/hr\n Action:\n Lytes checked\n Response:\n AM labs\n Plan:\n Monitor labs, lytes repletion\n Impaired Skin Integrity\n Assessment:\n Multiple skin issues, with skin tear and blisters\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597685, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, vented, on CPAP, PSV 5 and peep 5\n and O2 50%. RR 10-20 and o2 sats 95-98%. Bilateral lung sounds\n rhonchorous and diminished bases, large pink frothy secretion with\n suction\n Action:\n No vent changes overnight, continue pul toilet and MDI\ns as ordered\n Response:\n Plan:\n NPO after 4am for possible extubation in AM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received patient with lasix drip 8mg/hr and diamox po for three\n doses.UO 100-200mls/hr\n Action:\n Lytes checked\n Response:\n AM labs\n Plan:\n Monitor labs, lytes repletion\n Impaired Skin Integrity\n Assessment:\n Multiple skin issues, with skin tear and blisters, meplex dressing\n intact. On air bed, and on Tube feeding\n Action:\n Frequent position change, barier cream\n Response:\n unchanged\n Plan:\n Frequent position change, keep clean and dry, barrier cream\n Hyperglycemia\n Assessment:\n SBP 110-190,\n Action:\n Humalog insulin SS\n Response:\n Plan:\n Continue monitor finger sticks q 4hrs, and humalog SS, NPO for possible\n extubation\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Free water bolus q 4hrs\n Response:\n AM labs Na\n Plan:\n Continue monitor labs, and free water bolus as needed\n" }, { "category": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597699, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, vented, on CPAP, PSV 5 and peep 5\n and O2 50%. RR 10-20 and o2 sats 95-98%. Bilateral lung sounds\n rhonchorous and diminished bases, large pink frothy secretion with\n suction\n Action:\n No vent changes overnight, continue pul toilet and MDI\ns as ordered\n Response:\n Tolerating PSV 5/peep 5, O2 sats 100%\n Plan:\n NPO after 4am for possible extubation in AM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received patient with lasix drip 8mg/hr and diamox po for three\n doses.UO 100-200mls/hr\n Action:\n Lytes checked, repleted K 40meq\n Response:\n AM labs BUN 89/creat 3.2, UOP 100-150mls/hr\n Plan:\n Monitor labs, lytes repletion\n Impaired Skin Integrity\n Assessment:\n Multiple skin issues, with skin tear and blisters, meplex dressing\n intact. On air bed, and on Tube feeding\n Action:\n Frequent position change, barier cream\n Response:\n unchanged\n Plan:\n Frequent position change, keep clean and dry, barrier cream\n Hyperglycemia\n Assessment:\n Blood sugar 110-190,\n Action:\n Humalog insulin SS\n Response:\n BS 135 this AM, NPO for extubation\n Plan:\n Continue monitor finger sticks q 4hrs, and humalog SS, NPO for possible\n extubation\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Free water bolus300mls q 4hrs\n Response:\n AM labs Na 144\n Plan:\n Continue monitor labs, and free water bolus as needed\n" }, { "category": "Respiratory ", "chartdate": "2121-09-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597703, "text": "Demographics\n Day of mechanical ventilation: 12\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 25 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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: No morning abg results at this time.\n RSBI = 9 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597809, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated from yesterday morning. having strong cough,bringing out\n secretions,it sounds like congested down to the throat. Pt oriented\n x 1,confused. h/o renal failure.\n Action:\n Continued with face tent 50% . oraopharyngeal suction PRN done. But not\n very successful with suction. Nebs as ordered. Continued with\n antibiotics and lasix gtt 3mg/hr.\n Response:\n Sats 95-100% . LS with ronchi and diminished. Urine output adequate.\n Plan:\n Wean O2 as tolerated. Continue with nebs and suction PRN.\n Impaired Skin Integrity\n Assessment:\n Pt having multiple skin issues as documented.\n Action:\n Pt on air bed.change of postion as needed. Keep skin dry. Barrier\n cream applied. Bath given . tube feed for nutrition.\n Response:\n Pending\n Plan:\n Continue with skin care and feed.\n" }, { "category": "Physician ", "chartdate": "2121-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597466, "text": "Chief Complaint: This is a 74 y.o. Male with h.o.\n hypothyroidism/?hypoadrenalism, paranoid schizophrenia p/w septic\n shock, NSTEMI, hypothermia from acenetobacter pneumonia.\n 24 Hour Events:\n - SW called team regarding pt's placement, insurance should cover\n rehab, his dispo after rehab will be pending SW at rehba facility\n -psych recs: don't give clozarel on top of linezolid given that\n combination can lead to myelosuppresion; should ideally re-start it\n only after linezolid course complete (unclear how long linezolid\n effects last after stopping). When he does wake up, can give\n prophenazine 4 mg , with 2 mg PRN when agitated (PO). If doesn't\n take PO, can take 0.5 IM haldol but monitor QTCs. Avoid benzos.\n -continued on lasix drip\n -increased free water from 250 - 300 ccs q4 for hypernatremia: PM\n sodium was 148\n -Repeat Na at 1215 AM was 150; got D5W bolus: Nutren 2.0 discontinued\n from his tube feeds given high sodium content and switched to\n Novasource.\n -Repeat HCT in AM; nurse in secretions was frank rather than\n old, HCT at 23.7 this AM, transfused one unit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 11:57 AM\n Linezolid - 05:00 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:27 PM\n Heparin Sodium (Prophylaxis) - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.7\n HR: 58 (55 - 66) bpm\n BP: 163/59(88) {126/46(67) - 167/64(91)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 109.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 5 (4 - 11)mmHg\n Total In:\n 3,973 mL\n 1,872 mL\n PO:\n TF:\n 1,081 mL\n 289 mL\n IVF:\n 1,242 mL\n 983 mL\n products:\n Total out:\n 4,405 mL\n 1,990 mL\n Urine:\n 3,845 mL\n 1,990 mL\n NG:\n 110 mL\n Stool:\n 450 mL\n Drains:\n Balance:\n -432 mL\n -118 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 727 (505 - 729) mL\n PS : 12 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: 7.42/52/86./31/7\n Ve: 5.5 L/min\n PaO2 / FiO2: 174\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 217 K/uL\n 7.8 g/dL\n 241 mg/dL\n 3.9 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 98 mg/dL\n 106 mEq/L\n 146 mEq/L\n 23.7 %\n 7.5 K/uL\n [image002.jpg]\n 11:49 PM\n 02:33 AM\n 11:45 AM\n 12:06 PM\n 02:58 PM\n 05:30 PM\n 12:14 AM\n 12:31 AM\n 04:41 AM\n 04:53 AM\n WBC\n 5.8\n 7.5\n Hct\n 24.5\n 23.7\n 23.7\n Plt\n 156\n 217\n Cr\n 4.4\n 4.2\n 4.1\n 3.9\n TCO2\n 32\n 32\n 34\n 32\n 34\n 35\n Glucose\n 173\n 178\n 132\n 241\n pH 7.42\n pCO2 52\n pO2 87\n HCO3 35\n BaseXS 7\n Imaging: CXR showed something...\n Microbiology: Sputum - RESPIRATORY CULTURE ACINETOBACTER\n BAUMANNII COMPLEX. SPARSE GROWTH.\n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 282\n 0863K\n STAPH AUREUS COAG +. SPARSE GROWTH.\n YEAST. RARE GROWTH.\n All cultures negative to date\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. paranoid schizophrenia,\n hypothyroidism, hypoadrenalism p/w septic shock, NSTEMI, hypothermia\n with suspected pulmonary versus urine source.\n ##. Respiratory Failure/PNA: Likely a combination of Acinetobacter PNA\n and pulm edema from fluid rescusitation. Sputum culture from also\n show Staph aureus. Coag neg staph from (likely contaminant) from\n . s/p course of xygris .\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only.\n - Linezolid for Staph Aureus until sensitivities return\n - Call lab to confirm sensitivities will be obtained\n - no improvement in CXR, repeat AM CXR\n - Sputum from growing Acinetobacter, Coag + Staph Aureus\n - repeat Sputum\n -defer trial of SBP until respiratory status improves\n - continue aggressive diuresis\n - repeat ECHO to assess cardiac contribution to pulmonary edema\n - influenza antigen and legionella negative\n .\n # Hypertension\n Pt has systolic hypertension to 170s when awake. Will\n follow him through the day, despite antihypertensives.\n - on Lasix drip\n - no BB given bradycardia\n - no ACEI given renal failure\n - start hydral 10 po tid\n # Urinary infection - Pt was growing VRE sensitive to Ampicillin and\n Linezolid. Started on Linezolid per ID recs given pt was in septic\n shock.\n - His last urine was clean, continue Linezolid for 7 day course. Day\n 1= .\n - Monitor for CBC as pt on linezolid\n # : baseline 1.8-2, trending down slowly. 3.9 today, 4.4\n yesterday. Diuresing well.\n -will trend\n -volume overload will likely be indication for HD, if unable to\n diurese\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n - pm lytes\n #hypernatremia: hypernatremic to 150 yesterday after increasing free\n water boluses through OG to 300 q 4hr. Likely due to tube feeding and\n hypotonic diuresis in setting of lasix ggt. He was given a bolus of\n D5W. Tube feeds were changed from Nutren to Novasource which has less\n sodium.\n - continue free water in tube feeds at 300cc q 4h.\n - q8 sodium checks\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, 23.7\n down from 25. Given history of recent MI, transfuse one unit.\n Guaic was negative. Normocytic anemia, but high RDW.\n - hemolysis labs negative\n - no iron defiency\n - keep active type and screen\n - repeat stool guiac\n - serial Hct\n - f/u retic count\n - transfuse 1 unit\n - PPI\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n - was not on a statin upon admission\n # #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - wil restart perphenazine when awake at 4 mg , with 2 mg PRN when\n agitated (PO).\n - IM haldol if unable to tolerate PO\n - will not restart clozarin until linezolid course complete\n - SW following, he is OK for rehab upon d/c\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n #. Hypothyroidism: Will continue on home regimen of levothyroxine\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n # adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - will continue on IV Hydrocortisone, taper to 25q12 today ( pt on 2\n daily of decadron at home = 50mg IV hydrocortisone daily), titrate\n down today\n # DM: now back on insulin SQ - tighten ISS\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:57 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597676, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597677, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597835, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism p/w septic shock due to Staph and acinetobacter\n pneumonia, and NSTEMI in the setting of sepsis. Hospitalization\n complicated by acute on chornic renal failure, hypernatremia in the\n setting of diuresis, and hypertension.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:48 AM\n extubated!\n -free water flushes decreased now that sodium is improving\n -already met goal Is and Os; came down on the lasix\n -PM ABG was\n -started amlodipine; still on hydral,\n -talked to daughter about code status; not officially health\n care proxy but she makes decisions along with her brother when he is\n unable to; states that she wants his code status changed back to FULL\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:43 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.2\nC (97.1\n HR: 55 (52 - 72) bpm\n BP: 110/43(59) {110/41(59) - 147/63(82)} mmHg\n RR: 16 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,789 mL\n 716 mL\n PO:\n TF:\n 549 mL\n 310 mL\n IVF:\n 469 mL\n 155 mL\n Blood products:\n Total out:\n 3,720 mL\n 995 mL\n Urine:\n 3,070 mL\n 695 mL\n NG:\n Stool:\n 650 mL\n Drains:\n Balance:\n -1,931 mL\n -279 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 518 (518 - 518) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///38/\n Ve: 4.4 L/min\n Physical Examination\n Cardiovascular: Gen: NAD, extubated, breathing comfortably with face\n mask\n CV: RRR, no r/g/m, JVD not assessible\n Lungs: clear, intermittent crackles\n Abd: soft, NDNT, ABS\n Ext: trace edema, 2+ pulses bilat\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 298 K/uL\n 8.1 g/dL\n 167 mg/dL\n 3.2 mg/dL\n 38 mEq/L\n 4.0 mEq/L\n 89 mg/dL\n 105 mEq/L\n 146 mEq/L\n 26.2 %\n 7.6 K/uL\n [image002.jpg]\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n Hct\n 26.6\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n Plt\n 247\n 284\n 271\n 298\n Cr\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n TCO2\n 37\n 38\n 38\n Glucose\n 138\n 184\n 153\n 188\n 178\n 167\n Other labs: PT / PTT / INR:11.8/42.4/1.0, Ca++:7.8 mg/dL, Mg++:2.6\n mg/dL, PO4:3.8 mg/dL\n Imaging: CXR - bilateral pleural effusions + pulm edema, R>L. Improved\n from yesterday\n Microbiology: Blood cultures, negative to date\n Sputum + GNR, consistent with Acinetobacter\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (7 of 14) and linezolid (7 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 18.5L for f/u cultures and CXR\n - attempt SBT and trial of extubation\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - add Amlodipine 5 mg today and wean down PO hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - Na normalized, may decrease free water flushes\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - continue to trend daily HCT\ns with transfusion if HCT < 23\n will\n avoid transfusion immediately post-extubation to prevent volume\n overload and respiratory strain\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia\n #.Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: PICC line\n # Code: FULL\n # Disposition: ICU\n likely to the floor tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597778, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Pt was extubated successfully.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was initially intubated on PSV 5/PEEP 5, 50%. He was being\n suctioned for small amounts of white secretions. He was placed on a\n SBT at 8:30 with difficulties.\n Action:\n He was extubated at 10AM and placed on 50% face tent. His O2 sats\n initially were 94-95% however he has been coughing productively and his\n O2 sats have improved to 98-99%.\n Response:\n He has been coughing up blood tinged secretions since extubation. The\n blood has been decreasing since extubation and appears to be oral\n pharyngeal.\n Plan:\n Continue to monitor resp status, amount of blood in sputum and O2 sats.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt initially on Lasix gtt at 8mg/hr. His U\\O was 150-200cc/hr. Since\n extubation his U/O has remained ~the same.\n Action:\n The lasix gtt has been decreased to 5 then 3mg/hr and his U/O has\n remained.\n Response:\n He is currently ~1900cc net fluid balance negative.\n Plan:\n Goal was 1500cc negative so will continue to wean lasix gtt to U/O.\n Hyperglycemia\n Assessment:\n He was NPO for extubation so his blood sugars were 109 at 8am. At\n 12noon his blood sugar was 209\n Action:\n He was given 5 units at 1230 to cover the 209. The tube feedings were\n restarted at 1400 and quickly increased back to his goal rate of\n 45cc/hr. His blood sugar at 1600 was 122.\n Response:\n No humalog was given at that time.\n Plan:\n Continue to monitor blood sugar\n" }, { "category": "Physician ", "chartdate": "2121-09-19 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 597783, "text": "Chief Complaint:\n 24 Hour Events:\n - trial of PSV and decreased PEEP - RSBI @ 28, hopeful trial of\n extubation tomorrow\n - medications switched to PO to help reduce fluid load\n - lasix drip weaned with continued large urine output\n - diamox added to help diurese and waiste bicarbonate to elevate\n respiratory drive in setting of metabolic alkalosis\n - picc line placed, a-line removed as non-invassive BP correlates\n - NG exchanged for OG tube for anticipated swallowing difficulties s/p\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:36 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.5\n HR: 57 (52 - 66) bpm\n BP: 121/43(62) {105/39(55) - 167/70(92)} mmHg\n RR: 10 (8 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 8 (8 - 9)mmHg\n Total In:\n 4,027 mL\n 642 mL\n PO:\n TF:\n 1,080 mL\n 149 mL\n IVF:\n 877 mL\n 192 mL\n Blood products:\n Total out:\n 5,000 mL\n 1,520 mL\n Urine:\n 4,000 mL\n 870 mL\n NG:\n Stool:\n 1,000 mL\n 650 mL\n Drains:\n Balance:\n -973 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 855 (453 - 855) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 9\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.43/55/95./37/9\n Ve: 6 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General: NAD, responsive to commands\n Lungs: soft crackles at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, no CC, mod. pitting edema, DP 2+\n Labs / Radiology\n 271 K/uL\n 8.1 g/dL\n 178 mg/dL\n 3.2 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 89 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 8.7 K/uL\n [image002.jpg]\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n WBC\n 7.5\n 9.9\n 9.4\n 8.7\n Hct\n 23.7\n 26.6\n 28.2\n 26.6\n 25.4\n Plt\n 71\n Cr\n 3.9\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n TCO2\n 35\n 37\n 38\n 38\n Glucose\n 241\n 138\n 184\n 153\n 188\n 178\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\ns, no organisms, NGTD\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n extent of ventilated has substantially increased in upper\n and lower lobes bilaterally, persistent retrocardiac atelectasis with\n sparse air bronchograms\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (5 of 14) and linezolid (5 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 20L for 1L overnight\n - f/u cultures and CXR\n - attempt SBT and trial of extubation\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - add Amlodipine 5 mg today and wean down PO hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - Na normalized, may decrease free water flushes\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - continue to trend daily HCT\ns with transfusion if HCT < 23\n will\n avoid transfusion immediately post-extubation to prevent volume\n overload and respiratory strain\n # Schizophrenia: will hold clozarin until linezolid course complete\n for risk of pancyotopenia\n #.Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Picc line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: ICU\n likely to the floor tomorrow\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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 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: 74M DM, obesity, ?CHF, CRI (1.8-2.0) p/w\n severe pneumonia L>R c/b respiratory failure, ARF. Did well with SBT\n yesterday, NGT and PICC placed.\n Exam notable for Tm 98.0 BP 120/50 HR 55 RR 14 with sat 99 on PSV 5/5\n 0.5 7.43/35/95 CVP 12, UOP >100cc/h. Obese man, NAD. Coarse BS B. RRR\n s1s2. Soft +BS. 3+ edema. Labs notable for WBC 8K, HCT 25, K+ 3.5,\n Cr 3.2. CXR with improving B ASD.\n Agree with plan to manage ongoing respiratory distress with linezolid /\n vanco for MRSA / GNR pneumonia; can extubate today with close\n respiratory monitoring. Will wean lasix and continue diamox for\n alkalosis in the setting of ongoing volume overload. ARF improving with\n diuresis, baseline Cr around 2.0. Can decrease FWB for hypernatremia as\n this has improved. Continue home dexamethasone dose. Back on home psych\n meds. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 06:15 PM ------\n" }, { "category": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597694, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, vented, on CPAP, PSV 5 and peep 5\n and O2 50%. RR 10-20 and o2 sats 95-98%. Bilateral lung sounds\n rhonchorous and diminished bases, large pink frothy secretion with\n suction\n Action:\n No vent changes overnight, continue pul toilet and MDI\ns as ordered\n Response:\n Plan:\n NPO after 4am for possible extubation in AM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received patient with lasix drip 8mg/hr and diamox po for three\n doses.UO 100-200mls/hr\n Action:\n Lytes checked\n Response:\n AM labs BUN 89/creat 3.2\n Plan:\n Monitor labs, lytes repletion\n Impaired Skin Integrity\n Assessment:\n Multiple skin issues, with skin tear and blisters, meplex dressing\n intact. On air bed, and on Tube feeding\n Action:\n Frequent position change, barier cream\n Response:\n unchanged\n Plan:\n Frequent position change, keep clean and dry, barrier cream\n Hyperglycemia\n Assessment:\n SBP 110-190,\n Action:\n Humalog insulin SS\n Response:\n BS 135 this AM, NPO for extubation\n Plan:\n Continue monitor finger sticks q 4hrs, and humalog SS, NPO for possible\n extubation\n Hypernatremia (high sodium)\n Assessment:\n Na 146\n Action:\n Free water bolus q 4hrs\n Response:\n AM labs Na 144\n Plan:\n Continue monitor labs, and free water bolus as needed\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597796, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated from yesterday morning. having strong cough,bringing out\n secretions,it sounds like congested down to the throat. Pt oriented\n x 1,confused. h/o renal failure.\n Action:\n Continued with face tent 60% . oraopharyngeal suction PRN done. But not\n very successful with suction. Nebs as ordered. Continued with\n antibiotics and lasix gtt 3mg/hr.\n Response:\n Sats 95-100% . LS with ronchi and diminished. Urine output adequate.\n Plan:\n Wean O2 as tolerated. Continue with nebs and suction PRN.\n Impaired Skin Integrity\n Assessment:\n Pt having multiple skin issues as documented.\n Action:\n Pt on air bed.change of postion as needed. Keep skin dry. Barrier\n cream applied. Bath given . tube feed for nutrition.\n Response:\n Pending\n Plan:\n Continue with skin care and feed.\n" }, { "category": "Physician ", "chartdate": "2121-09-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597875, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism p/w septic shock due to Staph and acinetobacter\n pneumonia, and NSTEMI in the setting of sepsis. Hospitalization\n complicated by acute on chornic renal failure, hypernatremia in the\n setting of diuresis, and hypertension.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 09:48 AM\n extubated!\n -free water flushes decreased now that sodium is improving\n -already met goal Is and Os; came down on the lasix\n -PM ABG was\n -started amlodipine; still on hydral,\n -talked to daughter about code status; not officially health\n care proxy but she makes decisions along with her brother when he is\n unable to; states that she wants his code status changed back to FULL\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:43 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.2\nC (97.1\n HR: 55 (52 - 72) bpm\n BP: 110/43(59) {110/41(59) - 147/63(82)} mmHg\n RR: 16 (8 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,789 mL\n 716 mL\n PO:\n TF:\n 549 mL\n 310 mL\n IVF:\n 469 mL\n 155 mL\n Blood products:\n Total out:\n 3,720 mL\n 995 mL\n Urine:\n 3,070 mL\n 695 mL\n NG:\n Stool:\n 650 mL\n Drains:\n Balance:\n -1,931 mL\n -279 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 518 (518 - 518) mL\n PS : 5 cmH2O\n RR (Spontaneous): 10\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///38/\n Ve: 4.4 L/min\n Physical Examination\n Cardiovascular: Gen: NAD, extubated, breathing comfortably with face\n mask\n CV: RRR, no r/g/m, JVD not assessible\n Lungs: clear, intermittent crackles\n Abd: soft, NDNT, ABS\n Ext: trace edema, 2+ pulses bilat\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 298 K/uL\n 8.1 g/dL\n 167 mg/dL\n 3.2 mg/dL\n 38 mEq/L\n 4.0 mEq/L\n 89 mg/dL\n 105 mEq/L\n 146 mEq/L\n 26.2 %\n 7.6 K/uL\n [image002.jpg]\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n Hct\n 26.6\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n Plt\n 247\n 284\n 271\n 298\n Cr\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n TCO2\n 37\n 38\n 38\n Glucose\n 138\n 184\n 153\n 188\n 178\n 167\n Other labs: PT / PTT / INR:11.8/42.4/1.0, Ca++:7.8 mg/dL, Mg++:2.6\n mg/dL, PO4:3.8 mg/dL\n Imaging: CXR - bilateral pleural effusions + pulm edema, R>L. Improved\n from yesterday\n Microbiology: Blood cultures, negative to date\n Sputum + GNR, consistent with Acinetobacter\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (7 of 14) and linezolid (7 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 18.5L for f/u cultures and CXR\n - extubated\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - add Amlodipine 5 mg today and wean down PO hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine. Hasn\n required prn doses, no agitation.\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - Na normalized, may decrease free water flushes\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - continue to trend daily HCT\ns with transfusion if HCT < 23\n will\n avoid transfusion immediately post-extubation to prevent volume\n overload and respiratory strain\n #.Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: PICC line\n # Code: FULL\n # Disposition: ICU\n likely to the floor tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597934, "text": "Hyperglycemia\n Assessment:\n Pt\ns blood sugar being checked every 6 hrs. Pt\ns blood sugars over the\n last 48hrs have been ranging between 130-200\ns. Pt has a right nostril\n NGT that has TF running at goal of 45cc/hr.\n Action:\n Pt receiving humalog insulin per sliding scale. TF residuals being\n checked every 6 hrs.\n Response:\n Small amount of TF residual noted.\n Plan:\n Continue to monitor blood sugars and cover them appropriately per the\n sliding scale. Possible speech and swallow evaluation in the future\n prior to pt having NGT removed.\n Hypernatremia (high sodium)\n Assessment:\n Pt sodium being checked minimally twice a day. In the last 48 hrs pt\n has had a sodium level ranging146-148.\n Action:\n Free water boluses changed to 300cc every 6hrs.\n Response:\n Last sodium level was 144\n Plan:\n Continue to monitor sodium level, continue providing pt with free water\n flushes as per .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated . lung sounds very ronchourus more in the upper\n lobes than in he lower lobes bilaterally. Pt with intact gag and a\n strong productive cough. Pt with an SpO2 of 93-95% on face tent 50%,\n 15L.\n Action:\n Pt being turned in bed every 2-3 hrs and encouraged to cough and deep\n breath. Also pt receiving chest PT with every turn. Attempt was made to\n place pt on face tent 40%.\n Response:\n Pt had a low Po2 (venous) of 38, SpO2 was down to 90-91%. Subsequently\n pt was NT suctioned for large amount of thick frothy secretions, 3 L NC\n was added and pt is now with an SpO2 of 97%.\n Plan:\n Continue with pulmonary toileting, monitor SpO2, continue with chest\n PT, encourage pt to be OOB to improve lung expansion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with +4 general edema. Pt on a lasix GTT at 10mg/hr. for LOS pt is\n +18L.\n Action:\n Titrating lasix GTT for a goal of 1-2L negative per day. Renal\n functions being monitored.\n Response:\n BUN 90, CREAT 3.1, today\ns weight 107.3KG\n Plan:\n Continue lasix GTT, monitor I and O\ns, monitor renal functions.\n Bradycardia\n Assessment:\n Pt in a NSR/SB with a HR of 50-60\ns with no ectopy. When sleeping pt\n has had his HR drop to high 40\ns asymptomatic.\n Action:\n Pt not receiving any beta blockers or medications to increase HR.\n Response:\n Plan:\n Continue to monitor on telemetry.\n" }, { "category": "Physician ", "chartdate": "2121-09-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597950, "text": "Chief Complaint:\n 24 Hour Events:\n - Pt alert and awake\n - BP good. Was going to uptitrate amlodipine to 10 and d/c hydral.\n But if amlodipine is a AV nodal , y can't we just use a BB which\n would be cardioprotective???\n - was unable to reach family regarding pt's baseline mental status\n - continues to have thick secretions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 PM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 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: 78 (54 - 78) bpm\n BP: 124/50(68) {108/41(57) - 153/58(80)} mmHg\n RR: 22 (9 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,705 mL\n 758 mL\n PO:\n TF:\n 1,080 mL\n 315 mL\n IVF:\n 405 mL\n 98 mL\n Blood products:\n Total out:\n 2,670 mL\n 675 mL\n Urine:\n 2,370 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 35 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///36/\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 316 K/uL\n 8.0 g/dL\n 191 mg/dL\n 3.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 90 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.8 %\n 7.6 K/uL\n [image002.jpg]\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n Plt\n 247\n 284\n 271\n 298\n 316\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n TCO2\n 37\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (7 of 14) and linezolid (7 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 18.5L for f/u cultures and CXR\n - extubated\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - add Amlodipine 5 mg today and wean down PO hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine. Hasn\n required prn doses, no agitation.\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - Na normalized, may decrease free water flushes\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - continue to trend daily HCT\ns with transfusion if HCT < 23\n will\n avoid transfusion immediately post-extubation to prevent volume\n overload and respiratory strain\n #.Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: PICC line\n # Code: FULL\n # Disposition: ICU\n likely to the floor tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:19 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Respiratory ", "chartdate": "2121-09-20 00:00:00.000", "description": "Generic Note", "row_id": 597828, "text": "TITLE:Resp Care Note, Pt seen for Atrovent nebs Q6. Last 0600. BS\n rhonchi. Strong congestd cough with push. Mod amts thick white\n secretions.\n" }, { "category": "Physician ", "chartdate": "2121-09-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 597859, "text": "Chief Complaint: Septic shock, UTI/PNA, NSTEMI\n I saw and examined the patient, and was physically present with the ICU\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 - STOP 09:48 AM\n Extubated following SBT\n Free water replacement for hypernatremia\n Continues lasix drip - decreased to 3 mg/hour\n Started on amlodipine yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:43 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 PM\n Other medications:\n colace\n senna\n ASA\n RISS\n hydralazine\n levothyoxine\n dexamethasone\n lansoprazole\n free water boluses\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 Ear, Nose, Throat: Dry mouth\n Nutritional Support: No(t) NPO, Tube feeds\n Gastrointestinal: Constipation\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.8\nC (96.5\n HR: 58 (54 - 72) bpm\n BP: 126/41(60) {110/39(57) - 147/63(82)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,789 mL\n 1,093 mL\n PO:\n TF:\n 549 mL\n 503 mL\n IVF:\n 469 mL\n 189 mL\n Blood products:\n Total out:\n 3,720 mL\n 1,220 mL\n Urine:\n 3,070 mL\n 920 mL\n NG:\n Stool:\n 650 mL\n Drains:\n Balance:\n -1,931 mL\n -127 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///38/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.1 g/dL\n 298 K/uL\n 167 mg/dL\n 3.2 mg/dL\n 38 mEq/L\n 4.0 mEq/L\n 89 mg/dL\n 105 mEq/L\n 146 mEq/L\n 26.2 %\n 7.6 K/uL\n [image002.jpg]\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n Hct\n 26.6\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n Plt\n 247\n 284\n 271\n 298\n Cr\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n TCO2\n 37\n 38\n 38\n Glucose\n 138\n 184\n 153\n 188\n 178\n 167\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n Microbiology: No new growth\n Sputum: GNRs sparse growth, yeast\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM): Improving with free water replacement.\n ALTERED MENTAL STATUS (NOT DELIRIUM): Unclear what baseline mental\n status is. We are continue to treat underlying infections, correcting\n hypernatremia which are likely contributing.\n HYPERGLYCEMIA: Well controlled on RISS.\n IMPAIRED SKIN INTEGRITY: Stable.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Growing Acinetobacter and\n MRSA pneumonia. Repeat gram stain shows GNR, culture pending. Stable\n post-extubation albeit still briniging up moderate secretions, able to\n cough to back of throat. Continue current abx.\n UTI: Secondary to VRE on linezolid. Subsequent cultures are no\n growth to date.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr continues to\n improve, diuresing well, decreasing lasix drip.\n ANEMIA: Hct stable, following daily hcts.\n SCHIZOPHRENIA: Readdress with psychiatry service as far as\n restarting other medications.\n HYPOTHYROIDISM: Continues on replacement therapy.\n COPD, ACUTE EXACERBATION IN SETTING OF PNEUMONIA: Bronchodilators.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 PM 45 mL/hour\n Comments: Tube feeds at goal\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\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 Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597862, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597863, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2121-09-18 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 597598, "text": "Objective\n wt: 111.6 kg\n Pertinent medications: ISS, colace, lactulose, lasix drip,\n hydrocortisone, IV abx, KCl (40 mEq repletion), dextrose 5 @ 5 ml/hr\n Labs:\n Value\n Date\n Glucose\n 184 mg/dL\n 01:29 AM\n Glucose Finger Stick\n 162\n 08:00 AM\n BUN\n 94 mg/dL\n 01:29 AM\n Creatinine\n 3.5 mg/dL\n 01:29 AM\n Sodium\n 147 mEq/L\n 08:41 AM\n Potassium\n 3.4 mEq/L\n 08:41 AM\n Chloride\n 104 mEq/L\n 01:29 AM\n TCO2\n 35 mEq/L\n 01:29 AM\n PO2 (arterial)\n 120 mm Hg\n 08:54 AM\n PCO2 (arterial)\n 56 mm Hg\n 08:54 AM\n pH (arterial)\n 7.42 units\n 08:54 AM\n pH (urine)\n 5.0 units\n 01:24 PM\n CO2 (Calc) arterial\n 38 mEq/L\n 08:54 AM\n Calcium non-ionized\n 7.9 mg/dL\n 01:29 AM\n Phosphorus\n 3.8 mg/dL\n 01:29 AM\n Ionized Calcium\n 1.10 mmol/L\n 04:53 AM\n Magnesium\n 2.5 mg/dL\n 01:29 AM\n ALT\n 48 IU/L\n 04:00 AM\n Alkaline Phosphate\n 50 IU/L\n 04:00 AM\n AST\n 25 IU/L\n 04:00 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:00 AM\n WBC\n 9.9 K/uL\n 01:29 AM\n Hgb\n 9.2 g/dL\n 01:29 AM\n Hematocrit\n 28.2 %\n 01:29 AM\n Current diet order / nutrition support: Nutren 2.0@ 45 ml/hr = 2160\n kcals/ 86 g protein\n GI: soft, obese, +bowel sounds\n Assessment of Nutritional Status\n Specifics: Tube feeding running at goal which provides 100% of\n estimated nutritional needs. Patient is volume overloaded, on\n concentrated tube feeding. Lasix drip running to help with diuesis, wt\n down 7 kg in last week. Noted K repletion.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with current tube feeding order\n 2. Check chemistry 10 daily and replete\n" }, { "category": "Nutrition", "chartdate": "2121-09-18 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 597599, "text": "Objective\n wt: 111.6 kg\n Pertinent medications: ISS, colace, lactulose, lasix drip,\n hydrocortisone, IV abx, KCl (40 mEq repletion), dextrose 5 @ 5 ml/hr\n Labs:\n Value\n Date\n Glucose\n 184 mg/dL\n 01:29 AM\n Glucose Finger Stick\n 162\n 08:00 AM\n BUN\n 94 mg/dL\n 01:29 AM\n Creatinine\n 3.5 mg/dL\n 01:29 AM\n Sodium\n 147 mEq/L\n 08:41 AM\n Potassium\n 3.4 mEq/L\n 08:41 AM\n Chloride\n 104 mEq/L\n 01:29 AM\n TCO2\n 35 mEq/L\n 01:29 AM\n PO2 (arterial)\n 120 mm Hg\n 08:54 AM\n PCO2 (arterial)\n 56 mm Hg\n 08:54 AM\n pH (arterial)\n 7.42 units\n 08:54 AM\n pH (urine)\n 5.0 units\n 01:24 PM\n CO2 (Calc) arterial\n 38 mEq/L\n 08:54 AM\n Calcium non-ionized\n 7.9 mg/dL\n 01:29 AM\n Phosphorus\n 3.8 mg/dL\n 01:29 AM\n Ionized Calcium\n 1.10 mmol/L\n 04:53 AM\n Magnesium\n 2.5 mg/dL\n 01:29 AM\n ALT\n 48 IU/L\n 04:00 AM\n Alkaline Phosphate\n 50 IU/L\n 04:00 AM\n AST\n 25 IU/L\n 04:00 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:00 AM\n WBC\n 9.9 K/uL\n 01:29 AM\n Hgb\n 9.2 g/dL\n 01:29 AM\n Hematocrit\n 28.2 %\n 01:29 AM\n Current diet order / nutrition support: Nutren 2.0@ 45 ml/hr = 2160\n kcals/ 86 g protein\n GI: soft, obese, +bowel sounds\n Assessment of Nutritional Status\n Specifics: Tube feeding running at goal which provides 100% of\n estimated nutritional needs. Patient is volume overloaded, on\n concentrated tube feeding. Lasix drip running to help with diuesis, wt\n down 7 kg in last week. Noted K repletion.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with current tube feeding order\n 2. Multivitamin via tube feeding\n 3. Replete lytes prn\n 4. Will follow page with questions\n 5. Electronically signed by , RD 12:11\n 6.\n 7.\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 597902, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure. Pt was extubated on\n .\n Hyperglycemia\n Assessment:\n Pt\ns blood sugar being checked every 6 hrs. Pt\ns blood sugars over the\n last 48hrs have been ranging between 130-200\ns. Pt has a right nostril\n NGT that has TF running at goal of 45cc/hr.\n Action:\n Pt receiving humalog insulin per sliding scale. TF residuals being\n checked every 4 hrs.\n Response:\n Small amount of TF residual noted.\n Plan:\n Continue to monitor blood sugars and cover them appropriately per the\n sliding scale. Possible speech and swallow evaluation in the future\n prior to pt having NGT removed.\n Hypernatremia (high sodium)\n Assessment:\n Pt sodium being checked minimally twice a day. In the last 48 hrs pt\n has had a sodium level ranging146-148.\n Action:\n Free water boluses changed to 300cc every 6hrs.\n Response:\n Last sodium level was 146\n Plan:\n Continue to monitor sodium level, continue providing pt with free water\n flushes as per .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated . lung sounds very ronchourus more in the upper\n lobes than in he lower lobes bilaterally. P with intact gag and a\n strong productive cough.\n Action:\n Pt being turned in bed every 2-3 hrs and encouraged to cough and deep\n breath. Also pt receiving chest PT with every turn.\n Response:\n Pt with an SpO2 of 93-95%\n Plan:\n Continue with pulmonary toileting, monitor SpO2, continue with chest\n PT, encourage pt to be OOB to improve lung expansion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with +4 general edema. Pt on a lasix GTT at 8mg/hr. for LOS pt is\n +16L.\n Action:\n Titrating lasix GTT for a goal of 1-2L negative per day. Renal\n functions being monitored/\n Response:\n Plan:\n Continue lasix GTT, monitor I and O\ns, monitor renal functions.\n Bradycardia\n Assessment:\n Pt in a NSR/SB with a HR of 50-60\ns with no ectopy. When sleeping pt\n has had his HR drop to high 40\ns asymptomatic.\n Action:\n Pt not receiving any beta blockers or medications to increase HR.\n Response:\n Plan:\n Continue to monitor on telemetry.\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597903, "text": "Hyperglycemia\n Assessment:\n Pt\ns blood sugar being checked every 6 hrs. Pt\ns blood sugars over the\n last 48hrs have been ranging between 130-200\ns. Pt has a right nostril\n NGT that has TF running at goal of 45cc/hr.\n Action:\n Pt receiving humalog insulin per sliding scale. TF residuals being\n checked every 4 hrs.\n Response:\n Small amount of TF residual noted.\n Plan:\n Continue to monitor blood sugars and cover them appropriately per the\n sliding scale. Possible speech and swallow evaluation in the future\n prior to pt having NGT removed.\n Hypernatremia (high sodium)\n Assessment:\n Pt sodium being checked minimally twice a day. In the last 48 hrs pt\n has had a sodium level ranging146-148.\n Action:\n Free water boluses changed to 300cc every 6hrs.\n Response:\n Last sodium level was 146\n Plan:\n Continue to monitor sodium level, continue providing pt with free water\n flushes as per .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated . lung sounds very ronchourus more in the upper\n lobes than in he lower lobes bilaterally. P with intact gag and a\n strong productive cough.\n Action:\n Pt being turned in bed every 2-3 hrs and encouraged to cough and deep\n breath. Also pt receiving chest PT with every turn.\n Response:\n Pt with an SpO2 of 93-95%\n Plan:\n Continue with pulmonary toileting, monitor SpO2, continue with chest\n PT, encourage pt to be OOB to improve lung expansion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with +4 general edema. Pt on a lasix GTT at 8mg/hr. for LOS pt is\n +16L.\n Action:\n Titrating lasix GTT for a goal of 1-2L negative per day. Renal\n functions being monitored/\n Response:\n Plan:\n Continue lasix GTT, monitor I and O\ns, monitor renal functions.\n Bradycardia\n Assessment:\n Pt in a NSR/SB with a HR of 50-60\ns with no ectopy. When sleeping pt\n has had his HR drop to high 40\ns asymptomatic.\n Action:\n Pt not receiving any beta blockers or medications to increase HR.\n Response:\n Plan:\n Continue to monitor on telemetry.\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 597904, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure. Pt was extubated on\n .\n Hyperglycemia\n Assessment:\n Pt\ns blood sugar being checked every 6 hrs. Pt\ns blood sugars over the\n last 48hrs have been ranging between 130-200\ns. Pt has a right nostril\n NGT that has TF running at goal of 45cc/hr.\n Action:\n Pt receiving humalog insulin per sliding scale. TF residuals being\n checked every 4 hrs.\n Response:\n Small amount of TF residual noted.\n Plan:\n Continue to monitor blood sugars and cover them appropriately per the\n sliding scale. Possible speech and swallow evaluation in the future\n prior to pt having NGT removed.\n Hypernatremia (high sodium)\n Assessment:\n Pt sodium being checked minimally twice a day. In the last 48 hrs pt\n has had a sodium level ranging146-148.\n Action:\n Free water boluses changed to 300cc every 6hrs.\n Response:\n Last sodium level was 146\n Plan:\n Continue to monitor sodium level, continue providing pt with free water\n flushes as per .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated . lung sounds very ronchourus more in the upper\n lobes than in he lower lobes bilaterally. P with intact gag and a\n strong productive cough.\n Action:\n Pt being turned in bed every 2-3 hrs and encouraged to cough and deep\n breath. Also pt receiving chest PT with every turn.\n Response:\n Pt with an SpO2 of 93-95%\n Plan:\n Continue with pulmonary toileting, monitor SpO2, continue with chest\n PT, encourage pt to be OOB to improve lung expansion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with +4 general edema. Pt on a lasix GTT at 8mg/hr. for LOS pt is\n +18L.\n Action:\n Titrating lasix GTT for a goal of 1-2L negative per day. Renal\n functions being monitored/\n Response:\n Plan:\n Continue lasix GTT, monitor I and O\ns, monitor renal functions.\n Bradycardia\n Assessment:\n Pt in a NSR/SB with a HR of 50-60\ns with no ectopy. When sleeping pt\n has had his HR drop to high 40\ns asymptomatic.\n Action:\n Pt not receiving any beta blockers or medications to increase HR.\n Response:\n Plan:\n Continue to monitor on telemetry.\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597905, "text": "Hyperglycemia\n Assessment:\n Pt\ns blood sugar being checked every 6 hrs. Pt\ns blood sugars over the\n last 48hrs have been ranging between 130-200\ns. Pt has a right nostril\n NGT that has TF running at goal of 45cc/hr.\n Action:\n Pt receiving humalog insulin per sliding scale. TF residuals being\n checked every 6 hrs.\n Response:\n Small amount of TF residual noted.\n Plan:\n Continue to monitor blood sugars and cover them appropriately per the\n sliding scale. Possible speech and swallow evaluation in the future\n prior to pt having NGT removed.\n Hypernatremia (high sodium)\n Assessment:\n Pt sodium being checked minimally twice a day. In the last 48 hrs pt\n has had a sodium level ranging146-148.\n Action:\n Free water boluses changed to 300cc every 6hrs.\n Response:\n Last sodium level was 146\n Plan:\n Continue to monitor sodium level, continue providing pt with free water\n flushes as per .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated . lung sounds very ronchourus more in the upper\n lobes than in he lower lobes bilaterally. Pt with intact gag and a\n strong productive cough.\n Action:\n Pt being turned in bed every 2-3 hrs and encouraged to cough and deep\n breath. Also pt receiving chest PT with every turn.\n Response:\n Pt with an SpO2 of 93-95%\n Plan:\n Continue with pulmonary toileting, monitor SpO2, continue with chest\n PT, encourage pt to be OOB to improve lung expansion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with +4 general edema. Pt on a lasix GTT at 8mg/hr. for LOS pt is\n +18L.\n Action:\n Titrating lasix GTT for a goal of 1-2L negative per day. Renal\n functions being monitored.\n Response:\n Plan:\n Continue lasix GTT, monitor I and O\ns, monitor renal functions.\n Bradycardia\n Assessment:\n Pt in a NSR/SB with a HR of 50-60\ns with no ectopy. When sleeping pt\n has had his HR drop to high 40\ns asymptomatic.\n Action:\n Pt not receiving any beta blockers or medications to increase HR.\n Response:\n Plan:\n Continue to monitor on telemetry.\n" }, { "category": "Nursing", "chartdate": "2121-09-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598033, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: OOB to chair, still loads of secretions, coughing productively\n while in chair.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section ------\n Continuation from above\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section Addendum Entered By: , RN\n on: 18:54 ------\n" }, { "category": "Nursing", "chartdate": "2121-09-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598035, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: OOB to chair, still loads of secretions, coughing productively\n while in chair.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section ------\n Continuation from above\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section Addendum Entered By: , RN\n on: 18:54 ------\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2 requirements O/N were face tent at 40% with 3lNC. At 10am he was\n placed in a chair where he has been able to cough up and swallow all of\n his secretions.\n Action:\n His FiO2 was weaned to 40% face tent while in the chair. He was\n coughing frequently bring up copious secretions but he would swallow\n them refusing to have the yaunker suction them.\n Response:\n O2 sats have been 94-95% while up in the chair.\n Plan:\n Give good pulm toilet while back in bed until secretions start to\n decrease.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt continues on the lasix gtt at 10mg/hr.\n Action:\n U/O good but just maintaining due to the increase in free water\n boluses. At 1700 he was still net even.\n Response:\n The lasix gtt was increased to 12mg/hr with an increase in his u/o to\n 200cc.\n Plan:\n Increase lasix to keep pt fluid balance net negative.\n Hyperglycemia\n Assessment:\n Blood sugars were 181 at 1000 and 153 at 1600.\n Action:\n He was covered with 3units of humalog insulin at 1000 and did not get\n any at 1600.\n Response:\n He continues on tube feeding at goal rate of 45cc/hr and requiring very\n little insulin\n Plan:\n Continue to monitor q6h.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:50 ------\n" }, { "category": "Nursing", "chartdate": "2121-09-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598040, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt O2 requirements O/N were face tent at 40% with 3lNC. At 10am he was\n placed in a chair where he has been able to cough up and swallow all of\n his secretions.\n Action:\n His FiO2 was weaned to 40% face tent while in the chair. He was\n coughing frequently bring up copious secretions but he would swallow\n them refusing to have the yaunker suction them.\n Response:\n O2 sats have been 94-95% while up in the chair.\n Plan:\n Give good pulm toilet while back in bed until secretions start to\n decrease.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt continues on the lasix gtt at 10mg/hr.\n Action:\n U/O good but just maintaining due to the increase in free water\n boluses. At 1700 he was still net even.\n Response:\n The lasix gtt was increased to 12mg/hr with an increase in his u/o to\n 200cc.\n Plan:\n Increase lasix to keep pt fluid balance net negative.\n Hyperglycemia\n Assessment:\n Blood sugars were 181 at 1000 and 153 at 1600.\n Action:\n He was covered with 3units of humalog insulin at 1000 and did not get\n any at 1600.\n Response:\n He continues on tube feeding at goal rate of 45cc/hr and requiring very\n little insulin\n Plan:\n Continue to monitor q6h.\n" }, { "category": "Nursing", "chartdate": "2121-09-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598152, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 144\n Action:\n Free h20 decreased to 200ml q6\n Having chem. Panel checked\n Response:\n Stable NA\n Plan:\n Labs as ordered\n Free h2o as ordered\n Impaired Skin Integrity\n Assessment:\n Skin tear healing\n Action:\n Mepliex dressings on right arm changed\n Skin tears appear to be healing, presently are scabbed over\n Sacral area appears healed\n OOB to chair for 4 hours\n Switched from kinair bed to regular icu bed\n Response:\n Improvement in skin integrity\n Plan:\n Mepilex change q72\n Per nursing care plan\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat improving\n Action:\n Creat 3.0 this am\n Continues on lasix gtt at 15mg/hour\n Receiving 1u PC\ns for hct 23 this am\n Response:\n Improving renal function\n Plan:\n Lasix gtt as ordered\n Goal volume out is even to slightly neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Unable to wean o2\n Action:\n O2 sats 92-96% on 50% face tent\n Pt with congested cough, expectorating, but then swallows secretions\n Resistant to sunctioning with yankour\n NTS x1 with difficulty due to NGT and uncooperative\n Enc cough and deep breathing\n Response:\n Congested cough\n Plan:\n Wean o2 as tolerated\n Cont to diurese as ordered\n Pulmonary toilet\n" }, { "category": "Nursing", "chartdate": "2121-09-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597896, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt very rhonchous this am, suctioned with yaunker from the back of his\n throat. Sputum thick white. Remains on 50%.\n Action:\n Pt OOB to chair and he was able to cough up all his secretions.\n Response:\n When he returned to bed he continued to cough but he had more trouble\n to cough it out.\n Plan:\n Continue to given good pulmonary toilet.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues on lasix gtt at 3mg/hr.\n Action:\n U/O decreasing through the day from 100cc/hr to ~30cc/hr. His net\n fluid balance has been even today.\n Response:\n Generalized edema still present but decreased from the 2L removed\n yesterday.\n Plan:\n Continue on the 3mg/hr, keep pt even today.\n Hyperglycemia\n Assessment:\n Blood Sugars have been 130-181. when taken q4h.\n Action:\n He received 5units of humalog at 12n to cover the blood sugar of 181.\n Response:\n He continues on tube feedings at goal rate of 45cc/hr.\n Plan:\n Continue to monitor, ? need for q4h -? Lengthen time to q6h.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-21 00:00:00.000", "description": "Generic Note", "row_id": 597919, "text": "TITLE:Resp Care Note, PT SEEN X 2 FOR Atrovent nebs. NT suctioned for\n mod amts thick white secretions.Having desats into the 80\ns. Needs push\n to cough and deep breath.\n" }, { "category": "Nursing", "chartdate": "2121-09-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598022, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598023, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: OOB to chair, still loads of secretions, coughing productively\n while in chair.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598097, "text": "Chief Complaint:\n 24 Hour Events:\n No acute overnight events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:10 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 76 (56 - 84) bpm\n BP: 133/54(71) {102/39(57) - 133/54(71)} mmHg\n RR: 13 (11 - 20) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,637 mL\n 539 mL\n PO:\n TF:\n 1,080 mL\n 338 mL\n IVF:\n 402 mL\n 201 mL\n Blood products:\n Total out:\n 2,590 mL\n 675 mL\n Urine:\n 2,590 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 47 mL\n -136 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///34/\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 300 K/uL\n 7.6 g/dL\n 210 mg/dL\n 3.0 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 91 mg/dL\n 102 mEq/L\n 144 mEq/L\n 23.0 %\n 6.0 K/uL\n [image002.jpg]\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n Plt\n 247\n 284\n 271\n 298\n 316\n 300\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n TCO2\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n 210\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (8 of 14) and linezolid (8 of 14)\n - increase lasix gtt (titrated as low as possible) for continued\n diuresis as patient was positive yesterday + 19 for f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - continue to up-titrate Amlodipine and down titrate Hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.1 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and continue minimal lasix gtt to achieve -\n 1.5L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - contact family concerning baseline mental status and interactions\n - consider psychiatry consult\n # Urinary infection\n only urine Cx from positive for VRE,\n completed 7 day course of Linezolid. Most recent cultures from \n negative.\n - continue to follow with periodic surveillance cultures\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 in the\n setting of known PUD\n - re-guiac stool to r/o slow GIB\n - avoid transfusion if possible to avoid contributing to volume\n overload\n threshold is 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: possible to floor in PM\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:29 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598099, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n No acute overnight events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:10 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 76 (56 - 84) bpm\n BP: 133/54(71) {102/39(57) - 133/54(71)} mmHg\n RR: 13 (11 - 20) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,637 mL\n 539 mL\n PO:\n TF:\n 1,080 mL\n 338 mL\n IVF:\n 402 mL\n 201 mL\n Blood products:\n Total out:\n 2,590 mL\n 675 mL\n Urine:\n 2,590 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 47 mL\n -136 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///34/\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 300 K/uL\n 7.6 g/dL\n 210 mg/dL\n 3.0 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 91 mg/dL\n 102 mEq/L\n 144 mEq/L\n 23.0 %\n 6.0 K/uL\n [image002.jpg]\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n Plt\n 247\n 284\n 271\n 298\n 316\n 300\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n TCO2\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n 210\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Microbiology\n - sputum \n acinetobacter and MRSA\n - urine \n negative\n Imaging\n - None\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (9 of 14) and linezolid (9 of 14)\n - transition to lasix boluses for continued diuresis goal of neg. 1 L /\n day\n remains + 18.9 for limit free water flushes and IVF to assist in diuresis\n - f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - discontinue Hydralazine and add Amlodipine 10 mg q daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.0 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and transition to lasix bolus for goal of -\n 1.0 L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 now 23 in\n the setting of known PUD. Element of this could be dilutional with\n mobilization of fluid however other cell lines are not proportionately\n reduced.\n - re-guiac stool to r/o slow GIB\n - transfuse 1 unit PRBC\ns for goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: patient will likely benefit from transition to \n rehab as he requires significant nursing care with suctioning.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:29 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "General", "chartdate": "2121-09-22 00:00:00.000", "description": "Generic Note", "row_id": 598114, "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. Up in chair\n min interactive but alert\n 97.0 62 119/49\n Alert\n Chest\n mid insp crackles bilat\n CV distant w/o audible m\n Extrem\n 2+ edema\n WBC 6.0\n Hct 23\n Creat 3.0\n Contyinues to improve. Making slow progress with diuresis although\n still edematous despite nearly 6d of furosemide gtt. Cough is present\n and he does get phlegm to throat but remains tenuous needing occasional\n suctioning. Psychiatry meds other than clozeril have been restarted.\n Creat has come down sl\n hopefully will continue to improve despite\n diuresis. Retic count is inappropriate\n likely a combination of\n illness and chronic renal insuf.\n Time spent 40 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2121-09-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598117, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n No acute overnight events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:10 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 76 (56 - 84) bpm\n BP: 133/54(71) {102/39(57) - 133/54(71)} mmHg\n RR: 13 (11 - 20) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,637 mL\n 539 mL\n PO:\n TF:\n 1,080 mL\n 338 mL\n IVF:\n 402 mL\n 201 mL\n Blood products:\n Total out:\n 2,590 mL\n 675 mL\n Urine:\n 2,590 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 47 mL\n -136 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///34/\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 300 K/uL\n 7.6 g/dL\n 210 mg/dL\n 3.0 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 91 mg/dL\n 102 mEq/L\n 144 mEq/L\n 23.0 %\n 6.0 K/uL\n [image002.jpg]\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n Plt\n 247\n 284\n 271\n 298\n 316\n 300\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n TCO2\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n 210\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Microbiology\n - sputum \n acinetobacter and MRSA\n - urine \n negative\n Imaging\n - None\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (9 of 14) and linezolid (9 of 14)\n - transition to lasix boluses for continued diuresis goal of neg. 1 L /\n day\n remains + 18.9 for limit free water flushes and IVF to assist in diuresis\n - f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - discontinue Hydralazine and add Amlodipine 10 mg q daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.0 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and transition to lasix bolus for goal of -\n 1.0 L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 now 23 in\n the setting of known PUD. Element of this could be dilutional with\n mobilization of fluid however other cell lines are not proportionately\n reduced.\n - re-guiac stool to r/o slow GIB\n - transfuse 1 unit PRBC\ns for goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: patient will likely benefit from transition to \n rehab as he requires significant nursing care with suctioning.- touch\n base with case management\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:29 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598314, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continue thick secretions requiring active frequent suctioning and\n close nursing care\n - metolazone (5 mg) added to lasix (15 mg/hr) drip to improve diuresis\n now 400 negative since yesterday, positive for LOS and nearly\n 6 kg positive since admission weight\n - PT/OT consulted\n - transfused 1 unit PRBC\ns with jump from 23 => 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 67 (61 - 98) bpm\n BP: 106/42(58) {95/40(53) - 131/50(69)} mmHg\n RR: 13 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,942 mL\n 547 mL\n PO:\n TF:\n 1,080 mL\n 298 mL\n IVF:\n 547 mL\n 199 mL\n Blood products:\n 375 mL\n Total out:\n 2,995 mL\n 940 mL\n Urine:\n 2,895 mL\n 940 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -53 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool (15 L face tent\n FiO2 50%)\n SpO2: 95%\n ABG: ///38/\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 255 K/uL\n 8.2 g/dL\n 282 mg/dL\n 3.0 mg/dL\n 38 mEq/L\n 3.7 mEq/L\n 94 mg/dL\n 98 mEq/L\n 141 mEq/L\n 25.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n WBC\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n Hct\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n Plt\n \n Cr\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n TCO2\n 38\n Glucose\n 153\n 188\n 178\n 167\n 191\n 210\n 166\n 282\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.8 mg/dL, PO4:3.3 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n improved aeration of bilateral lung fields, continued\n blunting of CP angles c/w bilateral effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (10 of 14) and linezolid (10 of 14)\n - continue lasix drip with metolazone for goal of\n 1L / day\n - continue face mask with down titration as oxygen requirement permits\n - continue chest-PT\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone diuresis for goal of\n 1L / day\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 150 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse to goal > 23\n - consider EPO level in setting of CRF\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:42 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598322, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continue thick secretions requiring active frequent suctioning and\n close nursing care\n - metolazone (5 mg) added to lasix (15 mg/hr) drip to improve diuresis\n now 400 negative since yesterday, positive for LOS and nearly\n 6 kg positive since admission weight\n - PT/OT consulted\n - transfused 1 unit PRBC\ns with jump from 23 => 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 67 (61 - 98) bpm\n BP: 106/42(58) {95/40(53) - 131/50(69)} mmHg\n RR: 13 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,942 mL\n 547 mL\n PO:\n TF:\n 1,080 mL\n 298 mL\n IVF:\n 547 mL\n 199 mL\n Blood products:\n 375 mL\n Total out:\n 2,995 mL\n 940 mL\n Urine:\n 2,895 mL\n 940 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -53 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool (15 L face tent\n FiO2 50%)\n SpO2: 95%\n ABG: ///38/\n Physical Examination\n General: NAD, sleeping\n Lungs: coarse BS bilateral\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, 2+ PE\n Labs / Radiology\n 255 K/uL\n 8.2 g/dL\n 282 mg/dL\n 3.0 mg/dL\n 38 mEq/L\n 3.7 mEq/L\n 94 mg/dL\n 98 mEq/L\n 141 mEq/L\n 25.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n WBC\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n Hct\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n Plt\n \n Cr\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n TCO2\n 38\n Glucose\n 153\n 188\n 178\n 167\n 191\n 210\n 166\n 282\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.8 mg/dL, PO4:3.3 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n improved aeration of bilateral lung fields, continued\n blunting of CP angles c/w bilateral effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (10 of 14) and linezolid (10 of 14)\n - continue lasix drip with metolazone for goal of\n 1L / day\n - continue face mask with down titration as oxygen requirement permits\n - continue chest-PT\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone diuresis for goal of\n 1L / day\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 150 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse to goal > 23\n - consider EPO level in setting of CRF\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:42 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597756, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597757, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598069, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt with O2 requirements O/N were face tent at 50% with\n 15L.. Pt able to cough up and swallow most of his secretions.\n Action:\n Attempt to weaned his FiO2 to 40% face tent. Pt continues to be\n coughing frequently bring up copious secretions but he would swallow\n them refusing to have the yaunker suction them. Pt had to be NT\n suctioned X1 overnigyht for moderate amount of thick yellow secretions.\n Chest PT being done with every turn.\n Response:\n O2 sats have been 91-94% while in bed. Pt states no difficulty\n breathing.\n Plan:\n Give good pulm toilet while back in bed until secretions start to\n decrease.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt continues on the lasix gtt at 15mg/hr.\n Action:\n U/O good but just maintaining due to the increase in free water\n boluses. Pt continues to be 19+L for the LOS.\n Response:\n Pt averaging 100cc/hr of clear yellow urine via foley catheter. Pt\n weight was 106.3 KG\n Plan:\n Increase lasix to keep pt fluid balance net negative.\n Hyperglycemia\n Assessment:\n Blood sugars were 144 at 2200 and 176 at 0400.\n Action:\n He was covered with 3units of humalog insulin at 0400.\n Response:\n He continues on tube feeding at goal rate of 45cc/hr and requiring very\n little insulin\n Plan:\n Continue to monitor q6h.\n" }, { "category": "Nursing", "chartdate": "2121-09-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598196, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 144\n Action:\n Free h20 decreased to 200ml q6\n Having chem. Panel checked\n Response:\n Stable NA\n Plan:\n Labs as ordered\n Free h2o as ordered\n Impaired Skin Integrity\n Assessment:\n Skin tears healing\n Action:\n Mepliex dressings on right arm changed\n Skin tears appear to be healing, presently are scabbed over\n Sacral area appears healed\n OOB to chair for 4 hours\n Switched from kinair bed to regular icu bed\n Response:\n Improvement in skin integrity\n Plan:\n Mepilex change q72\n Per nursing care plan\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat improving\n Action:\n Creat 3.0 this am\n Continues on lasix gtt at 15mg/hour\n Receiving 1u PC\ns for hct 23 this am\n K repleted with 40meq pngt\n Response:\n Improving renal function\n Plan:\n Lasix gtt as ordered\n Goal volume out is even to slightly neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Unable to wean o2\n Action:\n O2 sats 92-96% on 50% face tent\n Pt with congested cough, expectorating, but then swallows secretions\n Resistant to sunctioning with yankour\n NTS x2 with difficulty due to NGT and uncooperative\n Enc cough and deep breathing\n Response:\n Congested cough\n Plan:\n Wean o2 as tolerated\n Cont to diurese as ordered\n Pulmonary toilet\n" }, { "category": "Nursing", "chartdate": "2121-09-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598408, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 141\n Action:\n Free h2o decreased to 150cc q6 hours\n Response:\n Stable NA\n Plan:\n Free h2o as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt more lethargic\n Action:\n Pt continues with congested cough\n Difficult to NTS due to deviated septum and NGT\n CPT done\n Pt more lethargic, and having more trouble clearing secretions\n Intub at ~1600\n ETT confirmed by CXR\n Pt inially on ac, switched to PSV\n Response:\n Intub for airway protection and secretion management\n Plan:\n Pulmonary toilet\n Wean from vent as tolerated\n ? will need trache\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat inc to 3.1\n Action:\n Received on lasix gtt at 15mg/hour\n Received metolozone 5mg po x1\n Repeat creat inc to 3.1\n Lasix gtt d/c\n Renal team consulted\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598176, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 144\n Action:\n Free h20 decreased to 200ml q6\n Having chem. Panel checked\n Response:\n Stable NA\n Plan:\n Labs as ordered\n Free h2o as ordered\n Impaired Skin Integrity\n Assessment:\n Skin tears healing\n Action:\n Mepliex dressings on right arm changed\n Skin tears appear to be healing, presently are scabbed over\n Sacral area appears healed\n OOB to chair for 4 hours\n Switched from kinair bed to regular icu bed\n Response:\n Improvement in skin integrity\n Plan:\n Mepilex change q72\n Per nursing care plan\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat improving\n Action:\n Creat 3.0 this am\n Continues on lasix gtt at 15mg/hour\n Receiving 1u PC\ns for hct 23 this am\n Response:\n Improving renal function\n Plan:\n Lasix gtt as ordered\n Goal volume out is even to slightly neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Unable to wean o2\n Action:\n O2 sats 92-96% on 50% face tent\n Pt with congested cough, expectorating, but then swallows secretions\n Resistant to sunctioning with yankour\n NTS x2 with difficulty due to NGT and uncooperative\n Enc cough and deep breathing\n Response:\n Congested cough\n Plan:\n Wean o2 as tolerated\n Cont to diurese as ordered\n Pulmonary toilet\n" }, { "category": "Nursing", "chartdate": "2121-09-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598312, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n LS-rhonchi with diminished bases. Continues to have congested cough.\n Unable to expectorate secretions. +gag. O2 sats 94-97%.\n Action:\n NT suctioned ~1-2hrs for moderate to copious amts of blood tinged,\n frothy secretions. Frequent position changes done.\n Response:\n Afebrile. No change resp status or amt of secretions.\n Plan:\n Suction PRN.\n Impaired Skin Integrity\n Assessment:\n R arm with 2 mepilex dressings. Sacrum pink.\n Action:\n Mepilex dressings intact, wounds appear to be healing. Frequent\n position changes.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care and frequent position changes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 94(93), Creat 3(2.9).\n Action:\n Continued on lasix gtt.\n Response:\n UOP 75-150cc/hr.\n Plan:\n Monitor labs. Monitor UOP.\n Hypernatremia (high sodium)\n Assessment:\n Na 141(145)\n Action:\n FWB 200cc/6hrs continued.\n Response:\n Plan:\n Monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2121-09-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598246, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n LS-rhonchi with diminished bases. Continues to have congested cough.\n Unable to expectorate secretions. +gag. O2 sats 94-97%.\n Action:\n NT suctioned ~1-2hrs for moderate to copious amts of blood tinged,\n frothy secretions. Frequent position changes done.\n Response:\n Afebrile. No change resp status or amt of secretions.\n Plan:\n Suction PRN.\n Impaired Skin Integrity\n Assessment:\n R arm with 2 mepilex dressings. Sacrum pink.\n Action:\n Mepilex dressings intact, wounds appear to be healing. Frequent\n position changes.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care and frequent position changes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598304, "text": "Chief Complaint:\n 24 Hour Events:\n continues to have thick secretions\n -given metolazone 5 mg + lasix drip (on 15 mcg/hr); was given\n metolazone b/c net balance was even. -200 balance at midnight\n -PT/OT consult called (need to speak with them to make him a priority\n so that discharge is not delayed)\n -touch base with case mgt tomorrow re: discharge\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 67 (61 - 98) bpm\n BP: 106/42(58) {95/40(53) - 131/50(69)} mmHg\n RR: 13 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,942 mL\n 547 mL\n PO:\n TF:\n 1,080 mL\n 298 mL\n IVF:\n 547 mL\n 199 mL\n Blood products:\n 375 mL\n Total out:\n 2,995 mL\n 940 mL\n Urine:\n 2,895 mL\n 940 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -53 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: ///38/\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 255 K/uL\n 8.2 g/dL\n 282 mg/dL\n 3.0 mg/dL\n 38 mEq/L\n 3.7 mEq/L\n 94 mg/dL\n 98 mEq/L\n 141 mEq/L\n 25.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n WBC\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n Hct\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n Plt\n \n Cr\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n TCO2\n 38\n Glucose\n 153\n 188\n 178\n 167\n 191\n 210\n 166\n 282\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.8 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (9 of 14) and linezolid (9 of 14)\n - transition to lasix boluses for continued diuresis goal of neg. 1 L /\n day\n remains + 18.9 for limit free water flushes and IVF to assist in diuresis\n - f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - discontinue Hydralazine and add Amlodipine 10 mg q daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.0 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and transition to lasix bolus for goal of -\n 1.0 L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 now 23 in\n the setting of known PUD. Element of this could be dilutional with\n mobilization of fluid however other cell lines are not proportionately\n reduced.\n - re-guiac stool to r/o slow GIB\n - transfuse 1 unit PRBC\ns for goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: patient will likely benefit from transition to \n rehab as he requires significant nursing care with suctioning.- touch\n base with case management\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:42 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Respiratory ", "chartdate": "2121-09-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597362, "text": "Demographics\n Day of intubation: 10\n Day of mechanical ventilation: 10\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 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: Blood Tinged / 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 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: Reduce PEEP as tolerated, Increase ventilatory\n support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n" }, { "category": "Physician ", "chartdate": "2121-09-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 597982, "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 Out of bed to chair this morning\n Still has high Fi02 requirments; desaturations with minimal exertion\n Wet cough\n Lasix drip increased to 10/hour\n Free H20 replacement increased\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 PM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 63 (54 - 78) bpm\n BP: 132/50(70) {108/41(57) - 153/58(80)} mmHg\n RR: 12 (9 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,705 mL\n 1,377 mL\n PO:\n TF:\n 1,080 mL\n 509 mL\n IVF:\n 405 mL\n 163 mL\n Blood products:\n Total out:\n 2,670 mL\n 1,240 mL\n Urine:\n 2,370 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 35 mL\n 137 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 95%\n ABG: ///36/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\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: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: scattered\n bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 316 K/uL\n 191 mg/dL\n 3.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 90 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.8 %\n 7.6 K/uL\n [image002.jpg]\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n Plt\n 247\n 284\n 271\n 298\n 316\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n TCO2\n 37\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM): Increased free water replacement.\n ALTERED MENTAL STATUS (NOT DELIRIUM): Unclear what baseline mental\n status is. We are continue to treat underlying infections, correcting\n hypernatremia which are likely contributing.\n\n HYPERGLYCEMIA/DIABETES: Well controlled on RISS.\n\n IMPAIRED SKIN INTEGRITY: Stable.\n\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Growing Acinetobacter\n and MRSA pneumonia. Repeat gram stain shows GNR, culture pending.\n Stable post-extubation albeit still briniging up moderate secretions,\n able to cough to back of throat. Continue current abx. More\n comfortable sitting up in chair. Desaturates with minimal exertion,\n continues high Fi02 requirement. Continue to monitor in ICU.\n\n UTI: Secondary to VRE on linezolid. Subsequent cultures are no\n growth to date.\n\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr continues\n stable. Needed to increase lasix drip given decreasing urine output.\n Follow electrolytes, replete K and Mg as needed. Goal 1L negative over\n next 24 hours.\n\n ANEMIA: Hct stable, following daily hcts.\n\n SCHIZOPHRENIA: Readdress with psychiatry service as far as\n restarting other medications.\n HYPOTHYROIDISM: Continues on replacement therapy.\n\n COPD, ACUTE EXACERBATION IN SETTING OF PNEUMONIA: Bronchodilators.\n NUTRITION: Tube feeds at goal.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:19 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-09-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597986, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continued thick secretions with high oxygen requirements\n - continued lasix gtt at 10 mcg, even yesterday and neg. 19,059 ml for\n LOS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 PM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 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: 78 (54 - 78) bpm\n BP: 124/50(68) {108/41(57) - 153/58(80)} mmHg\n RR: 22 (9 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,705 mL\n 758 mL\n PO:\n TF:\n 1,080 mL\n 315 mL\n IVF:\n 405 mL\n 98 mL\n Blood products:\n Total out:\n 2,670 mL\n 675 mL\n Urine:\n 2,370 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 35 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///36/\n Physical Examination\n General: NAD, wet cough\n Lungs: coarse cough and end-expiratory breath sounds\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: diffuse 2+ pitting edema, DP 2+\n Labs / Radiology\n 316 K/uL\n 8.0 g/dL\n 191 mg/dL\n 3.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 90 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.8 %\n 7.6 K/uL\n [image002.jpg]\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n Plt\n 247\n 284\n 271\n 298\n 316\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n TCO2\n 37\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.1 mg/dL\n Microbiology\n - none\n Imaging\n - none\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (8 of 14) and linezolid (8 of 14)\n - increase lasix gtt (titrated as low as possible) for continued\n diuresis as patient was positive yesterday + 19 for f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - continue to up-titrate Amlodipine and down titrate Hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.1 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and continue minimal lasix gtt to achieve -\n 1.5L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - contact family concerning baseline mental status and interactions\n - consider psychiatry consult\n # Urinary infection\n only urine Cx from positive for VRE,\n completed 7 day course of Linezolid. Most recent cultures from \n negative.\n - continue to follow with periodic surveillance cultures\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 in the\n setting of known PUD\n - re-guiac stool to r/o slow GIB\n - avoid transfusion if possible to avoid contributing to volume\n overload\n threshold is 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: possible to floor in PM\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:19 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Respiratory ", "chartdate": "2121-09-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598159, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Frothy\n Sputum source/amount: Suctioned / Copious\n Comments:\n Comments: Pt followed by resp for Q6 Nebs and was treated as per .\n BS course bilaterally with fair improvement noted s/p txs. Will cont to\n follow and treat as needed.\n" }, { "category": "General", "chartdate": "2121-09-23 00:00:00.000", "description": "Generic Note", "row_id": 598274, "text": "TITLE: Resp Care Note, Pt given Albuterol/ Atrovent nebs x3 last\n @0530.BS rhonchi and wheezes. Strong prod cough,swallowed.\n" }, { "category": "Nursing", "chartdate": "2121-09-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598381, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 141\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 Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597265, "text": "Chief Complaint: This is a 74 y.o. Male with h.o. hypothyroidism p/w\n septic shock, NSTEMI, hypothermia with suspected pulmonary versus urine\n source.\n 24 Hour Events:\n -patient placed on Lasix drip with goal outs of (-)1.5 L for volume\n overload as potential etiology of respiratory failure.\n -increased free water flushes for elevated Na 146\n -repeat CXR: increased bilateral airspace consolidation and atelectasis\n with small bilateral pleural effusions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 12:02 AM\n Linezolid - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 9 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (98.9\n HR: 68 (58 - 75) bpm\n BP: 154/55(83) {124/48(70) - 159/70(98)} mmHg\n RR: 18 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 15 (1 - 15)mmHg\n Total In:\n 3,549 mL\n 1,414 mL\n PO:\n TF:\n 1,020 mL\n 318 mL\n IVF:\n 1,153 mL\n 596 mL\n Blood products:\n Total out:\n 3,755 mL\n 1,075 mL\n Urine:\n 3,755 mL\n 1,075 mL\n NG:\n Stool:\n Drains:\n Balance:\n -206 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 21 cmH2O\n Plateau: 21 cmH2O\n Compliance: 38.2 cmH2O/mL\n SpO2: 94%\n ABG: 7.44/46/77/29/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 154\n Physical Examination\n Cardiovascular: Gen: NAD\n CV: RRR, no m/r/g, JVD\n Lungs: CTAB\n Ext: DP 2+ bilat, 2+ pitting 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 156 K/uL\n 8.0 g/dL\n 173 mg/dL\n 4.4 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 99 mg/dL\n 110 mEq/L\n 148 mEq/L\n 24.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:00 PM\n 04:00 PM\n 04:23 PM\n 06:33 PM\n 07:23 PM\n 03:46 AM\n 04:05 AM\n 08:05 PM\n 11:49 PM\n 02:33 AM\n WBC\n 4.4\n 5.8\n Hct\n 25.0\n 25.2\n 24.5\n Plt\n 111\n 156\n Cr\n 4.6\n 4.5\n 4.4\n 4.4\n TCO2\n 29\n 29\n 29\n 32\n Glucose\n 113\n 130\n 172\n 188\n 173\n Other labs: PT / PTT / INR:12.2/39.6/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:4.3 mg/dL\n Fluid analysis / Other labs: Iron: 116\n calTIBC: 142\n Ferritn: 879\n TRF: 109\n Imaging: CXR: - Increased bilateral airspace consolidation and\n atelectasis with\n small bilateral pleural effusions.\n Microbiology: Blood cultures, negative or NGTD\n - Cdiff negative\n - Urine - no growth (final)\n - Sputum - GNR\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year.\n - influenza antigen and legionella negative\n - off pressors\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only. currently growing vre sensitive to amp/linizolid on started\n on linezolid per ID recs. coag neg staph from blood (likely\n contaminant) from . Monitor for CBC as pt on linezolid\n - will continue on IV Hydrocortisone, currently on 25q8 today (=2.8\n daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n - fluid overloaded from rescusitation.\n - last urine was clean, continue linezolid for 5 day course, Day 1 =\n \n ##. Respiratory Failure: Likely a combination of Acinetobacter PNA and\n volume overload from fluid rescussitation.\n - Sats maintained in low to mid 90s\n - no improvement in CXR, ? worsening\n - Sputum from growing GNR, consistent with Acitenobacter\n -defer trial of SBP until respiratory status improves\n - continue aggressive diuresis\n # : baseline 1.8-2, trending down slowly. 4.4 today.\n -will trend\n -volume overload will likely be indication for HD, if unable to\n diurese\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n #hypernatremia: hypernatremic to 146 this am. Likely due to tube\n feeding and hypotonic diuresis in setting of lasix ggt.\n - will increase free water in tube feeds to 250cc q4h (from 200cc q4h)\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable at 25.\n -keep active type and screen\n -stool guiac negative\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated, and in the setting of linezolid\n -consider restart home psych med now that sedation off\n -psych consult regarding holding of medications\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n # adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n # DM: now back on insulin SQ, may need to tighten ss\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:16 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597355, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG to be sent in\n am, pt denies SOB when asked, Sats currently 96-97%\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, falls asleep\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597356, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG to be sent in\n am, pt denies SOB when asked, Sats currently 96-97%\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldo as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Physician ", "chartdate": "2121-09-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598369, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continue thick secretions requiring active frequent suctioning and\n close nursing care\n - metolazone (5 mg) added to lasix (15 mg/hr) drip to improve diuresis\n now 400 negative since yesterday, positive for LOS and nearly\n 6 kg positive since admission weight\n - PT/OT consulted\n - transfused 1 unit PRBC\ns with jump from 23 => 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 67 (61 - 98) bpm\n BP: 106/42(58) {95/40(53) - 131/50(69)} mmHg\n RR: 13 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,942 mL\n 547 mL\n PO:\n TF:\n 1,080 mL\n 298 mL\n IVF:\n 547 mL\n 199 mL\n Blood products:\n 375 mL\n Total out:\n 2,995 mL\n 940 mL\n Urine:\n 2,895 mL\n 940 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -53 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool (15 L face tent\n FiO2 50%)\n SpO2: 95%\n ABG: ///38/\n Physical Examination\n General: NAD, sleeping\n Lungs: coarse BS bilateral\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, 2+ PE\n Labs / Radiology\n 255 K/uL\n 8.2 g/dL\n 282 mg/dL\n 3.0 mg/dL\n 38 mEq/L\n 3.7 mEq/L\n 94 mg/dL\n 98 mEq/L\n 141 mEq/L\n 25.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n WBC\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n Hct\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n Plt\n \n Cr\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n TCO2\n 38\n Glucose\n 153\n 188\n 178\n 167\n 191\n 210\n 166\n 282\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.8 mg/dL, PO4:3.3 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n improved aeration of bilateral lung fields, continued\n blunting of CP angles c/w bilateral effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient appears more somnolent this AM with poor\n cough.\n - continue meropenum (10 of 14) and linezolid (10 of 14)\n - continue lasix drip with metolazone for goal of - 2L / day\n titrate\n to BP\n - continue face mask with down titration as oxygen requirement permits\n - continue chest-PT\n - patient will likely require re-intubation this PM for airway\n protection\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone diuresis for goal of\n 2L / day\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 150 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:42 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597237, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Hypernatremia (high sodium)\n Assessment:\n Pm Na 148\n Action:\n Free water 250cc q4h.\n Response:\n Awaiting am labs.\n Plan:\n lytes.\n Altered mental status (not Delirium)\n Assessment:\n Pt off sedation for >48 hours, pt easily arousable to voice,\n intermittently following commands, withdraws to pain, PERRL, denies\n pain.\n Action:\n Mental status evaluated q4h, pt oriented to time, place, situation as\n needed.\n Response:\n Pt\ns mental status continues to clear however per ICU team no plans of\n extubation until fluid balance is negative.\n Plan:\n Continue to assess mental status frequently, question need for sedation\n for comfort if no plans for extubation any time soon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute on chronic renal failure, pt\ns baseline Cr around 2.5,\n currently 4.4. UOP adequate on lasix drip, putting out >250cc q2h. K\n 2.9 on pm labs.\n Action:\n Conts on lasix gtt at 9mg/hr.Repleted K with 40 iv and 20 po.\n Response:\n Pt is only 200 neg at MN.\n Plan:\n Will continue diuresis for another few days in order to take off fluid,\n if fluid balance continues to be high pt will be consulted by renal for\n CRRT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV 50%/420/20/+10, pt rarely overbreathing vent, lung sounds\n rhonchorous throughout.\n Action:\n Turned to left side only as pt drops sat on right side. Suctioned for\n small to copious amounts of thick, blood tinged secretions, chest PT\n done with excellent effects. Lasix drip for fluid overload and\n pulmonary edema.\n Response:\n Pt sating 92-95%.Bld gas 7.44/46/77.UOP >200cc q2h.\n Plan:\n Continue pulmonary toilet, lasix drip, chest PT.\n" }, { "category": "Nursing", "chartdate": "2121-09-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598384, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 141\n Action:\n Free h2o decreased to 150cc q6 hours\n Response:\n Stable NA\n Plan:\n Free h2o as ordered\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt more lethargic\n Action:\n Pt continues with congested cough\n Difficult to NTS due to deviated septum and NGT\n CPT done\n Pt more lethargic, and having more trouble clearing secretions\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat inc to 3.1\n Action:\n Received on lasix gtt at 15mg/hour\n Received metolozone 5mg po x1\n Repeat creat inc to 3.1\n Lasix gtt d/c\n Renal team consulted\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2121-09-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598393, "text": "Demographics\n Day of mechanical ventilation: 1\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation; Comments: pt requiring frequent NTS, noticeably\n tiring, reintubated.\n Tube Type\n ETT:\n Position: 21 cm at lip\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 Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt re-intubated by anesthesia\n w/out incident; +ETCO2 +/=BLBS. Continues on A/C ventilation w/\n PIP/Pplat = 22/16.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597256, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Hypernatremia (high sodium)\n Assessment:\n Pm Na 148\n Action:\n Free water 250cc q4h.\n Response:\n Awaiting am labs.\n Plan:\n lytes.\n Altered mental status (not Delirium)\n Assessment:\n Pt off sedation for >48 hours, pt easily arousable to voice,\n intermittently following commands, withdraws to pain, PERRL, denies\n pain.\n Action:\n Mental status evaluated q4h, pt oriented to time, place, situation as\n needed.\n Response:\n Pt\ns mental status continues to clear however per ICU team no plans of\n extubation until fluid balance is negative.\n Plan:\n Continue to assess mental status frequently, question need for sedation\n for comfort if no plans for extubation any time soon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute on chronic renal failure, pt\ns baseline Cr around 2.5,\n currently 4.4. UOP adequate on lasix drip, putting out >250cc q2h. K\n 2.9 on pm labs.\n Action:\n Conts on lasix gtt at 9mg/hr.Repleted K with 40 iv and 20 po.\n Response:\n Pt is only 200 neg at MN.\n Plan:\n Will continue diuresis for another few days in order to take off fluid,\n if fluid balance continues to be high pt will be consulted by renal for\n CRRT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV 50%/420/20/+10, pt rarely overbreathing vent, lung sounds\n rhonchorous throughout.\n Action:\n Turned to left side only as pt drops sat on right side. Suctioned for\n small to copious amounts of thick, blood tinged secretions, chest PT\n done with excellent effects. Lasix drip for fluid overload and\n pulmonary edema.\n Response:\n Pt sating 92-95%.Bld gas 7.44/46/77.UOP >200cc q2h.\n Plan:\n Continue pulmonary toilet, lasix drip, chest PT.\n" }, { "category": "General", "chartdate": "2121-09-16 00:00:00.000", "description": "Generic Note", "row_id": 597286, "text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning.\n 99.0 61 163/60\n Sedated\n Chest\n crackles bilat\n CV\n 2/6 SEM\n Anasarca\n Na 149\n Hct 24\n UO\n 3.4 L\n Good UO on lasix gtt. Failed to make him signif negative overnight but\n creat seems to have peaked and we were able to keep him even. Will try\n today to keep him neg 50+/hour. Now improved hemodyn. And WBC 5.8 and\n afebrile so we are ready to peel off abx. Although oxygenation is good\n we are a long way from extubation. With good UO can avoid CVVH.\n Time spent 40 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2121-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597288, "text": "Chief Complaint: This is a 74 y.o. Male with h.o. hypothyroidism p/w\n septic shock, NSTEMI, hypothermia with suspected pulmonary versus urine\n source.\n 24 Hour Events:\n -patient placed on Lasix drip with goal outs of (-)1.5 L for volume\n overload as potential etiology of respiratory failure.\n -increased free water flushes for elevated Na 146\n -repeat CXR: increased bilateral airspace consolidation and atelectasis\n with small bilateral pleural effusions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 12:02 AM\n Linezolid - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 9 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (98.9\n HR: 68 (58 - 75) bpm\n BP: 154/55(83) {124/48(70) - 159/70(98)} mmHg\n RR: 18 (17 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 15 (1 - 15)mmHg\n Total In:\n 3,549 mL\n 1,414 mL\n PO:\n TF:\n 1,020 mL\n 318 mL\n IVF:\n 1,153 mL\n 596 mL\n Blood products:\n Total out:\n 3,755 mL\n 1,075 mL\n Urine:\n 3,755 mL\n 1,075 mL\n NG:\n Stool:\n Drains:\n Balance:\n -206 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 21 cmH2O\n Plateau: 21 cmH2O\n Compliance: 38.2 cmH2O/mL\n SpO2: 94%\n ABG: 7.44/46/77/29/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 154\n Physical Examination\n Cardiovascular: Gen: NAD\n CV: RRR, no m/r/g, JVD\n Lungs: CTAB\n Ext: DP 2+ bilat, 2+ pitting edema\n Labs / Radiology\n 156 K/uL\n 8.0 g/dL\n 173 mg/dL\n 4.4 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 99 mg/dL\n 110 mEq/L\n 148 mEq/L\n 24.5 %\n 5.8 K/uL\n [image002.jpg]\n 12:00 PM\n 04:00 PM\n 04:23 PM\n 06:33 PM\n 07:23 PM\n 03:46 AM\n 04:05 AM\n 08:05 PM\n 11:49 PM\n 02:33 AM\n WBC\n 4.4\n 5.8\n Hct\n 25.0\n 25.2\n 24.5\n Plt\n 111\n 156\n Cr\n 4.6\n 4.5\n 4.4\n 4.4\n TCO2\n 29\n 29\n 29\n 32\n Glucose\n 113\n 130\n 172\n 188\n 173\n Other labs: PT / PTT / INR:12.2/39.6/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.7 mg/dL, PO4:4.3 mg/dL\n Fluid analysis / Other labs: Iron: 116\n calTIBC: 142\n Ferritn: 879\n TRF: 109\n Imaging: CXR: - Increased bilateral airspace consolidation and\n atelectasis with\n small bilateral pleural effusions.\n Microbiology: Blood cultures, negative or NGTD\n - Cdiff negative\n - Urine - no growth (final)\n - Sputum - GNR\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n ##. Respiratory Failure: Likely a combination of Acinetobacter PNA and\n volume overload from fluid rescussitation.\n - Sats maintained in low to mid 90s\n - no improvement in CXR, repeat AM CXR\n - Sputum from growing GNR, consistent with Acitenobacter\n -defer trial of SBP until respiratory status improves\n - continue aggressive diuresis\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only. currently growing vre sensitive to amp/linizolid on started\n on linezolid per ID recs. coag neg staph from blood (likely\n contaminant) from . Monitor for CBC as pt on linezolid\n - pt completed xygris course\n - fluid overloaded from rescusitation.\n - last urine was clean, continue linezolid for day course, Day 1 =\n \n - influenza antigen and legionella negative\n # : baseline 1.8-2, trending down slowly. 4.4 today.\n -will trend\n -volume overload will likely be indication for HD, if unable to\n diurese\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n # Hypertension\n Pt has systolic hypertension to 170s when awake. Will\n follow him through the day, consider antihypertensive if continues to\n remain high.\n - on Lasix drip\n - no BB given bradycardia\n - no ACEI given renal failure\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n #hypernatremia: hypernatremic to 148 this am. Likely due to tube\n feeding and hypotonic diuresis in setting of lasix ggt.\n - continue free water in tube feeds to 250cc q4h (from 200cc q4h)\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable at 25.\n -keep active type and screen\n -stool guiac negative\n - rpt Hct,\n - po PPI\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated, and in the setting of linezolid\n -consider restart home psych med now that sedation off\n -psych consult regarding holding of medications\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n # adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - will continue on IV Hydrocortisone, currently on 25q8 today (=2.8\n daily of decadron, pt on 2 daily of decadron at home), titrate down\n today\n # DM: now back on insulin SQ, may need to tighten ss\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:16 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597289, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Hypernatremia (high sodium)\n Assessment:\n Pm Na 148\n Action:\n Free water 250cc q4h.\n Response:\n Awaiting am labs.\n Plan:\n lytes.\n Altered mental status (not Delirium)\n Assessment:\n Pt off sedation for >48 hours, pt easily arousable to voice,\n intermittently following commands, withdraws to pain, PERRL, denies\n pain.\n Action:\n Mental status evaluated q4h, pt oriented to time, place, situation as\n needed.\n Response:\n Pt\ns mental status continues to clear however per ICU team no plans of\n extubation until fluid balance is negative.\n Plan:\n Continue to assess mental status frequently, question need for sedation\n for comfort if no plans for extubation any time soon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute on chronic renal failure, pt\ns baseline Cr around 2.5,\n currently 4.4. UOP adequate on lasix drip, putting out >250cc q2h. K\n 2.9 on pm labs.\n Action:\n Conts on lasix gtt at 9mg/hr.Repleted K with 40 iv and 20 po.\n Response:\n Pt is only 200 neg at MN.\n Plan:\n Will continue diuresis for another few days in order to take off fluid,\n if fluid balance continues to be high pt will be consulted by renal for\n CRRT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV 50%/420/20/+10, pt rarely overbreathing vent, lung sounds\n rhonchorous throughout.\n Action:\n Turned to left side only as pt drops sat on right side. Suctioned for\n small to copious amounts of thick, blood tinged secretions, chest PT\n done with excellent effects. Lasix drip for fluid overload and\n pulmonary edema.\n Response:\n Pt sating 92-95%.Bld gas 7.44/46/77.UOP >200cc q2h.\n Plan:\n Continue pulmonary toilet, lasix drip, chest PT.\n" }, { "category": "Nursing", "chartdate": "2121-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597293, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Admit with urosepsis VRE, now with gram neg rods in sputum, tx for\n pneumonia, pos balance > 20l\n remains pos balance > 20l for LOS , lasix titrated for net\n neg 50cc/hr\n fluid bolus increased to 300cc q4, for re-check NA/K this\n eve [ team considering D5W]\n team aware of B/P 150-160 systolic [ no action unless\n maintained in 170\n psych team reviewed ? to re-commence psycyh meds\n AC switched to PS with stable abg\n Hct trending down, new T/S sent\n Hypernatremia (high sodium)\n Assessment:\n NA at 1200hrs = 149/ K at 3.2\n Action:\n Free water increased to 300 q4h. received 60 po K\n Response:\n For pm lytes @ 1900hrs\n Plan:\n Trend Na ? for DW5 if no decrease in level\nfollow K level and replete\n as necessary\n Altered mental status (not Delirium)\n Assessment:\n Pt off sedation for >48 hours, pt easily arousable to voice, constantly\n following commands, movement noted of all 4 limbs, PERRL, denies pain.\n Soft wrist restraints for safety of lines/tubes\n Action:\n Mental status evaluated q4h, pt oriented to person nods head\n appropriately and denies pain, seen by psych team this pm\n Response:\n Pt\ns mental status continues to clear\n Plan:\n Continue to assess mental status frequently, question need for sedation\n for comfort if no plans for extubation any time soon. ? to re-commence\n psych meds soon\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute on chronic renal failure, pt\ns baseline Cr around 2.0,\n currently 4.4. UOP adequate on lasix drip, putting out >250cc q2h.but\n remains in grossly pos balance [ due to free water that is needed for\n NA level\n Action:\n Team have asked for net neg balance of 50cc/hr, therefore aim\n 170-200cc/hr\n Response:\n U/O maintained at this time and pm creat down to 4.1, overall exam\n improved\n Plan:\n Aim net neg 50cc/hr,trean lytes\nif fluid balance continues to be high\n pt will be consulted by renal for CRRT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV 50%/420/20/+10, pt rarely overbreathing vent, lung sounds\n rhonchorous throughout.\n Action:\n Suctioned for small amounts of thick, blood tinged secretions, chest\n PT done with excellent effects. Lasix drip for fluid overload and\n pulmonary edema. CXR not improved but able to switch patient to PS this\n am to \n Response:\n Stbale abg on therefore lowered to \n Plan:\n Continue pulmonary toilet, lasix drip, chest PT. , sats maintained >\n 94% on , trend sats/abgs\n" }, { "category": "Nutrition", "chartdate": "2121-09-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 597295, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 100 kg\n 109.5 kg ( 12:00 PM)\n 30.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 78 kg\n 128% per admit wt\n 83.5 kg per admit wt\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 178 mg/dL\n 11:45 AM\n Glucose Finger Stick\n 240\n 12:00 PM\n BUN\n 100 mg/dL\n 11:45 AM\n Creatinine\n 4.2 mg/dL\n 11:45 AM\n Sodium\n 149 mEq/L\n 11:45 AM\n Potassium\n 3.2 mEq/L\n 11:45 AM\n Chloride\n 109 mEq/L\n 11:45 AM\n TCO2\n 30 mEq/L\n 11:45 AM\n PO2 (arterial)\n 81. mm Hg\n 02:58 PM\n PCO2 (arterial)\n 49 mm Hg\n 02:58 PM\n pH (arterial)\n 7.44 units\n 02:58 PM\n CO2 (Calc) arterial\n 34 mEq/L\n 02:58 PM\n Calcium non-ionized\n 7.7 mg/dL\n 02:33 AM\n Phosphorus\n 4.3 mg/dL\n 02:33 AM\n Ionized Calcium\n 1.13 mmol/L\n 04:12 AM\n Magnesium\n 2.7 mg/dL\n 02:33 AM\n WBC\n 5.8 K/uL\n 02:33 AM\n Hgb\n 8.0 g/dL\n 02:33 AM\n Hematocrit\n 23.7 %\n 11:45 AM\n Current diet order / nutrition support: NUtren 2.0 @45mL/hr (2160\n kcals/86 gr protein)\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Patient continues on tube feeds for full nutrition support. Tube feeds\n being tolerated at goal, meeting 100% estimated nutrition needs.\n Patient being diuresed via lasix drip. Feed is volume restricted to\n aid in diuresis. Free water boluses being adjusted in attempt to keep\n Na WNL-recently increased by 50mL to 300 q4 hr. It is unlikely that\n this will bring Na down as flushes were increased by 50mL yesterday and\n Na continues the upwards trend. Would consider D5W. K repletions\n noted. FSBG running high-which will likely worsen if D5 is given.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n Tube feeding recommendations: Continue c/ tube feeds @ goal\n Would consider IV D5W to bring Na WNL\n Continue to replete lytes prn\n Glucose management as you are- ? tighter sliding scale\n Please page c/?'s #\n" }, { "category": "General", "chartdate": "2121-09-23 00:00:00.000", "description": "Generic Note", "row_id": 598362, "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. Frequent suctioning.\n 98.5 61 121/47\n Very lethargic, weak cough\n Chest coarse mid insp crackles\n CV w/o m\n 3+ edema\n I&O\n neg 400 cc yesterday with lasix gtt\n Got 1U PRBC yesterday\n Remains 18l positive LOS\n Looks to be failing extubation due to inability to cough and protect\n his airway. Will speak with family about reintubation. Stopping tube\n feeds for intubation. Hct is stable so can hold on more blood. Creat\n is down to 3.0 so we may be able to make some more progress on\n diuresis.\n Time spent 40 min\n Critically ill\n" }, { "category": "Respiratory ", "chartdate": "2121-09-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597251, "text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 78\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: 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 claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597345, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\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": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597351, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\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": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597506, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV to 5 and peep down to 8, frequent mouth care, pul toilet and\n MDI\ns as ordered\n Response:\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Continued lasix drip as 15mg/hr, K 33.3 and repleted 40MEQ\n Response:\n AM labs\n Plan:\n Continue lasix as tolerated, check labs and replete\n Hypernatremia (high sodium)\n Assessment:\n Na 146, receiving free water bolus 300ml q 4hrs\n Action:\n Continue water bolus 300mls q 4hrs\n Response:\n Am labs Na 148\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-18 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 597653, "text": "Chief Complaint: 74 yom with hypothyroidism presenting with septic\n shock, NSTEMI, hypothermia with suspected pulmonary vs. urine source.\n Patient initially grew out enterococcus from urine and GNR from sputum,\n now with MRSA and acinetobacter growing from sputum\n 24 Hour Events:\n TTE performed: Overall left ventricular systolic function is low normal\n (LVEF 50-55%). The right ventricular cavity is moderately dilated with\n normal free wall contractility. Wall motion abnormalities could not be\n excluded do to technique.\n Received 1 unit PRBC\ns for gradual drop in HCT to 23.7 with bump to\n 26.6\n now stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:00 PM\n Meropenem - 12:09 AM\n Infusions:\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 06:14 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: 36.5\nC (97.7\n HR: 57 (52 - 76) bpm\n BP: 164/59(88) {131/57(85) - 182/77(104)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 112 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 6 (2 - 10)mmHg\n Total In:\n 5,142 mL\n 798 mL\n PO:\n TF:\n 1,079 mL\n 280 mL\n IVF:\n 1,708 mL\n 218 mL\n Blood products:\n 375 mL\n Total out:\n 5,785 mL\n 1,055 mL\n Urine:\n 4,985 mL\n 1,055 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n -643 mL\n -257 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (583 - 848) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.45/51/73./35/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 146\n Physical Examination\n General: NAD, alert and able to respond to commands\n Lungs: soft crackles at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: NT, pitting edema, DP 2+\n Labs / Radiology\n 247 K/uL\n 9.2 g/dL\n 184 mg/dL\n 3.5 mg/dL\n 35 mEq/L\n 3.3 mEq/L\n 94 mg/dL\n 104 mEq/L\n 148 mEq/L\n 28.2 %\n 9.9 K/uL\n [image002.jpg]\n 12:06 PM\n 02:58 PM\n 05:30 PM\n 12:14 AM\n 12:31 AM\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n WBC\n 7.5\n 9.9\n Hct\n 23.7\n 26.6\n 28.2\n Plt\n 217\n 247\n Cr\n 4.1\n 3.9\n 3.6\n 3.5\n TCO2\n 32\n 34\n 32\n 34\n 35\n 37\n Glucose\n 132\n 241\n 138\n 184\n Other labs: PT / PTT / INR:12.2/44.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n worsened bilateral pleural effusions and diffuse lung\n consolidations with superimposed oulmonary edema on background of\n multifocal consolidation\n Assessment and Plan\n This is a 74 yom w/h/o paranoid schizophrenia, hypothyroidism,\n hypoadrenalism p/w septic shock, NSTEMI and hypothermia with initial\n suspected pulmonary vs. urine source.\n ##. Respiratory Failure/PNA: most recent cultures positive for\n Acinetobacter and MRSA with superimposed pulmonary edema.\n Sensitivities include Tobraicin and Imipneum (Acinetobacter) AND\n Vancomycin, Linezolid (MRSA). Echo showed severe dysfunction and\n pulmonary edema likely resulted from combination of ATN with fluid\n resuscitation. Barriers to extubation include underlying infectious\n process and fluid overload\n - continue meropenum (4 of 14) and linezolid (4 of 14)\n switch to PO\n Linezolid to reduce free water loads\n - lasix gtt for continued diuresis + 20.9 L for LOS, - 1 L overnight,\n attempt to titrate down drip as long as UOP remains stable\n - attempt to wean vent to with SBT if tolrates\n - follow up cultures, CXR\n # Hypertension\n patient with continued HTN in 160\ns but holding ACE-I\n for RF and BB for bradycardia. Patient recently started on hydralazine\n 10 mg TID with minimal response. Patient continues on Lasix gtt.\n - consider increasing dose of hydralazine for improved BP control\n will consider adding back CCB amlodipine while avoiding any nodal\n agents as h/o bradycardia\n # Urinary infection\n initial urine cultures grew VRE and patient was\n started on Linezolid per ID with most recent urine culture negative.\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.6 from peak of 4.6\n - continue to trend Cr and UOP\n - continue lasix gtt for diuresis with goal of -1.5 L negative per day\n titrate down gtt while maintain UOP\n #hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor and treat with free water flushes and IVF PRN\n # Anemia: patient is s/p 1 unit PRBC\ns for gradually dropping HCT,\n responding with appropriate HCT bump. Patient dose have history of\n PUD; however, negative guiac, normocytic anemia with high RDW and\n negative hemolysis workup likely representing\n - continue to monitor with daily HCT\ns with goal HCT > 25\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - will not restart clozarin until linezolid course complete for risk\n of pancyotopenia\n #. Bradycardia: patient with noted bradycardia requiring atropine in\n the field and episode of sinus bradycardia while in the CCU\n - consider cardiology consult if continued problems with HR to evaluate\n for SSS AND continue to hold nodal blocking agents\n #. Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n #COPD: continue atrovent and albuterol\n #Adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - continue hydrocortisone 25 mg q 12 today = to home dose of decadron,\n may switch to decadron today\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:02 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 74M DM, obesity, ?CHF, CRI (1.8-2.0) p/w\n severe pneumonia L>R c/b respiratory failure, ARF. Xfused yesterday.\n Exam notable for Tm 97.8 BP 150/70 HR 60 RR 24 with sat 96 on PSV 5/10\n 0.5 7.42/56/120 CVP 12, UOP >100cc/h. Obese man, NAD. Coarse BS B. RRR\n s1s2. Soft +BS. 3+ edema. Labs notable for WBC 9K, HCT 28, K+ 3.3,\n Cr 3.5. CXR with L>R ASD.\n Agree with plan to manage ongoing respiratory distress with linezolid /\n vanco for MRSA / GNR pneumonia. Will try to wean lasix, add diamox for\n progressive alkalosis in the setting of ongoing volume overload, and\n will try PSV 5/5 today followed by SBT if able. ARF improving with\n diuresis, baseline Cr around 2.0. TF at goal, +BM, FWB for\n hypernatremia. Back on home psych meds. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 06:11 PM ------\n" }, { "category": "Rehab Services", "chartdate": "2121-09-23 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 598352, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pna / 480.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 74 yo M admitted\n with weakness and bradycardia, found to be in septic shock (urosepsis),\n ARF and respiratory distress requiring intubation, extubated .\n Past Medical / Surgical History: paranoid schizophrenia, h/o\n nephrectomy ', HTN, DM2, COPD, h/o pna\n Medications: aspirin, heparin, meropenem, fentanyl, furosemide,\n dexamthasone, amlodipine\n Radiology: CXR - Left perihilar consolidation probably pneumonia,\n and moderate bilateral pleural effusions have all improved; CXR \n pending\n Labs:\n 25.2\n 8.2\n 255\n 5.0\n [image002.jpg]\n Other labs:\n Activity Orders: OK for OOB per icu team\n Social / Occupational History: lives at home with daughter and son\n Environment: unknown, patient unable to relate\n Prior Functional Status / Activity Level: Per chart, patient minimally\n ambulatory at baseline, may use w/c, attends day care 2x/wk, has HHA\n 1x/wk for bathing.\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, non-verbal,\n follows simple commands inconsistently (50-75%), answers yes/no\n questions inconsistently by nodding/shaking head\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 70\n 124/40\n 96% on FM\n Activity\n 83\n 129/49\n 18\n 92% on FM\n Recovery\n 70\n /\n 95% on FM\n Total distance walked: 0\n Minutes:\n Pulmonary Status: shallow coarse BS, strong congested cough, did not\n expectorate. Tolerated CPT/percussion to B posterior lung fields in\n sitting. On 50% FiO2 via face mask.\n Integumentary / Vascular: 3+ peripheral edema B hands/feet, foley,\n rectal tube, NG tube, PICC, tele\n Sensory Integrity: patient unable to participate in sensation exam\n Pain / Limiting Symptoms: denies pain\n Posture: obese, kyphotic in sitting\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n moves B LE extremeties but not able to move against gravity, grossly 2\n to 2-/5 t/o.\n Motor Function: slowed tracking, minimal spontaneous or active movement\n in LE's\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: patient participating minimally in mobility. total\n assist slide transfer to stretcher chair.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Able to maintain static sitting at edge of bed once\n positioned, posterior and left lateral bias but able to return to\n midline with min cues. Standing not assessed\n Education / Communication: Reviewed PT , communicated with nsg re:\n status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired pulmonary hygiene\n 5.\n Impaired cognition\n 6.\n Impaired strength\n Clinical impression / Prognosis: 74 yo M with pneumonia/sepsis p/w\n above impairments a/w ventilatory pump dysfunction. He is most limited\n by general weakness and fatigue a/w prolonged icu hospitalization and\n intubation/sedation. He is significantly below his baseline status and\n unsafe for d/c home at this time. Prognosis remains guarded at this\n time given his low-level prior function as well as his minimal\n support. Would recommend rehab upon d/c to progress as able, PT to\n continue to follow while at acute level.\n Goals\n Time frame: 1 week\n 1.\n Mod A rolling and supine-to-sit, assess standing/transfers\n 2.\n S static sitting, assess standing balance\n 3.\n Tolerate OOB >/= 3 hours/day\n 4.\n Tolerate CPT daily, able to clear secretions independently\n 5.\n Follows 100% of simple commands\n 6.\n Tolerates strengthening/therex\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n bed mobility, transfers, balance, endurance, CPT, education,\n strengthening, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597343, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597344, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\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": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597440, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 146\n Action:\n Continues on free water bolus q4 300ml\n Repeat NA remains 146\n Tube feeds changed to Nutren 2.0 at goal rate 45ml/hour\n Response:\n Stable NA\n Plan:\n Follow chem. Panel\n Free water as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes made this shift\n Action:\n Remains on PSV 12 peep 10 50%\n Sx\nd q1-2 for thick blood tinged secretions\n Repeat sputum spec sent for cx\n Response:\n Stable on present vent settings\n Plan:\n Diurese as ordered\n Pulmonary toilet\n Wean from vent as tolerated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat slowly improving\n Action:\n Creat down to 3.6 this afternoon\n Lasix gtt increased to 15mg/hr to increase rate of diuresis\n Transfused 1u PC\ns for hct 23.7\n Hypertensive to 180\ns/, started on hydralizine 10mg pngt q8 with good\n effect\n Pt continues with edema throughput his body, weeping from area around\n right wrist aline, noted to have broken blisters around dressing site\n K 3.1, repleted with 60meq po\n Response:\n Plan:\n Lasix gtt as ordered\n Electrolyte repletion as ordered\n Hyperglycemia\n Assessment:\n FS 115-240\n Action:\n Sliding scale humalog increased to better cover elevated fs\n Response:\n Plan:\n FS q 4hours\n Humalog as ordered\n" }, { "category": "Physician ", "chartdate": "2121-09-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597555, "text": "Chief Complaint: 74 yom with hypothyroidism presenting with septic\n shock, NSTEMI, hypothermia with suspected pulmonary vs. urine source.\n Patient initially grew out enterococcus from urine and GNR from sputum,\n now with MRSA and acinetobacter growing from sputum\n 24 Hour Events:\n TTE performed: Overall left ventricular systolic function is low normal\n (LVEF 50-55%). The right ventricular cavity is moderately dilated with\n normal free wall contractility. Wall motion abnormalities could not be\n excluded do to technique.\n Received 1 unit PRBC\ns for gradual drop in HCT to 23.7 with bump to\n 26.6\n now stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:00 PM\n Meropenem - 12:09 AM\n Infusions:\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 06:14 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: 36.5\nC (97.7\n HR: 57 (52 - 76) bpm\n BP: 164/59(88) {131/57(85) - 182/77(104)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 112 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 6 (2 - 10)mmHg\n Total In:\n 5,142 mL\n 798 mL\n PO:\n TF:\n 1,079 mL\n 280 mL\n IVF:\n 1,708 mL\n 218 mL\n Blood products:\n 375 mL\n Total out:\n 5,785 mL\n 1,055 mL\n Urine:\n 4,985 mL\n 1,055 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n -643 mL\n -257 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (583 - 848) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.45/51/73./35/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 146\n Physical Examination\n General: NAD, alert and able to respond to commands\n Lungs: soft crackles at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: NT, pitting edema, DP 2+\n Labs / Radiology\n 247 K/uL\n 9.2 g/dL\n 184 mg/dL\n 3.5 mg/dL\n 35 mEq/L\n 3.3 mEq/L\n 94 mg/dL\n 104 mEq/L\n 148 mEq/L\n 28.2 %\n 9.9 K/uL\n [image002.jpg]\n 12:06 PM\n 02:58 PM\n 05:30 PM\n 12:14 AM\n 12:31 AM\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n WBC\n 7.5\n 9.9\n Hct\n 23.7\n 26.6\n 28.2\n Plt\n 217\n 247\n Cr\n 4.1\n 3.9\n 3.6\n 3.5\n TCO2\n 32\n 34\n 32\n 34\n 35\n 37\n Glucose\n 132\n 241\n 138\n 184\n Other labs: PT / PTT / INR:12.2/44.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n worsened bilateral pleural effusions and diffuse lung\n consolidations with superimposed oulmonary edema on background of\n multifocal consolidation\n Assessment and Plan\n This is a 74 yom w/h/o paranoid schizophrenia, hypothyroidism,\n hypoadrenalism p/w septic shock, NSTEMI and hypothermia with initial\n suspected pulmonary vs. urine source.\n ##. Respiratory Failure/PNA: most recent cultures positive for\n Acinetobacter and MRSA with superimposed pulmonary edema.\n Sensitivities include Tobraicin and Imipneum (Acinetobacter) AND\n Vancomycin, Linezolid (MRSA). Echo showed severe dysfunction and\n pulmonary edema likely resulted from combination of ATN with fluid\n resuscitation. Barriers to extubation include underlying infectious\n process and fluid overload\n - continue meropenum (4 of 14) and linezolid (4 of 14)\n consider\n switching to Vancomycin for reduced r/o thrombocytopenia\n - lasix gtt for aggressive diuresis + 20.9 L for LOS, - 1 L overnight\n - attempt to wean vent to with SBT if tolrates\n - follow up cultures, CXR\n # Hypertension\n patient with continued HTN in 160\ns but holding ACE-I\n for RF and BB for bradycardia. Patient recently started on hydralazine\n 10 mg TID with minimal response. Patient continues on Lasix gtt.\n - consider increasing dose of hydralazine for improved BP control\n will consider adding back CCB amlodipine as HR tolerates\n # Urinary infection\n initial urine cultures grew VRE and patient was\n started on Linezolid per ID with most recent urine culture negative.\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.6 from peak of 4.6\n - continue to trend Cr and UOP\n - continue lasix gtt for diuresis with goal of -1.5 L negative per day\n - consider CVVH for fluid overload state considering 20+ L positive as\n this is large barrier to extubation and course may be prolonged if\n diuresis is accomplished through lasix gtt\n #hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor and treat with free water flushes and IVF PRN\n # Anemia: patient is s/p 1 unit PRBC\ns for gradually dropping HCT,\n responding with appropriate HCT bump. Patient dose have history of\n PUD; however, negative guiac, normocytic anemia with high RDW and\n negative hemolysis workup\n - continue to monitor with HCT\ns with goal HCT > 25\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - wil restart perphenazine when awake at 4 mg , with 2 mg PRN when\n agitated (PO).\n - IM haldol if unable to tolerate PO\n - will not restart clozarin until linezolid course complete for risk of\n pancyotopenia\n #. Bradycardia: patient with noted bradycardia requiring atropine in\n the field and episode of sinus bradycardia while in the CCU\n - consider cardiology consult to evaluate for SSS AND hold nodal\n blocking agents\n #. Hypothyroidism: Will continue on home regimen of levothyroxine\n #COPD: continue atrovent and albuterol\n #Adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - continue hydrocortisone 25 mg q 12 today = to home dose of decadron,\n may switch to PO decadrone\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:02 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598420, "text": "Hypernatremia (high sodium)\n Assessment:\n NA stable at 141\n Action:\n Free h2o decreased to 150cc q6 hours\n Response:\n Stable NA\n Plan:\n Free h2o as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt more lethargic\n Action:\n Pt continues with congested cough\n Difficult to NTS due to deviated septum and NGT\n CPT done\n Pt more lethargic, and having more trouble clearing secretions\n Daughter called by resident and updated on pt\ns condition\n Intub at ~1600\n ETT confirmed by CXR\n Pt inially on ac 500 16 peep 5 100%, fio2 weaned to 40%\n Attempted to place on PSV, but pt apnic\n Response:\n Intub for airway protection and secretion management\n Plan:\n Pulmonary toilet\n Wean from vent as tolerated\n ? will need trache\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat inc to 3.1\n Action:\n Received on lasix gtt at 15mg/hour\n Received metolozone 5mg po x1\n Repeat creat inc to 3.1\n Lasix gtt d/c\n Renal team consulted\n Started on diamox 125mg po q12\n Response:\n Worsening creat\n Plan:\n Diurese as ordered\n" }, { "category": "Respiratory ", "chartdate": "2121-09-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597314, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597381, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG. Bun/Cr and Na levels all trending down slowly.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG= 7.42-52-87,\n pt denies SOB when asked, Sats currently 96-97% . Hct this am = 23.7 (\n same value as yesterday)\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered, CXR completed and results pending\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated. Transfuse as\n ordered and prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with right radial Aline with good waveform---aline oozing blood and\n dressing changed x 3, BP= 130-150\ns/50-60\ns, BP occasionally\n 160-170\ns/60\ns with stimulation, no antihypertensives at this time as\n MICU team will accept BP <170, Foley draining clear yellow urine\n >100ml/hr, IV lasix gtt initially at 9 mg/hr and increased to 10mg/hr,\n good output but large input negating diuretic effect, K= 3.3---replaced\n with total of 40mEq IV KCL and repeat K= 3.8, Bun down to 98 and\n Creatinine down to 3.9, pt remains positive > 20 liters for LOS\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W. Na level this am\n is down to 146.\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated but slightly improved this am.\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldol as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Physician ", "chartdate": "2121-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597393, "text": "Chief Complaint: This is a 74 y.o. Male with h.o.\n hypothyroidism/?hypoadrenalism, paranoid schizophrenia p/w septic\n shock, NSTEMI, hypothermia from acenetobacter pneumonia.\n 24 Hour Events:\n - SW called team regarding pt's placement, insurance should cover\n rehab, his dispo after rehab will be pending SW at rehba facility\n -psych recs: don't give clozarel on top of linezolid given that\n combination can lead to myelosuppresion; should ideally re-start it\n only after linezolid course complete (unclear how long linezolid\n effects last after stopping). When he does wake up, can give\n prophenazine 4 mg , with 2 mg PRN when agitated (PO). If doesn't\n take PO, can take 0.5 IM haldol but monitor QTCs. Avoid benzos.\n -continued on lasix drip\n -increased free water from 250 - 300 ccs q4 for hypernatremia: PM\n sodium was 148\n -Repeat Na at 1215 AM was 150; got D5W bolus: Nutren 2.0 discontinued\n from his tube feeds given high sodium content and switched to\n Novasource.\n -Repeat HCT in AM; nurse in secretions was frank rather than\n old, HCT have been relatively stable all day.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 11:57 AM\n Linezolid - 05:00 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 02:27 PM\n Heparin Sodium (Prophylaxis) - 06:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.7\n HR: 58 (55 - 66) bpm\n BP: 163/59(88) {126/46(67) - 167/64(91)} mmHg\n RR: 14 (9 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 109.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 5 (4 - 11)mmHg\n Total In:\n 3,973 mL\n 1,872 mL\n PO:\n TF:\n 1,081 mL\n 289 mL\n IVF:\n 1,242 mL\n 983 mL\n products:\n Total out:\n 4,405 mL\n 1,990 mL\n Urine:\n 3,845 mL\n 1,990 mL\n NG:\n 110 mL\n Stool:\n 450 mL\n Drains:\n Balance:\n -432 mL\n -118 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 727 (505 - 729) mL\n PS : 12 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n SpO2: 99%\n ABG: 7.42/52/86./31/7\n Ve: 5.5 L/min\n PaO2 / FiO2: 174\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 217 K/uL\n 7.8 g/dL\n 241 mg/dL\n 3.9 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 98 mg/dL\n 106 mEq/L\n 146 mEq/L\n 23.7 %\n 7.5 K/uL\n [image002.jpg]\n 11:49 PM\n 02:33 AM\n 11:45 AM\n 12:06 PM\n 02:58 PM\n 05:30 PM\n 12:14 AM\n 12:31 AM\n 04:41 AM\n 04:53 AM\n WBC\n 5.8\n 7.5\n Hct\n 24.5\n 23.7\n 23.7\n Plt\n 156\n 217\n Cr\n 4.4\n 4.2\n 4.1\n 3.9\n TCO2\n 32\n 32\n 34\n 32\n 34\n 35\n Glucose\n 173\n 178\n 132\n 241\n Other labs: PT / PTT / INR:12.2/44.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: pH 7.42\n pCO2 52\n pO2 87\n HCO3 35\n BaseXS 7\n Imaging: CXR showed something...\n Microbiology: Sputum - RESPIRATORY CULTURE ACINETOBACTER\n BAUMANNII COMPLEX. SPARSE GROWTH.\n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 282\n 0863K\n STAPH AUREUS COAG +. SPARSE GROWTH.\n YEAST. RARE GROWTH.\n All cultures negative to date\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. paranoid schizophrenia,\n hypothyroidism, hypoadrenalism p/w septic shock, NSTEMI, hypothermia\n with suspected pulmonary versus urine source.\n ##. Respiratory Failure/PNA: Likely a combination of Acinetobacter PNA\n and volume overload from fluid rescusitation. Sputum cultuer from \n also show Staph aureus. Coag neg staph from (likely contaminant)\n from . s/p course of xygris .\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only.\n - Start Vancomycin for Staph Aureus until sensitivities return\n - Call lab to confirm sensitivities will be obtained\n - no improvement in CXR, repeat AM CXR\n - Sputum from growing Acinetobacter, Coag + Staph Aureus\n -defer trial of SBP until respiratory status improves\n - continue aggressive diuresis\n - influenza antigen and legionella negative\n # Urinary infection - Pt was growing VRE sensitive to Ampicillin and\n Linezolid. Started on Linezolid per ID recs given pt was in septic\n shock.\n - His last urine was clean, continue Linezolid for 10 day course. Day\n 1= .\n - Monitor for CBC as pt on linezolid\n # : baseline 1.8-2, trending down slowly. 3.9 today, 4.4\n yesterday. Diuresing well.\n -will trend\n -volume overload will likely be indication for HD, if unable to\n diurese\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n #hypernatremia: hypernatremic to 150 yesterday after increasing free\n water boluses through OG to 300 q 4hr. Likely due to tube feeding and\n hypotonic diuresis in setting of lasix ggt. He was given a bolus of\n D5W. Tube feeds were changed from Nutren to Novasource which has less\n sodium.\n - continue free water in tube feeds at 300cc q 4h.\n - q8 sodium checks\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, 23.7\n down from 25. Given history of recent MI, transfuse one unit.\n Guaic was negative. Normocytic anemia, but high RDW.\n - hemolysis labs negative\n - no iron defiency\n - keep active type and screen\n - repeat stool guiac\n - serial Hct\n - f/u retic count\n - transfuse 1 unit\n - PPI\n # Hypertension\n Pt has systolic hypertension to 170s when awake. Will\n follow him through the day, consider antihypertensive if continues to\n remain high.\n - on Lasix drip\n - no BB given bradycardia\n - no ACEI given renal failure\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n - would like to start statin if no contraindication\n # #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - wil restart perphenazine when awake at 4 mg , with 2 mg PRN when\n agitated (PO).\n - IM haldol if unable to tolerate PO\n - will not restart clozarin until linezolid course complete\n - SW following, he is OK for rehab upon d/c\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n #. Hypothyroidism: Will continue on home regimen of levothyroxine\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n # adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - will continue on IV Hydrocortisone, taper to 25q12 today ( pt on 2\n daily of decadron at home = 50mg IV hydrocortisone daily), titrate\n down today\n # DM: now back on insulin SQ - tighten ISS\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:57 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2121-09-17 00:00:00.000", "description": "Generic Note", "row_id": 597413, "text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam.\n Agree substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. More alert. Somewhat\n agitated. Lasix gtt yesterday\n 97 55 180/65\n Sedated\n Chest\n crackles bilat\n CV 2/6 SEM\n 3+ edema\n Creat 3.9\n CXR\n Bilat pulm edema\n With renal failure we are having difficulty diuresing, although I&O neg\n yesterday. Will continue with lasix gtt, repeat echo. Suspect cardiac\n fxn is abnormal, but initial echo was v poor quality. If he continues\n to make good urine we should be able to diurese as BP is high. Remains\n on abx for Acinetobacter and Staph coverage from linezolid. Psych has\n made recommendations re his antipsychotics.\n Time spent 40 min\n Critically ill\n" }, { "category": "Respiratory ", "chartdate": "2121-09-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597430, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: 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: Wean PS as tol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597432, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 146\n Action:\n Continues on free water bolus q4 300ml\n Repeat NA remains 146\n Tube feeds changed to Nutren 2.0 at goal rate 45ml/hour\n Response:\n Stable NA\n Plan:\n Follow chem. Panel\n Free water as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes made this shift\n Action:\n Remains on PSV 12 peep 10 50%\n Sx\nd q1-2 for thick blood tinged secretions\n Repeat sputum spec sent for cx\n Response:\n Stable on present vent settings\n Plan:\n Diurese as ordered\n Pulmonary toilet\n Wean from vent as tolerated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat slowly improving\n Action:\n Creat down to 3.6 this afternoon\n Lasix gtt increased to 15mg/hr to increase rate of diuresis\n Transfused 1u PC\ns for hct 23.7\n Hypertensive to 180\ns/, started on hydralizine 10mg pngt q8 with good\n effect\n Pt continues with edema throughput his body, weeping from area around\n right wrist aline, noted to have broken blisters around dressing site\n K 3.1, repleted with 60meq po\n Response:\n Plan:\n Lasix gtt as ordered\n Electrolyte repletion as ordered\n Hyperglycemia\n Assessment:\n FS 115-240\n Action:\n Sliding scale humalog increased to better cover elevated fs\n Response:\n Plan:\n FS q 4hours\n Humalog as ordered\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597498, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597501, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV to 5 and peep down to 8, frequent mouth care, pul toilet and\n MDI\ns as ordered\n Response:\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Continued lasix drip as 15mg/hr, K 33.3 and repleted 40MEQ\n Response:\n AM labs\n Plan:\n Continue lasix as tolerated, check labs and replete\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597539, "text": "Chief Complaint:\n 74 y.o. Male with h.o. hypothyroidism p/w septic shock, NSTEMI,\n hypothermia with suspected pulmonary versus urine source.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 02:30 PM\n - Sputum cultures grew MRSA in addition to Acinetobacter, sensitive to\n Linezolid MIC<2.\n - Hct rose appropriately to 26.6 after one unit.\n - Retic count 0.6 - y he is not doing better!\n - TTE: Overall left ventricular systolic function is low normal (LVEF\n 50-55%). The right ventricular cavity is moderately dilated with normal\n free wall contractility.\n - Pt hypernatremic to 148, reduced Lasix gtt to 12\n - no psych recs today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:00 PM\n Meropenem - 12:09 AM\n Infusions:\n Furosemide (Lasix) - 12 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 06:14 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: 36.5\nC (97.7\n HR: 57 (52 - 76) bpm\n BP: 164/59(88) {131/57(85) - 182/77(104)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 112 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 6 (2 - 10)mmHg\n Total In:\n 5,142 mL\n 798 mL\n PO:\n TF:\n 1,079 mL\n 280 mL\n IVF:\n 1,708 mL\n 218 mL\n Blood products:\n 375 mL\n Total out:\n 5,785 mL\n 1,055 mL\n Urine:\n 4,985 mL\n 1,055 mL\n NG:\n Stool:\n 800 mL\n Drains:\n Balance:\n -643 mL\n -257 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (583 - 848) mL\n PS : 5 cmH2O\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.45/51/73./35/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 146\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 247 K/uL\n 9.2 g/dL\n 184 mg/dL\n 3.5 mg/dL\n 35 mEq/L\n 3.3 mEq/L\n 94 mg/dL\n 104 mEq/L\n 148 mEq/L\n 28.2 %\n 9.9 K/uL\n [image002.jpg]\n 12:06 PM\n 02:58 PM\n 05:30 PM\n 12:14 AM\n 12:31 AM\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n WBC\n 7.5\n 9.9\n Hct\n 23.7\n 26.6\n 28.2\n Plt\n 217\n 247\n Cr\n 4.1\n 3.9\n 3.6\n 3.5\n TCO2\n 32\n 34\n 32\n 34\n 35\n 37\n Glucose\n 132\n 241\n 138\n 184\n Other labs: PT / PTT / INR:12.2/44.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n worsened bilateral pleural effusions and diffuse lung\n consolidations with superimposed oulmonary edema on background of\n multifocal consolidation\n Assessment and Plan\n This is a 74 y.o. Male with h.o. paranoid schizophrenia,\n hypothyroidism, hypoadrenalism p/w septic shock, NSTEMI, hypothermia\n with suspected pulmonary versus urine source.\n ##. Respiratory Failure/PNA: Likely a combination of Acinetobacter PNA\n and pulm edema from fluid rescusitation. Sputum culture from also\n show Staph aureus. Coag neg staph from blood (likely contaminant) from\n . s/p course of xygris .\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only.\n - Linezolid for Staph Aureus until sensitivities return\n - Call lab to confirm sensitivities will be obtained\n - no improvement in CXR, repeat AM CXR\n - Sputum from growing Acinetobacter, Coag + Staph Aureus\n - repeat Sputum\n -defer trial of SBP until respiratory status improves\n - continue aggressive diuresis\n - repeat ECHO to assess cardiac contribution to pulmonary edema\n - influenza antigen and legionella negative\n .\n # Hypertension\n Pt has systolic hypertension to 170s when awake. Will\n follow him through the day, despite antihypertensives.\n - on Lasix drip\n - no BB given bradycardia\n - no ACEI given renal failure\n - start hydral 10 po tid\n # Urinary infection - Pt was growing VRE sensitive to Ampicillin and\n Linezolid. Started on Linezolid per ID recs given pt was in septic\n shock.\n - His last urine was clean, continue Linezolid for 7 day course. Day\n 1= .\n - Monitor for CBC as pt on linezolid\n # : baseline 1.8-2, trending down slowly. 3.9 today, 4.4\n yesterday. Diuresing well.\n -will trend\n -volume overload will likely be indication for HD, if unable to\n diurese\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n - pm lytes\n #hypernatremia: hypernatremic to 150 yesterday after increasing free\n water boluses through OG to 300 q 4hr. Likely due to tube feeding and\n hypotonic diuresis in setting of lasix ggt. He was given a bolus of\n D5W. Tube feeds were changed from Nutren to Novasource which has less\n sodium.\n - continue free water in tube feeds at 300cc q 4h.\n - q8 sodium checks\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, 23.7\n down from 25. Given history of recent MI, transfuse one unit.\n Guaic was negative. Normocytic anemia, but high RDW.\n - hemolysis labs negative\n - no iron defiency\n - keep active type and screen\n - repeat stool guiac\n - serial Hct\n - f/u retic count\n - transfuse 1 unit\n - PPI\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n - was not on a statin upon admission\n # #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - wil restart perphenazine when awake at 4 mg , with 2 mg PRN when\n agitated (PO).\n - IM haldol if unable to tolerate PO\n - will not restart clozarin until linezolid course complete\n - SW following, he is OK for rehab upon d/c\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n #. Hypothyroidism: Will continue on home regimen of levothyroxine\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n # adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - will continue on IV Hydrocortisone, taper to 25q12 today ( pt on 2\n daily of decadron at home = 50mg IV hydrocortisone daily), titrate\n down today\n # DM: now back on insulin SQ - tighten ISS\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 03:02 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597541, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n HCT stable at 28.2\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV down to 5, frequent mouth care, pul toilet and MDI\ns as ordered\n Response:\n Blood gas after vent changes satisfactory, O2 sats 95-98%,\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Lasix drip to 12mg/hr, K 3.3 and repleted 40MEQ\n Response:\n AM labs BUN 94and creat 3.5, neg 600ml/24hrs\n Plan:\n Continue lasix as tolerated, check labs and replete accordingly\n Hypernatremia (high sodium)\n Assessment:\n Na 146, receiving free water bolus 300ml q 4hrs\n Action:\n Continue water bolus 300mls q 4hrs, lasix drip down to 12mg/hr\n Response:\n Am labs Na 148\n Plan:\n Continue monitor\n Impaired Skin Integrity\n Assessment:\n Sacral area is pink and blanches, meplex dressing intact, rt groin\n small area of skin open, criticaid applied, iv site and A line site\n with blisters and leaking. Patient is on air bed,\n Action:\n Frequent position changes, dressings intact\n Response:\n unchanged\n Plan:\n Frequent position change, barrier cream, pressure sore dressing as\n needed, continue kinair bed and nutrition\n Hyperglycemia\n Assessment:\n FS 165-240\n Action:\n Sliding scale humalog\n Response:\n FS153-175\n Plan:\n FS q 4hours, Humalog as ordered\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597377, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG= 7.42-52-87,\n pt denies SOB when asked, Sats currently 96-97% . Hct this am = 23.7 (\n same value as yesterday)\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered, CXR completed and results pending\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated. Transfuse as\n ordered and prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with right radial Aline with good waveform---aline oozing blood and\n dressing changed x 3, BP= 130-150\ns/50-60\ns, BP occasionally\n 160-170\ns/60\ns with stimulation, no antihypertensives at this time as\n MICU team will accept BP <170, Foley draining clear yellow urine\n >100ml/hr, IV lasix gtt initially at 9 mg/hr and increased to 10mg/hr,\n good output but large input negating diuretic effect, K= 3.3---replaced\n with total of 40mEq IV KCL and repeat K= 3.8, Bun down to 98 and\n Creatinine down to 3.9, pt remains positive > 20 liters for LOS\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W. Na level this am\n is down to 146.\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated but slightly improved this am.\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldol as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597522, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV to 5 and peep down to 8, frequent mouth care, pul toilet and\n MDI\ns as ordered\n Response:\n Blood gas after vent changes satisfactory, O2 sats 95-98%,\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Lasix drip to 12mg/hr, K 3.3 and repleted 40MEQ\n Response:\n AM labs BUN 94and creat 3.5\n Plan:\n Continue lasix as tolerated, check labs and replete accordingly\n Hypernatremia (high sodium)\n Assessment:\n Na 146, receiving free water bolus 300ml q 4hrs\n Action:\n Continue water bolus 300mls q 4hrs, lasix drip down to 12mg/hr\n Response:\n Am labs Na 148\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597523, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV to 5 and peep down to 8, frequent mouth care, pul toilet and\n MDI\ns as ordered\n Response:\n Blood gas after vent changes satisfactory, O2 sats 95-98%,\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Lasix drip to 12mg/hr, K 3.3 and repleted 40MEQ\n Response:\n AM labs BUN 94and creat 3.5\n Plan:\n Continue lasix as tolerated, check labs and replete accordingly\n Hypernatremia (high sodium)\n Assessment:\n Na 146, receiving free water bolus 300ml q 4hrs\n Action:\n Continue water bolus 300mls q 4hrs, lasix drip down to 12mg/hr\n Response:\n Am labs Na 148\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n FS 165-240\n Action:\n Sliding scale humalog\n Response:\n Plan:\n FS q 4hours, Humalog as ordered\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597488, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597379, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG. Bun/Cr and Na levels all trending down slowly.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG= 7.42-52-87,\n pt denies SOB when asked, Sats currently 96-97% . Hct this am = 23.7 (\n same value as yesterday)\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered, CXR completed and results pending\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated. Transfuse as\n ordered and prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with right radial Aline with good waveform---aline oozing blood and\n dressing changed x 3, BP= 130-150\ns/50-60\ns, BP occasionally\n 160-170\ns/60\ns with stimulation, no antihypertensives at this time as\n MICU team will accept BP <170, Foley draining clear yellow urine\n >100ml/hr, IV lasix gtt initially at 9 mg/hr and increased to 10mg/hr,\n good output but large input negating diuretic effect, K= 3.3---replaced\n with total of 40mEq IV KCL and repeat K= 3.8, Bun down to 98 and\n Creatinine down to 3.9, pt remains positive > 20 liters for LOS\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W. Na level this am\n is down to 146.\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated but slightly improved this am.\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldol as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597521, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV to 5 and peep down to 8, frequent mouth care, pul toilet and\n MDI\ns as ordered\n Response:\n Blood gas after vent changes satisfactory, O2 sats 95-98%,\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Lasix drip to 12mg/hr, K 3.3 and repleted 40MEQ\n Response:\n AM labs\n Plan:\n Continue lasix as tolerated, check labs and replete\n Hypernatremia (high sodium)\n Assessment:\n Na 146, receiving free water bolus 300ml q 4hrs\n Action:\n Continue water bolus 300mls q 4hrs, lasix drip down to 12mg/hr\n Response:\n Am labs Na 148\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597527, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on CPAP, peep 10 and\n PSV 12, and O2 50%. Bilateral lung sounds rhonchorous and diminished\n bases. O2 sats 96-98%. Patient is lasix drip 15mg/hr, fluid balance\n -200ml over the day. Copious amount of blood tinged secretion with\n suction.\n Action:\n PSV to 5 and peep down to 8, frequent mouth care, pul toilet and\n MDI\ns as ordered\n Response:\n Blood gas after vent changes satisfactory, O2 sats 95-98%,\n Plan:\n Continue wean vent as tolerated, lasix drip take fluid off, continue\n antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 96/cr3.6, patient is on lasix drip 15mg/hr, UO 175-200ml/hr\n Action:\n Lasix drip to 12mg/hr, K 3.3 and repleted 40MEQ\n Response:\n AM labs BUN 94and creat 3.5\n Plan:\n Continue lasix as tolerated, check labs and replete accordingly\n Hypernatremia (high sodium)\n Assessment:\n Na 146, receiving free water bolus 300ml q 4hrs\n Action:\n Continue water bolus 300mls q 4hrs, lasix drip down to 12mg/hr\n Response:\n Am labs Na 148\n Plan:\n Impaired Skin Integrity\n Assessment:\n Sacral area is pink and blanches, meplex dressing intact, rt groin\n small area of skin open, criticaid applied, iv site and A line site\n with blisters and leaking. Patient is on air bed,\n Action:\n Frequent position changes, dressings intact\n Response:\n unchanged\n Plan:\n Frequent position change, barrier cream, pressure sore dressing as\n needed, continue kinair bed and nutrition\n Hyperglycemia\n Assessment:\n FS 165-240\n Action:\n Sliding scale humalog\n Response:\n Plan:\n FS q 4hours, Humalog as ordered\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597619, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 147\n Action:\n Repeat NA this am 147\n Continues on free h2o flushes 300cc q4 hours\n Response:\n NA stable on free h20 flushes\n Plan:\n Free water as ordered\n Impaired Skin Integrity\n Assessment:\n Healing skin wounds\n Action:\n Sacral ulcer healed over, mepilex removed, and left open to air\n Multiple skin tears around aline site, aline removed and currently\n pressure dressing on site\n Right ante cub skin tears dsd removed and mepilex dressing applied\n Skin tear in right groin and panus healing, barrier cream applied and\n left open to air\n PICC line placed in left ante cub\n Response:\n Improvement in multiple skin issues\n Plan:\n Per nursing care plan\n Change mepilex q72\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Weaning from PSV\n Action:\n Peep weaned to 5, PSV 5 50%\n Pt with less need for suctioning this shift\n Abg sent, please see flow sheet\n Vbg sent with abg to correlate\n IV linezolid changed to PO\n Response:\n Decrease in peep well tolerated\n Plan:\n Pulmonary toilet\n Wean from vent as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 3.5\n Action:\n Creat slowly improving\n Continues on lasix gtt weaned to 8mg/hour\n Started on diamox po\n K repleted with 40meq po this\n Response:\n Slowly improving renal failure\n Plan:\n Diurese as ordered\n Replete electrolytes as ordered\n" }, { "category": "Respiratory ", "chartdate": "2121-09-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597534, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 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 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: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: Patient\ns PSV decreased from 12 to 5 cm PSV.\n Resulting abg results determined a partially compensated metabolic\n alkalemia with mild hypoxemia on the current settings.\n No RSBI measured due to the level of PEEP required at this time.\n" }, { "category": "Physician ", "chartdate": "2121-09-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597708, "text": "Chief Complaint:\n 24 Hour Events:\n - trial of PSV and decreased PEEP - RSBI @ 28, hopeful trial of\n extubation tomorrow\n - medications switched to PO to help reduce fluid load\n - lasix drip weaned with continued large urine output\n - diamox added to help diurese and waiste bicarbonate to elevate\n respiratory drive in setting of metabolic alkalosis\n - picc line placed, a-line removed as non-invassive BP correlates\n - NG exchanged for OG tube for anticipated swallowing difficulties s/p\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:36 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.5\n HR: 57 (52 - 66) bpm\n BP: 121/43(62) {105/39(55) - 167/70(92)} mmHg\n RR: 10 (8 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 8 (8 - 9)mmHg\n Total In:\n 4,027 mL\n 642 mL\n PO:\n TF:\n 1,080 mL\n 149 mL\n IVF:\n 877 mL\n 192 mL\n Blood products:\n Total out:\n 5,000 mL\n 1,520 mL\n Urine:\n 4,000 mL\n 870 mL\n NG:\n Stool:\n 1,000 mL\n 650 mL\n Drains:\n Balance:\n -973 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 855 (453 - 855) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 9\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.43/55/95./37/9\n Ve: 6 L/min\n PaO2 / FiO2: 192\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 271 K/uL\n 8.1 g/dL\n 178 mg/dL\n 3.2 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 89 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 8.7 K/uL\n [image002.jpg]\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n WBC\n 7.5\n 9.9\n 9.4\n 8.7\n Hct\n 23.7\n 26.6\n 28.2\n 26.6\n 25.4\n Plt\n 71\n Cr\n 3.9\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n TCO2\n 35\n 37\n 38\n 38\n Glucose\n 241\n 138\n 184\n 153\n 188\n 178\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n This is a 74 yom w/h/o paranoid schizophrenia, hypothyroidism,\n hypoadrenalism p/w septic shock, NSTEMI and hypothermia with initial\n suspected pulmonary vs. urine source.\n ##. Respiratory Failure/PNA: most recent cultures positive for\n Acinetobacter and MRSA with superimposed pulmonary edema.\n Sensitivities include Tobraicin and Imipneum (Acinetobacter) AND\n Vancomycin, Linezolid (MRSA). Echo showed severe dysfunction and\n pulmonary edema likely resulted from combination of ATN with fluid\n resuscitation. Barriers to extubation include underlying infectious\n process and fluid overload\n - continue meropenum (4 of 14) and linezolid (4 of 14)\n switch to PO\n Linezolid to reduce free water loads\n - lasix gtt for continued diuresis + 20.9 L for LOS, - 1 L overnight,\n attempt to titrate down drip as long as UOP remains stable\n - attempt to wean vent to with SBT if tolrates\n - follow up cultures, CXR\n # Hypertension\n patient with continued HTN in 160\ns but holding ACE-I\n for RF and BB for bradycardia. Patient recently started on hydralazine\n 10 mg TID with minimal response. Patient continues on Lasix gtt.\n - consider increasing dose of hydralazine for improved BP control\n will consider adding back CCB amlodipine while avoiding any nodal\n agents as h/o bradycardia\n # Urinary infection\n initial urine cultures grew VRE and patient was\n started on Linezolid per ID with most recent urine culture negative.\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.6 from peak of 4.6\n - continue to trend Cr and UOP\n - continue lasix gtt for diuresis with goal of -1.5 L negative per day\n titrate down gtt while maintain UOP\n #hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor and treat with free water flushes and IVF PRN\n # Anemia: patient is s/p 1 unit PRBC\ns for gradually dropping HCT,\n responding with appropriate HCT bump. Patient dose have history of\n PUD; however, negative guiac, normocytic anemia with high RDW and\n negative hemolysis workup likely representing\n - continue to monitor with daily HCT\ns with goal HCT > 25\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - will not restart clozarin until linezolid course complete for risk\n of pancyotopenia\n #. Bradycardia: patient with noted bradycardia requiring atropine in\n the field and episode of sinus bradycardia while in the CCU\n - consider cardiology consult if continued problems with HR to evaluate\n for SSS AND continue to hold nodal blocking agents\n #. Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n #COPD: continue atrovent and albuterol\n #Adrenal insufficiency: on dexamethasone 2mg at home, will continue to\n wean hydrocort slowly and restart dexamethasone at home dose.\n - continue hydrocortisone 25 mg q 12 today = to home dose of decadron,\n may switch to decadron today\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2121-09-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597712, "text": "Chief Complaint:\n 24 Hour Events:\n - trial of PSV and decreased PEEP - RSBI @ 28, hopeful trial of\n extubation tomorrow\n - medications switched to PO to help reduce fluid load\n - lasix drip weaned with continued large urine output\n - diamox added to help diurese and waiste bicarbonate to elevate\n respiratory drive in setting of metabolic alkalosis\n - picc line placed, a-line removed as non-invassive BP correlates\n - NG exchanged for OG tube for anticipated swallowing difficulties s/p\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:36 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.5\n HR: 57 (52 - 66) bpm\n BP: 121/43(62) {105/39(55) - 167/70(92)} mmHg\n RR: 10 (8 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 8 (8 - 9)mmHg\n Total In:\n 4,027 mL\n 642 mL\n PO:\n TF:\n 1,080 mL\n 149 mL\n IVF:\n 877 mL\n 192 mL\n Blood products:\n Total out:\n 5,000 mL\n 1,520 mL\n Urine:\n 4,000 mL\n 870 mL\n NG:\n Stool:\n 1,000 mL\n 650 mL\n Drains:\n Balance:\n -973 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 855 (453 - 855) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 9\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.43/55/95./37/9\n Ve: 6 L/min\n PaO2 / FiO2: 192\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 271 K/uL\n 8.1 g/dL\n 178 mg/dL\n 3.2 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 89 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 8.7 K/uL\n [image002.jpg]\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n WBC\n 7.5\n 9.9\n 9.4\n 8.7\n Hct\n 23.7\n 26.6\n 28.2\n 26.6\n 25.4\n Plt\n 71\n Cr\n 3.9\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n TCO2\n 35\n 37\n 38\n 38\n Glucose\n 241\n 138\n 184\n 153\n 188\n 178\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\ns, no organisms, NGTD\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n extent of ventilated has substantially increased in upper\n and lower lobes bilaterally, persistent retrocardiac atelectasis with\n sparse air bronchograms\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (5 of 14) and linezolid (5 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 20L for 1L overnight\n - f/u cultures and CXR\n - attempt SBT and trial of extubation\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - will add back amlodipine to avoid additional nodal if BP\n require\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor and treat with free water flushes and IVF PRN\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - transfuse 1 unit PRBC\ns today\n - continue to trend daily HCT\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - will not restart clozarin until linezolid course complete for risk\n of pancyotopenia\n #. Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n #COPD: continue atrovent and albuterol\n #Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Picc line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: to the floor in PM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2121-09-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597715, "text": "Chief Complaint:\n 24 Hour Events:\n - trial of PSV and decreased PEEP - RSBI @ 28, hopeful trial of\n extubation tomorrow\n - medications switched to PO to help reduce fluid load\n - lasix drip weaned with continued large urine output\n - diamox added to help diurese and waiste bicarbonate to elevate\n respiratory drive in setting of metabolic alkalosis\n - picc line placed, a-line removed as non-invassive BP correlates\n - NG exchanged for OG tube for anticipated swallowing difficulties s/p\n extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 04:35 AM\n Meropenem - 12:36 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.5\n HR: 57 (52 - 66) bpm\n BP: 121/43(62) {105/39(55) - 167/70(92)} mmHg\n RR: 10 (8 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 111.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 8 (8 - 9)mmHg\n Total In:\n 4,027 mL\n 642 mL\n PO:\n TF:\n 1,080 mL\n 149 mL\n IVF:\n 877 mL\n 192 mL\n Blood products:\n Total out:\n 5,000 mL\n 1,520 mL\n Urine:\n 4,000 mL\n 870 mL\n NG:\n Stool:\n 1,000 mL\n 650 mL\n Drains:\n Balance:\n -973 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 855 (453 - 855) mL\n PS : 5 cmH2O\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 9\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.43/55/95./37/9\n Ve: 6 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General: NAD, responsive to commands\n Lungs: soft crackles at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, no CC, mod. pitting edema, DP 2+\n Labs / Radiology\n 271 K/uL\n 8.1 g/dL\n 178 mg/dL\n 3.2 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 89 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 8.7 K/uL\n [image002.jpg]\n 04:41 AM\n 04:53 AM\n 02:22 PM\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n WBC\n 7.5\n 9.9\n 9.4\n 8.7\n Hct\n 23.7\n 26.6\n 28.2\n 26.6\n 25.4\n Plt\n 71\n Cr\n 3.9\n 3.6\n 3.5\n 3.2\n 3.3\n 3.2\n TCO2\n 35\n 37\n 38\n 38\n Glucose\n 241\n 138\n 184\n 153\n 188\n 178\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n New Microbiology\n - sputum \n PMN\ns, no organisms, NGTD\n - sputum \n MRSA, Acinetobacter, Yeast\n - urine \n negative\n Old Microbiology\n - urine \n enterococcus\n - sputum \n GNR\n sparse growth\n Imaging\n - CXR \n extent of ventilated has substantially increased in upper\n and lower lobes bilaterally, persistent retrocardiac atelectasis with\n sparse air bronchograms\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism p/w\n septic shock, NSTEMI and hypothermia with initial suspected pulmonary\n vs. urine source.\n ##. Respiratory Failure/PNA: most recent positive cultures from \n show Acinetobacter and MRSA with superimposed pulmonary edema and fluid\n overload which likely resulted from a combination of ATN and\n resuscitation. Barriers to extubation include underlying infectious\n process, fluid overload, body habitus, muscle weakness. Patient had a\n SBT yesterday with RSBI of 28.\n - continue meropenum (5 of 14) and linezolid (5 of 14)\n - continue lasix gtt (titrated as low as possible) for continued\n diuresis + 20L for 1L overnight\n - f/u cultures and CXR\n - attempt SBT and trial of extubation\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine 10mg PO TID.\n - will add back amlodipine to avoid additional nodal if BP\n require\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.2 from peak of 4.6\n - continue to trend Cr and UOP\n - continue minimal lasix gtt to achieve - 1.5L per day\n # Urinary infection\n only urine Cx from positive for VRE\n - continue Linezolid day \n - monitor CBC for drug induced thrombocytopenia and pancytopenia\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor and treat with free water flushes and IVF PRN\n # Anemia: patient with continued mildly dropping HCT from 28.2 -> 25.4\n over 1 day in the setting of known PUD.\n - re-guiac stool to r/o slow GIB\n - transfuse 1 unit PRBC\ns today\n - continue to trend daily HCT\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated.\n - will not restart clozarin until linezolid course complete for risk\n of pancyotopenia\n #. Hypothyroidism: will continue on home regimen of levothyroxine,\n switching to PO to decrease free water\n #COPD: continue atrovent and albuterol\n #Adrenal insufficiency: patient transitioned to home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Picc line\n # Code: DNR (chemical code ok)\n should d/w family today as clinical\n status has improved\n # Disposition: to the floor in PM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597648, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 147\n Action:\n Repeat NA this am 147\n Continues on free h2o flushes 300cc q4 hours\n Response:\n NA stable on free h20 flushes\n Plan:\n Free water as ordered\n Impaired Skin Integrity\n Assessment:\n Healing skin wounds\n Action:\n Sacral ulcer healed over, mepilex removed, and left open to air\n Multiple skin tears around aline site, aline removed and currently\n pressure dressing on site\n Right ante cub skin tears dsd removed and mepilex dressing applied\n Skin tear in right groin and panus healing, barrier cream applied and\n left open to air\n PICC line placed in left ante cub\n Response:\n Improvement in multiple skin issues\n Plan:\n Per nursing care plan\n Change mepilex q72\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Weaning from PSV\n Action:\n Peep weaned to 5, PSV 5 50%\n RSBI 28, placed on SBT and after 1 hour developed increasing frothy\n secretions, placed back on PSV 5 peep 5\n Pt with less need for suctioning this shift\n Abg sent, please see flow sheet\n Vbg sent with abg to correlate\n IV linezolid changed to PO\n Response:\n Decrease in peep well tolerated\n Plan:\n Pulmonary toilet\n Wean from vent as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat 3.5\n Action:\n Creat slowly improving\n Continues on lasix gtt weaned to 8mg/hour\n Started on diamox po\n K repleted with 40meq po this am, and 60 meq po this pm\n Response:\n Slowly improving renal failure\n Plan:\n Diurese as ordered\n Replete electrolytes as ordered\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597366, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG to be sent in\n am, pt denies SOB when asked, Sats currently 96-97% with repeat ABG=\n 7.42-52-87\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining clear yellow urine >100ml/hr, IV lasix gtt initially at\n 9 mg/hr and increased to 10mg/hr, good output but large input negating\n diuretic effect, K= 3.3---replaced with total of 40mEq IV KCL, Bun=\n Cr.=\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldo as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597367, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG to be sent in\n am, pt denies SOB when asked, Sats currently 96-97% with repeat ABG=\n 7.42-52-87\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with right radial Aline with good waveform---aline oozing blood and\n dressing changed x 3, BP= 130-150\ns/50-60\ns, BP occasionally\n 160-170\ns/60\ns with stimulation, no antihypertensives at this time as\n MICU team will accept BP <170, Foley draining clear yellow urine\n >100ml/hr, IV lasix gtt initially at 9 mg/hr and increased to 10mg/hr,\n good output but large input negating diuretic effect, K= 3.3---replaced\n with total of 40mEq IV KCL, Bun= Cr.=\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldo as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Nursing", "chartdate": "2121-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597368, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Events: Unable to diurese to goal due to Hypernatremia and pt\n requiring free water boluses and D5W bolus. Good urine output with\n Lasix gtt but remains positive >20 liters for length of stay. Vent on\n CPAP+PS at 50% with Sats down to low 90\ns and pO2 down to 69---PS\n increased to 12 and Peep increased to 10 with improvement in Sats and\n improved ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs with rhonchi bilat upper lobes and diminished at bases, strong\n prod cough of thick bloody sputum, ETtube suctioned for thick bloody\n sputum approx Q 1-2 hrs, Oral suction for yellow-tinged sputum, RR=\n , received pt on CPAP+PS at 50% with PS=8 and Peep=8. ABG fair\n 7.43-50-69 and 02 Sats down to 90-92%. Vent changed to CPAP+PS at 50%\n with PS increased to 12 and Peep increased to 10 with ABG= 7.42-52-87,\n pt denies SOB when asked, Sats currently 96-97%\n Action:\n Aggressive pulmonary toileting, MICU team aware of bloody sputum, ABG\n sent with vent changes, vent changed with PS and Peep settings\n increased, Freq. monitoring of resp status, Antibx as ordered, nebs as\n ordered, CXR completed and results pending\n Response:\n Improved Sats with vent change, Freq. suctioning required all shift\n Plan:\n Continue aggressive pulmonary toileting and diuresis, If hemoptysis\n continues may need bronchoscopy, monitor ABG\ns, CXR\ns and Hct, Continue\n antibx and nebs as ordered, Wean vent as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with right radial Aline with good waveform---aline oozing blood and\n dressing changed x 3, BP= 130-150\ns/50-60\ns, BP occasionally\n 160-170\ns/60\ns with stimulation, no antihypertensives at this time as\n MICU team will accept BP <170, Foley draining clear yellow urine\n >100ml/hr, IV lasix gtt initially at 9 mg/hr and increased to 10mg/hr,\n good output but large input negating diuretic effect, K= 3.3---replaced\n with total of 40mEq IV KCL, Bun= Cr.= , pt remains positive >\n 20 liters for LOS\n Action:\n Strict I+O, attempted to diurese to goal neg. of 50ml/hr, lytes\n monitored and replaced prn\n Response:\n Good urine output from Lasix gtt but unable to effectively diurese pt\n overnight\n Plan:\n Continue Lasix gtt and titrate to goal neg. of 50ml/hr, if unable to\n effectively diurese then consider CVVHD, monitor lytes and replace prn,\n Hypernatremia (high sodium)\n Assessment:\n Na level initially 148 during evening. Pt receiving 300ml free water\n via OG tube Q4hr as ordered, Repeat Na level up to 150----continues\n with free water boluses and pt received 500ml IV D5W\n Action:\n Na levels monitored closely, tube feedings changed from Nutren to\n Novasource renal due to lower sodium content in Novasource, D5W fluid\n bolus as ordered, free water fluid boluses as ordered\n Response:\n Sodium levels remain elevated\n Plan:\n Continue to monitor sodium levels closely, need more freq. bolus\n doses of D5W\n Altered mental status (not Delirium)\n Assessment:\n Alert, opens eyes spontaneously and tracks, follows all commands,\n PEARL, moving all extremities---although lower extremities are weaker\n than upper extremites, denies pain when asked, able to communicate with\n head nods and blinking of eyes, attempts to mouth words but not\n successful in communicating that way, occasional attempts to grab at\n lines and tubes---bilat wrist restraints to prevent pt from pulling at\n medical equip, no sedation, no pain meds, lethargic, easily arouseable\n but drifts back to sleep after being stimulated, no agitation\n Action:\n Sedation and pain meds held, psych service saw pt yesterday and all\n psych meds still being held\n Response:\n Improved mental status off all sedation, remains lethargic but easily\n arouseable\n Plan:\n Continue to hold psych meds while on linezolid and for 2 weeks\n following completion of linezolid treatment, start trilafon if\n needed and prn haldol as per psych. Continue freq. safety checks and\n neuro checks.\n" }, { "category": "Nursing", "chartdate": "2121-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597618, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 147\n Action:\n Repeat NA this am 147\n Continues on free h2o flushes 300cc q4 hours\n Response:\n NA stable on free h20 flushes\n Plan:\n Free water as ordered\n Impaired Skin Integrity\n Assessment:\n Helaing skin wounds\n Action:\n Sacral ulcer healed over, mepilex removed, and left open to air\n Multiple skin tears around aline site, aline removed and currently\n pressure dressing on site\n Right antecub skin tears dsd removed and mepilex dressing applied\n Skin tear in right groin and panus healing, barrier cream applied and\n left open to air\n Response:\n Improvement in multiple skin issues\n Plan:\n Per nursing care plan\n Change mepilex q72\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Weaning from PSV\n Action:\n Peep weaned to 5, PSV 5 50%\n Pt with less need for suctioning this shift\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599008, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently, PERRLA, 3mm, brisk.\n Inconsistently nods head to yes/no questions. Moving extremities on\n bed, occasionally lifts upper extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CPAP 5/5, 50%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions. Lasix gtt\n continued.\n Response:\n O2 sats 93-96% Nods no when asked if having resp difficulty. ~500cc\n neg since MN (goal- neg 2L).\n Plan:\n Monitor resp status. Suction PRN. Place on trach collar today.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx reddened but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 599434, "text": "Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Suctioned for copious amounts of bloody secretions. Remains on 60%\n Hi-flow system via T-piece. Renal function improving. Pt scheduled to\n be dc\nd to tomorrow AM.\n" }, { "category": "Nursing", "chartdate": "2121-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599489, "text": "The patient is a 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism admitted with pneumosepsis vs, urosepsis c/b by NSTEMI\n and now VAP with acinetobacter and MRSA, now extubated and trached but\n continued thick secretions and elevated oxygen requirements. He is\n being transferred to @ 10am\n Electrolyte & fluid disorder, other\n Assessment:\n Repeat Na at beginning of shift 155, up from 150\n Action:\n Increase FW to 250 ml q 2 h. 1L D5w given\n Response:\n Repeat NA 147\n Plan:\n Trend and cont FW boluses q2\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont on 60% fi02 w/ t-piece. Copious thick tan and blood-tinged\n secretions. Sp02 95%, O2 Sats 94-97%\n Action:\n ETT suction PRN, TCDB, pulm toilet. Cont supplemental 02\n Response:\n Resp status stable.\n Plan:\n Wean 02 support as tol.\n .H/O psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt essentially oriented and alert, nods yes / no appropriately.\n Follows comands, MAEs. Calm, cooperative.\n Action:\n Admin psych meds as directed perphenazine.\n Response:\n Stable.\n Plan:\n Re-admin clozaril as directed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 60-150 ml/hr.\n Action:\n No changes in treatment\n Response:\n BUN / Cre trending down, UOP stable.\n Plan:\n follow UOP and labs.\n" }, { "category": "Physician ", "chartdate": "2121-10-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 599504, "text": "Chief Complaint: Respiratory Failure, Spetic shock (resolved)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n No complaints\n 24 Hour Events:\n No further bleeding for trach site overnight\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\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: No(t) Fever\n Ear, Nose, Throat: trach\n Nutritional Support: Tube feeds\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 69 (61 - 78) bpm\n BP: 121/59(75) {89/44(58) - 149/72(89)} mmHg\n RR: 14 (12 - 17) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,979 mL\n 1,169 mL\n PO:\n TF:\n 1,081 mL\n 419 mL\n IVF:\n 1,088 mL\n Blood products:\n Total out:\n 2,250 mL\n 820 mL\n Urine:\n 2,250 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 729 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 95%\n ABG: ///34/\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 8.3 g/dL\n 225 K/uL\n 179 mg/dL\n 2.2 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 64 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.3 %\n 8.2 K/uL\n [image002.jpg]\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n 04:40 PM\n 03:50 AM\n 09:55 AM\n 02:36 AM\n WBC\n 4.9\n 6.1\n 7.1\n 8.3\n 8.3\n 8.2\n Hct\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n 28.3\n 28.3\n 26.3\n Plt\n 179\n 194\n 198\n 223\n 223\n 225\n Cr\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n 2.5\n 2.3\n 2.2\n Glucose\n 192\n 117\n 194\n 220\n 221\n 193\n 179\n Other labs: PT / PTT / INR:12.1/32.7/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:2.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ELECTROLYTE & FLUID DISORDER, OTHER\n PULMONARY EDEMA\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:04 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-10-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 599505, "text": "Chief Complaint: Respiratory Failure, Spetic shock (resolved)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n No complaints\n 24 Hour Events:\n No further bleeding for trach site overnight\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\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: No(t) Fever\n Ear, Nose, Throat: trach\n Nutritional Support: Tube feeds\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 69 (61 - 78) bpm\n BP: 121/59(75) {89/44(58) - 149/72(89)} mmHg\n RR: 14 (12 - 17) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,979 mL\n 1,169 mL\n PO:\n TF:\n 1,081 mL\n 419 mL\n IVF:\n 1,088 mL\n Blood products:\n Total out:\n 2,250 mL\n 820 mL\n Urine:\n 2,250 mL\n 820 mL\n NG:\n Stool:\n Drains:\n Balance:\n 729 mL\n 349 mL\n Respiratory support\n O2 Delivery Device: High flow nasal cannula\n SpO2: 95%\n ABG: ///34/\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 8.3 g/dL\n 225 K/uL\n 179 mg/dL\n 2.2 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 64 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.3 %\n 8.2 K/uL\n [image002.jpg]\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n 04:40 PM\n 03:50 AM\n 09:55 AM\n 02:36 AM\n WBC\n 4.9\n 6.1\n 7.1\n 8.3\n 8.3\n 8.2\n Hct\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n 28.3\n 28.3\n 26.3\n Plt\n 179\n 194\n 198\n 223\n 223\n 225\n Cr\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n 2.5\n 2.3\n 2.2\n Glucose\n 192\n 117\n 194\n 220\n 221\n 193\n 179\n Other labs: PT / PTT / INR:12.1/32.7/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:2.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ELECTROLYTE & FLUID DISORDER, OTHER\n PULMONARY EDEMA\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. Now trach masking\n during the day. To LTAC later this AM\n 1)Respiratory Failure-\n Trach mask trials during the day\n continues to improve\n 2)Renal Failure-\n Renal function stable\n 3)Trach site bleeding: No further bleeding from site\n 4)Hypernatremia: Na 147 today\n will need continuing fH20 flushes\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:04 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598472, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n High creatinine\n Action:\n On diamox, K repleted\n Response:\n u/o>100/h, creat down to 2.9\n Plan:\n Monitor lites, u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on AC 5 peep\n Action:\n Was tried to be on CPAP , suction PRN, VAP protocol, frequent turns\n Response:\n Failed CPAP, back to A/C,. thick tan/yellow sputum, maintains sat>94\n Plan:\n Plan to trach , wean to CPAP when awake enough\n Impaired Skin Integrity\n Assessment:\n Multiple skin breakdown areas\n Action:\n Mepliex dressings on right arm intact\n Sacral area dark purple with minimal breakdown\n Frequent turns\n Response:\n No new skin breakdown areas\n Plan:\n Per nursing care plan\n" }, { "category": "Case Management ", "chartdate": "2121-09-24 00:00:00.000", "description": "Discharge Planning Note", "row_id": 598561, "text": "Case Management Discharge Planning Note\n The patient is a 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism admitted with pneumosepsis vs, urosepsis c/b by NSTEMI\n and now VAP with acinetobacter and MRSA, now extubated but continued\n thick secretions and elevated oxygen requirements. He is likely to\n need LTACH placement at discharge.\n This nurse case manager has spoken with the patient\ns delegated \n case manager\n (\n about discharge\n planning. \n number is (. The network of\n LTACSs available to the patient is somewhat limited. named\n in and in .\n has clinically accepted the patient. is not able to\n accept the patient without a guardian in place. \n is looking into whether one is in place for the patient.\n The patient is now re-intubated and not stable for LYCAH transfer. NCM\n to follow. Please page for assistance.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Pager: \n" }, { "category": "Nursing", "chartdate": "2121-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598623, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt is alert and follows commands consistently, PERL brisk. Pt will\n shake his head\n when asked if he is in pain but does not respond to\n any other questions.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received intubated on AC/500x16/+5/40%. Pt not overbreathing\n ventilator.\n Action:\n No vent changes made today resp status addressed above. Suctioned\n q2-3 hour for moderate to copious amounts of thick tan secretions.\n Response:\n RR 16 with sats 95-99%.\n Plan:\n Continue to monitor resp status, suction PRN, trach on Thursday or\n Friday.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. They appear to be\n healing skin tears from tape. Also with reddened but blanchable area on\n his coccyx.\n Action:\n Skin kept clean and dry, healing skin tear on right wrist left OTA and\n healing skin tear on right forearm was covered with adaptic and DSD to\n prevent excoriation from BP cuff. Barrier cream applied liberally to\n coccyx. Pt repositioned frequently. Pt also met with PT today.\n Response:\n No further breakdown in skin.\n Plan:\n Continue with provide skin care, change dressings, and reposition\n frequently.\n" }, { "category": "Nursing", "chartdate": "2121-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599328, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands more consistently. Occasionally mouthing\n words. PERRLA, 3mm, brisk. Moving extremities on bed, occasionally\n lifts upper extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On trach T-piece, FiO2 60%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions. Continues\n to bleed from trach site-MICU team aware. Appears to be clotting.\n Response:\n O2 sats 93-96%. Nods no when asked if having resp difficulty.\n Plan:\n Monitor resp status. Suction PRN. Monitor trach site.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx pink but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598555, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 21 cm at lip\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: 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 Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally intubated on\n full mechanical support; no vent changes made this shift; attempted PSV\n wean but pt has no spontaneous respirations despite the fact that he\n will respond appropriately. Continues on A/C ventilation w/ PIP/Pplat\n = 20/15.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\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: Intolerant of\n weaning attempts\n" }, { "category": "Respiratory ", "chartdate": "2121-09-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598905, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n 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: Clear\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 / 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:\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 remains on stable on current vent support, with no issues\n this shift. Pt is still bleeding around trach site. Pt had copious\n secretions all shift, suctioned for blood tinge. Pt to remain on\n current support and to be assessed by MD team.\n BEDSIDE RSBI- 39\n" }, { "category": "Nursing", "chartdate": "2121-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599170, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently(although improved since last\n night), PERRLA, 3mm, brisk. Inconsistently nods head to yes/no\n questions. Moving extremities on bed, occasionally lifts upper\n extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On trach T-piece, FiO2 60%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions. Placed on\n vent overnight to rest.\n Response:\n O2 sats 93-96% Nods no when asked if having resp difficulty.\n Plan:\n Monitor resp status. Suction PRN. Place on trach T-piece today. OOB\n to chair if tolerated.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx pink but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 599171, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n 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: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\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 was performing trach t-piece trial well, and lasted for 13\n hours with good SpO2, RR within normal range, and showed no dyspnea.\n Pt was then put on vent, where he remained normal, for rest over\n night. Pt has clear, but diminished lung sounds and secretions have\n decreased in size. Pt to continue current support and to be assessed\n by MD \nIDE RSBI- 51\n" }, { "category": "Respiratory ", "chartdate": "2121-09-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 599252, "text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\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 / Small\n Comments: Pt data as above/ per Meta-V. Remains w/ an 8.0 Portex\n Trach in place and a tracheal cuff pressure of 28 cm H2O. Spent about\n 15 hours on a 60 % T-Piece yesterday and did very well w/out c/o\n dyspnea at the end of the trial. Occasionally desaturates down to the\n 80\n s r/t very copious and thick blood-tinged sputum which is resolved\n easily w/ suctioning. Will c/w 60 % T-Piece as tolerated.\n" }, { "category": "Nursing", "chartdate": "2121-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599426, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Na 150 this AM (149).\n Action:\n Increase FW to 250 ml q 6 h. Lytes .\n Response:\n Awaiting lab results for PM.\n Plan:\n Trend and cont FW boluses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 60% fi02 w/ t-piece. Copious thick tan and blood-tinged\n secretions. Trach site oozing BRB. Sp02 95%, pt will desat to 86% on\n RA. WBC WNL.\n Action:\n ETT suction PRN, TCDB, pulm toilet. Cont supplemental 02. IP consult\n for trach\n Response:\n Trach site improved w/o further intervention. Resp status stable.\n Plan:\n Wean 02 support as tol.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct trending down to 27.5 last 48 hrs (28.3 at 3am).\n Action:\n Trend.\n Response:\n Stable at 28.3 at 9am.\n Plan:\n Monitor.\n .H/O psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt essentially oriented and alert, nods yes / no appropriately.\n Follows coomands, MAEs. Calm, cooperative.\n Action:\n Admin psych meds asdir: perphenazine.\n Response:\n Stable.\n Plan:\n Re-admin clozaril asdir.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 60-160 ml/hr. BUN / Cre elevated above baseline.\n Action:\n Monitor, lasix gtt d/c\n Response:\n BUN / Cre trending down, UOP stable.\n Plan:\n Admin lasix if necessary, follow UOP and labs.\n" }, { "category": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598466, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n High creatinine\n Action:\n On diamox, K repleted\n Response:\n u/o>100/h, creat down to 2.9\n Plan:\n Monitor lites, u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on AC 5 peep\n Action:\n Was tried to be on CPAP , suction PRN, VAP protocol, frequent turns\n Response:\n Failed CPAP, back to A/C,. thick tan/yellow sputum, maintains sat>94\n Plan:\n Plan to trach , wean to CPAP when awake enough\n" }, { "category": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598607, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt is alert and follows commands consistently, PERL brisk. Pt will\n shake his head\n when asked if he is in pain but does not respond to\n any other questions.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received intubated on AC/500x16/+5/40%. Pt not overbreathing\n ventilator.\n Action:\n No vent changes made today resp status addressed above. Suctioned\n q2-3 hour for moderate to copious amounts of thick tan secretions.\n Response:\n RR 16 with sats 95-99%.\n Plan:\n Continue to monitor resp status, suction PRN, trach on Thursday or\n Friday.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. They appear to be\n healing skin tears from tape. Also with reddened but blanchable area on\n his coccyx.\n Action:\n Skin kept clean and dry, healing skin tear on right wrist left OTA and\n healing skin tear on right forearm was covered with adaptic and DSD to\n prevent excoriation from BP cuff. Barrier cream applied liberally to\n coccyx. Pt repositioned frequently. Pt also met with PT today.\n Response:\n No further breakdown in skin.\n Plan:\n Continue with provide skin care, change dressings, and reposition\n frequently.\n" }, { "category": "Physician ", "chartdate": "2121-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598660, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - trach and peg scheduled for tomorrow, may require DDAVP prior to\n procedure\n - TTE: LVEF > 55% with likely normal regional systolic function\n - left submandibular mass noticed by nursing, overlying skin is\n slightly erythematous and warm, appears to be tender, unable to explore\n mouth but patient has h/o poor dentition - non-contrast CT: no\n calcifications intraparotid lymph node, two submandibular lymph nodes\n with surrounding inflammation, asymmetric enlargement of\n parotid and submandibular glands\n - should receive ENT consult in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:13 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 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: 36.6\nC (97.9\n HR: 56 (53 - 79) bpm\n BP: 125/53(69) {100/43(56) - 139/92(100)} mmHg\n RR: 16 (15 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,390 mL\n 517 mL\n PO:\n TF:\n 1,080 mL\n 289 mL\n IVF:\n 450 mL\n 228 mL\n Blood products:\n Total out:\n 2,060 mL\n 925 mL\n Urine:\n 2,060 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 903 (903 - 903) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n SpO2: 97%\n ABG: ///42/\n Ve: 4.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 237 K/uL\n 7.6 g/dL\n 150 mg/dL\n 2.8 mg/dL\n 42 mEq/L\n 3.4 mEq/L\n 87 mg/dL\n 101 mEq/L\n 146 mEq/L\n 24.7 %\n 5.7 K/uL\n [image002.jpg]\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n WBC\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n Hct\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n Plt\n 298\n 316\n 300\n 255\n 243\n 227\n 237\n Cr\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n Glucose\n 167\n 191\n 210\n 166\n 282\n 168\n 126\n 141\n 150\n Other labs: PT / PTT / INR:11.6/33.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient now re-intubated for airway protection.\n Barriers to extubation include excess secretions and airway protection,\n fluid overload, mental status.\n - mental status: trach / peg for Thursday\n - pneumonia: continue meropenum (11 of 14) and linezolid (11 of 14)\n - pulmonary edema: restart lasix drip with metolazone and add\n acetazolamide for goal of - 2L / day\n titrating to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - restart Lasix gtt with Mitolazone and Acetazolamide for goal of -2L\n / day, titrating as BP tolerates\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:43 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599213, "text": "Chief Complaint:\n 24 Hour Events:\n -\n -bleeding from tracheostomy increased overnight, IP injected trach site\n with epinephrine.\n -bleeding stopped on morning rounds, with good clot formation.\n - bed not available today, decided anyway to keep at least one\n more day to monitor HCT, make sure bleeding is stopped.\n -PM labs - Hct up to 28.5, potassium improved to 3.8\n -Trach mask trial in the evening, tolerated well.\n -\n -Lasix gtt stopped, did not require any Lasix boluses and UOP of 1L\n -Na 150 yesterday, increased free water flushes to 200mL q6\n -CXR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.7\n HR: 66 (64 - 75) bpm\n BP: 98/52(63) {98/45(63) - 136/68(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,930 mL\n 290 mL\n PO:\n TF:\n 1,043 mL\n 290 mL\n IVF:\n 156 mL\n Blood products:\n Total out:\n 2,500 mL\n 380 mL\n Urine:\n 2,500 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 484 (98 - 506) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ///38/\n Ve: 5.2 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 198 K/uL\n 8.9 g/dL\n 220 mg/dL\n 2.5 mg/dL\n 38 mEq/L\n 3.6 mEq/L\n 78 mg/dL\n 107 mEq/L\n 149 mEq/L\n 27.5 %\n 7.1 K/uL\n [image002.jpg]\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n WBC\n 5.7\n 4.9\n 4.9\n 6.1\n 7.1\n Hct\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n Plt\n 237\n 198\n 179\n 194\n 198\n Cr\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n TCO2\n 37\n Glucose\n 150\n 183\n 231\n 192\n 117\n 194\n 220\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Microbiology: most recent cultures from showing Acinetobacter and\n MRSA pneumonia\n Imaging:\n CXR\n Assessment and Plan\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: lasix gtt stopped yesterday, no lasix boluses\n required, UOP >1L since d/c\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. ENT believes this is to low\n secretion in the setting of being chronically NPO. Trach performed.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 27.5.\n - trend HCT and transfuse PRN to goal > 23\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:53 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599214, "text": "Chief Complaint:\n 24 Hour Events:\n -\n -bleeding from tracheostomy increased overnight, IP injected trach site\n with epinephrine.\n -bleeding stopped on morning rounds, with good clot formation.\n - bed not available today, decided anyway to keep at least one\n more day to monitor HCT, make sure bleeding is stopped.\n -PM labs - Hct up to 28.5, potassium improved to 3.8\n -Trach mask trial in the evening, tolerated well.\n -\n -Lasix gtt stopped, did not require any Lasix boluses and UOP of 1L\n -Na 150 yesterday, increased free water flushes to 200mL q6\n -out of bed to chair all day\n -T-piece all day yesterday, tolerated well, on AC overnight to rest\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.7\n HR: 66 (64 - 75) bpm\n BP: 98/52(63) {98/45(63) - 136/68(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,930 mL\n 290 mL\n PO:\n TF:\n 1,043 mL\n 290 mL\n IVF:\n 156 mL\n Blood products:\n Total out:\n 2,500 mL\n 380 mL\n Urine:\n 2,500 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 484 (98 - 506) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ///38/\n Ve: 5.2 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 198 K/uL\n 8.9 g/dL\n 220 mg/dL\n 2.5 mg/dL\n 38 mEq/L\n 3.6 mEq/L\n 78 mg/dL\n 107 mEq/L\n 149 mEq/L\n 27.5 %\n 7.1 K/uL\n [image002.jpg]\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n WBC\n 5.7\n 4.9\n 4.9\n 6.1\n 7.1\n Hct\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n Plt\n 237\n 198\n 179\n 194\n 198\n Cr\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n TCO2\n 37\n Glucose\n 150\n 183\n 231\n 192\n 117\n 194\n 220\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Microbiology: most recent cultures from showing Acinetobacter and\n MRSA pneumonia\n Imaging:\n CXR\n Assessment and Plan\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: lasix gtt stopped yesterday, no lasix boluses\n required, UOP >1L since d/c\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. ENT believes this is to low\n secretion in the setting of being chronically NPO. Trach performed.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 27.5.\n - trend HCT and transfuse PRN to goal > 23\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:53 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599245, "text": "Chief Complaint:\n 24 Hour Events:\n -\n -bleeding from tracheostomy increased overnight, IP injected trach site\n with epinephrine.\n -bleeding stopped on morning rounds, with good clot formation.\n - bed not available today, decided anyway to keep at least one\n more day to monitor HCT, make sure bleeding is stopped.\n -PM labs - Hct up to 28.5, potassium improved to 3.8\n -Trach mask trial in the evening, tolerated well.\n -\n -Lasix gtt stopped, did not require any Lasix boluses and UOP of 1L\n -Na 150 yesterday, increased free water flushes to 200mL q6\n -out of bed to chair all day\n -T-piece all day yesterday, tolerated well, on AC overnight to rest\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.7\n HR: 66 (64 - 75) bpm\n BP: 98/52(63) {98/45(63) - 136/68(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,930 mL\n 290 mL\n PO:\n TF:\n 1,043 mL\n 290 mL\n IVF:\n 156 mL\n Blood products:\n Total out:\n 2,500 mL\n 380 mL\n Urine:\n 2,500 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 484 (98 - 506) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ///38/\n Ve: 5.2 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 198 K/uL\n 8.9 g/dL\n 220 mg/dL\n 2.5 mg/dL\n 38 mEq/L\n 3.6 mEq/L\n 78 mg/dL\n 107 mEq/L\n 149 mEq/L\n 27.5 %\n 7.1 K/uL\n [image002.jpg]\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n WBC\n 5.7\n 4.9\n 4.9\n 6.1\n 7.1\n Hct\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n Plt\n 237\n 198\n 179\n 194\n 198\n Cr\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n TCO2\n 37\n Glucose\n 150\n 183\n 231\n 192\n 117\n 194\n 220\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Microbiology: most recent cultures from showing Acinetobacter and\n MRSA pneumonia\n Imaging:\n CXR\n Assessment and Plan\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: lasix gtt stopped yesterday, no lasix boluses\n required, UOP >1L since d/c\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. ENT believes this is to low\n secretion in the setting of being chronically NPO. Trach performed.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 27.5.\n - trend HCT and transfuse PRN to goal > 23\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:53 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599246, "text": "Chief Complaint:\n 24 Hour Events:\n -Lasix gtt stopped, did not require any Lasix boluses and UOP of 1L\n -Na 150 yesterday, increased free water flushes to 200mL q6\n -out of bed to chair all day\n -T-piece all day yesterday, tolerated well, on AC overnight to rest\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.7\n HR: 66 (64 - 75) bpm\n BP: 98/52(63) {98/45(63) - 136/68(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,930 mL\n 290 mL\n PO:\n TF:\n 1,043 mL\n 290 mL\n IVF:\n 156 mL\n Blood products:\n Total out:\n 2,500 mL\n 380 mL\n Urine:\n 2,500 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 484 (98 - 506) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ///38/\n Ve: 5.2 L/min\n Physical Examination\n General: awake\n CV: RRR\n Pulm: CTA b/l\n Abd: soft, NT, ND\n Peripheral Vascular: 2+ pulses\n Neurologic: Follows commands\n Labs / Radiology\n 198 K/uL\n 8.9 g/dL\n 220 mg/dL\n 2.5 mg/dL\n 38 mEq/L\n 3.6 mEq/L\n 78 mg/dL\n 107 mEq/L\n 149 mEq/L\n 27.5 %\n 7.1 K/uL\n [image002.jpg]\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n WBC\n 5.7\n 4.9\n 4.9\n 6.1\n 7.1\n Hct\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n Plt\n 237\n 198\n 179\n 194\n 198\n Cr\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n TCO2\n 37\n Glucose\n 150\n 183\n 231\n 192\n 117\n 194\n 220\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Microbiology: most recent cultures from showing Acinetobacter and\n MRSA pneumonia\n Imaging:\n CXR: Bilateral pleural effusions, decreased as compared to prior\n Assessment and Plan\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: lasix gtt stopped yesterday, no lasix boluses\n required, UOP >1L since d/c, improved pulmonary edema\n # Neck Mass: concern for infection vs inflammation given tenderness of\n adenopathy, overlying erythema and warmth. ENT believes this is to\n low secretion in the setting of being chronically NPO. Trach\n performed. Now improving.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 27.5.\n - trend HCT and transfuse PRN to goal > 23\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:53 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598463, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n High creatinine\n Action:\n On diamox, K repleted\n Response:\n u/o>100/h, creat down to 2.9\n Plan:\n Monitor lites, u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on AC 5 peep\n Action:\n Was tried to be on CPAP , suction PRN, VAP protocol, frequent turns\n Response:\n Failed CPAP, back to A/C,. thick tan/yellow sputum, maintains sat>94\n Plan:\n Plan to trach , wean to CPAP when awake enough\n" }, { "category": "Respiratory ", "chartdate": "2121-09-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598467, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\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 Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n 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: Not triggering\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": "2121-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598664, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - trach and peg scheduled for tomorrow, may require DDAVP prior to\n procedure\n - TTE: LVEF > 55% with likely normal regional systolic function\n - left submandibular mass noticed by nursing, overlying skin is\n slightly erythematous and warm, appears to be tender, unable to explore\n mouth but patient has h/o poor dentition - non-contrast CT: no\n calcifications intraparotid lymph node, two submandibular lymph nodes\n with surrounding inflammation, asymmetric enlargement of\n parotid and submandibular glands\n - should receive ENT consult in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:13 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 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: 36.6\nC (97.9\n HR: 56 (53 - 79) bpm\n BP: 125/53(69) {100/43(56) - 139/92(100)} mmHg\n RR: 16 (15 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,390 mL\n 517 mL\n PO:\n TF:\n 1,080 mL\n 289 mL\n IVF:\n 450 mL\n 228 mL\n Blood products:\n Total out:\n 2,060 mL\n 925 mL\n Urine:\n 2,060 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 903 (903 - 903) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n SpO2: 97%\n ABG: ///42/\n Ve: 4.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 237 K/uL\n 7.6 g/dL\n 150 mg/dL\n 2.8 mg/dL\n 42 mEq/L\n 3.4 mEq/L\n 87 mg/dL\n 101 mEq/L\n 146 mEq/L\n 24.7 %\n 5.7 K/uL\n [image002.jpg]\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n WBC\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n Hct\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n Plt\n 298\n 316\n 300\n 255\n 243\n 227\n 237\n Cr\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n Glucose\n 167\n 191\n 210\n 166\n 282\n 168\n 126\n 141\n 150\n Other labs: PT / PTT / INR:11.6/33.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n ET tube 5 cm above carina, NGT in proximal stomach should\n be advanced 10 cm, bibasilar atelectasis, mild unchanged pulmonary\n edema, stable bilateral pleural effusions\n - CT neck \n see above\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Barriers to extubation include excess secretions and\n airway protection, fluid overload, mental status.\n - mental status: trach / peg today\n - pneumonia: continue meropenum (12 of 14) and linezolid (12 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for procedure\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:43 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598665, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently, PERRLA, 3mm, brisk.\n Inconsistently nods head to yes/no questions. Moving extremities on\n bed.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings AC/500x16/+5/40%. Not overbreathing vent. LS clear with\n diminished bases. O2 sats 94-98%.\n Action:\n O2 sats decreased to 90-91%. FiO2 increased to 50%. Suctioned q2-3\n hrs for moderate-copious amt of thick/tan secretions. Diuril given and\n Lasix gtt started.\n Response:\n O2 sats 95-98%. Nods no when asked if having resp difficulty. UOP\n >100cc/hr.\n Plan:\n Monitor resp status. Suction PRN. Plan for trach/PEG today (TF off at\n MN).\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx reddened but\n blanchable. Patient found to have a pink/red, swollen area on L side of\n neck. Grimaces with palpation of neck. Continues to have blood tinged\n oral secretions.\n Action:\n CT neck done. Continued wound care as documented. Pt repositioned\n frequently.\n Response:\n CT showed significant swelling of lymph node. Neck appears to be\n slightly redder.\n Plan:\n Continue wound care. Frequent position changes. ENT to be consulted\n today.\n" }, { "category": "Physician ", "chartdate": "2121-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598669, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - trach and peg scheduled for tomorrow, may require DDAVP prior to\n procedure\n - TTE: LVEF > 55% with likely normal regional systolic function\n - left submandibular mass noticed by nursing, overlying skin is\n slightly erythematous and warm, appears to be tender, unable to explore\n mouth but patient has h/o poor dentition - non-contrast CT: no\n calcifications intraparotid lymph node, two submandibular lymph nodes\n with surrounding inflammation, asymmetric enlargement of\n parotid and submandibular glands\n - should receive ENT consult in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:13 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 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: 36.6\nC (97.9\n HR: 56 (53 - 79) bpm\n BP: 125/53(69) {100/43(56) - 139/92(100)} mmHg\n RR: 16 (15 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,390 mL\n 517 mL\n PO:\n TF:\n 1,080 mL\n 289 mL\n IVF:\n 450 mL\n 228 mL\n Blood products:\n Total out:\n 2,060 mL\n 925 mL\n Urine:\n 2,060 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 903 (903 - 903) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n SpO2: 97%\n ABG: ///42/\n Ve: 4.3 L/min\n Physical Examination\n General: NAD\n ENT: large firm submandibular mass with overlying warmth and erythema,\n tender\n Chest: CTAB\n Heart: RRR no MRG\n Abdomen: soft, NTND\n Extremities: NT, WWP, 2+ PE\n Labs / Radiology\n 237 K/uL\n 7.6 g/dL\n 150 mg/dL\n 2.8 mg/dL\n 42 mEq/L\n 3.4 mEq/L\n 87 mg/dL\n 101 mEq/L\n 146 mEq/L\n 24.7 %\n 5.7 K/uL\n [image002.jpg]\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n WBC\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n Hct\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n Plt\n 298\n 316\n 300\n 255\n 243\n 227\n 237\n Cr\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n Glucose\n 167\n 191\n 210\n 166\n 282\n 168\n 126\n 141\n 150\n Other labs: PT / PTT / INR:11.6/33.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n ET tube 5 cm above carina, NGT in proximal stomach should\n be advanced 10 cm, bibasilar atelectasis, mild unchanged pulmonary\n edema, stable bilateral pleural effusions\n - CT neck \n see above\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Barriers to extubation include excess secretions and\n airway protection, fluid overload, mental status.\n - mental status: trach / peg today\n - pneumonia: continue meropenum (12 of 14) and linezolid (12 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for procedure\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:43 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598809, "text": "Events: Moderate amount of bleeding at trach site- saturated gauze x 3\n able to suction blood from trach. NO vent changes. Pt\n awake/sleeping on off throughout shift- sporadically follows commands,\n NAD. Given 1 x bolus 25mcg Fentanyl w/ facial grimacing with trach\n care- will intermittently shake head t question of pain, 1x dose 1mg\n Versed for awake, RR 30. T max 99.0. NPO overnight- plan for PEG in\n OR today.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n + cough, weak gag with subglottal suctioning, mod amount oral\n secretions, mod-large amount bleeding at trach site, suctioning blood\n from trach\n Action:\n Suctioning PRN, not increase bleeding from trach site but did not\n increase\n Response:\n Pt tolerating, no de-saturating, minimal sedating medications\n Plan:\n Trach care, suctioning PRN, minimize sedating medication though going\n to OR for PEG placement,\n" }, { "category": "Nursing", "chartdate": "2121-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598814, "text": "Events: Moderate amount of bleeding at trach site- saturated gauze x 3\n able to suction blood from trach. NO vent changes. Pt\n awake/sleeping on off throughout shift- sporadically follows commands,\n NAD. Given 1 x bolus 25mcg Fentanyl w/ facial grimacing with trach\n care- will intermittently shake head t question of pain, 1x dose 1mg\n Versed for awake, RR 30. T max 99.0. NPO overnight- plan for PEG in\n OR today.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n + cough, weak gag with subglottal suctioning, mod amount oral\n secretions, mod-large amount bleeding at trach site, suctioning blood\n from trach\n Action:\n Suctioning PRN, not increase bleeding from trach site but did not\n increase\n Response:\n Pt tolerating, no de-saturating, minimal sedating medications\n Plan:\n Trach care, suctioning PRN, minimize sedating medication though going\n to OR for PEG placement,\n" }, { "category": "Physician ", "chartdate": "2121-09-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 599234, "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 T-poece for entire day yesterday and did well\n Back on A/C overnight\n 24 Hour Events:\n No further bleeding from trach site\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: trach\n Gastrointestinal: PEG\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: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 76 (64 - 76) bpm\n BP: 123/63(77) {98/45(63) - 135/68(85)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,932 mL\n 721 mL\n PO:\n TF:\n 1,045 mL\n 505 mL\n IVF:\n 156 mL\n 142 mL\n Blood products:\n Total out:\n 2,500 mL\n 950 mL\n Urine:\n 2,500 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -568 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: T-piece\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 484 (98 - 506) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 10 cmH2O\n SpO2: 96%\n ABG: ///38/\n Ve: 5.2 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: Clear : )\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\n Labs / Radiology\n 8.9 g/dL\n 198 K/uL\n 220 mg/dL\n 2.5 mg/dL\n 38 mEq/L\n 3.6 mEq/L\n 78 mg/dL\n 107 mEq/L\n 149 mEq/L\n 27.5 %\n 7.1 K/uL\n [image002.jpg]\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n WBC\n 5.7\n 4.9\n 4.9\n 6.1\n 7.1\n Hct\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n Plt\n 237\n 198\n 179\n 194\n 198\n Cr\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n TCO2\n 37\n Glucose\n 150\n 183\n 231\n 192\n 117\n 194\n 220\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ELECTROLYTE & FLUID DISORDER, OTHER\n PULMONARY EDEMA\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. Now trach masking\n during the day.\n 1)Respiratory Failure- completed /linezolid\n Cont trach mask during day. No further active diuresis for now\n 2)Renal Failure-\n Renal function stable\n To when bed available.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:34 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2121-09-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 598752, "text": "Subjective\n Patient trached. Resting comfortably.\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 150 mg/dL\n 03:22 AM\n Glucose Finger Stick\n 142, 175, 153\n \n BUN\n 87 mg/dL\n 03:22 AM\n Creatinine\n 2.8 mg/dL\n 03:22 AM\n Sodium\n 146 mEq/L\n 03:22 AM\n Potassium\n 3.4 mEq/L\n 03:22 AM\n Chloride\n 101 mEq/L\n 03:22 AM\n TCO2\n 42 mEq/L\n 03:22 AM\n Albumin\n 2.3 g/dL\n 02:07 AM\n Calcium non-ionized\n 8.3 mg/dL\n 03:22 AM\n Phosphorus\n 3.7 mg/dL\n 03:22 AM\n Magnesium\n 3.1 mg/dL\n 03:22 AM\n WBC\n 5.7 K/uL\n 03:22 AM\n Hgb\n 7.6 g/dL\n 03:22 AM\n Hematocrit\n 24.7 %\n 03:22 AM\n Current diet order / nutrition support: Nutren 2.0 @45mL/hr (2160\n kcals/86 grams protein)- on hold\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Specifics:\n Tube feeds currently off as patient had trach done today. PEG was\n aborted d/t inability to illuminate. Tube feeds were previously well\n tolerated @ goal, and met 100% estimated nutrition needs. Per\n discussion c/ RN, team may place dobhoff while determining if patient\n will go to OR for GTube placement.\n Patient continues on lasix drip for diuresis. Diamox added in setting\n of contraction alkalosis.\n Blood sugars elevated-more so when tube feeds infusing than now.\n K repletion noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Resume feeds when able-either via NGT or DHT\n Consider changing to RISS vs Humalog, for more consistent\n coverage on continuous feeds\n Lyte management as you are\n Following #\n" }, { "category": "Physician ", "chartdate": "2121-09-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598800, "text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 10:30 AM\n -trach was placed; on ASSIST control ventilation\n -PEG could not be placed with IP secondary to difficulties they had w/\n transillumination. GI consulted; they will place endoscopically guided\n PEG tube tomorrow AM. NPO after midnight.\n -PM HCT stable: 24 -> 23\n -evening Is Os: net -1 L balance which is at goal (no metolazone was\n necessary)\n -ENT consulted: they felt his parotitis likely secondary to low PO\n intake, low secretion of salivation. Recommended warm compresses q4\n hours and massage; also suggested juice but we held on this\n because of risk of aspiration.\n -increased dose of acetozolamide\n -ddAVP given prior to trach\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 02:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Midazolam (Versed) - 04:00 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 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 66) bpm\n BP: 106/50(63) {75/40(50) - 123/58(74)} mmHg\n RR: 16 (12 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,882 mL\n 146 mL\n PO:\n TF:\n 315 mL\n IVF:\n 1,167 mL\n 146 mL\n Blood products:\n Total out:\n 3,455 mL\n 520 mL\n Urine:\n 3,455 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n -374 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n SpO2: 94%\n ABG: ///37/\n Ve: 7.5 L/min\n Physical Examination\n Cardiovascular: Gen: NAD\n HEENT: large, firm non tender mass on left parotid. warm\n CV: RRR, nl S1,S2\n Lungs: reduced breath sounds at bases\n Abd: soft, ND, NT ABS\n Ext: 2+ edema bilaterally, upper and lower extremities.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 198 K/uL\n 6.9 g/dL\n 231 mg/dL\n 2.9 mg/dL\n 37 mEq/L\n 3.2 mEq/L\n 86 mg/dL\n 100 mEq/L\n 145 mEq/L\n 21.8 %\n 4.9 K/uL\n [image002.jpg]\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n WBC\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n 4.9\n Hct\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n Plt\n 300\n 255\n 243\n 227\n 237\n 198\n Cr\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n TCO2\n 45\n Glucose\n 68\n 126\n 141\n 150\n 183\n 231\n Other labs: PT / PTT / INR:12.2/43.4/1.0, Albumin:2.3 g/dL, Ca++:8.0\n mg/dL, Mg++:2.9 mg/dL, PO4:4.6 mg/dL\n Imaging: CXR: bilateral pulmonary effusions and pulmonary edema\n Microbiology: sputum - acinetobacter\n sputum - coag + staph aureus (MRSA), and acinetobacter\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy yesterday. Barriers to extubation\n include excess secretions and airway protection, fluid overload, mental\n status.\n - mental status: trach\n - pneumonia: continue meropenum (13 of 14) and linezolid (13 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. Mass appears to be caudal and lateral\n to airway and do not anticipate any problems with trach ENT believes\n this is to low secretion in the setting of being chronically NPO.\n - warm compresses and massage q4h\n - juice to stimulate secretion\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n - transfuse one unit today\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for PEG placement\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2121-09-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598801, "text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 10:30 AM\n -trach was placed; on ASSIST control ventilation\n -PEG could not be placed with IP secondary to difficulties they had w/\n transillumination. GI consulted; they will place endoscopically guided\n PEG tube tomorrow AM. NPO after midnight.\n -PM HCT stable: 24 -> 23\n -evening Is Os: net -1 L balance which is at goal (no metolazone was\n necessary)\n -ENT consulted: they felt his parotitis likely secondary to low PO\n intake, low secretion of salivation. Recommended warm compresses q4\n hours and massage; also suggested juice but we held on this\n because of risk of aspiration.\n -increased dose of acetozolamide\n -ddAVP given prior to trach\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 02:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Midazolam (Versed) - 04:00 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 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 66) bpm\n BP: 106/50(63) {75/40(50) - 123/58(74)} mmHg\n RR: 16 (12 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,882 mL\n 146 mL\n PO:\n TF:\n 315 mL\n IVF:\n 1,167 mL\n 146 mL\n Blood products:\n Total out:\n 3,455 mL\n 520 mL\n Urine:\n 3,455 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n -374 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n SpO2: 94%\n ABG: ///37/\n Ve: 7.5 L/min\n Physical Examination\n Cardiovascular: Gen: NAD\n HEENT: large, firm non tender mass on left parotid. warm\n CV: RRR, nl S1,S2\n Lungs: reduced breath sounds at bases\n Abd: soft, ND, NT ABS\n Ext: 2+ edema bilaterally, upper and lower extremities.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 198 K/uL\n 6.9 g/dL\n 231 mg/dL\n 2.9 mg/dL\n 37 mEq/L\n 3.2 mEq/L\n 86 mg/dL\n 100 mEq/L\n 145 mEq/L\n 21.8 %\n 4.9 K/uL\n [image002.jpg]\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n WBC\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n 4.9\n Hct\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n Plt\n 300\n 255\n 243\n 227\n 237\n 198\n Cr\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n TCO2\n 45\n Glucose\n 68\n 126\n 141\n 150\n 183\n 231\n Other labs: PT / PTT / INR:12.2/43.4/1.0, Albumin:2.3 g/dL, Ca++:8.0\n mg/dL, Mg++:2.9 mg/dL, PO4:4.6 mg/dL\n Imaging: CXR: bilateral pulmonary effusions and pulmonary edema\n Microbiology: sputum - acinetobacter\n sputum - coag + staph aureus (MRSA), and acinetobacter\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy yesterday. Barriers to extubation\n include excess secretions and airway protection, fluid overload, mental\n status.\n - mental status: trach\n - pneumonia: continue meropenum (13 of 14) and linezolid (13 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. Mass appears to be caudal and lateral\n to airway and do not anticipate any problems with trach ENT believes\n this is to low secretion in the setting of being chronically NPO.\n - warm compresses and massage q4h\n - juice to stimulate secretion\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n - transfuse one unit today\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for PEG placement\n by GI today\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2121-09-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598890, "text": "Chief Complaint:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 10:30 AM\n -trach was placed; on ASSIST control ventilation\n -PEG could not be placed with IP secondary to difficulties they had w/\n transillumination. GI consulted; they will place endoscopically guided\n PEG tube tomorrow AM. NPO after midnight.\n -PM HCT stable: 24 -> 23\n -evening Is Os: net -1 L balance which is at goal (no metolazone was\n necessary)\n -ENT consulted: they felt his parotitis likely secondary to low PO\n intake, low secretion of salivation. Recommended warm compresses q4\n hours and massage; also suggested juice but we held on this\n because of risk of aspiration.\n -increased dose of acetozolamide\n -ddAVP given prior to trach\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 02:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Midazolam (Versed) - 04:00 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 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 66) bpm\n BP: 106/50(63) {75/40(50) - 123/58(74)} mmHg\n RR: 16 (12 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,882 mL\n 146 mL\n PO:\n TF:\n 315 mL\n IVF:\n 1,167 mL\n 146 mL\n Blood products:\n Total out:\n 3,455 mL\n 520 mL\n Urine:\n 3,455 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n -374 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n SpO2: 94%\n ABG: ///37/\n Ve: 7.5 L/min\n Physical Examination\n Cardiovascular: Gen: NAD\n HEENT: large, firm non tender mass on left parotid. warm\n CV: RRR, nl S1,S2\n Lungs: reduced breath sounds at bases\n Abd: soft, ND, NT ABS\n Ext: 2+ edema bilaterally, upper and lower extremities.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 198 K/uL\n 6.9 g/dL\n 231 mg/dL\n 2.9 mg/dL\n 37 mEq/L\n 3.2 mEq/L\n 86 mg/dL\n 100 mEq/L\n 145 mEq/L\n 21.8 %\n 4.9 K/uL\n [image002.jpg]\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n WBC\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n 4.9\n Hct\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n Plt\n 300\n 255\n 243\n 227\n 237\n 198\n Cr\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n TCO2\n 45\n Glucose\n 68\n 126\n 141\n 150\n 183\n 231\n Other labs: PT / PTT / INR:12.2/43.4/1.0, Albumin:2.3 g/dL, Ca++:8.0\n mg/dL, Mg++:2.9 mg/dL, PO4:4.6 mg/dL\n Imaging: CXR: bilateral pulmonary effusions and pulmonary edema\n Microbiology: sputum - acinetobacter\n sputum - coag + staph aureus (MRSA), and acinetobacter\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy yesterday. Barriers to extubation\n include excess secretions and airway protection, fluid overload, mental\n status.\n - mental status: trach\n - pneumonia: continue meropenum (13 of 14) and linezolid (13 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. Mass appears to be caudal and lateral\n to airway and do not anticipate any problems with trach ENT believes\n this is to low secretion in the setting of being chronically NPO.\n - warm compresses and massage q4h\n - juice to stimulate secretion\n # Trach site\n site is still bleeding actively. D/w IP regarding this:\n recommended silver nitrate or lidocaine with epi.\n #PEG placement\n PEG tube to be placed today. Pt NPO for procedure\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct 21.7 this AM\n - trend HCT and transfuse PRN to goal > 23\n - transfuse 2 units today\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for PEG placement\n by GI today\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\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": "2121-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598659, "text": "Chief Complaint:\n 24 Hour Events:\n - trach and peg scheduled for tomorrow, may require DDAVP prior to\n procedure\n - TTE: LVEF > 55% with likely normal regional systolic function\n - left submandibular mass noticed by nursing, overlying skin is\n slightly erythematous and warm, appears to be tender, unable to explore\n mouth but patient has h/o poor dentition - non-contrast CT: no\n calcifications intraparotid lymph node, two submandibular lymph nodes\n with surrounding inflammation, asymmetric enlargement of\n parotid and submandibular glands\n - should receive ENT consult in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:13 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 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: 36.6\nC (97.9\n HR: 56 (53 - 79) bpm\n BP: 125/53(69) {100/43(56) - 139/92(100)} mmHg\n RR: 16 (15 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,390 mL\n 517 mL\n PO:\n TF:\n 1,080 mL\n 289 mL\n IVF:\n 450 mL\n 228 mL\n Blood products:\n Total out:\n 2,060 mL\n 925 mL\n Urine:\n 2,060 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 903 (903 - 903) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n SpO2: 97%\n ABG: ///42/\n Ve: 4.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 237 K/uL\n 7.6 g/dL\n 150 mg/dL\n 2.8 mg/dL\n 42 mEq/L\n 3.4 mEq/L\n 87 mg/dL\n 101 mEq/L\n 146 mEq/L\n 24.7 %\n 5.7 K/uL\n [image002.jpg]\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n WBC\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n Hct\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n Plt\n 298\n 316\n 300\n 255\n 243\n 227\n 237\n Cr\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n Glucose\n 167\n 191\n 210\n 166\n 282\n 168\n 126\n 141\n 150\n Other labs: PT / PTT / INR:11.6/33.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient now re-intubated for airway protection.\n Barriers to extubation include excess secretions and airway protection,\n fluid overload, mental status.\n - mental status: trach / peg for Thursday\n - pneumonia: continue meropenum (11 of 14) and linezolid (11 of 14)\n - pulmonary edema: restart lasix drip with metolazone and add\n acetazolamide for goal of - 2L / day\n titrating to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - restart Lasix gtt with Mitolazone and Acetazolamide for goal of -2L\n / day, titrating as BP tolerates\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:43 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598799, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2121-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598805, "text": "Events: Moderate amount of bleeding at trach site- saturated gauze x 3\n able to suction blood from trach. NO vent changes. Pt\n awake/sleeping on off throughout shift- sporatically follows commands,\n NAD. Given 1 x bolus 25mcg Fentanyl w/ facial grimacing with trach\n care- will intermittently shake head t question of pain, 1x dose 1mg\n Versed for awake, RR 30. T max 99.0. NPO overnight- plan for PEG in\n OR today.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2121-09-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598880, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\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 Airway problems: Oozing blood from Trach site\n Comments: Improved w/ Lidocaine/ Epinephrine per IP\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n :\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n" }, { "category": "Respiratory ", "chartdate": "2121-09-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598969, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt data as above/ per meta-V. PSV decreased to 5 today and\n doing pretty well w/ VT\ns about 350-450 cc. RSBI 39 this AM. One\n episode of desaturation this shift of 83 % r/t a bloody mucous plug\n which resolved w/ lavage-suctioning.\n" }, { "category": "Nursing", "chartdate": "2121-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598974, "text": "74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. He has had continued\n need for ventilatory support with slow wean from ventilator attempted\n but with trach/PEG required for ongoing care.\n" }, { "category": "Physician ", "chartdate": "2121-09-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598977, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism admitted with pneumosepsis vs, urosepsis c/b by NSTEMI\n and now VAP with acinetobacter and MRSA, re-intubated for airway\n protection due to continued respiratory secretions and tiring cough.\n Trach placed. Waiting for rehab bed.\n 24 Hour Events:\n PEG INSERTION - At 09:10 AM\n - accepted him. waiting for a bed.\n - bleeding from tracheostomy improved\n - started on a PPI for coffee grounds noted during peg placement\n - PEG placed by GI, waiting for GI okay to use\n - s/p 2 units of blood for Hct 21.7. (recent NSTEMI)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:45 PM\n Cefazolin - 01:04 PM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:52 PM\n Fentanyl - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:47 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 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 55 (53 - 79) bpm\n BP: 128/47(67) {101/41(55) - 132/65(82)} mmHg\n RR: 11 (11 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,572 mL\n 348 mL\n PO:\n TF:\n IVF:\n 872 mL\n 168 mL\n Blood products:\n 700 mL\n Total out:\n 3,540 mL\n 1,140 mL\n Urine:\n 3,540 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,968 mL\n -792 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): 527 (472 - 560) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 39\n PIP: 15 cmH2O\n Plateau: 14 cmH2O\n SpO2: 95%\n ABG: 7.46/51/94./35/10\n Ve: 6.7 L/min\n PaO2 / FiO2: 188\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 179 K/uL\n 8.2 g/dL\n 192 mg/dL\n 2.8 mg/dL\n 35 mEq/L\n 2.8 mEq/L\n 85 mg/dL\n 95 mEq/L\n 147 mEq/L\n 24.7 %\n 4.9 K/uL\n [image002.jpg]\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n WBC\n 4.7\n 4.9\n 5.7\n 4.9\n 4.9\n Hct\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n Plt\n 243\n 227\n 237\n 198\n 179\n Cr\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n 37\n Glucose\n 168\n 126\n 141\n 150\n 183\n 231\n 192\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:7.9 mg/dL, Mg++:2.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy yesterday. Barriers to extubation\n include excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: day 14/14 for both meropenem and linezolid\n will DC both\n after today.\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. ENT believes this is to low\n secretion in the setting of being chronically NPO. Trach performed.\n - warm compresses and massage q4h\n # Trach site\n site with more mild bleeding overnight. IP injected\n lidocaine with epi.\n - monitor bleeding, will repeat HCT this afternoon.\n #PEG placement\n PEG placed yesterday successfully, site appears clean\n and dry.\n - will start tube feeds today\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 24.7. Will re-check hematocrit this afternoon to\n determine if this represents a real drop or a continuing trend.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, waiting for bed at rehab, potentially DC tomorrow if\n HCT stable and otherwise doing well.\n" }, { "category": "Nursing", "chartdate": "2121-09-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598980, "text": "74 yo male admitted with sepsis from pulmonary source, now with\n prolonged hospital course leading to trach/PEG placement. He has had\n continued need for ventilatory support lg amt secretions/ pulmonary\n edema. Pt currently on a lasix gtt.\n EVENTS: TF restarted @ 1430, now running @ 20cc/hr with goal of\n 45cc/hr. increase @ 2230 by 10cc if residual not greater than 150.\n Trach site injected with lido/epi by IP this AM for continued bleeding,\n and bleeding has since ceased.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with prolonged hospital course c/b sepsis from pulmonary source. Now\n s/p trach with lg amts thick blood tinged secretions being suctioned.\n Pt received on vent @ PSV 50%/, on lasix gtt @ 8mg/hr for diuresis\n for pulmonary edema.\n Action:\n IV abx DCd today as course complete. Pt switched to PSV 50%/. Lasix\n gtt increased to 10mg/hr to obtain goal diuresis of 2L negative daily.\n Frequent suctioning.\n Response:\n Cont with lasix gtt, cont frequent suctioning. Pt tolerating PSV 5/5 so\n trialed on trach mask briefly this pm for 30mins and tolerating well.\n Plan:\n Cont lasix gtt with goal 2L negative daily. Cont frequent suctioning,\n trach care. Likely switch to trach mask for longer trial in am.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt with AM HCT 24.7, has been bleeding from trach site since placement\n and already s/p lido/epi injection by IP yesterday pm.\n Action:\n Pt transfused with 2 units PRBCs yesterday. Trach site injected again\n this AM with lido/epi by IP fellow and trach site covered with\n surgicel. PM HCT rechecked.\n Response:\n PM HCT up to 28.3. No further bleeding noted at trach site.\n Plan:\n Cont to monitor HCTs, watch for s/s bleeding. Contact IP for further\n bleeding at trach site.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with AM K+ 2.8 (likely low lasix gtt and no nutrition x 2 days);\n repleted per potassium sliding scale with 60 mEq IV KCl by RN.\n Action:\n PO KCl sliding scale ordered by MD and 40 mEq PO KCl given MD. \ntes checked.\n Response:\n PM K+ came back at 3.8 so per PO sliding scale pt given another 40 mEq\n PO KCl.\n Plan:\n Cont to monitor lytes, especially potatssium while on lasix gtt, and\n replete as necessary. TF restarted which will hopefully help increase\n K+.\n" }, { "category": "Physician ", "chartdate": "2121-09-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 599084, "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 No further bleeding from trach overnight\n 24 Hour Events:\n Trach mask trial last evening - tolerated well\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 PM\n Infusions:\n Furosemide (Lasix) - 7 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\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: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Respiratory: tracheostomy\n Gastrointestinal: PEG\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:58 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.9\nC (98.4\n HR: 66 (56 - 73) bpm\n BP: 110/54(68) {108/44(60) - 136/61(77)} mmHg\n RR: 14 (10 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,341 mL\n 1,144 mL\n PO:\n TF:\n 162 mL\n 539 mL\n IVF:\n 478 mL\n 155 mL\n Blood products:\n Total out:\n 3,455 mL\n 1,670 mL\n Urine:\n 3,455 mL\n 1,670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,114 mL\n -526 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 98 (98 - 502) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 44\n PIP: 0 cmH2O\n SpO2: 94%\n ABG: ///38/\n Ve: 8.8 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: 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, movements slow\n but does interact\n Labs / Radiology\n 9.0 g/dL\n 194 K/uL\n 194 mg/dL\n 2.8 mg/dL\n 38 mEq/L\n 3.5 mEq/L\n 82 mg/dL\n 103 mEq/L\n 147 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n WBC\n 4.7\n 4.9\n 5.7\n 4.9\n 4.9\n 6.1\n Hct\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n Plt\n 243\n 227\n 237\n 198\n 179\n 194\n Cr\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n TCO2\n 37\n Glucose\n 126\n 141\n 150\n 183\n 94\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ELECTROLYTE & FLUID DISORDER, OTHER\n PULMONARY EDEMA\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. He has had continued\n need for ventilatory support with slow wean from ventilator attempted\n but with trach/PEG required for ongoing care.\n 1)Respiratory Failure- completed /linezolid\n Cont trach mask trials. Goal neg 1L per day. Change Lasix to bolus\n from drip\n 2)Renal Failure-\n 1L negative as above\n To when bed available.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:40 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-09-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599205, "text": "Chief Complaint:\n 24 Hour Events:\n -\n -bleeding from tracheostomy increased overnight, IP injected trach site\n with epinephrine.\n -bleeding stopped on morning rounds, with good clot formation.\n - bed not available today, decided anyway to keep at least one\n more day to monitor HCT, make sure bleeding is stopped.\n -PM labs - Hct up to 28.5, potassium improved to 3.8\n -Trach mask trial in the evening, tolerated well.\n -\n -Lasix gtt stopped, did not require any Lasix boluses and UOP of 1L\n -Na 150 yesterday, increased free water flushes to 200mL q6\n -CXR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.7\n HR: 66 (64 - 75) bpm\n BP: 98/52(63) {98/45(63) - 136/68(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,930 mL\n 290 mL\n PO:\n TF:\n 1,043 mL\n 290 mL\n IVF:\n 156 mL\n Blood products:\n Total out:\n 2,500 mL\n 380 mL\n Urine:\n 2,500 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 484 (98 - 506) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 51\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ///38/\n Ve: 5.2 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 198 K/uL\n 8.9 g/dL\n 220 mg/dL\n 2.5 mg/dL\n 38 mEq/L\n 3.6 mEq/L\n 78 mg/dL\n 107 mEq/L\n 149 mEq/L\n 27.5 %\n 7.1 K/uL\n [image002.jpg]\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n WBC\n 5.7\n 4.9\n 4.9\n 6.1\n 7.1\n Hct\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n Plt\n 237\n 198\n 179\n 194\n 198\n Cr\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n TCO2\n 37\n Glucose\n 150\n 183\n 231\n 192\n 117\n 194\n 220\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: lasix gtt stopped yesterday, no lasix boluses\n required, UOP >1L since d/c\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. ENT believes this is to low\n secretion in the setting of being chronically NPO. Trach performed.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 27.5.\n - trend HCT and transfuse PRN to goal > 23\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:53 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "General", "chartdate": "2121-09-24 00:00:00.000", "description": "Generic Note", "row_id": 598532, "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.\n 96.9 60 114/43\n Lethargic but awake\n Chest\n coarse mid insp crackles bilat\n Extrem 2+ edema\n 3L negative yesterday without lasix\n diuresed after intubation\n CXR pulm edema lessening, bilat effusions\n Response to intubation suggests he may have more cardiac dis than we\n think. Will repeat echo since he did have an NSTEMI on adm. Plan to\n move to trache and PEG this week. Will meanwhile continue to try to\n maintain negative.\n Time spent 40 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2121-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598652, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently, PERRLA, 3mm, brisk.\n Inconsistently nods head to yes/no questions. Moving extremities on\n bed.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings AC/500x16/+5/40%. Not overbreathing vent. LS clear with\n diminished bases. O2 sats 94-98%.\n Action:\n O2 sats decreased to 90-91%. FiO2 increased to 50%. Suctioned q2-3\n hrs for moderate-copious amt of thick/tan secretions. Diuril given and\n Lasix gtt started.\n Response:\n O2 sats 95-98%. Nods no when asked if having resp difficulty. UOP\n >100cc/hr.\n Plan:\n Monitor resp status. Suction PRN. Plan for trach/PEG today (TF off at\n MN).\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx reddened but\n blanchable. Patient found to have a pink/red, swollen area on L side of\n neck. Grimaces with palpation of neck. Continues to have blood tinged\n oral secretions.\n Action:\n CT neck done. Continued wound care as documented. Pt repositioned\n frequently.\n Response:\n CT showed significant swelling of lymph node. Neck appears to be\n slightly redder.\n Plan:\n Continue wound care. Frequent position changes. ENT to be consulted\n today.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598743, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\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: 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 Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / 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 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 Respiratory Care Shift Procedures\n Bedside Procedures:\n Bedside tracheostomy (1100)\n Comments: pt trached and pegged at bedside with 8.0 perc portex by IP\n" }, { "category": "Nursing", "chartdate": "2121-09-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598882, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure and tx of PNA vs\n urosepsis.\n Events: PEG tube placed this AM by GI service, clamped and intact.\n Active bleeding at trach site so lidocaine gel w/ epinephrine injection\n performed this afternoon by IP, site improved, 2 units PRBCs transfused\n and Hct pending, INR 1.0.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has trach in place, placed yesterday. Sp02 94-96%. Received pt on\n AC 50%/500/16/5. No SRR noted, bolus sedation d/t mult procedures.\n Lasix gtt 15 mg/hr for pulm edema + FB LOS, UOP 150-200 ml/hr. ABG\n 7.46/51/94/10/37.\n Action:\n Vent change to 50% PS 10/5. Lasix titrated to 12 mg/hr. Admin ABX.\n Response:\n Sp02 94, SRR 13, Vt 500, Vm 6 L. PM lytes pending.\n Plan:\n Wean vent as tol, pt accepted to Rehab\n .H/O psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has psych hx: schizophrenia. Nonverbal but inconsistently nods yes\n / no to ?\n Action:\n Admin psych meds asdir.\n Response:\n Pt appears comfortable, no anxiety noted, no agitation.\n Plan:\n Monitor and admin meds.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN / Cre rising this admission.\n Action:\n Monitor ans support lyte requirement.\n Response:\n BUN / Cre trending down this AM: 86 / 2.9.\n Plan:\n Monitor, maintain perfusion to kidneys.\n" }, { "category": "Physician ", "chartdate": "2121-09-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599067, "text": "Chief Complaint:\n 24 Hour Events:\n \n - accepted him. waiting for a bed.\n - bleeding from tracheostomy improved\n - started on a PPI for coffee grounds noted during peg placement\n - PEG placed by GI, waiting for GI okay to use\n - s/p 2 units of blood for Hct 21.7. (recent NSTEMI)\n -\n -bleeding from tracheostomy increased overnight, IP injected trach site\n with epinephrine.\n -bleeding stopped on morning rounds, with good clot formation.\n - bed not available today, decided anyway to keep at least one\n more day to monitor HCT, make sure bleeding is stopped.\n -PM labs - Hct up to 28.5, potassium improved to 3.8\n -Trach mask trial in the evening, tolerated well.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:45 PM\n Cefazolin - 01:04 PM\n Infusions:\n Furosemide (Lasix) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.9\nC (98.4\n HR: 69 (56 - 69) bpm\n BP: 128/56(74) {108/44(60) - 130/60(77)} mmHg\n RR: 14 (10 - 16) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,341 mL\n 630 mL\n PO:\n TF:\n 162 mL\n 328 mL\n IVF:\n 478 mL\n 102 mL\n Blood products:\n Total out:\n 3,455 mL\n 980 mL\n Urine:\n 3,455 mL\n 980 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,114 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 502 (440 - 502) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 44\n PIP: 11 cmH2O\n SpO2: 95%\n ABG: ///38/\n Ve: 6.9 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 194 K/uL\n 9.0 g/dL\n 194 mg/dL\n 2.8 mg/dL\n 38 mEq/L\n 3.5 mEq/L\n 82 mg/dL\n 103 mEq/L\n 147 mEq/L\n 27.5 %\n 6.1 K/uL\n [image002.jpg]\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n WBC\n 4.7\n 4.9\n 5.7\n 4.9\n 4.9\n 6.1\n Hct\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n Plt\n 243\n 227\n 237\n 198\n 179\n 194\n Cr\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n TCO2\n 37\n Glucose\n 126\n 141\n 150\n 183\n 94\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:5.3 mg/dL\n Imaging: CXR:\n Mild interval increase in bilateral pleural effusions and atelectasis.\n Continued mild congestive failure.\n Microbiology: most recent cultures from showing Acinetobacter and\n MRSA pneumonia\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: day 14/14 for both meropenem and linezolid\n abx\n stopped.\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. ENT believes this is to low\n secretion in the setting of being chronically NPO. Trach performed.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above.\n - follow lytes.\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. On\n home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes.\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct slightly decreased\n this morning to 24.7. Will re-check hematocrit this afternoon given\n bleeding around trach site yesterday.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, advance tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:40 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "General", "chartdate": "2121-09-30 00:00:00.000", "description": "Generic Note", "row_id": 599403, "text": "TITLE: Nutrition\n Patient continues on full tube feeds, meeting estimated kcal and\n protein needs. Team c/ ?\ns re changing tube feeds to aid in treatment\n of hypernatremia. Can change to slightly less fluid restricted formula\n and continue c/ free water boluses of 250mL q6 hrs which were ordered\n today. New tube feeds will be Nutren Pulmonary @60mL/hr. Plan for\n discharge tomorrow am noted. Will complete page 2 referral. Following\n #.\n" }, { "category": "Nursing", "chartdate": "2121-09-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599048, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently, PERRLA, 3mm, brisk.\n Inconsistently nods head to yes/no questions. Moving extremities on\n bed, occasionally lifts upper extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CPAP 5/5, 50%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions. Lasix gtt\n continued.\n Response:\n O2 sats 93-96% Nods no when asked if having resp difficulty. ~500cc\n neg since MN (goal- neg 2L).\n Plan:\n Monitor resp status. Suction PRN. Place on trach collar today.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx reddened but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Nursing", "chartdate": "2121-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599201, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently (although improved since last\n night), PERRLA, 3mm, brisk. Inconsistently nods head to yes/no\n questions. Moving extremities on bed, occasionally lifts upper\n extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On trach T-piece, FiO2 60%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions. Placed on\n vent overnight to rest.\n Response:\n O2 sats 93-96%. Nods no when asked if having resp difficulty.\n Plan:\n Monitor resp status. Suction PRN. Place on trach T-piece today. OOB\n to chair if tolerated.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx pink but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Physician ", "chartdate": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598499, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continue thick secretions requiring active frequent suctioning and\n close nursing care\n - metolazone (5 mg) added to lasix (15 mg/hr) drip to improve diuresis\n now 400 negative since yesterday, positive for LOS and nearly\n 6 kg positive since admission weight\n - PT/OT consulted\n - transfused 1 unit PRBC\ns with jump from 23 => 25.2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 67 (61 - 98) bpm\n BP: 106/42(58) {95/40(53) - 131/50(69)} mmHg\n RR: 13 (10 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 106.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,942 mL\n 547 mL\n PO:\n TF:\n 1,080 mL\n 298 mL\n IVF:\n 547 mL\n 199 mL\n Blood products:\n 375 mL\n Total out:\n 2,995 mL\n 940 mL\n Urine:\n 2,895 mL\n 940 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -53 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool (15 L face tent\n FiO2 50%)\n SpO2: 95%\n ABG: ///38/\n Physical Examination\n General: NAD, sleeping\n Lungs: coarse BS bilateral\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, 2+ PE\n Labs / Radiology\n 255 K/uL\n 8.2 g/dL\n 282 mg/dL\n 3.0 mg/dL\n 38 mEq/L\n 3.7 mEq/L\n 94 mg/dL\n 98 mEq/L\n 141 mEq/L\n 25.2 %\n 5.0 K/uL\n [image002.jpg]\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n WBC\n 9.4\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n Hct\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n Plt\n \n Cr\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n TCO2\n 38\n Glucose\n 153\n 188\n 178\n 167\n 191\n 210\n 166\n 282\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.8 mg/dL, PO4:3.3 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n improved aeration of bilateral lung fields, continued\n blunting of CP angles c/w bilateral effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient appears more somnolent this AM with poor\n cough.\n - continue meropenum (10 of 14) and linezolid (10 of 14)\n - continue lasix drip with metolazone for goal of - 2L / day\n titrate\n to BP\n - continue face mask with down titration as oxygen requirement permits\n - continue chest-PT\n - patient will likely require re-intubation this PM for airway\n protection\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone diuresis for goal of\n 2L / day\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 150 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 09:42 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596722, "text": "Chief Complaint:\n 24 Hour Events:\n -got 500mg of vanc for trough of 15\n -continued on just levophed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 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 07:50 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: 35.8\nC (96.5\n HR: 67 (62 - 73) bpm\n BP: 120/54(75) {104/47(65) - 150/70(92)} mmHg\n RR: 9 (6 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 117.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (8 - 14)mmHg\n Total In:\n 2,792 mL\n 996 mL\n PO:\n TF:\n 1,005 mL\n 337 mL\n IVF:\n 1,697 mL\n 658 mL\n Blood products:\n Total out:\n 1,890 mL\n 635 mL\n Urine:\n 1,890 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 902 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 582 (582 - 582) mL\n PS : 15 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 11 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.36/40/177/21/-2\n Ve: 11.1 L/min\n PaO2 / FiO2: 354\n Physical Examination\n Cardiovascular: gen: intubated, sedated\n cv: RRR\n resp: CTA anteriorly\n abd: soft, +BS, obese\n ext: sig b/l edema\n Labs / Radiology\n 73 K/uL\n 7.5 g/dL\n 125 mg/dL\n 4.5 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 100 mg/dL\n 106 mEq/L\n 141 mEq/L\n 22.3 %\n 7.0 K/uL\n [image002.jpg]\n 12:08 AM\n 04:00 AM\n 04:09 AM\n 03:43 PM\n 03:54 PM\n 09:19 PM\n 09:39 PM\n 04:00 AM\n 04:12 AM\n 06:12 AM\n WBC\n 5.5\n 7.8\n 7.3\n 7.0\n Hct\n 23.2\n 23.9\n 23.0\n 22.3\n Plt\n 55\n 64\n 76\n 73\n Cr\n 4.1\n 4.2\n 4.5\n TCO2\n 23\n 24\n 24\n 24\n 24\n 24\n Glucose\n 110\n 125\n Other labs: PT / PTT / INR:12.3/56.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro and vancomycin.\n currently growing vre sensitive to amp, gnrs from sputum gram stain x2\n and coag neg staph from blood (likely contaminant) from . Likely\n dc vancomycin today\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 50q6h (=7.5 daily of\n decadron, pt on 2 daily of decadron at home) will switch to 25q6h\n - pt on xygris high apache score, check coags. low threshold to\n dc xygris if any coag abnormalities\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n # : baseline 1.8-2, current Cr is 4.5 up from 4 yesterday. Likely\n this is ATN. UOP has gone from low to high so perhaps renal\n function is in process of improving.\n -will trend\n -no acute indications for HD at this point\n -pt is on lasix at home, could consider giving lasix\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -switched to PPI\n -stool guiac negative\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin\n .# SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, f/u tube feed recs\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:28 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598500, "text": "Chief Complaint:\n 24 Hour Events:\n - patient re-intubated\n - patient scheduled for trach / peg on thursday by , require\n dose of DDVAP prio.\n - renal: recommended continuing lasix and metolazone and adding\n acetazolamide for contraction alkalosis\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:25 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:30 PM\n Midazolam (Versed) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 10:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 67 (57 - 84) bpm\n BP: 97/38(53) {97/37(53) - 144/89(96)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,941 mL\n 783 mL\n PO:\n TF:\n 787 mL\n 314 mL\n IVF:\n 574 mL\n 170 mL\n Blood products:\n Total out:\n 4,990 mL\n 740 mL\n Urine:\n 4,140 mL\n 740 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -3,049 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.49/58/400/41/18\n Ve: 7.4 L/min\n PaO2 / FiO2: 1,000\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 8.1 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 41 mEq/L\n 3.1 mEq/L\n 96 mg/dL\n 99 mEq/L\n 145 mEq/L\n 25.0 %\n 4.7 K/uL\n [image002.jpg]\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n WBC\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n Hct\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n Plt\n 271\n 298\n 316\n 300\n 255\n 243\n Cr\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n TCO2\n 45\n Glucose\n 178\n 167\n 191\n \n 168\n 126\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient appears more somnolent this AM with poor\n cough.\n - continue meropenum (10 of 14) and linezolid (10 of 14)\n - continue lasix drip with metolazone for goal of - 2L / day\n titrate\n to BP\n - continue face mask with down titration as oxygen requirement permits\n - continue chest-PT\n - patient will likely require re-intubation this PM for airway\n protection\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone diuresis for goal of\n 2L / day\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 150 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598501, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - patient re-intubated\n - patient scheduled for trach / peg on thursday by , require\n dose of DDVAP prio.\n - renal: recommended continuing lasix and metolazone and adding\n acetazolamide for contraction alkalosis\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:25 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:30 PM\n Midazolam (Versed) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 10:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 67 (57 - 84) bpm\n BP: 97/38(53) {97/37(53) - 144/89(96)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,941 mL\n 783 mL\n PO:\n TF:\n 787 mL\n 314 mL\n IVF:\n 574 mL\n 170 mL\n Blood products:\n Total out:\n 4,990 mL\n 740 mL\n Urine:\n 4,140 mL\n 740 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -3,049 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.49/58/400/41/18\n Ve: 7.4 L/min\n PaO2 / FiO2: 1,000\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 8.1 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 41 mEq/L\n 3.1 mEq/L\n 96 mg/dL\n 99 mEq/L\n 145 mEq/L\n 25.0 %\n 4.7 K/uL\n [image002.jpg]\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n WBC\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n Hct\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n Plt\n 271\n 298\n 316\n 300\n 255\n 243\n Cr\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n TCO2\n 45\n Glucose\n 178\n 167\n 191\n \n 168\n 126\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n -\n Imaging\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient appears more somnolent this AM with poor\n cough.\n - continue meropenum (10 of 14) and linezolid (10 of 14)\n - continue lasix drip with metolazone for goal of - 2L / day\n titrate\n to BP\n - continue face mask with down titration as oxygen requirement permits\n - continue chest-PT\n - patient will likely require re-intubation this PM for airway\n protection\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone diuresis for goal of\n 2L / day\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 150 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598512, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - patient re-intubated for airway protection\n - scheduled for trach / peg on Thursday by , require dose of\n DDVAP prior.\n - renal: continue lasix and metolazone and add acetazolamide for\n contraction alkalosis\n - urine output picked up s/p intubation with\n3L for day\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:25 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:30 PM\n Midazolam (Versed) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 10:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 67 (57 - 84) bpm\n BP: 97/38(53) {97/37(53) - 144/89(96)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,941 mL\n 783 mL\n PO:\n TF:\n 787 mL\n 314 mL\n IVF:\n 574 mL\n 170 mL\n Blood products:\n Total out:\n 4,990 mL\n 740 mL\n Urine:\n 4,140 mL\n 740 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -3,049 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.49/58/400/41/18\n Ve: 7.4 L/min\n PaO2 / FiO2: 1,000\n Physical Examination\n General: NAD\n Lungs: coarse BS at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, 2+ PE\n Labs / Radiology\n 243 K/uL\n 8.1 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 41 mEq/L\n 3.1 mEq/L\n 96 mg/dL\n 99 mEq/L\n 145 mEq/L\n 25.0 %\n 4.7 K/uL\n [image002.jpg]\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n WBC\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n Hct\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n Plt\n 271\n 298\n 316\n 300\n 255\n 243\n Cr\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n TCO2\n 45\n Glucose\n 178\n 167\n 191\n \n 168\n 126\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n stable pulmonary edema and effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient now re-intubated for airway protection.\n Barriers to extubation include excess secretions and airway protection,\n fluid overload, mental status.\n - mental status: trach / peg for Thursday\n - pneumonia: continue meropenum (11 of 14) and linezolid (11 of 14)\n - pulmonary edema: restart lasix drip with metolazone and add\n acetazolamide for goal of - 2L / day\n titrating to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - restart Lasix gtt with Mitolazone and Acetazolamide for goal of -2L\n / day, titrating as BP tolerates\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Rehab Services", "chartdate": "2121-09-24 00:00:00.000", "description": "Generic Note", "row_id": 598528, "text": "TITLE:\n Rehab Services: OT\n Consult received and appreciated. Pt was intubated this morning and\n discussed plan of care with PT and CM. Per CM, pt likely does not need\n OT eval to qualify for rehab at this time. Please defer OT eval to\n discharge facility and re-consult as appropriate.\n OT/L \n" }, { "category": "Physician ", "chartdate": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598590, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - patient re-intubated for airway protection\n - scheduled for trach / peg on Thursday by , require dose of\n DDVAP prior.\n - renal: continue lasix and metolazone and add acetazolamide for\n contraction alkalosis\n - urine output picked up s/p intubation with\n3L for day\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:25 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:30 PM\n Midazolam (Versed) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 10:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 67 (57 - 84) bpm\n BP: 97/38(53) {97/37(53) - 144/89(96)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,941 mL\n 783 mL\n PO:\n TF:\n 787 mL\n 314 mL\n IVF:\n 574 mL\n 170 mL\n Blood products:\n Total out:\n 4,990 mL\n 740 mL\n Urine:\n 4,140 mL\n 740 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -3,049 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.49/58/400/41/18\n Ve: 7.4 L/min\n PaO2 / FiO2: 1,000\n Physical Examination\n General: NAD\n Lungs: coarse BS at bilateral bases\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, 2+ PE\n Labs / Radiology\n 243 K/uL\n 8.1 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 41 mEq/L\n 3.1 mEq/L\n 96 mg/dL\n 99 mEq/L\n 145 mEq/L\n 25.0 %\n 4.7 K/uL\n [image002.jpg]\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n WBC\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n Hct\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n Plt\n 271\n 298\n 316\n 300\n 255\n 243\n Cr\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n TCO2\n 45\n Glucose\n 178\n 167\n 191\n \n 168\n 126\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n stable pulmonary edema and effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient now re-intubated for airway protection.\n Barriers to extubation include excess secretions and airway protection,\n fluid overload, mental status.\n - mental status: trach / peg for Thursday\n - pneumonia: continue meropenum (11 of 14) and linezolid (11 of 14)\n - pulmonary edema: restart lasix drip with metolazone and add\n acetazolamide for goal of - 2L / day\n titrating to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - restart Lasix gtt with Mitolazone and Acetazolamide for goal of -2L\n / day, titrating as BP tolerates\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599200, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently (although improved since last\n night), PERRLA, 3mm, brisk. Inconsistently nods head to yes/no\n questions. Moving extremities on bed, occasionally lifts upper\n extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On trach T-piece, FiO2 60%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions. Placed on\n vent overnight to rest.\n Response:\n O2 sats 93-96%. Nods no when asked if having resp difficulty.\n Plan:\n Monitor resp status. Suction PRN. Place on trach T-piece today. OOB\n to chair if tolerated.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx pink but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-30 00:00:00.000", "description": "Generic Note", "row_id": 599307, "text": "TITLE: Resp Care Note, Pt seen for trach check x2. H20 filled on\n t-piece 60%. Suctioned for mod amts thick bld tinged secretions.All\n equipment present. Will cont to follow.\n" }, { "category": "Physician ", "chartdate": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598505, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - patient re-intubated\n - patient scheduled for trach / peg on thursday by , require\n dose of DDVAP prio.\n - renal: recommended continuing lasix and metolazone and adding\n acetazolamide for contraction alkalosis\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:25 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:30 PM\n Midazolam (Versed) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 10:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 67 (57 - 84) bpm\n BP: 97/38(53) {97/37(53) - 144/89(96)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,941 mL\n 783 mL\n PO:\n TF:\n 787 mL\n 314 mL\n IVF:\n 574 mL\n 170 mL\n Blood products:\n Total out:\n 4,990 mL\n 740 mL\n Urine:\n 4,140 mL\n 740 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -3,049 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.49/58/400/41/18\n Ve: 7.4 L/min\n PaO2 / FiO2: 1,000\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 8.1 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 41 mEq/L\n 3.1 mEq/L\n 96 mg/dL\n 99 mEq/L\n 145 mEq/L\n 25.0 %\n 4.7 K/uL\n [image002.jpg]\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n WBC\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n Hct\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n Plt\n 271\n 298\n 316\n 300\n 255\n 243\n Cr\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n TCO2\n 45\n Glucose\n 178\n 167\n 191\n \n 168\n 126\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n stable pulmonary edema and effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient now re-intubated for airway protection.\n - mental status: trach / peg scheduled for Thursday\n - pneumonia: continue meropenum (11 of 14) and linezolid (11 of 14)\n - pulmonary edema: continue lasix drip with metolazone and\n acetazolamide for goal of - 2L / day\n titrate to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone and Acetazolamide diuresis for goal\n of\n 2L / day, titrating as BP tolerates\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 200 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "2121-09-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598506, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - patient re-intubated\n - patient scheduled for trach / peg on thursday by , require\n dose of DDVAP prio.\n - renal: continue lasix and metolazone and adding acetazolamide for\n contraction alkalosis\n - urine output picked up s/p intubation with\n3L for day\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:25 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:30 PM\n Midazolam (Versed) - 05:00 PM\n Heparin Sodium (Prophylaxis) - 10:09 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.9\nC (98.5\n HR: 67 (57 - 84) bpm\n BP: 97/38(53) {97/37(53) - 144/89(96)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,941 mL\n 783 mL\n PO:\n TF:\n 787 mL\n 314 mL\n IVF:\n 574 mL\n 170 mL\n Blood products:\n Total out:\n 4,990 mL\n 740 mL\n Urine:\n 4,140 mL\n 740 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n -3,049 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n SpO2: 98%\n ABG: 7.49/58/400/41/18\n Ve: 7.4 L/min\n PaO2 / FiO2: 1,000\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 8.1 g/dL\n 126 mg/dL\n 2.9 mg/dL\n 41 mEq/L\n 3.1 mEq/L\n 96 mg/dL\n 99 mEq/L\n 145 mEq/L\n 25.0 %\n 4.7 K/uL\n [image002.jpg]\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n WBC\n 8.7\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n Hct\n 25.4\n 28.0\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n Plt\n 271\n 298\n 316\n 300\n 255\n 243\n Cr\n 3.2\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n TCO2\n 45\n Glucose\n 178\n 167\n 191\n \n 168\n 126\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n stable pulmonary edema and effusions\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now extubated but continued thick secretions\n and elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Patient now re-intubated for airway protection.\n - mental status: trach / peg scheduled for Thursday\n - pneumonia: continue meropenum (11 of 14) and linezolid (11 of 14)\n - pulmonary edema: continue lasix drip with metolazone and\n acetazolamide for goal of - 2L / day\n titrate to BP\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 3.0. Cr remains\n constant despite aggressive diuresis.\n - continue Lasix gtt and Mitolazone and Acetazolamide diuresis for goal\n of\n 2L / day, titrating as BP tolerates\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes, transition to 200 QID\n # Anemia: patient received 1 unit PRBC\ns with slightly lower than\n expected HCT bump. Patient has poor reticulocyte output suggestive\n marrow suppression or low epo as source. Stool remains guiac negative.\n - continue to trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds at goal\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as require significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Respiratory ", "chartdate": "2121-09-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598638, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5cm\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: Tan / Plug\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: RSBI 18\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: pt going to have a tracheostomy and peg today, will continue\n to follow WOB and wean pt as tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Pending procedure / OR, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 2200\n" }, { "category": "Physician ", "chartdate": "2121-09-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 598943, "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 S/P trach and PEG\n Needed injection at trach site due to oozing\n Now down to PSV 5/5\n 24 Hour Events:\n PEG INSERTION - At 09:10 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:45 PM\n Cefazolin - 01:04 PM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:52 PM\n Fentanyl - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:47 PM\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: No(t) Fever\n Cardiovascular: No(t) Tachycardia\n Nutritional Support: No(t) NPO\n Respiratory: mechanical ventilation\n Gastrointestinal: PEG\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:15 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 61 (52 - 79) bpm\n BP: 114/51(66) {101/41(55) - 132/65(82)} mmHg\n RR: 12 (10 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,572 mL\n 730 mL\n PO:\n TF:\n IVF:\n 872 mL\n 310 mL\n Blood products:\n 700 mL\n Total out:\n 3,540 mL\n 1,800 mL\n Urine:\n 3,540 mL\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,968 mL\n -1,070 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): 480 (472 - 560) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 39\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.46/51/94./35/10\n Ve: 7.2 L/min\n PaO2 / FiO2: 188\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: 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 8.2 g/dL\n 179 K/uL\n 192 mg/dL\n 2.8 mg/dL\n 35 mEq/L\n 2.8 mEq/L\n 85 mg/dL\n 95 mEq/L\n 147 mEq/L\n 24.7 %\n 4.9 K/uL\n [image002.jpg]\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n WBC\n 4.7\n 4.9\n 5.7\n 4.9\n 4.9\n Hct\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n Plt\n 243\n 227\n 237\n 198\n 179\n Cr\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n 37\n Glucose\n 168\n 126\n 141\n 150\n 183\n 231\n 192\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:7.9 mg/dL, Mg++:2.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. He has had continued\n need for ventilatory support with slow wean from ventilator attempted\n but with trach/PEG required for ongoing care.\n 1)Respiratory Failure- last day of /linezolid today\n Should be able to start trach mask trials\n Trach appears to have no further bleeding at moment --> continue to\n monitor, recheck Hct today\n 2)Renal Failure-\n Continues to diurese as tolerated with Lasix gtt--> goal 2L negative\n If pt remains stable from trach bleeding standpoint, hopefully to\n later this weekend\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\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": "2121-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599306, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands more consistently. Occasionally mouthing\n words. PERRLA, 3mm, brisk. Moving extremities on bed, occasionally\n lifts upper extremities.\n Action:\n Mental status monitored.\n Response:\n No change in mental status.\n Plan:\n Continue to monitor mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On trach T-piece, FiO2 60%. RR 10-15. LS rhonchi throughout. O2 sats\n 94-96%.\n Action:\n Suctioned q2-3 hrs for moderate-copious amt of thick/blood-tinged\n secretions. Continues to have blood tinged oral secretions.\n Response:\n O2 sats 93-96%. Nods no when asked if having resp difficulty.\n Plan:\n Monitor resp status. Suction PRN.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx pink but\n blanchable. Continues to have a pink/red, swollen area on L side of\n neck, appears improved.\n Action:\n Continued wound care as documented. Pt repositioned frequently.\n Response:\n No change in skin integrity.\n Plan:\n Continue wound care. Frequent position changes.\n" }, { "category": "Case Management ", "chartdate": "2121-09-30 00:00:00.000", "description": "Discharge Plan Note", "row_id": 599397, "text": "Case Management Discharge Plan\n The patient is a 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism admitted with pneumosepsis vs, urosepsis c/b by NSTEMI\n and now VAP with acinetobacter and MRSA, now extubated and trached but\n continued thick secretions and elevated oxygen requirements. He is\n ready for LTACH transfer according to the MICU team.\n This nurse case manager has spoken with the patient\ns daughter \n who has agreed to a transfer to in which has\n a contract with his insurance plan. The bed will not be available\n until tomorrow, and transfer is planned for 10 AM. This NCM notified\n the patient\ns nurse and the MICU resident of the plan, and will stop by\n the ICU in the morning to assist in facilitating the discharge.\n The transfer facility is:\n \n , \n \n Phone: (\n Please page this NCM for any changes in the discharge plan or for any\n additional case management assistance.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Pager: \n" }, { "category": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598583, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt is alert and follows commands consistently, PERL brisk. Pt will\n shake his head\n when asked if he is in pain but does not respond to\n any other questions.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received intubated on AC/500x16/+5/40%. Pt not overbreathing\n ventilator.\n Action:\n No vent changes made today resp status addressed above. Suctioned\n q2-3 hour for moderate to copious amounts of thick tan secretions.\n Response:\n RR 16 with sats 95-99%.\n Plan:\n Continue to monitor resp status, suction PRN, trach on Thursday or\n Friday.\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. They appear to be\n healing skin tears from tape. Also with reddened but blanchable area on\n his coccyx.\n Action:\n Skin kept clean and dry, healing skin tear on right wrist left OTA and\n healing skin tear on right forearm was covered with adaptic and DSD to\n prevent excoriation from BP cuff. Barrier cream applied liberally to\n coccyx. Pt repositioned frequently. Pt also met with PT today.\n Response:\n No further breakdown in skin.\n Plan:\n Continue with provide skin care, change dressings, and reposition\n frequently.\n" }, { "category": "Physician ", "chartdate": "2121-09-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599387, "text": "Chief Complaint:\n 24 Hour Events:\n -slight bleeding from around trach site\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 73 (68 - 84) bpm\n BP: 141/67(85) {106/55(68) - 141/67(85)} mmHg\n RR: 14 (12 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,342 mL\n 324 mL\n PO:\n TF:\n 1,082 mL\n 292 mL\n IVF:\n 185 mL\n 32 mL\n Blood products:\n Total out:\n 2,075 mL\n 700 mL\n Urine:\n 2,075 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -733 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: T-piece\n Ventilator mode: Standby\n RR (Spontaneous): 16\n FiO2: 60%\n SpO2: 95%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 223 K/uL\n 9.2 g/dL\n 193 mg/dL\n 2.3 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 75 mg/dL\n 110 mEq/L\n 150 mEq/L\n 28.3 %\n 8.3 K/uL\n [image002.jpg]\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n 04:40 PM\n 03:50 AM\n WBC\n 4.9\n 4.9\n 6.1\n 7.1\n 8.3\n Hct\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n 28.3\n Plt\n 198\n 179\n 194\n 198\n 223\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n 2.5\n 2.3\n TCO2\n 37\n Glucose\n 94\n 220\n 221\n 193\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: UOP -1L almost daily, improving pulmonary edema\n .\n # Neck Mass: concern for infection vs inflammation given tenderness of\n adenopathy, overlying erythema and warmth. ENT believes this is to\n low secretion in the setting of being chronically NPO. Trach\n performed. Now improving.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable, given some bleeding for last\n several days IP will be by to look at it\n -applying silver nitrate to area\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n #Metabolic alkalosis - HCO3- has ranged from 35 to 40 over last week or\n so. ABG from is pH of 7.46 - 7.5. pCO2 is 51, which suggests\n there is respiratory compensation with an additional respiratory\n acidosis on top. (0.7)(Bicarb) + 20 = pCO expected = 44. Most likely\n causes of metabolic alkalosis in him is likely a combination of\n contraction alkalosis with some post-hypercapnic alkalosis. Possibly\n also related to hyperaldosteronism because has refractory hypernatremia\n and has been hypokalemic in past. Without resolution could make\n extubation more difficult because is promoting compensatory respiratory\n hypoventilation.\n -Consider administration of acetozolamide\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.3. Resolving.\n -Trend creatinines\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. Can\n restart . On home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of renal failure and hypertonic\n tube feeds\n -Talk to nutrition about formula\n -Can increase free water flushes to 250 q6\n - lytes\n -Consider underlying hyperaldosteronism\n # Anemia: HCTs stable, likely secondary to underlying renal disease.\n - trend HCTs daily\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, continue tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:19 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Nursing", "chartdate": "2121-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599464, "text": "The patient is a 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism admitted with pneumosepsis vs, urosepsis c/b by NSTEMI\n and now VAP with acinetobacter and MRSA, now extubated and trached but\n continued thick secretions and elevated oxygen requirements. He is\n being transferred to @ 10am\n Electrolyte & fluid disorder, other\n Assessment:\n Repeat Na at beginning of shift 155, up from 150\n Action:\n Increase FW to 250 ml q 2 h. 1L D5w given\n Response:\n Repeat NA 147\n Plan:\n Trend and cont FW boluses q2\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont on 60% fi02 w/ t-piece. Copious thick tan and blood-tinged\n secretions. Sp02 95%, O2 Sats 94-97%\n Action:\n ETT suction PRN, TCDB, pulm toilet. Cont supplemental 02\n Response:\n Resp status stable.\n Plan:\n Wean 02 support as tol.\n .H/O psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt essentially oriented and alert, nods yes / no appropriately.\n Follows comands, MAEs. Calm, cooperative.\n Action:\n Admin psych meds as directed perphenazine.\n Response:\n Stable.\n Plan:\n Re-admin clozaril as directed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 60-150 ml/hr.\n Action:\n No changes in treatment\n Response:\n BUN / Cre trending down, UOP stable.\n Plan:\n follow UOP and labs.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 598782, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: 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: 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 / 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: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Hemodynimic\n instability; Comments: Pt is stable on full CMV settings. Pt showed\n vital signs, RR, SpO2 and Expiratory tidal volumes within normal\n range. Pt had clear lung sounds by end of shift. Pt has bloody\n secretions all shift. No spontaneous respiration during RSBI trial.\n Pt to continue current support\n" }, { "category": "Respiratory ", "chartdate": "2121-09-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 599124, "text": "Respiratory Care Service: Pt appears comfortable on a 60 % Trach\n Collar/ T-Piece since 0800 this morning. RR 12-16 BPM and SPO2 94-98 %.\n Sx very thick/ copious amts of blood-tinged sputum. Will c/w the 60 %\n T-Piece as tolerated and rest on PSV 5/5 PEEP FIO2 .50 as necessary.\n" }, { "category": "Nursing", "chartdate": "2121-09-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599125, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert, awake and follows commands. Pt has a flat affect and his psych\n meds are on hold for now per psych consult done a few days ago.\n Action:\n Neuro checks done q 4 hrs and prn.\n Response:\n Pt reports he feels better.\n Plan:\n Continue evaluation of MS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA with diminished bases after deep sx.\n Action:\n Pt OOB to chair this am at 8am and was placed on T-piece. Pt back in\n bed as of 3 :30 pm and remains on T-piece and it is tolerated well by\n pt. Pt has been deep sx\nd q2 hrs and prn for mod amounts of thick blood\n tinged tan secretions. No bleeding noted from trach site. HOB > 30\n VAP protocol.\n Response:\n O2sat 04-96%.\n Plan:\n Plan for resp rehab. Continue current treatment for now.\n" }, { "category": "Respiratory ", "chartdate": "2121-10-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 599459, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\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: 24 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 Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\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: Rehab later today\n Pt remains on t-piece with high flow 60%, copious secretions present\n (tan/blood tinged). Pt to go to rehab later today.\n" }, { "category": "Nursing", "chartdate": "2121-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599462, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Repeat Na at beginning of shift 155, up from 150\n Action:\n Increase FW to 250 ml q 2 h. 1L D5w given\n Response:\n Repeat NA 147\n Plan:\n Trend and cont FW boluses q2\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont on 60% fi02 w/ t-piece. Copious thick tan and blood-tinged\n secretions. Sp02 95%, O2 Sats 94-97%\n Action:\n ETT suction PRN, TCDB, pulm toilet. Cont supplemental 02\n Response:\n Resp status stable.\n Plan:\n Wean 02 support as tol.\n .H/O psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt essentially oriented and alert, nods yes / no appropriately.\n Follows comands, MAEs. Calm, cooperative.\n Action:\n Admin psych meds as directed perphenazine.\n Response:\n Stable.\n Plan:\n Re-admin clozaril as directed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 60-150 ml/hr.\n Action:\n No changes in treatment\n Response:\n BUN / Cre trending down, UOP stable.\n Plan:\n Admin lasix if necessary, follow UOP and labs.\n" }, { "category": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598493, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n High creatinine\n Action:\n On diamox, K repleted\n Response:\n u/o>100/h, creat down to 2.9\n Plan:\n Monitor lites, u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on AC 5 peep\n Action:\n Was tried to be on CPAP , suction PRN, VAP protocol, frequent turns\n Response:\n Failed CPAP, back to A/C,. thick tan/yellow sputum, maintains sat>94\n Plan:\n Plan to trach , wean to CPAP when awake enough\n Impaired Skin Integrity\n Assessment:\n Multiple skin breakdown areas\n Action:\n Aquacel dressings on right arm changed/intact\n Sacral area dark purple with minimal breakdown\n Frequent turns\n Response:\n No new skin breakdown areas\n Plan:\n Per nursing care plan\n" }, { "category": "Physician ", "chartdate": "2121-09-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 598843, "text": "Chief Complaint: Sepsis\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 10:30 AM\n -Trach and PEG in place\n -Significant oozing around trach site\n -2 units PRBC prior to PEG placement\n History obtained from Medical records\n Patient unable to provide history: Sedated, interactive--not giving\n full history\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 02:00 PM\n Infusions:\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Fentanyl - 04:00 PM\n Midazolam (Versed) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:11 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (98.9\n HR: 69 (50 - 69) bpm\n BP: 114/55(69) {85/40(50) - 123/58(74)} mmHg\n RR: 19 (16 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,882 mL\n 830 mL\n PO:\n TF:\n 315 mL\n IVF:\n 1,167 mL\n 495 mL\n Blood products:\n 335 mL\n Total out:\n 3,455 mL\n 1,380 mL\n Urine:\n 3,455 mL\n 1,380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 14 cmH2O\n SpO2: 96%\n ABG: ///37/\n Ve: 10 L/min\n Physical Examination\n Head, Ears, Nose, Throat: left parotid area without change\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 6.9 g/dL\n 198 K/uL\n 231 mg/dL\n 2.9 mg/dL\n 37 mEq/L\n 3.2 mEq/L\n 86 mg/dL\n 100 mEq/L\n 145 mEq/L\n 21.8 %\n 4.9 K/uL\n [image002.jpg]\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n WBC\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n 4.9\n Hct\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n Plt\n 300\n 255\n 243\n 227\n 237\n 198\n Cr\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n TCO2\n 45\n Glucose\n 68\n 126\n 141\n 150\n 183\n 231\n Other labs: PT / PTT / INR:12.2/43.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:4.6 mg/dL\n Imaging: CXR-\n Assessment and Plan\n 74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. He has had continued\n need for ventilatory support with slow wean from ventilator attempted\n but with trach/PEG required for ongoing care.\n 1)Respiratory Failure-\n -Vanco/Meropenem/Linezolid\n -Will move to PSV as tolerated today\n -Will discuss with IP strategy for control of post procedure bleeding\n -Will maintain minimization of sedation at this time\n 2)Renal Failure-\n -Patient with creatinine without change\n -Will continue with lasix gtt for aid in diuresis\n -Follow creatinine\n 3)Sepsis-\n -Continue with ABX\n -No need for pressors\n ICU Care\n Nutrition: G-tube in place\nwill start feeds with clearance from GI\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\nwill need to assure bleeding from trach stabilized\n prior to transfer to any facility\n Total time spent: 38 minutes\n" }, { "category": "General", "chartdate": "2121-10-01 00:00:00.000", "description": "Resident Progress Note", "row_id": 599534, "text": "TITLE:\n ------ Protected Section------\n Note in error\n ------ Protected Section Error Entered By: , MD on:\n 13:21 ------\n" }, { "category": "Physician ", "chartdate": "2121-10-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599535, "text": "Chief Complaint:\n 24 Hour Events:\n - has bed at rehab, to be d/c'd tomorrow\n - hypernatremia 150 -> 155, increased free water boluses and 1L D5W,\n rpt sodium improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 01:26 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 68 (61 - 78) bpm\n BP: 123/51(68) {89/44(58) - 149/72(89)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,979 mL\n 1,266 mL\n PO:\n TF:\n 1,081 mL\n 516 mL\n IVF:\n 1,088 mL\n Blood products:\n Total out:\n 2,250 mL\n 940 mL\n Urine:\n 2,250 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 729 mL\n 326 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ///34/\n Physical Examination\n Cardiovascular: Gen: NAD\n Trach site c/d/i\n CV: RRR, nl S1 and S2\n Resp: rhonchi, + secretions in trach tube\n Abd: soft, NDNT ABS\n Ext: trace edema bilat\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\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 8.3 g/dL\n 179 mg/dL\n 2.2 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 64 mg/dL\n 108 mEq/L\n 147 mEq/L\n 26.3 %\n 8.2 K/uL\n [image002.jpg]\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n 04:40 PM\n 03:50 AM\n 09:55 AM\n 02:36 AM\n WBC\n 4.9\n 6.1\n 7.1\n 8.3\n 8.3\n 8.2\n Hct\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n 28.3\n 28.3\n 26.3\n Plt\n 179\n 194\n 198\n 223\n 223\n 225\n Cr\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n 2.5\n 2.3\n 2.2\n Glucose\n 192\n 117\n 194\n 220\n 221\n 193\n 179\n Other labs: PT / PTT / INR:12.1/32.7/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:2.6 mg/dL, PO4:2.5 mg/dL\n Imaging: no imaging\n Microbiology: no new micro\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ELECTROLYTE & FLUID DISORDER, OTHER\n PULMONARY EDEMA\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: autodiuresis\n # Neck Mass: concern for infection vs inflammation given tenderness of\n adenopathy, overlying erythema and warmth. ENT believes this is to\n low secretion in the setting of being chronically NPO. Trach\n performed. Now improving.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - bleeding stopped\n #PEG placement\n PEG placed, site appears clean and dry.\n - tolerating TF\n #Metabolic alkalosis - Improving, waiting for full kidney functioning.\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now at 2.2\n - Trend creatinines\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. Can\n restart at dose of 200mg and restart slowly. On home dose of\n perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of renal failure and hypertonic\n tube feeds\n - increase free water flushes to 250 q6\n # Anemia: HCTs stable, likely secondary to underlying renal disease.\n - trend HCTs daily\n - outpt GI scope and colonoscopy\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, continue tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \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: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598921, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism admitted with pneumosepsis vs, urosepsis c/b by NSTEMI\n and now VAP with acinetobacter and MRSA, now re-intubated for airway\n protection do to continued respiratory secretions and tiring cough.\n Trach placed. Currently accepted at , waiting for bed.\n 24 Hour Events:\n PEG INSERTION - At 09:10 AM\n - accepted him. waiting for a bed.\n - bleeding from tracheostomy improved\n - started on a PPI for coffee grounds noted during peg placement\n - PEG placed by GI, waiting for GI okay to use\n - s/p 2 units of blood for Hct 21.7. (recent NSTEMI)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:45 PM\n Cefazolin - 01:04 PM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:52 PM\n Fentanyl - 06:52 PM\n Heparin Sodium (Prophylaxis) - 08:47 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 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.2\n HR: 55 (53 - 79) bpm\n BP: 128/47(67) {101/41(55) - 132/65(82)} mmHg\n RR: 11 (11 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 101.8 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,572 mL\n 348 mL\n PO:\n TF:\n IVF:\n 872 mL\n 168 mL\n Blood products:\n 700 mL\n Total out:\n 3,540 mL\n 1,140 mL\n Urine:\n 3,540 mL\n 1,140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,968 mL\n -792 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): 527 (472 - 560) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 39\n PIP: 15 cmH2O\n Plateau: 14 cmH2O\n SpO2: 95%\n ABG: 7.46/51/94./35/10\n Ve: 6.7 L/min\n PaO2 / FiO2: 188\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 179 K/uL\n 8.2 g/dL\n 192 mg/dL\n 2.8 mg/dL\n 35 mEq/L\n 2.8 mEq/L\n 85 mg/dL\n 95 mEq/L\n 147 mEq/L\n 24.7 %\n 4.9 K/uL\n [image002.jpg]\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n 05:41 PM\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n WBC\n 4.7\n 4.9\n 5.7\n 4.9\n 4.9\n Hct\n 26.5\n 25.0\n 24.4\n 24.7\n 23.0\n 21.8\n 27.7\n 24.7\n Plt\n 243\n 227\n 237\n 198\n 179\n Cr\n 3.1\n 2.9\n 2.8\n 2.8\n 2.7\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n 37\n Glucose\n 168\n 126\n 141\n 150\n 183\n 231\n 192\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:7.9 mg/dL, Mg++:2.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy yesterday. Barriers to extubation\n include excess secretions and airway protection, fluid overload, mental\n status.\n - mental status: trach\n - pneumonia: continue meropenum (13 of 14) and linezolid (13 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. Mass appears to be caudal and lateral\n to airway and do not anticipate any problems with trach ENT believes\n this is to low secretion in the setting of being chronically NPO.\n - warm compresses and massage q4h\n - juice to stimulate secretion\n # Trach site\n site is still bleeding actively. D/w IP regarding this:\n recommended silver nitrate or lidocaine with epi.\n #PEG placement\n PEG tube to be placed today. Pt NPO for procedure\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative. Hct 21.7 this AM\n - trend HCT and transfuse PRN to goal > 23\n - transfuse 2 units today\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for PEG placement\n by GI today\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2121-09-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599280, "text": "Hypernatremia (high sodium)\n Assessment:\n Na this AM 149 (150).\n Action:\n Free water bolus 200 ml q 6 h.\n Response:\n Na this PM still 149.\n Plan:\n Cont FW bolus via PEG tube / TFs.\n Altered mental status (not Delirium)\n Assessment:\n Pt will nod appropriately yes or no to questions. MAEs, PERRLA.\n Action:\n Pt OOB today for 4.5 hrs. Monitor MS and encourage interaction.\n Response:\n Stable.\n Plan:\n Monitor, cont anti-psych meds, ready for rehab.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on T-piece 60%, sp02 92-93%. RR 15. Trach site oozing w/\n fresh blood. Pt desat to 86% on RA.\n Action:\n Suction PRN, change surgicel dressing at site.\n Response:\n Resp status stable, trach site still oozing.\n Plan:\n Maintain resp support, consult IP if oozing persists.\n" }, { "category": "Nursing", "chartdate": "2121-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598633, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently, PERRLA, 3mm, brisk.\n Inconsistently nods head to yes/no questions. Moving extremities on\n bed.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings AC/500x16/+5/40%. Not overbreathing vent. LS clear with\n diminished bases. O2 sats 94-98%.\n Action:\n O2 sats decreased to 90-91%. FiO2 increased to 50%. Suctioned q2-3\n hrs for moderate-copious amt of thick/tan secretions. Diuril given and\n Lasix gtt started.\n Response:\n O2 sats 95-98%. Nods no when asked if having resp difficulty. UOP\n >100cc/hr.\n Plan:\n Monitor resp status. Suction PRN. Plan for trach/PEG today (TF off at\n MN).\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx reddened but\n blanchable. Patient found to have a pink/red, swollen area on L side of\n neck. Grimaces with palpation of neck. Continues to have blood tinged\n oral secretions.\n Action:\n CT neck done. Continued wound care as documented. Pt repositioned\n frequently.\n Response:\n CT showed significant swelling of lymph node. Neck appears to be\n slightly redder.\n Plan:\n Continue wound care. Frequent position changes. ENT to be consulted\n today.\n" }, { "category": "Physician ", "chartdate": "2121-09-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 599342, "text": "Chief Complaint:\n 24 Hour Events:\n -slight bleeding from around trach site\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 73 (68 - 84) bpm\n BP: 141/67(85) {106/55(68) - 141/67(85)} mmHg\n RR: 14 (12 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,342 mL\n 324 mL\n PO:\n TF:\n 1,082 mL\n 292 mL\n IVF:\n 185 mL\n 32 mL\n Blood products:\n Total out:\n 2,075 mL\n 700 mL\n Urine:\n 2,075 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -733 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: T-piece\n Ventilator mode: Standby\n RR (Spontaneous): 16\n FiO2: 60%\n SpO2: 95%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 223 K/uL\n 9.2 g/dL\n 193 mg/dL\n 2.3 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 75 mg/dL\n 110 mEq/L\n 150 mEq/L\n 28.3 %\n 8.3 K/uL\n [image002.jpg]\n 02:25 AM\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n 04:40 PM\n 03:50 AM\n WBC\n 4.9\n 4.9\n 6.1\n 7.1\n 8.3\n Hct\n 21.8\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n 28.3\n Plt\n 198\n 179\n 194\n 198\n 223\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n 2.5\n 2.3\n TCO2\n 37\n Glucose\n 94\n 220\n 221\n 193\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 74 yo M w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough. Trach placed.\n Currently accepted at , waiting for bed.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. s/p Tracheostomy. Barriers to extubation include\n excess secretions and airway protection, fluid overload, mental\n status.\n - pneumonia: completed 14d course both meropenem and linezolid\n abx\n stopped .\n - pulmonary edema: UOP -1L almost daily, improving pulmonary edema\n .\n # Neck Mass: concern for infection vs inflammation given tenderness of\n adenopathy, overlying erythema and warmth. ENT believes this is to\n low secretion in the setting of being chronically NPO. Trach\n performed. Now improving.\n - warm compresses and massage q4h\n # Trach site\n IP injected lidocaine with epi.\n - monitor bleeding, HCTs have been stable, given some bleeding for last\n several days IP will be by to look at it\n -applying silver nitrate to area\n #PEG placement\n PEG placed, site appears clean and dry.\n - Started TF\n #Metabolic alkalosis - HCO3- has ranged from 35 to 40 over last week or\n so. ABG from is pH of 7.46 - 7.5. pCO2 is 51, which suggests\n there is respiratory compensation with an additional respiratory\n acidosis on top. (0.7)(Bicarb) + 20 = pCO expected = 44. Most likely\n causes of metabolic alkalosis in him is likely a combination of\n contraction alkalosis with some post-hypercapnic alkalosis. Possibly\n also related to hyperaldosteronism because has refractory hypernatremia\n and has been hypokalemic in past. Without resolution could make\n extubation more difficult because is promoting compensatory respiratory\n hypoventilation.\n -Consider administration of acetozolamide\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.3. Resolving.\n -Trend creatinines\n # Schizophrenia: will hold clozaril until 2 weeks after completing\n linezolid course (2 weeks from today), for risk of pancyotopenia. Can\n restart . On home dose of perphenzine.\n - prn perphenazine for agitation\n # Hypernatremia: likely combination of renal failure and hypertonic\n tube feeds\n -Talk to nutrition about formula\n -Can increase free water flushes to 250 q6\n - lytes\n -Consider underlying hyperaldosteronism\n # Anemia: HCTs stable, likely secondary to underlying renal disease.\n - trend HCTs daily\n # Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, continue tube feeds\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: bed pending at \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:19 AM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Rehab Services", "chartdate": "2121-09-30 00:00:00.000", "description": "Occupational Therapy Evaluation Note", "row_id": 599362, "text": "History\n Attending M.D.: hg\n Referral Date: \n Reason for Referral: Eval and treat\n Medical Dx / ICD - 9: 038.9\n Activity Orders: oob c A\n HPI / Subjective Complaint: 74 yo M admitted with septic shock,\n NSTEMI, hypothermia requiring intubation, prolonged hospital course\n requiring tracheostomy on , peg on .\n Past Medical / Surgical History: paranoid schizophrenia, h/o\n nephrectomy, htn, DM 2, COPD, h/o pna\n Medications: Heparin, ASA, amlodipine\n Labs\n Hematocrit (serum): 28.3 ...\n Hematocrit (whole blood - calculated): 31 ...\n Hemoglobin: 9.2 ... g/dl\n WBC: 8.3 ...\n Platelet Count: 223 ...\n Occupational History\n Occupational Profile: attends day program 2/week\n Performance Patterns: lives with daughter and son per chart\n Baseline Occupational Performance: HHA 1 x a week for bathing, minimla\n ambulation, uses w/c\n Environmental History: unknown\n Current Activities of Daily Living\n Self Feeding: (Dependent)\n Grooming: (min A)\n UE Bathing: (mod A)\n LE Bathing: (mod A)\n UE Dressing: (mod A)\n LE Dressing: (max A)\n Toileting: (Dependent)\n Specify: min A to wipe face\n Performance Skills\n Process Skills: pt alert, aware in the hospital, nods yes to \n and woman's, able to follow step simple commands, able to state\n month and appropriately choose year when given options\n Communication / Interactive Skills: Mouthing words, able to answer\n yes/no, able to make eye contact\n Motor Skills - Functional Transfers\n Rolling: (max A)\n Supine / Side-lying to Sit: (mod A) x2\n Functional Transfers Clarification: mod x2 supine-sit\n Functional Balance: able to sit EOB cg with ue support\n Aerobic Capacity: Rest\n Rest HR: 80\n Rest BP: 140/65\n Rest O2 sat: 93 %\n Supplemental O2: humidified air via t-tube\n Aerobic Capacity: Activity\n Activity HR: 84\n Activity BP: 142/73\n Activity O2 sat: 88 %\n Aerobic Capacity: Recovery\n Recovery HR: 68\n Recovery O2 sat: 95 %\n Range of Motion\n Range of Motion: B UE WFL\n Muscle Performance: strength, power, endurance\n Muscle Performance: B shoulder flexion 3-/5, otherwise \n Additional Performance Skills\n Motor Control: no abnormal movements noted\n Coordination: NT\n Pain (0 - 10): 0 / 10\n Sensation: B UE intact to light touch\n Integumentary: trach, foley, picc, flexiseal\n Team Communication: with RN, PT co treat\n Patient Education: role of OT\n Diagnosis\n Diagnosis 1: decreased adls\n Diagnosis 2: decreased balance\n Diagnosis 3: decreased bed mobility\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: 74 year old male with septic shock who\n present as above. Pt is significantly deconditioned from medical\n complications and hospital course and is currently unsafe to return\n home. Recommend a d/c to rehab for intense, pt/ot daily to maximize\n capabilities and return home with family.\n Goals: patient / family, objective, measurable\n Goal 1: I wash face\n Goal 2: sit EOB Ily for 5 minutes for adls\n Goal 3: min A rolling for hygiene\n Time Frame (expected attainment): By one week\n Anticipated Discharge: Rehab\n Treatment Plan: Interventions; patient / family education, community\n resources\n Treatment Plan: f/u for adls, functional mobility, balance\n Frequency / Duration: x week\n Therapist Information\n Therapist's Name: \n Date: \n Time: 815-840\n Pager #: \n" }, { "category": "Physician ", "chartdate": "2121-09-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 599369, "text": "Chief Complaint: Respiratory Failure, shock (resolved)\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n No complaints - continues to trach mas\n 24 Hour Events:\n More bleeding around trach site - not as severe as previous\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:22 PM\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: No(t) Fever\n Ear, Nose, Throat: trach\n Cardiovascular: No(t) Tachycardia\n Nutritional Support: Tube feeds\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 73 (68 - 84) bpm\n BP: 141/67(85) {120/55(72) - 141/67(85)} mmHg\n RR: 14 (12 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.5 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 1,342 mL\n 525 mL\n PO:\n TF:\n 1,082 mL\n 473 mL\n IVF:\n 185 mL\n 53 mL\n Blood products:\n Total out:\n 2,075 mL\n 700 mL\n Urine:\n 2,075 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -733 mL\n -175 mL\n Respiratory support\n O2 Delivery Device: T-piece\n Ventilator mode: Standby\n RR (Spontaneous): 17\n FiO2: 60%\n SpO2: 95%\n ABG: ///35/\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\n Labs / Radiology\n 9.2 g/dL\n 223 K/uL\n 193 mg/dL\n 2.3 mg/dL\n 35 mEq/L\n 4.1 mEq/L\n 75 mg/dL\n 110 mEq/L\n 150 mEq/L\n 28.3 %\n 8.3 K/uL\n [image002.jpg]\n 05:29 PM\n 05:48 PM\n 03:31 AM\n 02:47 PM\n 02:37 AM\n 01:56 PM\n 02:40 AM\n 04:40 PM\n 03:50 AM\n 09:55 AM\n WBC\n 4.9\n 6.1\n 7.1\n 8.3\n 8.3\n Hct\n 27.7\n 24.7\n 28.5\n 27.5\n 27.5\n 28.3\n 28.3\n Plt\n 179\n 194\n 198\n 223\n 223\n Cr\n 2.8\n 2.8\n 2.8\n 2.8\n 2.7\n 2.5\n 2.5\n 2.3\n TCO2\n 37\n Glucose\n 192\n 117\n 194\n 220\n 221\n 193\n Other labs: PT / PTT / INR:13.1/55.5/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ELECTROLYTE & FLUID DISORDER, OTHER\n PULMONARY EDEMA\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 74 yo male admit with sepsis with pulmonary source now with prolonged\n hospital course leading to trach/PEG placment. Now trach masking\n during the day.\n 1)Respiratory Failure- completed /linezolid\n Trach mask trials during the day\n 2)Renal Failure-\n Renal function stable\n 3)Trach site bleeding: Slowing down. IP to evaluate today - perhaps\n inject\n 4)Hypernatremia: Increase fH20 flushes.\n To when bed available.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:19 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2121-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599447, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Repeat Na at beginning of shift 155, up from 150\n Action:\n Increase FW to 250 ml q 2 h. 1L D5w given\n Response:\n Repeat NA\n Plan:\n Trend and cont FW boluses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont on 60% fi02 w/ t-piece. Copious thick tan and blood-tinged\n secretions. Sp02 95%, O2 Sats 94-97%\n Action:\n ETT suction PRN, TCDB, pulm toilet. Cont supplemental 02\n Response:\n Resp status stable.\n Plan:\n Wean 02 support as tol.\n .H/O psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt essentially oriented and alert, nods yes / no appropriately.\n Follows comands, MAEs. Calm, cooperative.\n Action:\n Admin psych meds as directed perphenazine.\n Response:\n Stable.\n Plan:\n Re-admin clozaril as directed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 60-150 ml/hr. BUN / Cre elevated above baseline.\n Action:\n Response:\n BUN / Cre trending down, UOP stable.\n Plan:\n Admin lasix if necessary, follow UOP and labs.\n" }, { "category": "Nursing", "chartdate": "2121-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 599522, "text": "Pt lookas comfortable this morning,VSS,Alert and able to follow\n commands.pt getting TF through peg tube. BS this morning\n At 1000 is 202, received 3units humalog. Pt given his med as ordered.\n Pt Discharged to around 1100.\n" }, { "category": "Nursing", "chartdate": "2121-09-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598476, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n High creatinine\n Action:\n On diamox, K repleted\n Response:\n u/o>100/h, creat down to 2.9\n Plan:\n Monitor lites, u/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on AC 5 peep\n Action:\n Was tried to be on CPAP , suction PRN, VAP protocol, frequent turns\n Response:\n Failed CPAP, back to A/C,. thick tan/yellow sputum, maintains sat>94\n Plan:\n Plan to trach , wean to CPAP when awake enough\n Impaired Skin Integrity\n Assessment:\n Multiple skin breakdown areas\n Action:\n Aquacel dressings on right arm changed/intact\n Sacral area dark purple with minimal breakdown\n Frequent turns\n Response:\n No new skin breakdown areas\n Plan:\n Per nursing care plan\n" }, { "category": "Nursing", "chartdate": "2121-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598626, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert and follows commands inconsistently, PERRLA, 3mm, brisk.\n Inconsistently nods head to yes/no questions. Moving extremities on\n bed.\n Action:\n Neuros assessed. Attempted to place pt on CPAP.\n Response:\n Pt unable to tolerate CPAP because he was not taking any spontaneous\n breaths. Pt\ns eyes open at time and pt encouraged to breath but with\n no success.\n Plan:\n Continue to monitor mental status. Pt to be trach/PEG Thursday or\n Friday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings AC/500x16/+5/40%. Not overbreathing vent. LS clear with\n diminished bases. O2 sats 94-98%.\n Action:\n O2 sats decreased to 90-91%. FiO2 increased to 50%. Suctioned q2-3\n hrs for moderate-copious amt of thick/tan secretions. Diuril given and\n Lasix gtt started.\n Response:\n O2 sats 95-98%. Nods no when asked if having resp difficulty. UOP\n >100cc/hr.\n Plan:\n Monitor resp status. Suction PRN. Plan for trach/PEG today (TF off at\n MN).\n Impaired Skin Integrity\n Assessment:\n Right arm with erythematous areas that are dry. Coccyx reddened but\n blanchable. Patient found to have a pink/red, swollen area on L side of\n neck. Grimaces with palpation of neck. Continues to have blood tinged\n oral secretions.\n Action:\n CT neck done. Continued wound care as documented. Pt repositioned\n frequently.\n Response:\n CT showed significant swelling of lymph node. No further breakdown in\n skin.\n Plan:\n Continue wound care. Frequent position changes. ENT to be consulted\n today.\n" }, { "category": "Physician ", "chartdate": "2121-09-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 598701, "text": "Chief Complaint: Sepsis\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 02:28 PM\n -CT Neck--extensive adenopathy noted in region of enlarging neck mass\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:13 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:34 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: 54 (51 - 79) bpm\n BP: 108/51(65) {100/43(56) - 139/92(100)} mmHg\n RR: 16 (12 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,391 mL\n 727 mL\n PO:\n TF:\n 1,080 mL\n 315 mL\n IVF:\n 451 mL\n 412 mL\n Blood products:\n Total out:\n 2,060 mL\n 1,575 mL\n Urine:\n 2,060 mL\n 1,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n 331 mL\n -848 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 903 (903 - 903) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 21 cmH2O\n Plateau: 13 cmH2O\n SpO2: 97%\n ABG: ///42/\n Ve: 8 L/min\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Endotracheal tube, Increased area of swelling\n in neck region overnight\nthis is left sided and in region of parotid\n gland with extension to sub-mandibular area\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.6 g/dL\n 237 K/uL\n 150 mg/dL\n 2.8 mg/dL\n 42 mEq/L\n 3.4 mEq/L\n 87 mg/dL\n 101 mEq/L\n 146 mEq/L\n 24.7 %\n 5.7 K/uL\n [image002.jpg]\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n WBC\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n Hct\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n Plt\n 298\n 316\n 300\n 255\n 243\n 227\n 237\n Cr\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n Glucose\n 167\n 191\n 210\n 166\n 282\n 168\n 126\n 141\n 150\n Other labs: PT / PTT / INR:11.6/33.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Imaging: CT Neck--see HPI\n CXR--no new\n Microbiology: Sputum----MRSA and Acinetobacter\n Assessment and Plan\n 78 yo male admit with sepsis now with persistent respiratory failure\n and move to trach and PEG today. Importantly he has had evolution of\n his neck mass and CT scan showing adenopathy.\n 1)Respiratory Failure-He is limited by substantial secretions,\n persistent volume overload and altered mental status and difficulty\n with compliance with previous attempts at extubation.\n -Diamox/Lasix 10mg//hr for volume\n -Goal 2 liters negative\n -Will continue broad spectrum ABX\n -Will suction PRN now\n -Will pursue trach/PEG today\n -ENT to eval neck mass and plan going forward\nwill have to assure IP\n comfort with tracheostomy in light of new mass.\n 2)Sepsis-Off pressors, able to pursue diuresis\n -Meropenem\n -Diruesis\n Additional issues to be addressed as defined in the housestaff note of\n this date.\n ICU Care\n Nutrition: NPO for procedure\nwill resume with G-tube in place\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2121-09-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 598702, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - trach and peg scheduled for tomorrow, may require DDAVP prior to\n procedure\n - TTE: LVEF > 55% with likely normal regional systolic function\n - left submandibular mass noticed by nursing, overlying skin is\n slightly erythematous and warm, appears to be tender, unable to explore\n mouth but patient has h/o poor dentition - non-contrast CT: no\n calcifications intraparotid lymph node, two submandibular lymph nodes\n with surrounding inflammation, asymmetric enlargement of\n parotid and submandibular glands\n - should receive ENT consult in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 05:00 PM\n Meropenem - 12:13 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 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: 36.6\nC (97.9\n HR: 56 (53 - 79) bpm\n BP: 125/53(69) {100/43(56) - 139/92(100)} mmHg\n RR: 16 (15 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 107 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,390 mL\n 517 mL\n PO:\n TF:\n 1,080 mL\n 289 mL\n IVF:\n 450 mL\n 228 mL\n Blood products:\n Total out:\n 2,060 mL\n 925 mL\n Urine:\n 2,060 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 903 (903 - 903) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 24 cmH2O\n Plateau: 14 cmH2O\n SpO2: 97%\n ABG: ///42/\n Ve: 4.3 L/min\n Physical Examination\n General: NAD\n ENT: large firm submandibular mass with overlying warmth and erythema,\n tender\n Chest: CTAB\n Heart: RRR no MRG\n Abdomen: soft, NTND\n Extremities: NT, WWP, 2+ PE\n Labs / Radiology\n 237 K/uL\n 7.6 g/dL\n 150 mg/dL\n 2.8 mg/dL\n 42 mEq/L\n 3.4 mEq/L\n 87 mg/dL\n 101 mEq/L\n 146 mEq/L\n 24.7 %\n 5.7 K/uL\n [image002.jpg]\n 04:07 AM\n 03:36 AM\n 02:39 AM\n 02:40 PM\n 02:54 AM\n 12:37 PM\n 05:48 PM\n 02:07 AM\n 06:00 PM\n 03:22 AM\n WBC\n 7.6\n 7.6\n 6.0\n 5.0\n 4.7\n 4.9\n 5.7\n Hct\n 26.2\n 25.8\n 23.0\n 25.2\n 26.5\n 25.0\n 24.4\n 24.7\n Plt\n 298\n 316\n 300\n 255\n 243\n 227\n 237\n Cr\n 3.2\n 3.1\n 3.0\n 2.9\n 3.0\n 3.1\n 2.9\n 2.8\n 2.8\n TCO2\n 45\n Glucose\n 167\n 191\n 210\n 166\n 282\n 168\n 126\n 141\n 150\n Other labs: PT / PTT / INR:11.6/33.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.3\n g/dL, LDH:275 IU/L, Ca++:8.3 mg/dL, Mg++:3.1 mg/dL, PO4:3.7 mg/dL\n Microbiology\n - sputum \n MRSA (vancomycin), acinetobacter (meropenem)\n Imaging\n - CXR \n ET tube 5 cm above carina, NGT in proximal stomach should\n be advanced 10 cm, bibasilar atelectasis, mild unchanged pulmonary\n edema, stable bilateral pleural effusions\n - CT neck \n see above\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism\n admitted with pneumosepsis vs, urosepsis c/b by NSTEMI and now VAP with\n acinetobacter and MRSA, now re-intubated for airway protection do to\n continued respiratory secretions and tiring cough.\n #. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema. Barriers to extubation include excess secretions and\n airway protection, fluid overload, mental status.\n - mental status: trach / peg today\n - pneumonia: continue meropenum (12 of 14) and linezolid (12 of 14)\n - pulmonary edema: continue lasix drip with diuril and acetazolamide\n for goal of - 2L / day\n titrating to BP\n # Neck Mass: concern for infection given tenderness of adenopathy,\n overlying erythema and warmth. Mass appears to be caudal and lateral\n to airway and do not anticipate any problems with trach\n - ENT consult re: course of further evaluation\n # Hypertension\n patient remains normotensive and now transitioned back\n to home Amlodipine dose.\n - continue Amlodipine 10 mg daily\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak of 4.6 to 2.8. Cr remains\n constant despite aggressive diuresis. Of note patient is s/p prior\n nephrectomy.\n - continue diuresis as discussed above\n - follow lytes\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - lytes and titrate free water flushes, transition to 200 QID for\n Na of 145\n # Anemia: poor reticulocyte output suggestive marrow suppression or low\n epo as source. Stool remains guiac negative.\n - trend HCT and transfuse PRN to goal > 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol nebs\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: lytes with PRN repleteion, tube feeds held for procedure\n # Prophylaxis: SQH , bowel regimine, lansoprazole\n # Access: PICC line\n # Code: FULL\n # Disposition: d/w case management placement into step down unit at\n Rehab as requires significant level of nursing care\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 04:43 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Respiratory ", "chartdate": "2121-09-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 599014, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n 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: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: 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: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt started shift off on trach collar and lasted one full hour\n before being switched back ventilator. Pt was stable on vent, with\n minimal spontaneous settings this shift. Pt had many blood tinge\n secretions suctioned this shift. Pt is stable and to be reassessed by\n MD team\n" }, { "category": "Rehab Services", "chartdate": "2121-09-30 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 599353, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pna / 480.9\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 74 yo M admitted\n with septic shock, NSTEMI, hypothermia requiring intubation,\n prolonged hospital course requiring tracheostomy on , peg on .\n Past Medical / Surgical History: see initial eval\n Medications: aspirin, heparin, dexamethasone, amlodipine, fentanyl,\n midazolam\n Radiology: CXR - Mild pulmonary edema has improved. Small\n bilateral pleural effusions, right greater than left, have decreased in\n amount. Bibasilar consolidations are minimally increased in the right\n base\n Labs:\n 28.3\n 9.2\n 223\n 8.3\n [image002.jpg]\n Other labs:\n Activity Orders: ok for edge of bed per icu team\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented to\n self and hospital, attempting to mouth words minimally, nods/shakes\n head for yes/no answers, follows simple commands.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 80\n 140/65\n 15\n 93% with t-tube\n Activity\n 84\n 142/73\n 20\n 88%\n Recovery\n 68\n /\n 14\n 95%\n Total distance walked: 0\n Minutes:\n Pulmonary Status: coarse upper BS, strong congested cough, large\n amounts of thick bloody secretions\n Integumentary / Vascular: trach, peg, L PIV, foley, rectal tube, tele,\n Sensory Integrity: intact to light touch B LE's\n Pain / Limiting Symptoms: denies pain\n Posture: obese, kyphotic posture, FHP\n Range of Motion\n Muscle Performance\n B LE's WNL\n B LE's grossly t/o, not able to tolerate resistance\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n \n Mod\n Max\n Gait, Locomotion: slide-transfers to stretcher chair with total assist\n :\n\n\n\n\n\n T\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\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: able to maintain static sitting with CG at edge of bed once\n positioned, able to weight shift minimally. Standing balance not\n tested.\n Education / Communication: Reviewed PT and d/c planning, encouraged\n deep breathing/coughing. Communicated with nsg re: status\n Intervention: CPT/percussion to B posterior lung fields in sitting\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired pulmonary hygiene\n 5.\n Impaired strength\n Clinical impression / Prognosis: 74 yo M with pneumonia p/w above\n impairments a/w ventilatory pump dysfunction. He is most limited by\n general weakness a/w prolonged icu hospitalization, as well as poor\n pulmonary hygiene. He is significantly below his baseline, and\n prognosis remains guarded given his medical status, however he will be\n a good rehab candidate given his prior level of function. Recommend\n rehab when medically appropriate, PT to continue to follow and progress\n as able at acute level.\n Goals\n Time frame: 1 week\n 1.\n Mod A , A supine-to-sit, assess sit-to-stand and transfers\n 2.\n S static/dynamic sitting balance, assess standing balance\n 3.\n Tolerate OOB >/= 3 hours/day\n 4.\n Tolerates daily CPT and able to clear secretions with A\n 5.\n Tolerates daily strengthening\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n bed mobility, transfers, balance, endurance, strengthening, education,\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "General", "chartdate": "2121-10-01 00:00:00.000", "description": "Resident Progress Note", "row_id": 599497, "text": "TITLE:\n" }, { "category": "Rehab Services", "chartdate": "2121-09-24 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 598571, "text": "Subjective:\n vented\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, other:\n Updated medical status: CXR - Bibasilar atelectasis is\n present, although infection might be underlying. The mild pulmonary\n edema is unchanged. There is bilateral pleural effusion, small.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n X2\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 58\n 115/95\n 16\n 96% on CMV\n Activity\n Sit\n 80\n 129/59\n 22\n 95% on CMV\n Recovery\n 60\n 134/92\n 16\n 99% on CMV\n Total distance walked: 0\n Minutes:\n Gait: not assessed\n Balance: able to maintain static sitting at edge of bed for 20-30\n seconds at a time, posterior bias requiring cues to anterior weight\n shift to prevent LOB. Standing balance not assessed.\n Education / Communication: Reviewed PT and encouraged deep\n breathing/coughing. Communicated with nsg re: status.\n Other: on CMV via oral tube, 40% FiO2\n Patient able to nod/shake head to simple yes/no answers, follows simple\n commands\n Rhonchorous BS L>R upper lungs\n CPT/perucssion to all lung fields, inline suction small amt thick\n secretions\n Assessment: 74 yo M with sepsis/pna making slow progress in PT with\n mobility and pulmonary hygiene, now with recent setback requiring\n re-intubation. He continues to be well below his baseline level, would\n continue to recommend rehab when medically appropriate to progress as\n able upon d/c\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Nursing", "chartdate": "2121-09-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 598766, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock (urosepsis),\n acute renal failure, and respiratory failure. Per family, patient was\n taken to OSH for unresponsiveness at home, with SBPs reportedly in the\n 40s. Hypothermic and bradycardic, intubated for airway protection,\n given fluids, ABX, and multiple vasopressors. Transferred to via\n Med flight, then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure and tx of PNA vs\n urosepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 50%/500/16/5. Sp02 96%.\n Action:\n Trach at bedside today. MDIs, suction PRN, oral care. Lasix gtt.\n Response:\n Site intact, pt is back on AC. Hct 23.\n Plan:\n Wean vent support as tol. Pt will go to OR tomoroow for PEG w/ GI\n sevice, NPO tonight. Goal FB 2 L neg today.\n Shock, septic\n Assessment:\n Pt normotensive. Afebrile. WBC WNL. SB w/ no ectopy noted. Mod amt\n thick ETT secretion, urine clear and lught yellow.\n Action:\n Admin ABX asdir.\n Response:\n Pt stable.\n Plan:\n Cont abx course, monitor VS and labs.\n Hypernatremia (high sodium)\n Assessment:\n Pt chronically hi NA this admission.\n Action:\n 150 ml free h20 q 6 h.\n Response:\n Na in AM 146, PM levels pending.\n Plan:\n Monitor.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes spontaneously, MAEs but does not follow commands. Pt\n answers yes or no to pain, nods head. PERRL.\n Action:\n Bolus sedation / analgesia PRN. Admin antipsychotic meds asdir.\n Response:\n MS stable.\n Plan:\n Monitor.\n" }, { "category": "Physician ", "chartdate": "2121-09-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597090, "text": "Chief Complaint:\n 24 Hour Events:\n - all pressors off\n - patient did OK on 0/5 trial. Will attempt to wean vent today.\n - started subQ heparin and restarted ASA\n - some bloody secretions\n - holding Bblocker and ACEi b/c of bradycardia and renal function\n respectively\n - on lasix 40mg PO BID at home; goal of 1.5 liters diuresis today, gave\n 40mg IV lasix in AM only 250 cc negative by 7pm. Gave additional 40mg\n IV lasix\n -RSBI 33; lots of secretions and poor mental status. will try SBT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Piperacillin/Tazobactam (Zosyn) - 01:10 AM\n Ciprofloxacin - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:27 PM\n Heparin Sodium (Prophylaxis) - 09:27 PM\n Furosemide (Lasix) - 10:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 61 (53 - 82) bpm\n BP: 136/58(82) {104/41(58) - 146/62(88)} mmHg\n RR: 14 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 14 (4 - 15)mmHg\n Total In:\n 1,438 mL\n 418 mL\n PO:\n TF:\n 557 mL\n 49 mL\n IVF:\n 832 mL\n 369 mL\n Blood products:\n Total out:\n 1,960 mL\n 365 mL\n Urine:\n 1,960 mL\n 365 mL\n NG:\n Stool:\n Drains:\n Balance:\n -522 mL\n 53 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (537 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 93%\n ABG: 7.40/45/81./26/1\n Ve: 7.1 L/min\n PaO2 / FiO2: 162\n Physical Examination\n gen: intubated\n cv: rrr\n resp: cta anteriorly\n abd: obese, +BS\n ext: pitting edema\n Labs / Radiology\n 91 K/uL\n 7.3 g/dL\n 105 mg/dL\n 4.6 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 103 mg/dL\n 107 mEq/L\n 149 mEq/L\n 21.6 %\n 5.4 K/uL\n [image002.jpg]\n 03:55 PM\n 09:11 PM\n 10:35 PM\n 04:28 AM\n 05:01 AM\n 12:17 PM\n 03:31 PM\n 06:38 PM\n 12:03 AM\n 04:32 AM\n WBC\n 7.9\n 6.5\n 5.4\n Hct\n 23.0\n 22.8\n 22.4\n 21.6\n Plt\n 67\n 79\n 91\n Cr\n 4.2\n 4.4\n 4.6\n TCO2\n 25\n 24\n 28\n 25\n 25\n 29\n Glucose\n \n Other labs: PT / PTT / INR:12.0/34.6/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.7 mg/dL, PO4:5.0 mg/dL\n Microbiology: GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n RESPIRATORY CULTURE (Preliminary):\n Further incubation required to determine the presence or absence\n of\n commensal respiratory flora.\n YEAST. MODERATE GROWTH.\n ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ACINETOBACTER BAUMANNII COMPLEX\n |\n AMPICILLIN/SULBACTAM-- =>32 R\n CEFEPIME-------------- 32 R\n CEFTAZIDIME----------- =>64 R\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ 8 I\n IMIPENEM-------------- 2 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- =>16 R\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors since this AM\n - currently on zosyn/, broaden zosyn to given\n acinetobacter in sputum s to imi and tobra only. currently growing vre\n sensitive to amp for which ID would like to start linezolid and coag\n neg staph from blood (likely contaminant) from . dc'ed\n vancomycin yesterday\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 25q6h, will space to\n 25q8 today (=2.8 daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n .\n ##. Respiratory Failure:\n - will aim for SBT today\n - off sedation\n .\n # : baseline 1.8-2, current Cr is 4.6, was 4.2 yesterday prior to\n diuresis but increased slightly over course of the day.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - consider add bblocker and ace pending improvement of bradycardia and\n RF respectively\n - restart ASA now that xigris is off\n .\n #hypernatremia: hypernatremic to 149 this am. will increase free water\n in tube feeds.\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -on PPI\n -stool guiac negative\n .\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med now that sedation off\n -consider psych consult when extubated.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n .\n # DM: now back on insulin SQ, may need to tighten ss\n .\n # SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, tube feeds at goal\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Right IJ, A-line\n .\n # Code: DNR (chemical code ok)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (chemical code ok)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597179, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 01:18 PM\n URINE CULTURE - At 01:18 PM\n -talked to ID about how to cover both vre (urine) and acinetobacter\n (lungs), pt now on for acinetobacter (day ) and linezolid for\n VRE day .\n -hypernatremic in the am, increased free water in tube feeds,\n afternoon sodium was corrected at 138, tube feed free water was\n decreased from 250q4h to 200q4h, now Na is 146.\n -transfused for hct of 21 which then bumped appropriately. repleting K\n gently given \n -plan to do SBT on hold given desats with O2 sat in the high 80s. ABG\n was drawn and showed 7.26, pCO2 61, pO2 65. Pt was put on a rate of 20,\n PEEP was increased from 5->10. CXR was repeated which showed no change.\n Repeat ABG was 7.33/53/94\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 12:29 AM\n Linezolid - 05:19 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.1\nC (95.1\n HR: 59 (44 - 73) bpm\n BP: 137/56(82) {106/51(72) - 159/68(98)} mmHg\n RR: 20 (11 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 10 (10 - 303)mmHg\n Total In:\n 2,160 mL\n 706 mL\n PO:\n TF:\n 268 mL\n 224 mL\n IVF:\n 1,118 mL\n 482 mL\n Blood products:\n 375 mL\n Total out:\n 3,385 mL\n 1,225 mL\n Urine:\n 3,385 mL\n 1,225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -518 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 341 (341 - 620) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 92%\n ABG: 7.40/45/84./24/1\n Ve: 9 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Cardiovascular: General: Elderly Caucasian Male intubated in NARD.\n Psych: Localizes to pain, opens eyes to verbal stimuli\n Gen: elderly Caucasian male, no acute distress. Breathing with mask\n HEENT: Sclera anicteric, MMM\n Neck: difficult to eval JVP given IJ\n Lungs: Crackles noted diffusely on anterior exam with diminished\n crackles over left lung field.\n CV: Borderline bradycardic (50), S1 + S2, no murmurs, rubs, gallops\n Abdomen: abdomen soft, ND, NT, + bowel sounds present, no rebound\n tenderness or guarding\n Ext: 2+ edema noted in all extremities.\n Neurologic: responds appropriately to questions\n Labs / Radiology\n 111 K/uL\n 8.6 g/dL\n 172 mg/dL\n 4.5 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 104 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.2 %\n 4.4 K/uL\n [image002.jpg]\n 12:03 AM\n 04:32 AM\n 08:00 AM\n 12:00 PM\n 04:00 PM\n 04:23 PM\n 06:33 PM\n 07:23 PM\n 03:46 AM\n 04:05 AM\n WBC\n 5.4\n 4.4\n Hct\n 21.6\n 25.0\n 25.2\n Plt\n 91\n 111\n Cr\n 4.6\n 4.6\n 4.5\n TCO2\n 29\n 29\n 29\n 29\n Glucose\n 105\n 130\n 113\n 130\n 172\n Other labs: PT / PTT / INR:12.0/35.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.8 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: ABG\n pH7.40\n pCO2 45\n pO2 84\n HCO329\n BaseXS1\n Iron studies pending\n Imaging: CXR - Bilateral patchy air space opacities with improved\n aeration at the RLL and more confluent opacity in the left perihilar\n region. Unchanged bilateral\n pleural effusions. Stable lines and tubes.\n Microbiology: Blood cultures 9/22, , - NGTD\n Urine culture - no growth,\n - NGTD\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only. currently growing vre sensitive to amp/linizolid on started\n on linezolid per ID recs. coag neg staph from blood (likely\n contaminant) from . Monitor for CBC as pt on linezolid\n - f/u pan culture results\n - will continue on IV Hydrocortisone, currently on 25q8 today (=2.8\n daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n ##. Respiratory Failure:\n - sats in the low 90s, repeat CXR showed left lung opacification,\n likely to mucus plug.\n - trial of chest PT\n - rpt CXR\n - possible bronch if no improvement\n -defer trial of SBP until respiratory status improves\n - currently not on mechanical ventilation\n # : baseline 1.8-2, current Cr is 4.5, was 4.6 yesterday prior to\n diuresis but increased slightly over course of the day.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n #hypernatremia: hypernatremic to 146 this am. Likely due to tube\n feeding and hypotonic diuresis in setting of lasix ggt.\n - will increase free water in tube feeds to 250cc q4h (from 200cc q4h)\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -stool guiac negative\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated, and in the setting of linezolid\n -consider restart home psych med now that sedation off\n -psych consult regarding holding of medications\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n # DM: now back on insulin SQ, may need to tighten ss\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:16 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597181, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 01:18 PM\n URINE CULTURE - At 01:18 PM\n -talked to ID about how to cover both vre (urine) and acinetobacter\n (lungs), pt now on for acinetobacter (day ) and linezolid for\n VRE day .\n -hypernatremic in the am, increased free water in tube feeds,\n afternoon sodium was corrected at 138, tube feed free water was\n decreased from 250q4h to 200q4h, now Na is 146.\n -transfused for hct of 21 which then bumped appropriately. repleting K\n gently given \n -plan to do SBT on hold given desats with O2 sat in the high 80s. ABG\n was drawn and showed 7.26, pCO2 61, pO2 65. Pt was put on a rate of 20,\n PEEP was increased from 5->10. CXR was repeated which showed no change.\n Repeat ABG was 7.33/53/94\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 12:29 AM\n Linezolid - 05:19 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.1\nC (95.1\n HR: 59 (44 - 73) bpm\n BP: 137/56(82) {106/51(72) - 159/68(98)} mmHg\n RR: 20 (11 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 10 (10 - 303)mmHg\n Total In:\n 2,160 mL\n 706 mL\n PO:\n TF:\n 268 mL\n 224 mL\n IVF:\n 1,118 mL\n 482 mL\n Blood products:\n 375 mL\n Total out:\n 3,385 mL\n 1,225 mL\n Urine:\n 3,385 mL\n 1,225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -518 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 341 (341 - 620) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 92%\n ABG: 7.40/45/84./24/1\n Ve: 9 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Cardiovascular: General: Elderly Caucasian Male intubated in NARD.\n Psych: Localizes to pain, opens eyes to verbal stimuli\n Gen: elderly Caucasian male, no acute distress. Breathing with mask\n HEENT: Sclera anicteric, MMM\n Neck: difficult to eval JVP given IJ\n Lungs: Crackles noted diffusely on anterior exam with diminished\n crackles over left lung field.\n CV: Borderline bradycardic (50), S1 + S2, no murmurs, rubs, gallops\n Abdomen: abdomen soft, ND, NT, + bowel sounds present, no rebound\n tenderness or guarding\n Ext: 2+ edema noted in all extremities.\n Neurologic: responds appropriately to questions\n Labs / Radiology\n 111 K/uL\n 8.6 g/dL\n 172 mg/dL\n 4.5 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 104 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.2 %\n 4.4 K/uL\n [image002.jpg]\n 12:03 AM\n 04:32 AM\n 08:00 AM\n 12:00 PM\n 04:00 PM\n 04:23 PM\n 06:33 PM\n 07:23 PM\n 03:46 AM\n 04:05 AM\n WBC\n 5.4\n 4.4\n Hct\n 21.6\n 25.0\n 25.2\n Plt\n 91\n 111\n Cr\n 4.6\n 4.6\n 4.5\n TCO2\n 29\n 29\n 29\n 29\n Glucose\n 105\n 130\n 113\n 130\n 172\n Other labs: PT / PTT / INR:12.0/35.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.8 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: ABG\n pH7.40\n pCO2 45\n pO2 84\n HCO329\n BaseXS1\n Iron studies pending\n Imaging: CXR - Bilateral patchy air space opacities with improved\n aeration at the RLL and more confluent opacity in the left perihilar\n region. Unchanged bilateral\n pleural effusions. Stable lines and tubes.\n Microbiology: Blood cultures 9/22, , - NGTD\n Urine culture - no growth,\n - NGTD\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only. currently growing vre sensitive to amp/linizolid on started\n on linezolid per ID recs. coag neg staph from blood (likely\n contaminant) from . Monitor for CBC as pt on linezolid\n - f/u pan culture results\n - will continue on IV Hydrocortisone, currently on 25q8 today (=2.8\n daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n ##. Respiratory Failure:\n - sats in the low 90s, repeat CXR showed left lung opacification,\n likely to mucus plug.\n - trial of chest PT\n - rpt CXR\n - possible bronch if no improvement\n -defer trial of SBP until respiratory status improves\n - currently not on mechanical ventilation\n # : baseline 1.8-2, current Cr is 4.5, was 4.6 yesterday prior to\n diuresis but increased slightly over course of the day.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n #hypernatremia: hypernatremic to 146 this am. Likely due to tube\n feeding and hypotonic diuresis in setting of lasix ggt.\n - will increase free water in tube feeds to 250cc q4h (from 200cc q4h)\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -stool guiac negative\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated, and in the setting of linezolid\n -consider restart home psych med now that sedation off\n -psych consult regarding holding of medications\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n # DM: now back on insulin SQ, may need to tighten ss\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:16 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Error under Assessment and Plan\n Respiratory Failure. Pt IS currently\n on respiratory support as indicated in the objective section. He is\n off of sedation.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:41 ------\n" }, { "category": "Respiratory ", "chartdate": "2121-09-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597189, "text": "ETT:\n Position: 24 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 ordered\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally intubated on\n full mechanical support. No vent changes made this shift, continues on\n A/C ventilation w/ PIP/Pplat = 24/20. ETT secure/patent.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596367, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely cause is PNA seen on Cxray; however also ruling out for\n influenza & legionella, some WBC\ns in urine. Received patient on 3\n pressors (dopamine, levophed & vasopressin) s/p total of 8 liters NS\n given in ED & 9 liters LR in CCU (patient with generalized body edema).\n On 3 antibiotic regimen & steroids. Patient now normothermic off\n warming blanket, WBC 10.4, Continues to require vent support. Aline\n waveform dampening.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin gtt off.\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT/INR monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Vanco level sent 6 am.\n Goal BG level <200, maintained with insulin gtt ranging\n 0.5-2.5 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CMV 80%, rate set at 24, PEEP 13. ABG at\n start of shift: 7.31/40/93. patient synchronous with the vent, no\n overbreathing noted. Lungs diminished with some fine crackles at\n intervals, partially diminished body habitus. Suctioned for small\n amounts bloody secretions. Clear oral secretions draining from mouth.\n Patient sedated to .\n Action:\n ABG monitoring\n Maintained sedation to keep patient synchronous with the\n vent.\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Versed @ 5 mg/hr\n Fentanyl @ 200 mcg/hr\n Patient continues to be synchronous with the vent on current\n sedation\n Re-peat ABG 7.34/41/170\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. Potential for placement of esophageal .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.4/82. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06), likely r/u in for an MI- Cards\n consulted. Adequate hourly urine output. Elevated K+ level 5.8.\n Action:\n Electrolyte monitoring, especially potassium level\n given\n kayexelate at 1 am.\n No IVF administered this shift\n Monitored UO\n Response:\n Am CR/BUN;\n Am K+ 5.5, no stool output following kayexelate\n administration\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned q 2 hours. Oral care.\n Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596467, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR\nCPR not indicated, but would\n use pressors.\n Shock, septic\n Assessment:\n Ruled out for influenza and legionella, blood cultures from OSH\n with GPC . Urine sample from OSH + for VRE. MRSA +. Received pt on\n levophed, dopamine and vasopressin had been weaned off over night.\n Action/Response:\n Hemodynamics monitored: CVP 10-12, Vigileo monitoring in\n place: CO 4.7-5.3, CI 2.1-2.4, Scvo2 low 80\ns high 70\n No further fluid boluses\n Levophed weaned from 0.5 mcg/kg/min to with goal MAP\n >65\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn. Vanco dose\n given late awaiting trough level\ntrough 8 on q 48 hour dosing.\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) @ 20 mcg/kg/min, H/H, PLTS & PT/INR\n monitored .\n Assessed for bleeding\nno expansion of L groin hematoma (site\n soft and ecchymotic), GI asps bilious, ETS\nold bloody secretions.\n Insulin gtt remains @ 0.5 unit/hour with BS 150\ns-160\n (goal 150-200)\n Droplet precautions d/c\nd, remains on contact precautions\n d/t VRE\n Blood cultures X2 sent, urine culture repeated, sputum\n culture sent.\n T 97.9-98 po\n U/O 40-80cc/hour, Cr 3.5 (3.4)\n Plan:\n Continue with contact precautions. Follow Temp, antibiotics as\n ordered. Please note that pt is to have trough Vanco drawn \nplease\n draw at 1100. Continue with hemodynamic monitoring. Wean levo as able\n to keep MAP >65. Plan as per team is to let pt autodiurese for now and\n monitor Cr. Steroids IV q 6 hours with plan to decrease dose tomorrow\n as per team. Monitor BS hourly on insulin gtt\nmay need to ^ dose as\n TF is advanced. Monitor labs with Xigris infusion, assess for bleeding,\n guiac stool. Team would like to remove sepsis cath as possible and\n change to PICC.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 420/ 24, PEEP 13. Not overbreathing vent.\n Fentanyl @ 200mcg/hour, Versed @ 5mg/hour. Lungs with diminished\n breath sounds, occ rhonchi. 1.\n Action/Response:\n Sedation weaned q 2 hours while following neuro assessment.\n Breathing breathes over vent.\n Fi O2 weaned to 50%\ns stable.\n PEEP weaned to 10 with stable ABG and O2 sat until turned on\n L side. Then sat decreased to 90%. ABG sent, RT notifed, MDI\n given.\n VAP prevention including HOB > 40, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n ETS\nscant old bldy secretions.\n Plan:\n Continue sedation weaning to allow for further spontaneous resps.\n Will need to be cautious of mental status as history of schizophrenia\n and not currently on his medications. Wean PEEP down to 10, and then\n ? begin CPAP if pt with enough spontaneous resps.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.5 (3.4 )\n Action:\n K 5.1 following K exalate last night.\n ? Cr falsely low given Vanco trough levels.\n Mg and Calcium replaced as per sliding scale orders.\n Response:\n Plan:\n Cotninue to monitor urine output & labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, sacral area pink, blanchable\n with central flakey area which resembles Seborrheic Keratosis (pt has\n many on his back). L groin with soft ecchymotic area s/p aline\n removal, right AC site of old PIV opened blister that is oozing clear\n with dressing in place.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear, fanned 4X4 gauze over site to prevent skin from\n touching skin.\n L Panus with criticaid and fanned 4X4 gauze over pinkened\n area.\n Sacral area- applied aloe vesta lotion\n Right AC- mepilex dressing placed & re-inforced with pink\n hy-tape intact.\n Nutren 2.0 TF begun, to titrate up to 40 cc/hour goal.\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\nstopped oozing.\n Plan:\n Continue careful skin assessment. Reposition q 2 hours, avoid back.\n Advance TF towards goal.\n" }, { "category": "Physician ", "chartdate": "2121-09-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596555, "text": "Chief Complaint:\n 24 Hour Events:\n -from : growing coag neg staph of 2 morphologies out of blood\n and growing >100,000 VRE from urine. the VRE is sensitive to ampicillin\n in addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n -also growing enterococcus from urine on admission here\n -got more blood cultures and urine culture and sputum culture today\n -got records from pt's pcp ( #)\n -Dr reports that pt's home living situation is very poor. In past\n has had vna and they feel unsafe their for health reasons (in\n disarray, dirty). Pt not able to care for self and sister also very\n debilitated by psych issues. Dr feels strongly that pt belongs in\n , but sister has been reluctant to pursue in the past. Will consult\n sw.\n -consider picc tomorrow or friday\n -does have mild chronic cri s/p nephrectomy for hematoma\n -weaned sedation down, weaned levo\n -tried to wean peep down from 12 to 10, but patient later desaturated\n when turned, and PaO2 of 64. turned peep back up to 12\n -HCT of 22.5, gave one unit PRBC\n -6pm, called for brady to 40's, but then spontaneously resolved.\n happened while nurse lines, but doesnt seem vagal. On\n tele, was sinus. By the time we got there he was back in the 60's\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:30 AM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 50 mcg/hour\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Insulin - Regular - 1.5 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Famotidine (Pepcid) - 03:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.2\nC (97.1\n HR: 66 (42 - 71) bpm\n BP: 103/50(66) {103/50(66) - 160/73(95)} mmHg\n RR: 19 (18 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (10 - 14)mmHg\n Total In:\n 3,981 mL\n 934 mL\n PO:\n 120 mL\n TF:\n 170 mL\n 294 mL\n IVF:\n 3,211 mL\n 640 mL\n Blood products:\n 350 mL\n Total out:\n 1,740 mL\n 590 mL\n Urine:\n 1,740 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,241 mL\n 344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 32.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/40/108/21/-1\n Ve: 10.5 L/min\n PaO2 / FiO2: 216\n Physical Examination\n gen: intubated, sedated\n cv: RRR\n resp: clear anteriorly\n abd: obese, hypoactive bowel sounds\n ext: edematous\n Labs / Radiology\n 55 K/uL\n 7.7 g/dL\n 110 mg/dL\n 4.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 88 mg/dL\n 103 mEq/L\n 137 mEq/L\n 23.2 %\n 5.5 K/uL\n [image002.jpg]\n 12:32 PM\n 03:49 PM\n 04:03 PM\n 04:41 PM\n 05:22 PM\n 05:35 PM\n 12:00 AM\n 12:08 AM\n 04:00 AM\n 04:09 AM\n WBC\n 6.7\n 6.9\n 5.5\n Hct\n 22.9\n 22.5\n 23.7\n 23.2\n Plt\n 72\n 58\n 55\n Cr\n 4.1\n TCO2\n 22\n 21\n 22\n 22\n 23\n 24\n Glucose\n 110\n Other labs: PT / PTT / INR:13.8/86.9/1.2, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:45/30, Alk Phos / T Bili:42/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:644 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Microbiology: 8:52 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n RESPIRATORY CULTURE (Preliminary):\n HEAVY GROWTH Commensal Respiratory Flora.\n YEAST. HEAVY GROWTH.\n GRAM NEGATIVE ROD(S). SPARSE GROWTH.\n from : growing coag neg staph of 2 morphologies out of blood and\n growing >100,000 VRE from urine. the VRE is sensitive to ampicillin in\n addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n also growing enterococcus from blood cultures from here, sensitivities\n pending\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro and vancomycin.\n currently growing vre sensitive to amp, gnrs from sputum and coag neg\n staph from blood (likely contaminant)\n - f/u panculture results, continue surveillance blood cultures\n - will continue on IV Hydrocortisone, wean starting tomorrow\n - pt on xygris high apache score, check coags\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - continue ardsnet\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n # : baseline.\n -Consider urine sediment.\n -Check urine lytes to diff bet prerenal v atn, most likely atn\n -pt does have some chronic renal insufficiency\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult for ? sick sinus syndrome, seems less c/w vagal\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration\n -keep active type and screen\n -increase H2B to \n -guiac stool\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine\n (home dose is 50 and pt on 25, will increase to 50)\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych meds\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n .\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin\n .\n # SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, f/u tube feed recs\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:38 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597185, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 01:18 PM\n URINE CULTURE - At 01:18 PM\n -talked to ID about how to cover both vre (urine) and acinetobacter\n (lungs), pt now on for acinetobacter (day ) and linezolid for\n VRE day .\n -hypernatremic in the am, increased free water in tube feeds,\n afternoon sodium was corrected at 138, tube feed free water was\n decreased from 250q4h to 200q4h, now Na is 146.\n -transfused for hct of 21 which then bumped appropriately. repleting K\n gently given \n -plan to do SBT on hold given desats with O2 sat in the high 80s. ABG\n was drawn and showed 7.26, pCO2 61, pO2 65. Pt was put on a rate of 20,\n PEEP was increased from 5->10. CXR was repeated which showed no change.\n Repeat ABG was 7.33/53/94\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 12:29 AM\n Linezolid - 05:19 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.1\nC (95.1\n HR: 59 (44 - 73) bpm\n BP: 137/56(82) {106/51(72) - 159/68(98)} mmHg\n RR: 20 (11 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 10 (10 - 303)mmHg\n Total In:\n 2,160 mL\n 706 mL\n PO:\n TF:\n 268 mL\n 224 mL\n IVF:\n 1,118 mL\n 482 mL\n Blood products:\n 375 mL\n Total out:\n 3,385 mL\n 1,225 mL\n Urine:\n 3,385 mL\n 1,225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -518 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 341 (341 - 620) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 92%\n ABG: 7.40/45/84./24/1\n Ve: 9 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Cardiovascular: General: Elderly Caucasian Male intubated in NARD.\n Psych: Localizes to pain, opens eyes to verbal stimuli\n Gen: elderly Caucasian male, no acute distress. Breathing with mask\n HEENT: Sclera anicteric, MMM\n Neck: difficult to eval JVP given IJ\n Lungs: Crackles noted diffusely on anterior exam with diminished\n crackles over left lung field.\n CV: Borderline bradycardic (50), S1 + S2, no murmurs, rubs, gallops\n Abdomen: abdomen soft, ND, NT, + bowel sounds present, no rebound\n tenderness or guarding\n Ext: 2+ edema noted in all extremities.\n Neurologic: responds appropriately to questions\n Labs / Radiology\n 111 K/uL\n 8.6 g/dL\n 172 mg/dL\n 4.5 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 104 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.2 %\n 4.4 K/uL\n [image002.jpg]\n 12:03 AM\n 04:32 AM\n 08:00 AM\n 12:00 PM\n 04:00 PM\n 04:23 PM\n 06:33 PM\n 07:23 PM\n 03:46 AM\n 04:05 AM\n WBC\n 5.4\n 4.4\n Hct\n 21.6\n 25.0\n 25.2\n Plt\n 91\n 111\n Cr\n 4.6\n 4.6\n 4.5\n TCO2\n 29\n 29\n 29\n 29\n Glucose\n 105\n 130\n 113\n 130\n 172\n Other labs: PT / PTT / INR:12.0/35.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.8 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: ABG\n pH7.40\n pCO2 45\n pO2 84\n HCO329\n BaseXS1\n Iron studies pending\n Imaging: CXR - Bilateral patchy air space opacities with improved\n aeration at the RLL and more confluent opacity in the left perihilar\n region. Unchanged bilateral\n pleural effusions. Stable lines and tubes.\n Microbiology: Blood cultures 9/22, , - NGTD\n Urine culture - no growth,\n - NGTD\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors\n - Broad coverage with given acinetobacter in sputum s to imi and\n tobra only. currently growing vre sensitive to amp/linizolid on started\n on linezolid per ID recs. coag neg staph from blood (likely\n contaminant) from . Monitor for CBC as pt on linezolid\n - f/u pan culture results\n - will continue on IV Hydrocortisone, currently on 25q8 today (=2.8\n daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n ##. Respiratory Failure:\n - sats in the low 90s, repeat CXR showed left lung opacification,\n likely to mucus plug.\n - trial of chest PT\n - rpt CXR\n - possible bronch if no improvement\n -defer trial of SBP until respiratory status improves\n - currently not on mechanical ventilation\n # : baseline 1.8-2, current Cr is 4.5, was 4.6 yesterday prior to\n diuresis but increased slightly over course of the day.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - Would like to start BB and ace, pending improvement of bradycardia\n and RF respectively\n - on ASA now that xigris is off\n #hypernatremia: hypernatremic to 146 this am. Likely due to tube\n feeding and hypotonic diuresis in setting of lasix ggt.\n - will increase free water in tube feeds to 250cc q4h (from 200cc q4h)\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -stool guiac negative\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated, and in the setting of linezolid\n -consider restart home psych med now that sedation off\n -psych consult regarding holding of medications\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n # DM: now back on insulin SQ, may need to tighten ss\n # SW: consult regarding concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:16 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Error under Assessment and Plan\n Respiratory Failure. Pt IS currently\n on respiratory support as indicated in the objective section. He is\n off of sedation.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:41 ------\n Error under respiratory status. No CXR opacification. Pt likely to\n be fluid overloaded given h/o IVF fluid resuscitation. require\n more aggressive diuresis. Plan is to repeat CXR to assess volume\n status. Uptitrate diuresis to negative 1.5-2L daily.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:56 ------\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596350, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: aspiration PNA/UTI or a\n combination; ruling out for influenza.\n Recievied patient hypotensive: on 2 pressors ( dopamine at 20\n mcg/kg/min & levophed @ 0.24 mcg/kg/min) s/p 8 liters NS given in ED\n Received patient hypothermic: temp 91.8\n Urine culture from ED with WBC\n ED had sent BC x 1, urine culture\n Action:\n Continued to culture patient to attempt to identify source:\n BC x1, RRT sent influenza DFA, MRSA nasal swab, urine\n specimen for legionella\n Increased doses of dopamine and levophed to support\n hemodynamics\n CVP monitoring, goal 13-15; Given total of 8 liters LR for\n fluid resuscitation\n Vigileo in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score\n Type & cross specimen sent\n Response:\n Results cultures are pending\n Dopamine now at 20 mcg/kg/min, Levophed now @ 0.4\n mcg/kg/min; required addition of vasopressin at 2.4 units/hour; patient\n BP appears most responsive to fluid resusication ; patient now with\n worsening edema, periorbital, facial, bilateral upper & lower\n extremities\n CVP now 13-15; 9^th & 10^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration; levels elevated 1\n x dose 12 units humalog administered\n Xigris on hold at 0500 given potentially low Hgb level-\n re-peat level sent for confirmation\n MICU team in contact with primary contact family members\n regarding patient\ns tenuous status; they plan to travel in today to\n visit with patient.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring. Potentially re-start\n Xigris gtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596351, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: PNA/UTI or a combination;\n however ruling out for influenza.\n Recievied patient on 3 pressors ( dopamine, levophed &vasopressin) s/p\n total of 8 liters NS given in ED 7 9 liters LR (patient with\n generalized body edema). Patient now normothermic off warming blanket,\n WBC now 10.4, Continues to require vent support.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin to 1.2 units/hour (from 2.4).\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight\n Vigileo monitoring in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT monitored\n Maintained precautions for influenza\n Response:\n Dopamine gtt remains off.\n Levophed remains at 0.5 mcg/kg/min\n Vasopressin remains at 1.2 units/hour\n CVP now 13-15; 9^th & 10^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration; levels elevated 1\n x dose 12 units humalog administered\n Xigris on hold at 0500 given potentially low Hgb level-\n re-peat level sent for confirmation\n MICU team in contact with primary contact family members\n regarding patient\ns tenuous status; they plan to travel in today to\n visit with patient.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring. Potentially re-start\n Xigris gtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n Agree with plan to manage shock with IVF based on SVV / CVP / ScvO2,\n will check CO / echo and try to wean dopa. Will continue HC 50 q6h for\n ? adrenal insufficiency. Will check sputum cx, legionella ag, and flu\n swab while continuing zosyn / cipro / vanco and APC. Resp failure /\n ARDS - continue VAC 420 x24, place , tolerate elevated\n pCO2. AMI is stable, check echo, confirm LB3 is old, asa. Evolving ARF\n - continue IVF support, RD meds, check lytes and sediment while\n monitoring K+ closely. Will start insulin drip for goal <200, NPO for\n now. Will meet with family, very poor prognosis. Remainder of plan as\n outlined above\n" }, { "category": "Respiratory ", "chartdate": "2121-09-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596469, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 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: Bloody / 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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2121-09-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596529, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: 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 response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596820, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR; now on 1 pressor, 2 IV abx:\n xigris & insulin gtt d/c\n Shock, septic\n Assessment:\n Pneumonia/urosepsis c/b septic shock. Patient with MRSA + nasal swab,\n +VRE from OSH lab reports. Received patient on levophed gtt only. s/p\n multiple liters of fluid this admission- generalized body edema. Now on\n 2 antibiotic therapy including ciprofloxacin & zosyn. WBC 7, Continues\n to require vent support. Aline waveform dampening at intervals.\n Action:\n Hemodynamics:\n Attempted to wean levophed gtt @ intervals overnight.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 2 antibiotic therapy: Cipro & zosyn\n Given IV steroids as ordered q 6 hours (now 25 ml q 6 hours)\n Xigris discontinued prior shift decreasing HCT level &\n oozing from lines\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact precautions\n Response:\n Levophed remains at 0.03 mcg/kg/min- MAP\ns <65 when gtt\n d/c\n CVP range 7-10; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Insulin gtt d/c\nd at 1 am.\n Re-peat labs show HCT improving to 23 (21.7) no blood\n administered.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CMV 80%, rate set at 24, PEEP 13. ABG at\n start of shift: 7.31/40/93. patient synchronous with the vent, no\n overbreathing noted. Lungs diminished with some fine crackles at\n intervals, partially diminished body habitus. Suctioned for small\n amounts bloody secretions. Clear oral secretions draining from mouth.\n Patient sedated to .\n Action:\n ABG monitoring\n Maintained sedation to keep patient synchronous with the\n vent.\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Versed @ 5 mg/hr\n Fentanyl @ 200 mcg/hr\n Patient continues to be synchronous with the vent on current\n sedation\n Re-peat ABG\ns 7.34/41/170 & 7.33/41/168\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. Potential for placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.4/82. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06), likely r/u in for an MI- Cards\n consulted. Adequate hourly urine output. Elevated K+ level 5.8.\n Action:\n Electrolyte monitoring, especially potassium level\n given\n kayexelate at 1 am.\n No IVF administered this shift\n Monitored UO\n Response:\n Am CR/BUN; pending\n Am K+ 5.5, no stool output following kayexelate\n administration\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal, right AC site of old PIV\n opened blister that is oozing clear fluid & is at risk for skin\n breakdown given fluid status & pressor requirement.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear\n Sacral area- applied aloe vesta lotion\n Right AC- mepilex dressing placed & re-inforced with pink\n hy-tape\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596828, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 24 cm at lip\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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments: MDI's given alb/atr as ordered\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: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH; Comments: ABG 7.36/47/161. no rsbi due to ^ peep. Plan to\n initiate diurese today. Vent changes noc were to increase ps back to\n 15 due to periods of low VE's\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596923, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597082, "text": "Altered mental status (not Delirium)\n Assessment:\n Opens eyes when name\n\n called. Nods head to indicate that he isn\n having pain. Moving arms and legs on the bed. Midazolam and Fentanyl\n gtts off over 48hrs.\n Action:\n No sedation given for over 48hrs\n Response:\n Staff members who have assessed him over the last few days note that he\n is more awake.\n Plan:\n Continue to allow sedating drugs to wear off\n possibley resume antipsychotic medication on (Clonazine,\n Profenazide)\n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact over coccyx intact. General edema continues with\n weight 14.5kg above noted dry weight. Seeping serous fluid from\n edematous scrotum. Stage II skin breakdown noted R antecubital space,\n underneath panus.\n Action:\n Transferred patient to KCI air bed\n Open skin cleansed with wound cleanser and gauze placed to\n absorb serous fluid\n Response:\n No new skin breakdown noted\n Mepilex dressing over coccyx intact\n Plan:\n Continue to keep skin dry and clean.\n Turn side to side but patient not tolerating positioning on right side\n (drops SPO2)\n Bradycardia\n Assessment:\n Some brief episodes of bradycardia to 47. SBP > 120 at the time of\n bradycardia. When patient HR down, patient noted to appear to be\n napping. SBP as high as 151.\n Action:\n Requested prn antihypertensive medication\n Response:\n No betablockers or ace inhibitors to be given at this time\n Plan:\n Continue to monitor closely.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Rhonchi bilaterally. Diminished breathsounds at bases. SPO2 to 89-90%\n during CPAP trial with peep to 5. Many episodes of endotracheal\n suctioning required. No gag reflex noted with subglotal suctioning.\n ETT suctioned for blood tinged white/tan secretions. Agonal appearing\n respirations at times with use of accessory muscles noted.\n Hydrocortisone weaning. Hct to 21.6 overnight.\n Action:\n Attempted to keep patient at minimum of 45 degree angle\n Attempted to suction ett as often as needed\n Response:\n Failed wean attempt today around 0700\n Plan:\n Additional diuresis using Lasix bolus and gtt with 24hour negative\n balance goal of 1.5-2 liters\n Hypernatremia (high sodium)\n Assessment:\n Na to 149 this A.M.\n Action:\n Free water boluses of 200cc ordered every 4hrs via sump tube\n 400cc total boluses given\n Response:\n Na to 138\n Plan:\n Plan to check on need to continue free water\n No family phone inquiries, no visitors this shift.\n Vigieo montoring equipment discontinued today with septic shock\n resolved.\n" }, { "category": "Nursing", "chartdate": "2121-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597085, "text": "Altered mental status (not Delirium)\n Assessment:\n Opens eyes when name\n\n called. Nods head to indicate that he isn\n having pain. Moving arms and legs on the bed. Midazolam and Fentanyl\n gtts off over 48hrs.\n Action:\n No sedation given for over 48hrs\n Response:\n Staff members who have assessed him over the last few days note that he\n is more awake.\n Plan:\n Continue to allow sedating drugs to wear off\n possibley resume antipsychotic medication on (Clonazine,\n Profenazide)\n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact over coccyx intact. General edema continues with\n weight 14.5kg above noted dry weight. Seeping serous fluid from\n edematous scrotum. Stage II skin breakdown noted R antecubital space,\n underneath panus.\n Action:\n Transferred patient to KCI air bed\n Open skin cleansed with wound cleanser and gauze placed to\n absorb serous fluid\n Response:\n No new skin breakdown noted\n Mepilex dressing over coccyx intact\n Plan:\n Continue to keep skin dry and clean.\n Turn side to side but patient not tolerating positioning on right side\n (drops SPO2)\n Bradycardia\n Assessment:\n Some brief episodes of bradycardia to 47. SBP > 120 at the time of\n bradycardia. When patient HR down, patient noted to appear to be\n napping. SBP as high as 151.\n Action:\n Requested prn antihypertensive medication\n Response:\n No betablockers or ace inhibitors to be given at this time\n Plan:\n Continue to monitor closely.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Rhonchi bilaterally. Diminished breathsounds at bases. SPO2 to 89-90%\n during CPAP trial with peep to 5. Many episodes of endotracheal\n suctioning required. No gag reflex noted with subglotal suctioning.\n ETT suctioned for blood tinged white/tan secretions. Agonal appearing\n respirations at times with use of accessory muscles noted. ABG sent\n late this shift (7.26-61-65-0-29-89%) on CPAP 50% 5/5.\n Hydrocortisone weaning. Hct to 21.6 overnight.\n Action:\n Attempted to keep patient at minimum of 45 degree angle\n Attempted to suction ett as often as needed\n Dr. (#) called to bedside to evaluate respiratory\n status\n Response:\n Failed wean attempt today around 0700\n Respiratory acidosis\n Plan:\n Additional diuresis using Lasix bolus and gtt with 24hour negative\n balance goal of 1.5-2 liters\n Return patient to SIMV ventilation\n Possible need for sedation with SIMV per respiratory therapist\n use fentanyl boluses per Dr. if patient appears\n uncomfortable\n Repeat CXR\n Hypernatremia (high sodium)\n Assessment:\n Na to 149 this A.M.\n Action:\n Free water boluses of 200cc ordered every 4hrs via sump tube\n 400cc total boluses given\n Response:\n Na to 138\n Plan:\n Plan to check on need to continue free water\n No family phone inquiries, no visitors this shift.\n Vigieo montoring equipment discontinued today with septic shock\n resolved.\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596256, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: aspiration PNA/UTI or a\n combination.\n Recievied patient hypotensive: on 2 pressors ( dopamine at\n 20 mcg/kg/min & levophed @ 0.24 mcg/kg/min) s/p 8 liters NS given in ED\n Received patient hypothermic: temp 91.8\n Urine culture from ED with WBC\n ED had sent BC x 1, urine culture\n Action:\n Continued to culture patient to attempt to identify source:\n BC x1, RRT sent influenza DFA, MRSA nasal swab, urine\n specimen for legionella\n Increased doses of dopamine and levophed to support\n hemodynamics\n CVP monitoring, goal 13-15; Given total of 8 liters LR for\n fluid resuscitation\n Vigileo in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score\n Type & cross specimen sent\n Response:\n Results cultures are pending\n Dopamine now at 20 mcg/kg/min, Levophed now @ 0.4\n mcg/kg/min; required addition of vasopressin at 2.4 units/hour; patient\n BP appears most responsive to fluid resusication ; patient now with\n worsening edema, periorbital, facial, bilateral upper & lower\n extremities\n CVP now 13-15; 9^th & 10^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration; levels elevated 1\n x dose 12 units humalog administered\n Xigris on hold at 0500 given potentially low Hgb level-\n re-peat level sent for confirmation\n MICU team in contact with primary contact family members\n regarding patient\ns tenuous status; they plan to travel in today to\n visit with patient.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring. Potentially re-start\n Xigris gtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596258, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: aspiration PNA/UTI or a\n combination.\n Recievied patient hypotensive: on 2 pressors ( dopamine at\n 20 mcg/kg/min & levophed @ 0.24 mcg/kg/min) s/p 8 liters NS given in ED\n Received patient hypothermic: temp 91.8\n Urine culture from ED with WBC\n ED had sent BC x 1, urine culture\n Action:\n Continued to culture patient to attempt to identify source:\n BC x1, RRT sent influenza DFA, MRSA nasal swab, urine\n specimen for legionella\n Increased doses of dopamine and levophed to support\n hemodynamics\n CVP monitoring, goal 13-15; Given total of 8 liters LR for\n fluid resuscitation\n Vigileo in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score\n Type & cross specimen sent\n Response:\n Results cultures are pending\n Dopamine now at 20 mcg/kg/min, Levophed now @ 0.4\n mcg/kg/min; required addition of vasopressin at 2.4 units/hour; patient\n BP appears most responsive to fluid resusication ; patient now with\n worsening edema, periorbital, facial, bilateral upper & lower\n extremities\n CVP now 13-15; 9^th & 10^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration; levels elevated 1\n x dose 12 units humalog administered\n Xigris on hold at 0500 given potentially low Hgb level-\n re-peat level sent for confirmation\n MICU team in contact with primary contact family members\n regarding patient\ns tenuous status; they plan to travel in today to\n visit with patient.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring. Potentially re-start\n Xigris gtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596981, "text": "Shock, septic\n Assessment:\n Pt orally intubated. Awakes to voice, opens eyes and follows commands,\n MAE. Following commands more consistently through shift. Shakes head\n when questioned about pain. Lungs coarse bilat with thick blood\n tinged secretions from ETT. Pt grossly edematous with rising BUN/CR.\n Pedal pulses palp. SBP stable off pressors 100-130\ns most of noc. On\n zosyn and cipro IV. HCT 21.6 this AM. Vigileo indicates CO>7, CI>3\n scvo2 68-72. values vary with pt position.\n Action:\n Monitored, oriented frequently. vap care. lasix IV admin x1. IV abx\n admin as ordered. Team notified of HCT. Team notified of\n inconsistency in vigileo values.\n Response:\n Pt more awake through noc. Remains too lethargic to protect airway.\n Large amount of secretions from ETT. Moderate diuresis from lasix,\n remains grossly overloaded. HCT slightly decreased from yesterday\n afternoon. Stable BP. Unreliable vigileo data. Abg acceptable on\n current vent settings, no changes made.\n Plan:\n Continue to monitor, continue vap care and IV abx. Monitor renal labs\n and fluid balance. Orient PRN. Continue to monitor abg values and\n RSBI. ?SBT as tolerated later today.\n Impaired Skin Integrity\n Assessment:\n Pt edematous with several areas of blistering/excoriation and weeping\n skin. R antecube, testicles, bilat groins, pressure ulcer on coccyx.\n See flow sheet for details.\n Action:\n Criticaid to back/buttocks/testicles. Mepilex dressing CDI. R AC\n adaptic and kerlix changed. Bilat groins criticaid and gaze.\n Tubefeeds restarted. Turned and positioned.\n Response:\n Tolerating tubefeeds. Wounds pending.\n Plan:\n Continue skincare, turn and position, advance tubefeeds q4 hours to\n goal 45 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2121-09-09 00:00:00.000", "description": "ICU Attending", "row_id": 596251, "text": "CRITICAL CARE ATTENDING\n 00:25\n I saw and examined Mr. with Dr. , whose note reflects my\n input. I would add/emphasize that this desperately ill 74-year-old man\n presents with severe septic shock, acute renal failure, and respiratory\n failure. Background history is limited (from family; records limited\n and patient unable to discuss): COPD, schizophrenia, diabetes,\n hypothyroidism, and ?adrenal insufficiency are noted. Limited prodrome\n per family; taken to for unresponsiveness, with SBPs reportedly\n in the 40s. Markedly hypothermic and quite bradycardic. Intubated,\n given fluids, ABX, and multiple vasopressors. Transferred to .\n CVL and art line placed in ED.\n Now:\n T 91.8\n 94.6. HR 63. BP 112/51 on dopa @ 20 and Levophed @ 0.24.\n CVP 8\n A/C 420, RR20, PEEP 10, FiO2 0\n 7.20 / 33 / 99\n Distant heart\n Decreased BS on left\n Soft abdomen\n Labs reviewed. EKG reviewed, Imaging reviewed and esp notable for cr\n 3.7, CK 1836, MB 230, trop .06, UA with 21-50 WBC, leucopenia, 29%\n bands.\n Assessment and Plan\n 74-year-old man with\n Septic shock\n Respiratory failure\n Acute renal failure\n Acute MI\n Acidosis\n By history from the family, there was no meningitic prodrome, no\n diarrhea, and no abdominal symptoms. Suspect that initial event is\n either UTI and PNA, or UTI\n encephalopathy\n aspiration. At present,\n identified sources include urine and lung. Syndrome could be influenza\n staphylococcal pneumonia, but influenza-like prodrome not compelling.\n We will plan:\n Septic shock\n ABX/source control\n o Cover HCAP (recent hospitalizations), CAP (including\n Legionella), and UTI: vanco, zosyn, and quinolone are adequate.\n o Fully cult ue, including influenza DFA\n Hemodynamics\n o Currently on substantial doses of dopa and Levophed\n o Although his respiratory status is tenuous, will try to trade\n fluids for vasopressors until CVP in the 13-15 range or off pressors.\n Will need close monitoring for increased hypoxemia, etc.\n o Continue to follow EGDT protocol\n Steroids (at sepsis doses) given history of adrenal\n insufficiency and receipt of steroids\n Drotrecogin: given multiple organ failures, APACHE II >> 24\n (~37 by my calculation, depending on how one treats GCS), and absence\n of contraindications, we will proceed with drotrecogin.\n Respiratory failure\n 6cc/kg/breath (PBW)\n Sedate further to improve synchrony\n Increase PEEP to ARDSnet ladder\n If difficulty, consider esophageal balloon\n Acute renal failure\n Likely hemodynamic and sepsis-related.\n Check urine lytes\n Acidosis\n Mostly metabolic: suspect mixed lactic and non-anion gap\n from saline\n However, need repeat lytes\n Follow closely\n SQH / H2B / VAP prophylaxis / etc.\n Discussed by our team with his family.\n He is critically ill: 80 minutes\n ------ Protected Section ------\n Addendum\n 0700\n Seen multiple times throughout the night for respiratory failure and\n shock. Hypoxemia responded well to PEEP and hemodynamic management,\n and acidosis improved. Hemodymamics have been very challenging: now on\n norepi, dopa, and vasopressin after receiving approx 17L total. Has\n appeared fluid-responsive throughout the night (both to fluid trials\n and to maneuvers such as manipulation of PEEP), but suspect we are\n getting close. Will check stroke-volume variation and cardiac output\n assessment via art line, and consider whether inotropes might be\n worthwhile (doubt, given ScVO2). We have called the family and asked\n them to come back in.\n 45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 07:29 ------\n" }, { "category": "Physician ", "chartdate": "2121-09-09 00:00:00.000", "description": "MICU Attending Progress Note", "row_id": 596339, "text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient, and was physically present with the\n ICU team for the key portions of the services provided. I agree with\n the note above, including the assessment and plan. I would emphasize\n and add the following points: 74M severe pneumonia L>R c/b refractory\n septic shock. Family notes malaise, hypothermia and lethargy over 48h,\n brought to OSH - hypotensive, bradycardic, intubated, triple pressors,\n IVF, abx, steroids - transferred to .\n Exam notable for Tm 99.6 BP 100/60 HR 84 RR 24 with sat 97 on VAC\n 420x24 0.8 13 7.27/48/75. Obese man, NAD not overbreathin. Coarse BS B.\n RRR s1s2. Soft +BS. 3+ edema. Labs notable for WBC 2.1K, HCT 30, K+\n 6.1, Cr 3.2. CXR with L>R ASD, EKG LB3.\n Agree with plan to manage shock with IVF based on SVV / CVP / ScvO2,\n will check CO / echo and try to wean dopa. Will continue HC 50 q6h for\n ? adrenal insufficiency. Will check sputum cx, legionella ag, and flu\n swab while continuing zosyn / cipro / vanco and APC. Resp failure /\n ARDS - continue VAC 420 x24, place , tolerate elevated\n pCO2. AMI is stable, check echo, confirm LB3 is old, asa. Evolving ARF\n - continue IVF support, RD meds, check lytes and sediment while\n monitoring K+ closely. Will start insulin drip for goal <200, NPO for\n now. Will meet with family, very poor prognosis. Remainder of plan as\n outlined above.\n Addendum\n case d/w family at length. Will continue aggressive\n supportive care for now with the exception of CPR / shock.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596627, "text": "y/o w/ limited PMH including DM, COPD & Schizophrenia, hypothyroidism.\n P/w severe septic shock, ARF & resp failure. Per fam, pt taken to\n for unresponsiveness at home (persisted from evening prior to\n day of admission into the AM of admission), w/ SBPs reportedly in the\n 40s, hypothermic & bradycardic. Intubated, given IVF, abx & mult\n pressors. to CCU as MICU pt. TLC presep & aline placed.\n R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx bottles from\n OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o flu &\n legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 23.less bleeding from mouth,lines,ett secretions blood tinged\n ,platelets increasing ,ptt decreasing by holding sc heparin .bp tol\n levo wean ,no bradycardia ,ci 6 ,tol tf ,no stool,lactulose ordered .\n rectal exam showed soft brown guiac neg stool,ng aspirate guiac neg\n also\n Action:\n Triple abx ,vanco level 15.4, dose to be adjusted\n Levo weaned\n Sedation dc\n Response:\n Tol levo wean,abgs good\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo wean goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleedingno\n Continue Xigris til 07:30\ncheck coags/CBC \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since noon No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n Weaned peep to 11\n VAP protocol, HOB elevated\n Response:\n ABGs. 7.39/38/97/24\n Plan:\n Wean vent as tol,\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 45cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 73-200s\n Action:\n Insulin gtt of f at 73 but quickly rose to 200 despite\n drip being restarted at previous rate\n Response:\n hyperglycemic\n Plan:\n Continue to titrate ,hrly bs\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area duoderm in place . L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\ndsd d/I\n Action:\n Turned q2,aloe vesta ,criticare applied\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Nursing", "chartdate": "2121-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596705, "text": "Shock, septic\n Assessment:\n HCT 22.3 (23). Afebrile. MAPs >65 on Levo. HR 60-70s SR w/o ectopy.\n Gross general body edema.\n Action:\n Triple abx\n Levo weaned\n Response:\n Unable to wean Levo off\nMAPs fall below 65. Adequate UOP. BUN/Cr\n 100/4.5 (94/4.2). PLT 73(76). Random vanco level this AM 18.0\n Plan:\n Monitor hemodynamics\nvigileo\n ? Transfusion PRBC today\n Continue levo for goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleeding\n Continue Xigris til 07:30\ncheck coags/CBC \n Type and Screen expires tonight at 23:59. Please send\n another w/ routine labs today\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96% on AC 50% 420x24 11 PEEP. Overbreathing 4 breaths,\n appearing desynchronous. PF ratio 184\n Action:\n VAP care per protocol, HOB up 45 degrees\n Placed on CPAP at 04:30\n Response:\n Appearing more comfortable. Sats 97% on CPAP, ABG gd: 7.36/40/177/97%\n Plan:\n Wean vent as tol, follow ABGs\n Hyperglycemia\n Assessment:\n TF @ goal rate 45cc/hr w/ mod amts residuals. On Steroids Q6hrs. FSGB\n high 100s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Constipation (Obstipation, FOS)\n Assessment:\n No BM since at least admission \n Action:\n Aggressive bowel regimen\n Response:\n X-lg amts formed stool, then lg amts loose stool\nunable to place\n flexi-seal consistency. Guiac POS\n Plan:\n Hold Bowel meds for now\n Altered mental status (not Delirium)\n Assessment:\n Sedation off since noon . No spontaneous mvmts. No corneals.\n Action:\n Neuro assessment monitored\n Response:\n + corneal reflexes in AM, resisting eye exam. Rare RUE mvmts. BUN 100\n (94)\n Plan:\n Continue to monitor neuro exam--? adding just bolus sedation\n PRN\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid. R radial aline site w/ blisters from\n ? tegaderm\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Thin duoderm to\n protect site from friction intact (placed )\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed at 00:00\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF. Incontinent care\n ? DC RIJ TLC and Place PICC once Xigris off.\n" }, { "category": "Physician ", "chartdate": "2121-09-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596909, "text": "Chief Complaint:\n 24 Hour Events:\n -discontinued vancomycin and weaned hydrocortisone to 25 mg q 6hr\n -xigris discontinued\n -insulin drip changed from gtt to SQ\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 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 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96\n HR: 56 (55 - 68) bpm\n BP: 138/55(83) {104/47(65) - 142/93(102)} mmHg\n RR: 14 (7 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 115.7 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 7 (6 - 12)mmHg\n Total In:\n 2,410 mL\n 751 mL\n PO:\n TF:\n 1,083 mL\n 327 mL\n IVF:\n 1,327 mL\n 424 mL\n Blood products:\n Total out:\n 2,025 mL\n 590 mL\n Urine:\n 2,025 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n 161 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 860 (755 - 910) mL\n PS : 15 cmH2O\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n SpO2: 100%\n ABG: 7.36/47/161/24/0\n Ve: 5.5 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 7.5 g/dL\n 201 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 97 mg/dL\n 109 mEq/L\n 143 mEq/L\n 22.8 %\n 7.9 K/uL\n [image002.jpg]\n 09:39 PM\n 04:00 AM\n 04:12 AM\n 06:12 AM\n 03:32 PM\n 03:55 PM\n 09:11 PM\n 10:35 PM\n 04:28 AM\n 05:01 AM\n WBC\n 7.0\n 7.9\n Hct\n 22.3\n 21.7\n 23.0\n 22.8\n Plt\n 73\n 67\n Cr\n 4.5\n 4.2\n TCO2\n 24\n 24\n 24\n 25\n 24\n 28\n Glucose\n 125\n 201\n Other labs: PT / PTT / INR:11.6/32.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:5.4 mg/dL\n Imaging: Single AP chest radiograph compared to shows\n unchanged left\n mid lower lung consolidation. Right lower lobe airspace opacity and\n perihilar\n hazziness continues to improve compatible with decreased fluid\n overload. The\n cardiomediastinal contour is stable. There is no pneumothorax. Right IJ\n central venous catheter tip overlies the proximal SVC. NG tube tip is\n in the\n stomach. ET tube terminates 3 cm above the carina.\n Microbiology: STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B\n TEST-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY\n {YEAST, GRAM NEGATIVE ROD(S)} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST,\n GRAM NEGATIVE ROD(S)} INPATIENT\n URINE Legionella Urinary Antigen -FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL;\n DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT\n MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN\n RESISTANT STAPH AUREUS} INPATIENT\n URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors since this AM\n - will continue on broad coverage with Zosyn, Cipro. currently growing\n vre sensitive to amp, gnrs from sputum gram stain x2 and coag neg staph\n from blood (likely contaminant) from . dc'ed vancomycin\n yesterday\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 25q6h (=3.75 daily\n of decadron, pt on 2 daily of decadron at home)\n - pt finished course of xygris yesterday.\n .\n ##. Respiratory Failure:\n - will aim for SBT today\n - off sedation\n .\n # : baseline 1.8-2, current Cr is 4.2 down from 4.5 yesterday.\n Likely this is ATN. UOP has gone from low to high so perhaps renal\n function is in process of improving.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will give 40mg IV lasix this AM\n and follow UOP for goal of 1.5L negative today\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - consider add bblocker and ace pending improvement of bradycardia and\n RF respectively\n - restart ASA now that xigris is off\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -on PPI\n -stool guiac negative\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med now that sedation off\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n .\n # DM: now back on insulin SQ\n .\n .# SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, tube feeds at goal\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (chemical code ok)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:36 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2121-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597074, "text": "Altered mental status (not Delirium)\n Assessment:\n Opens eyes when name\n\n called. Nods head to indicate that he isn\n having pain. Moving arms and legs on the bed. Midazolam and Fentanyl\n gtts off over 48hrs.\n Action:\n No sedation given for over 48hrs\n Response:\n Staff members who have assessed him over the last few days note that he\n is more awake.\n Plan:\n Continue to allow sedating drugs to wear off\n possibley resume antipsychotic medication on (Clonazine,\n Profenazide)\n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact over coccyx intact. General edema continues with\n weight 14.5kg above noted dry weight. Seeping serous fluid from\n edematous scrotum. Stage II skin breakdown noted R antecubital space,\n underneath panus.\n Action:\n Transferred patient to KCI air bed\n Open skin cleansed with wound cleanser and gauze placed to\n absorb serous fluid\n Response:\n No new skin breakdown noted\n Mepilex dressing over coccyx intact\n Plan:\n Continue to keep skin dry and clean.\n Turn side to side but patient not tolerating positioning on right side\n (drops SPO2)\n Bradycardia\n Assessment:\n Some brief episodes of bradycardia to 47. SBP > 120 at the time of\n bradycardia. When patient HR down, patient noted to appear to be\n napping. SBP as high as 151.\n Action:\n Requested prn antihypertensive medication\n Response:\n No betablockers or ace inhibitors to be given at this time\n Plan:\n Continue to monitor closely.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Rhonchi bilaterally. Diminished breathsounds at bases. SPO2 to 89-90%\n during CPAP trial with peep to 5. Many episodes of endotracheal\n suctioning required. No gag reflex noted with subglotal suctioning.\n ETT suctioned for blood tinged white/tan secretions.\n Hydrocortisone weaning. Hct to 21.6 overnight.\n Action:\n Response:\n Failed wean attempt today around 0700\n Plan:\n Additional diuresis using Lasix bolus and gtt with 24hour negative\n balance goal of 1.5-2 liters\n No family phone inquiries, no visitors this shift.\n Vigieo montoring equipment discontinued today with septic shock\n resolved.\n" }, { "category": "General", "chartdate": "2121-09-15 00:00:00.000", "description": "Generic Note", "row_id": 597162, "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. Sedated on\n ventilator. Does not respond to commands.\n 99.2 73 131/50\n Unresponsive\n Chest\n distant few crackles\n CV distant\n Extrem\n 4+ edema\n Creat 4.5\n I&O\n 1L yesterday\n Low grade fever. CXR yesterday suggested worsening infiltrates. We are\n continuing linezolid and for his VRE and Acinetobacter. On lasix\n gtt he was negative. Will try to increase dose today with goal of >\n 2L/d negative. Now on increased ventilator support\n not a candidate\n for weaning yet so will leave in CMV. Not on beta blocker after MI but\n HR 50\ns so will hold off.\n Time spent 45 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596817, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely cause is PNA seen on Cxray; however also ruling out for\n influenza & legionella, some WBC\ns in urine. Received patient on 3\n pressors (dopamine, levophed & vasopressin) s/p total of 8 liters NS\n given in ED & 9 liters LR in CCU (patient with generalized body edema).\n On 3 antibiotic regimen & steroids. Patient now normothermic off\n warming blanket, WBC 10.4, Continues to require vent support. Aline\n waveform dampening at intervals.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin gtt off.\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT/INR monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Vanco level sent 6 am.\n Goal BG level 150-200, maintained with insulin gtt ranging\n 0.5-2 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CMV 80%, rate set at 24, PEEP 13. ABG at\n start of shift: 7.31/40/93. patient synchronous with the vent, no\n overbreathing noted. Lungs diminished with some fine crackles at\n intervals, partially diminished body habitus. Suctioned for small\n amounts bloody secretions. Clear oral secretions draining from mouth.\n Patient sedated to .\n Action:\n ABG monitoring\n Maintained sedation to keep patient synchronous with the\n vent.\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Versed @ 5 mg/hr\n Fentanyl @ 200 mcg/hr\n Patient continues to be synchronous with the vent on current\n sedation\n Re-peat ABG\ns 7.34/41/170 & 7.33/41/168\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. Potential for placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.4/82. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06), likely r/u in for an MI- Cards\n consulted. Adequate hourly urine output. Elevated K+ level 5.8.\n Action:\n Electrolyte monitoring, especially potassium level\n given\n kayexelate at 1 am.\n No IVF administered this shift\n Monitored UO\n Response:\n Am CR/BUN; pending\n Am K+ 5.5, no stool output following kayexelate\n administration\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal, right AC site of old PIV\n opened blister that is oozing clear fluid & is at risk for skin\n breakdown given fluid status & pressor requirement.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear\n Sacral area- applied aloe vesta lotion\n Right AC- mepilex dressing placed & re-inforced with pink\n hy-tape\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Physician ", "chartdate": "2121-09-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597137, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 01:18 PM\n URINE CULTURE - At 01:18 PM\n -talked to ID about how to cover both vre (urine) and acinetobacter\n (lungs), pt now on for acinetobacter (day ) and linezolid for\n VRE day .\n -hypernatremic in the am, increased free water in tube feeds,\n afternoon sodium was corrected at 138, tube feed free water was\n decreased from 250q4h to 200q4h, now Na is 146.\n -transfused for hct of 21 which then bumped appropriately. repleting K\n gently given \n -plan to do SBT on am of (should ask resp therapy and/or nsg re\n this prior to rounds so perhaps pt can be on sbt during rounds)\n -pt noted to be acutely desatting with O2 sat in the high 80s. ABG was\n drawn and showed 7.26, pCO2 61, pO2 65. Pt was put on a rate of 20,\n PEEP was increased from 5->10. CXR was repeated which showed no change.\n Repeat ABG was 7.33/53/94\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:07 AM\n Meropenem - 12:29 AM\n Linezolid - 05:19 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.1\nC (95.1\n HR: 59 (44 - 73) bpm\n BP: 137/56(82) {106/51(72) - 159/68(98)} mmHg\n RR: 20 (11 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 10 (10 - 303)mmHg\n Total In:\n 2,160 mL\n 706 mL\n PO:\n TF:\n 268 mL\n 224 mL\n IVF:\n 1,118 mL\n 482 mL\n Blood products:\n 375 mL\n Total out:\n 3,385 mL\n 1,225 mL\n Urine:\n 3,385 mL\n 1,225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -518 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 341 (341 - 620) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 17 cmH2O\n Plateau: 23 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 92%\n ABG: 7.40/45/84./24/1\n Ve: 9 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Cardiovascular: General: Elderly Caucasian Male intubated in NARD.\n Psych: Localizes to pain, opens eyes to verbal stimuli\n HEENT: Sclera anicteric, MMM\n Neck: difficult to eval JVP given IJ\n Lungs: Crackles noted diffusely on anterior exam with diminished\n crackles over left lung field.\n CV: Borderline bradycardic (50), S1 + S2, no murmurs, rubs, gallops\n Abdomen: no grimacing noted on abdominal palpation, non-distended,\n obese, + bowel sounds present, no rebound tenderness or guarding\n Ext: 2+ edema noted in all extremities.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 111 K/uL\n 8.6 g/dL\n 172 mg/dL\n 4.5 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 104 mg/dL\n 109 mEq/L\n 146 mEq/L\n 25.2 %\n 4.4 K/uL\n [image002.jpg]\n 12:03 AM\n 04:32 AM\n 08:00 AM\n 12:00 PM\n 04:00 PM\n 04:23 PM\n 06:33 PM\n 07:23 PM\n 03:46 AM\n 04:05 AM\n WBC\n 5.4\n 4.4\n Hct\n 21.6\n 25.0\n 25.2\n Plt\n 91\n 111\n Cr\n 4.6\n 4.6\n 4.5\n TCO2\n 29\n 29\n 29\n 29\n Glucose\n 105\n 130\n 113\n 130\n 172\n Other labs: PT / PTT / INR:12.0/35.5/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.8 mg/dL, Mg++:2.8 mg/dL, PO4:5.4 mg/dL\n Fluid analysis / Other labs: ABG\n pH7.40\n pCO2 45\n pO2 84\n HCO329\n BaseXS1\n Iron studies pending\n Imaging: CXR - Bilateral patchy air space opacities with improved\n aeration at the RLL and more confluent opacity in the left perihilar\n region. Unchanged bilateral\n pleural effusions. Stable lines and tubes.\n Microbiology: Blood cultures 9/22, , - NGTD\n Urine culture - no growth,\n - NGTD\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors since yesterday\n - was on zosyn/cipro, broadened to given acinetobacter in sputum\n s to imi and tobra only. currently growing vre sensitive to\n amp/linizolid on started on linezolid per ID recs. coag neg staph\n from blood (likely contaminant) from . Monitor for CBC as pt on\n linezolid\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 25q6h, will space to\n 25q8 today (=2.8 daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n -urine eos ordered to r/o AIN as pt has been getting lots of beta\n lactams since admission (most likely etiology is by far atn) also wbc\n on ua wnl, not so suggestive of AIN. should f/u in am though.\n ##. Respiratory Failure:\n - sats in the low 90s, defer trial of SBP until respiratory status\n improves\n - off sedation\n # : baseline 1.8-2, current Cr is 4.5, was 4.6 yesterday prior to\n diuresis but increased slightly over course of the day.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis c\n lasix gtt\n -if renal function does not improve, will consult renal\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - consider add bblocker and ace pending improvement of bradycardia and\n RF respectively\n - on ASA now that xigris is off\n #hypernatremia: hypernatremic to 146 this am. will increase free water\n in tube feeds.\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -on PPI\n -stool guiac negative\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated, and in the setting of linezolid\n -consider restart home psych med now that sedation off\n -consider psych consult when extubated.\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n # DM: now back on insulin SQ, may need to tighten ss\n # SW: will consult sw re concerns about pt's home situation\n # FEN: replete electrolytes, tube feeds at goal\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: Right IJ, A-line\n # Code: DNR (chemical code ok)\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:16 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 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": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596325, "text": "74 yo with known PMH, adult onset DM, COPD & Schizophrenia,\n hypothyroidism, nephrectomy, asp pna req hospitalizations (intubated),\n ?adrenal insufficiency who presents to OSH unresponsive w/ sbp\n 40\ns marked hypothermia and bradycardia. Pt w/ severe septic shock,\n acute renal failure, and respiratory failure. Pt was Intubated, given\n fluids, ABX, and multiple vasopressors. Transferred to via\n . TLC presep cath & arterial line placed in ED. Transferred\n to CCU as MICU border.\n Shock, septic\n Assessment:\n Rec\nd pt on triple pressors including dopamine 20mcg/kg/min,\n vasopressin 2.4units/hr and levophed 0.5mcg/kg/min. BP\n 90-110/50-60\ns. HR 70-80\ns nsr w/ rare apc. Temp normothermic 99.6.\n CVP\ns 15 down to 11.\n CR/BUN 3.3/81. Approx 20L positive.\n Action:\n Triple pressors cont, but dopamine has been decreased throught day.\n Triple abx continue.\n 1000cc LR administered for low CVP@ 11am.\n Xigris restarted 20mg/hr. H/H, coags and lytes monitoring q6hrs\n Vigileo monitoring\n CO 5.5-5.3. SVV .\n IV steriods conintue.\n Insulin gtt started.\n Response:\n Culture results are pending\n Tolerating Dopa wean, maintaining SBP >110.\n No significant CVP response to IVF bolus.\n Patient now with worsening edema, periorbital, facial, bilateral upper\n & lower extremities\n BG now controlled w/ insulin gtt.\n H/H 29.9/9.3, and 28.6/9.2. WBC 9.2 INR 1.2.\n u/o 0-70cc/hr.\n Plan:\n Continue septic shock management with MICU team. Attempt to wean dopa\n as tolerated, Close monitoring of labs on xigris, cont insulin gtt as\n necessary, close monitoring i/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont intubated and ventilated 80%/420/24/13peep. Breathing in synch\n w/ vent.\n Pt sedated 200mcgs/hr fentanyl, Versed 5mg/hr.\n Action:\n ABG\ns q4-6hr, 7.25/41/106/- and 7.31/40/93/-\n Aggressive pulmonary toileting\n VAP care per protocol\n Sedation unchanged.\n Response:\n Sx for sm amts thick tan, blood tinged secretions via ETT. Copious\n clear oral secretions noted.\n Comfortable on current fent/versed regime.\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Cont fent and\n versed for comfort.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement. Blister noted r ac area\n underneath tegaderm iv dsg, becoming deroofed and is oozing lg amts\n clear.\n Action:\n Turned and positioned q2-4 hrs. Barrier cream to sacrum, elbows and\n heels\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment w/ close monitoring elbows\n and knees.\n Social\n lives w/ son and daughter in MA. Family met at length w/\n Dr. and this RN. Have been thoroughly updated on POC. Pt is DNR\n (no CPR or shock), but will continue aggressive management for septic\n shock.\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596241, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: aspiration PNA/UTI or a\n combination.\n Recievied patient hypotensive: on 2 pressors ( dopamine at\n 20 mcg/kg/min & levophed @ 0.24 mcg/kg/min) s/p 8 liters NS given in ED\n Received patient hypothermic: temp 91.8\n Urine culture from ED with WBC\n ED had sent BC x 1, urine culture\n Action:\n Continued to culture patient to attempt to identify source:\n BC x1, RRT sent influenza DFA, MRSA nasal swab, urine\n specimen for legionella\n Maitnained & increased doses of dopamine and levophed to\n support hemodynamics\n CVP monitoring, goal 13-15; Given total of 4 liters LR for\n fluid resuscitation\n Vigileo in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score\n Response:\n Results cultures are pending\n Dopamine now at 20 mcg/kg/min, Levophed now @ 0.4 mcg/kg/min\n CVP remains ; 5^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n 4 am ABG:\n Plan:\n Potential for placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06)\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 4 liters\n Response:\n Am CR/BUN\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium level:\n Re-peat K+ level:\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n" }, { "category": "Physician ", "chartdate": "2121-09-12 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 596807, "text": "Chief Complaint:\n 24 Hour Events:\n -got 500mg of vanc for trough of 15\n -continued on just levophed, weaning\n -did have bm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 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 07:50 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: 35.8\nC (96.5\n HR: 67 (62 - 73) bpm\n BP: 120/54(75) {104/47(65) - 150/70(92)} mmHg\n RR: 9 (6 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 117.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (8 - 14)mmHg\n Total In:\n 2,792 mL\n 996 mL\n PO:\n TF:\n 1,005 mL\n 337 mL\n IVF:\n 1,697 mL\n 658 mL\n Blood products:\n Total out:\n 1,890 mL\n 635 mL\n Urine:\n 1,890 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 902 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 582 (582 - 582) mL\n PS : 15 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 11 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.36/40/177/21/-2\n Ve: 11.1 L/min\n PaO2 / FiO2: 354\n Physical Examination\n Cardiovascular: gen: intubated, sedated, can open eyes\n cv: RRR\n resp: CTA anteriorly\n abd: soft, +BS, obese\n ext: sig b/l edema\n Labs / Radiology\n 73 K/uL\n 7.5 g/dL\n 125 mg/dL\n 4.5 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 100 mg/dL\n 106 mEq/L\n 141 mEq/L\n 22.3 %\n 7.0 K/uL\n [image002.jpg]\n 12:08 AM\n 04:00 AM\n 04:09 AM\n 03:43 PM\n 03:54 PM\n 09:19 PM\n 09:39 PM\n 04:00 AM\n 04:12 AM\n 06:12 AM\n WBC\n 5.5\n 7.8\n 7.3\n 7.0\n Hct\n 23.2\n 23.9\n 23.0\n 22.3\n Plt\n 55\n 64\n 76\n 73\n Cr\n 4.1\n 4.2\n 4.5\n TCO2\n 23\n 24\n 24\n 24\n 24\n 24\n Glucose\n 110\n 125\n Other labs: PT / PTT / INR:12.3/56.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro. currently growing\n vre sensitive to amp, gnrs from sputum gram stain x2 and coag neg staph\n from blood (likely contaminant) from . dc vancomycin today\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 50q6h (=7.5 daily of\n decadron, pt on 2 daily of decadron at home) will switch to 25q6h\n - pt on xygris high apache score, check coags. low threshold to\n dc xygris if any coag abnormalities. Xygris course done tomorrow.\n .\n ##. Respiratory Failure:\n - will aim to wean PSV today, will try \n - lighten Fentanyl and Midazolam\n .\n # : baseline 1.8-2, current Cr is 4.5 up from 4 yesterday. Likely\n this is ATN. UOP has gone from low to high so perhaps renal\n function is in process of improving.\n -will trend\n -no acute indications for HD at this point\n -pt is on lasix at home, could consider giving lasix gtt once off\n pressors\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -switched to PPI\n -stool guiac negative\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin. Will switch to subcutaneous once off pressors\n .\n .# SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, tube feeds at goal\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (chemical code ok)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:28 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\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: 74M DM, obesity, ?CHF, CRI (1.8-2.0) p/w\n severe pneumonia L>R c/b refractory septic shock. Weaning pressors,\n increased UOP. Weaning pressors.\n Exam notable for Tm 97.8 BP 120/52 HR 87 RR 24 with sat 96 on PSV 15/11\n 0.5 7.36/40/177 CVP 12, UOP >100cc/h. Obese man, NAD. Coarse BS B. RRR\n s1s2. Soft +BS. 3+ edema. Labs notable for WBC 7K, HCT 22, plts 76, K+\n 4.0, Cr 4.5. CXR with L>R ASD.\n Agree with plan to manage pneumonia / urosepsis c/b septic shock with\n wean of vasopressors (plan to d/c levo today) as we decrease sedation\n and PEEP (change to 10/10). Will decrease HC to 25 q6h for ? adrenal\n insufficiency. Will contine zosyn / cipro in addition to APC; can stop\n vanco today. Resp failure / ARDS - continue VAC 420 x24, wean PEEP. AMI\n is stable, will treat medically as condition improves. ARF - RD meds,\n monitor K+ closely, UOP , start lasix gtt when durably off\n pressors. Monitor HCT on APC. Will continue insulin drip for goal <200,\n change to SC when off pressors. TF at goal, bowel regimen. DNR.\n Remainder of plan as outlined above.\n Addendum\n HCT down this PM, will d/c APC now, guiac stools, NGT to\n suction, BBS, serial HCT, xfuse to >25%, PPI.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 09:06 PM ------\n" }, { "category": "Respiratory ", "chartdate": "2121-09-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596974, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 24 cm at lip\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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments: MDI's of alb/atr given as ordered, no adverse reactions\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: ABG 7.40/45/81 with RSBI=33.\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: Plan to wean to SBT then possible extubation?\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2121-09-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596435, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n - TTE: extremely poor image windows. LV systolic function is probably\n normal LVEF > 55 %. Other structures of the heart are not well\n visualized.\n - Cx from ED: 2/4 bottles with GPC in clusters - f/u speciation\n and sensitivities \n - Weaned off Dopamine and vasopressin, still on max levophed\n - Potassium persistently elevated > 5.5 treated with Kayexalate but did\n not have BM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Norepinephrine - 0.5 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Famotidine (Pepcid) - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 72 (62 - 85) bpm\n BP: 109/74(90) {90/50(64) - 142/5,955(162)} mmHg\n RR: 24 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (11 - 18)mmHg\n Total In:\n 21,885 mL\n 1,316 mL\n PO:\n 120 mL\n TF:\n IVF:\n 13,885 mL\n 1,136 mL\n Blood products:\n Total out:\n 842 mL\n 415 mL\n Urine:\n 842 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 21,043 mL\n 903 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 13 cmH2O\n FiO2: 80%\n PIP: 30 cmH2O\n Plateau: 25 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 97%\n ABG: 7.33/41/168/20/-4\n Ve: 9.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n Cardiovascular: gen: intubated, sedated\n cv: RRR\n resp: reduced breath sounds anteriorly\n abd: soft, hypoactive bowel sounds\n ext: edematous diffusely\n Labs / Radiology\n 88 K/uL\n 9.0 g/dL\n 176 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 5.5 mEq/L\n 82 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.4 %\n 10.4 K/uL\n [image002.jpg]\n 05:13 AM\n 06:26 AM\n 06:43 AM\n 11:49 AM\n 12:19 PM\n 05:51 PM\n 06:16 PM\n 11:58 PM\n 12:33 AM\n 06:22 AM\n WBC\n 2.1\n 6.1\n 9.4\n 10.4\n Hct\n 31\n 30.2\n 29.9\n 28.6\n 27.4\n Plt\n 115\n 100\n 103\n 88\n Cr\n 3.2\n 3.3\n 3.5\n 3.4\n TropT\n 0.09\n TCO2\n 23\n 19\n 21\n 23\n 23\n Glucose\n 76\n Other labs: PT / PTT / INR:14.7/96.0/1.3, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:57/63, Alk Phos / T Bili:43/0.2,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:661 mg/dL, LDH:259 IU/L, Ca++:6.8 mg/dL, Mg++:1.4\n mg/dL, PO4:3.1 mg/dL\n Microbiology: GPCs in clusters from \n legionella neg\n flu neg\n cultures pending\n sputum gram stain:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n TTE: Extreemly poor image windows. The left atrium is normal in size.\n Due to suboptimal technical quality, a focal wall motion abnormality\n cannot be fully excluded. Overall left ventricular systolic function is\n probably normal (LVEF>55%). RV not well seen. The aortic valve is not\n well seen. There is no aortic valve stenosis. The mitral valve leaflets\n are not well seen. There is no pericardial effusion.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro for coverage of\n Gram+, Gram -, atypicals and double coverage for Pseudomonas.\n Vancomycin for MRSA. Blood cx from OSH growing GPCs in clusters. Will\n wait to confirm that this is not contaminant before narrowing coverage\n - f/u panculture results, continue surveillance blood cultures\n - will continue on IV Hydrocortisone, wean starting tomorrow\n - pt on xygris high apache score, check coags\n .\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - continue ardsnet\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n #hyperkalemia: could be to renal failure, but pt is making urine.\n Also ? hypoaldo as pmh and home meds. Most likely to comb\n of renal insuff plus repletion c LR. Will call PCP today Dr \n today to get better sense of pmh.\n -f/u am K\n -may need additional kayexelate, but will hold for now\n .\n # : baseline.\n -Consider urine sediment.\n -Check urine lytes to diff bet prerenal v atn, most likely atn\n -ask pcp about baseline GFR\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring Atropine in the\n field for HR in the 40s. Bradycardia is likely due to his hypothermia.\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration\n -keep active type and screen\n -increase H2B to \n -guiac stool\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine.\n .\n #housekeeping: will call PCP to learn more about overall status of pt\n .\n # FEN: replete electrolytes, consider OGT and tube feeds.\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-10 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 596452, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n - TTE: extremely poor image windows. LV systolic function is probably\n normal LVEF > 55 %. Other structures of the heart are not well\n visualized.\n - Cx from ED: 2/4 bottles with GPC in clusters - f/u speciation\n and sensitivities \n - Weaned off Dopamine and vasopressin, still on max levophed\n - Potassium persistently elevated > 5.5 treated with Kayexalate but did\n not have BM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Norepinephrine - 0.5 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Famotidine (Pepcid) - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 72 (62 - 85) bpm\n BP: 109/74(90) {90/50(64) - 142/5,955(162)} mmHg\n RR: 24 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (11 - 18)mmHg\n Total In:\n 21,885 mL\n 1,316 mL\n PO:\n 120 mL\n TF:\n IVF:\n 13,885 mL\n 1,136 mL\n Blood products:\n Total out:\n 842 mL\n 415 mL\n Urine:\n 842 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 21,043 mL\n 903 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 13 cmH2O\n FiO2: 80%\n PIP: 30 cmH2O\n Plateau: 25 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 97%\n ABG: 7.33/41/168/20/-4\n Ve: 9.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n Cardiovascular: gen: intubated, sedated\n cv: RRR\n resp: reduced breath sounds anteriorly\n abd: soft, hypoactive bowel sounds\n ext: edematous diffusely\n Labs / Radiology\n 88 K/uL\n 9.0 g/dL\n 176 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 5.5 mEq/L\n 82 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.4 %\n 10.4 K/uL\n [image002.jpg]\n 05:13 AM\n 06:26 AM\n 06:43 AM\n 11:49 AM\n 12:19 PM\n 05:51 PM\n 06:16 PM\n 11:58 PM\n 12:33 AM\n 06:22 AM\n WBC\n 2.1\n 6.1\n 9.4\n 10.4\n Hct\n 31\n 30.2\n 29.9\n 28.6\n 27.4\n Plt\n 115\n 100\n 103\n 88\n Cr\n 3.2\n 3.3\n 3.5\n 3.4\n TropT\n 0.09\n TCO2\n 23\n 19\n 21\n 23\n 23\n Glucose\n 76\n Other labs: PT / PTT / INR:14.7/96.0/1.3, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:57/63, Alk Phos / T Bili:43/0.2,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:661 mg/dL, LDH:259 IU/L, Ca++:6.8 mg/dL, Mg++:1.4\n mg/dL, PO4:3.1 mg/dL\n Microbiology: GPCs in clusters from \n legionella neg\n flu neg\n cultures pending\n sputum gram stain:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n TTE: Extreemly poor image windows. The left atrium is normal in size.\n Due to suboptimal technical quality, a focal wall motion abnormality\n cannot be fully excluded. Overall left ventricular systolic function is\n probably normal (LVEF>55%). RV not well seen. The aortic valve is not\n well seen. There is no aortic valve stenosis. The mitral valve leaflets\n are not well seen. There is no pericardial effusion.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro for coverage of\n Gram+, Gram -, atypicals and double coverage for Pseudomonas.\n Vancomycin for MRSA. Blood cx from OSH growing GPCs in clusters. Will\n wait to confirm that this is not contaminant before narrowing coverage\n - f/u panculture results, continue surveillance blood cultures\n - will continue on IV Hydrocortisone, wean starting tomorrow\n - pt on xygris high apache score, check coags\n .\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - continue ardsnet\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n #hyperkalemia: could be to renal failure, but pt is making urine.\n Also ? hypoaldo as pmh and home meds. Most likely to comb\n of renal insuff plus repletion c LR. Will call PCP today Dr \n today to get better sense of pmh.\n -f/u am K\n -may need additional kayexelate, but will hold for now\n .\n # : baseline.\n -Consider urine sediment.\n -Check urine lytes to diff bet prerenal v atn, most likely atn\n -ask pcp about baseline GFR\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring Atropine in the\n field for HR in the 40s. Bradycardia is likely due to his hypothermia.\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration\n -keep active type and screen\n -increase H2B to \n -guiac stool\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine.\n .\n #housekeeping: will call PCP to learn more about overall status of pt\n .\n # FEN: replete electrolytes, consider OGT and tube feeds.\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\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: 74M severe pneumonia L>R c/b refractory\n septic shock. Weaning pressors, increased UOP. BCx GPC / clusters x2.\n Exam notable for Tm 99.6 BP 110/70 HR 72 RR 24 with sat 97 on VAC\n 420x24 0.5 13 7.33/41/168 CVP 18, +21L. Obese man, NAD not\n overbreathing. Coarse BS B. RRR s1s2. Soft +BS. 3+ edema. Labs notable\n for WBC 9K, HCT 26, K+ 5.1, Cr 3.4. CXR with L>R ASD.\n Agree with plan to manage likely staph pneumonia c/b septic shock with\n wean of vasopressors as we decrease sedation and PEEP. Will decrease HC\n to 25 q6h in AM for ? adrenal insufficiency. Will contine zosyn / cipro\n / vanco to level in addition to APC, will likely be able to d/c GNR\n coverage if cx remain negative here. Resp failure / ARDS - continue VAC\n 420 x24, wean PEEP. AMI is stable, will treat medically as condition\n improves. ARF - continue IVF support, RD meds, monitor K+ closely, UOP\n rising, hold on further boluses for now. Will continue insulin drip for\n goal <200, NPO for now. ADAT, bowel regimen. DNR. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:36 ------\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596453, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR\nCPR not indicated, but would\n use pressors.\n Shock, septic\n Assessment:\n Ruled out for influenza and legionella, blood cultures from OSH\n with GPC . Urine sample from OSH + for VRE. Received pt on levophed,\n dopamine and vasopressin had been weaned off over night.\n Action/Response:\n Hemodynamics monitored: CVP 10-12, Vigileo monitoring in\n place: CO 4.7-5.3, CI 2.1-2.4, Scvo2 low 80\ns high 70\n No further fluid boluses\n Levophed weaned from 0.5 mcg/kg/min to with goal MAP >65\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn. Vanco dose\n given late awaiting trough level\ntrough 8 on q 48 hour dosing.\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) @ 20 mcg/kg/min, H/H, PLTS & PT/INR\n monitored .\n Assessed for bleeding\nno expansion of L groin hematoma (site\n soft and ecchymotic), GI asps bilious, ETS\nold bloody secretions.\n Insulin gtt remains @ 0.5 unit/hour with BS 150\ns-160\n (goal 150-200)\n Droplet precautions d/c\nd, remains on contact precautions\n d/t VRE\n Blood cultures X2 sent, urine culture repeated, sputum\n culture:\n T 97.9-98 po\n U/O 40-80cc/hour, Cr 3.5 (3.4)\n Plan:\n Continue with contact precautions. Follow Temp, antibiotics as\n ordered. Please note that pt is to have trough Vanco drawn \nplease\n draw at 1100. Continue with hemodynamic monitoring. Wean levo as able\n to keep MAP >65. Plan as per team is to let pt autodiurese for now and\n monitor Cr. Steroids IV q 6 hours with plan to decrease dose tomorrow\n as per team. Monitor BS hourly on insulin gtt\nmay need to ^ dose as\n TF is advanced. Monitor labs with Xigris infusion, assess for bleeding,\n guiac stool. Team would like to remove sepsis cath as possible and\n change to PICC.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 420/ 24, PEEP 13. Not overbreathing vent.\n Fentanyl @ 200mcg/hour, Versed @ 5mg/hour. Lungs with diminished\n breath sounds, occ rhonchi. 1.\n Action/Response:\n Sedation weaned q 2 hours while following neuro assessment.\n Breathing breathes over vent.\n Fi O2 weaned to 50%, then PEEP weaning begun\ns stable\n VAP prevention including HOB > 40, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n ETS\nscant old bldy secretions.\n Plan:\n Continue sedation weaning. Wean PEEP down to 10, and then ? begin CPAP\n if pt with enough spontaneous resps.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.5 (3.4 )\n Action:\n K 5.1 following K exalate last night.\n ? Cr falsely low given Vanco trough levels.\n Mg and Calcium replaced as per sliding scale orders.\n Response:\n Plan:\n Cotninue to monitor urine output & labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, sacral area pink, blanchable\n with central flakey area which resembles Seborrheic Keratosis (pt has\n many on his back). L groin with soft ecchymotic area s/p aline\n removal, right AC site of old PIV opened blister that is oozing clear\n with dressing in place.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear, fanned 4X4 gauze over site to prevent skin from\n touching skin.\n L Panus with criticaid and fanned 4X4 gauze over pinkened\n area.\n Sacral area- applied aloe vesta lotion\n Right AC- mepilex dressing placed & re-inforced with pink\n hy-tape intact.\n Nutren 2.0 TF begun, to titrate up to 40 cc/hour goal.\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\nstopped oozing.\n Plan:\n Continue careful skin assessment. Reposition q 2 hours, avoid back.\n Advance TF towards goal.\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596614, "text": "y/o w/ limited PMH including DM, COPD & Schizophrenia, hypothyroidism.\n P/w severe septic shock, ARF & resp failure. Per fam, pt taken to\n for unresponsiveness at home (persisted from evening prior to\n day of admission into the AM of admission), w/ SBPs reportedly in the\n 40s, hypothermic & bradycardic. Intubated, given IVF, abx & mult\n pressors. to CCU as MICU pt. TLC presep & aline placed.\n R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx bottles from\n OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o flu &\n legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 23.less bleeding from mouth,lines,ett secretions blood tinged\n ,platelets increasing ,ptt decreasing by holding sc heparin .bp tol\n levo wean ,no bradycardia ,ci 6 ,tol tf ,no stool,lactulose ordered .\n rectal exam showed soft brown guiac neg stool,ng aspirate guiac neg\n also\n Action:\n Triple abx ,vanco level 15.4, dose to be adjusted\n Levo weaned\n Sedation dc\n Response:\n Tol levo wean,abgs good\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo wean goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleedingno\n Continue Xigris til 07:30\ncheck coags/CBC \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since noon No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n Weaned peep to 11\n VAP protocol, HOB elevated\n Response:\n ABGs. 7.39/38/97/24\n Plan:\n Wean vent as tol,\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 45cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 73-200s\n Action:\n Insulin gtt of f at 73 but quickly rose to 200 despite\n drip being restarted at previous rate\n Response:\n hyperglycemic\n Plan:\n Continue to titrate ,hrly bs\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area duoderm in place . L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\ndsd d/I\n Action:\n Turned q2,aloe vesta ,criticare applied\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Nursing", "chartdate": "2121-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596796, "text": "y/o w/ limited PMH including DM, COPD & Schizophrenia, hypothyroidism.\n P/w severe septic shock, ARF & resp failure. Per fam, pt taken to\n for unresponsiveness at home (persisted from evening prior to\n day of admission into the AM of admission), w/ SBPs reportedly in the\n 40s, hypothermic & bradycardic. Intubated, given IVF, abx & mult\n pressors. to CCU as MICU pt. TLC presep & aline placed.\n R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx bottles from\n OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o flu &\n legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT21. bleeding from,lines,ett secretions blood tinged , ,ptt slightly\n elevated at 4pm despite no heparin .bp tol levo wean ,no bradycardia\n ,ci 5 ,tol tf ,large amt of stool,lactulose held,flexiseal. Stool\n trace guiac , sedation off starting to move l arm,restraints\n applied ,seems to try to open eyes to name\n Action:\n ,vanco dc ,continue zoysin ,ciprofloxacin\n Levo weaned\n Xigris dc due to low hct\n Response:\n Tol levo wean,abgs good\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo wean goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleedingno\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off 24.hrs .\n Action:\n Cpap ,\n VAP protocol, HOB elevated ,sx copious thick bloody\n Response:\n ABGs. 7.36/42/163/25 ,pulmonary toilet\n Plan:\n Wean vent as tol,\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 45cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 73-200s\n Action:\n Insulin gtt of f at 73 and restarted when at 98, slowly bs\n increasing to 150,insulin adjusted to 2units hr ,steroid dose\n decreased\n Response:\n Better control than yesterday\n Plan:\n Continue to titrate ,hrly bs\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin,small area on sacrum now open ,duoderm dc and\n mepilex applied . L groin soft ecchymotic area s/p aline removal. R\n AC site of old PIV opened blister\ndsd d/I ,scrotum swollen ,criticare\n applied\n Action:\n Turned q2,aloe vesta ,criticare applied\n Response:\n Small area open ,pt stooling frequently, flexisael in place\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Respiratory ", "chartdate": "2121-09-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596225, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 25 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: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / 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 Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Vent synchrony improved dramatically with increased sedation.\n No AM RSBI due to peep and FiO2 requirements. ABG metabolic acidosis\n with normoxia on high FiO2 and High minute ventilation.\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n ------ Protected Section ------\n Error in report of suction of frothy secretions , no secretions were\n obtained via suction. Last ABG showed improved oxygenation with a\n respiratory compensated metabolic acidosis. FiO2 and minuted\n ventilation decreased.\n ------ Protected Section Addendum Entered By: , RTT\n on: 04:39 ------\n" }, { "category": "Physician ", "chartdate": "2121-09-11 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 596606, "text": "Chief Complaint:\n 24 Hour Events:\n -from : growing coag neg staph of 2 morphologies out of blood\n and growing >100,000 VRE from urine. the VRE is sensitive to ampicillin\n in addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n -also growing enterococcus from urine on admission here\n -got more blood cultures and urine culture and sputum culture today\n -got records from pt's pcp ( #)\n -Dr reports that pt's home living situation is very poor. In past\n has had vna and they feel unsafe their for health reasons (in\n disarray, dirty). Pt not able to care for self and sister also very\n debilitated by psych issues. Dr feels strongly that pt belongs in\n , but sister has been reluctant to pursue in the past. Will consult\n sw.\n -consider picc tomorrow or friday\n -does have mild chronic cri s/p nephrectomy for hematoma\n -weaned sedation down, weaned levo\n -tried to wean peep down from 12 to 10, but patient later desaturated\n when turned, and PaO2 of 64. turned peep back up to 12\n -HCT of 22.5, gave one unit PRBC\n -6pm, called for brady to 40's, but then spontaneously resolved.\n happened while nurse lines, but doesnt seem vagal. On\n tele, was sinus. By the time we got there he was back in the 60's\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:30 AM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 50 mcg/hour\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Insulin - Regular - 1.5 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Famotidine (Pepcid) - 03:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.2\nC (97.1\n HR: 66 (42 - 71) bpm\n BP: 103/50(66) {103/50(66) - 160/73(95)} mmHg\n RR: 19 (18 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (10 - 14)mmHg\n Total In:\n 3,981 mL\n 934 mL\n PO:\n 120 mL\n TF:\n 170 mL\n 294 mL\n IVF:\n 3,211 mL\n 640 mL\n Blood products:\n 350 mL\n Total out:\n 1,740 mL\n 590 mL\n Urine:\n 1,740 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,241 mL\n 344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 32.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/40/108/21/-1\n Ve: 10.5 L/min\n PaO2 / FiO2: 216\n Physical Examination\n gen: intubated, sedated\n cv: RRR\n resp: clear anteriorly\n abd: obese, hypoactive bowel sounds\n ext: edematous\n Labs / Radiology\n 55 K/uL\n 7.7 g/dL\n 110 mg/dL\n 4.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 88 mg/dL\n 103 mEq/L\n 137 mEq/L\n 23.2 %\n 5.5 K/uL\n [image002.jpg]\n 12:32 PM\n 03:49 PM\n 04:03 PM\n 04:41 PM\n 05:22 PM\n 05:35 PM\n 12:00 AM\n 12:08 AM\n 04:00 AM\n 04:09 AM\n WBC\n 6.7\n 6.9\n 5.5\n Hct\n 22.9\n 22.5\n 23.7\n 23.2\n Plt\n 72\n 58\n 55\n Cr\n 4.1\n TCO2\n 22\n 21\n 22\n 22\n 23\n 24\n Glucose\n 110\n Other labs: PT / PTT / INR:13.8/86.9/1.2, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:45/30, Alk Phos / T Bili:42/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:644 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Microbiology: 8:52 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n RESPIRATORY CULTURE (Preliminary):\n HEAVY GROWTH Commensal Respiratory Flora.\n YEAST. HEAVY GROWTH.\n GRAM NEGATIVE ROD(S). SPARSE GROWTH.\n from : growing coag neg staph of 2 morphologies out of blood and\n growing >100,000 VRE from urine. the VRE is sensitive to ampicillin in\n addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n also growing enterococcus from blood cultures from here, sensitivities\n pending\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro and vancomycin.\n currently growing vre sensitive to amp, gnrs from sputum and coag neg\n staph from blood (likely contaminant). Likely dc vancomycin tomorrow\n - f/u panculture results\n - will continue on IV Hydrocortisone, weaned to 50q6h (=7.5 daily of\n decadron, pt on 2 daily of decadron at home)\n - pt on xygris high apache score, check coags. Will dc xygris\n today if PTT stays high this afternoon.\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n # : baseline 1.8-2, current Cr is 4. Likely this is ATN. UOP\n has gone from low to high so likely renal function is in process of\n improving.\n -will trend\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers.\n -keep active type and screen\n -increase H2B to \n -guiac stool\n -likely dc xygris given falling hct\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych meds\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n .\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin\n .\n # SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, f/u tube feed recs\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:38 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\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: 74M DM, obesity, ?CHF, CRI (1.8-2.0) p/w\n severe pneumonia L>R c/b refractory septic shock. Weaning pressors,\n increased UOP. VRE in urine, amp sensitive, xfused one unit PRBCs,\n sinus brady.\n Exam notable for Tm 97.9 BP 117/52 HR 66 RR 24 with sat 94 on VAC\n 420x24 0.5 13 7.33/41/168 CVP 12, +23L, UOP >100cc/h. Obese man, NAD\n not overbreathing. Coarse BS B. RRR s1s2. Soft +BS. 3+ edema. Labs\n notable for WBC 5K, HCT 23, plts 55, K+ 4.0, Cr 4.1. CXR with L>R ASD.\n Agree with plan to manage pneumonia / urosepsis c/b septic shock with\n wean of vasopressors as we decrease sedation and PEEP. Will decrease HC\n to 25 q6h for ? adrenal insufficiency. Will contine zosyn / cipro /\n vanco to level in addition to APC. Resp failure / ARDS - continue VAC\n 420 x24, wean PEEP. AMI is stable, will treat medically as condition\n improves. ARF - continue IVF support, RD meds, monitor K+ closely, UOP\n rising, hold on further boluses for now. HCT down with abnormal coags,\n BBS, guiac above / below, d/c APC if evidence of frank bleeding. Will\n continue insulin drip for goal <200, NPO for now. ADAT, bowel regimen.\n DNR. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:55 PM ------\n" }, { "category": "Physician ", "chartdate": "2121-09-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 596891, "text": "TITLE:\n Chief Complaint: shock and respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Off pressors.\n Drotrecogin d/c'd given drop in Hct.\n Steorids weaned.\n vanco d/c'd.\n insulin converted to SQ.\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 PM\n Other medications:\n levothyroxine, zosyn, cipro, ppi, hydrocort, CHG, colace, senna,\n lactulose, MDIs\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.2\nC (95.4\n HR: 57 (53 - 68) bpm\n BP: 129/57(79) {104/47(65) - 146/61(88)} mmHg\n RR: 12 (7 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 115.7 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 13 (4 - 13)mmHg\n Total In:\n 2,410 mL\n 969 mL\n PO:\n TF:\n 1,083 mL\n 482 mL\n IVF:\n 1,327 mL\n 487 mL\n Blood products:\n Total out:\n 2,025 mL\n 870 mL\n Urine:\n 2,025 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n 99 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 860 (755 - 910) mL\n PS : 10 cmH2O\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n SpO2: 97%\n ABG: 7.36/47/161/24/0\n Ve: 5.5 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Non -purposeful,\n Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 67 K/uL\n 201 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 97 mg/dL\n 109 mEq/L\n 143 mEq/L\n 22.8 %\n 7.9 K/uL\n [image002.jpg]\n 09:39 PM\n 04:00 AM\n 04:12 AM\n 06:12 AM\n 03:32 PM\n 03:55 PM\n 09:11 PM\n 10:35 PM\n 04:28 AM\n 05:01 AM\n WBC\n 7.0\n 7.9\n Hct\n 22.3\n 21.7\n 23.0\n 22.8\n Plt\n 73\n 67\n Cr\n 4.5\n 4.2\n TCO2\n 24\n 24\n 24\n 25\n 24\n 28\n Glucose\n 125\n 201\n Other labs: PT / PTT / INR:11.6/32.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:5.4 mg/dL\n Imaging: CXR not particularly changed\n Assessment and Plan\n 74-year-old man with respiratory failure, septic shock (now off\n pressors), NSTEMI related to demand, anemia, thrombocytopenia, and\n acute renal failure. He has made substantial progress.\n Respiratory failure\n diurese today. We will try an SBT (RSBI 60s),\n though he may derecruit. Continue antibiotics for pneumonia, and\n follow cultures.\n Shock\n resolved\n Acute renal failure\n likely due to ATN. Non-oliguric.\n Anemia\n PM Hct. On PPI given prior hx of ulcers.\n NSTEMI\n start aspirin. If HR stays non-bradycardic, consider beta\n blockade.\n ICU Care\n Nutrition: hold TF for SBT\n Glycemic Control: Comments: SQ insulin\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: Boots(add SQH)\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 min\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2121-09-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597063, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 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: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / 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: Sedated / Paralyzed,\n Cannot protect airway\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": "2121-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597135, "text": "Altered mental status (not Delirium)\n Assessment:\n Off fent/versed gtt over 60 hrs.Pt responsive to voice and obeys\n command.\n Action:\n No sedation.Cont to orient pt.Soft restraints on.\n Response:\n Pt seem to be more awake.\n Plan:\n Continue to allow sedating drugs to wear off, frequent reorientation\n and neuro checks.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Received the pt on CMV 50%/peep 10/RR20.LS rhonchorous.Suctioned for\n small amount of bloody secretions.Had SBT yesterday with poor results.\n Pt with GNR in sputum and VRE in urine.\n Action:\n Conts to be on CMV.Will try RSBI in am.Started to diuresis with\n frusemide,aiming for 1.5-2lit neg.On Linezolid and meropeem.\n Response:\n Pt is neg 1.2 lit for 24hrs at MN.Pt desats when on his rt side.\n Plan:\n Cont ot diuresis.Monitor Cr.?try SBT this am.IV Abx.\n Hypernatremia (high sodium)\n Assessment:\n Na to\n Action:\n Free water boluses of 200cc ordered every 4hrs via sump tube\n Response:\n Na to 138\n Plan:\n Plan to check on need to continue free water\n" }, { "category": "Respiratory ", "chartdate": "2121-09-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596224, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 25 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: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / 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 Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Vent synchrony improved dramatically with increased sedation.\n No AM RSBI due to peep and FiO2 requirements. ABG metabolic acidosis\n with normoxia on high FiO2 and High minute ventilation.\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596610, "text": "y/o w/ limited PMH including DM, COPD & Schizophrenia, hypothyroidism.\n P/w severe septic shock, ARF & resp failure. Per fam, pt taken to\n for unresponsiveness at home (persisted from evening prior to\n day of admission into the AM of admission), w/ SBPs reportedly in the\n 40s, hypothermic & bradycardic. Intubated, given IVF, abx & mult\n pressors. to CCU as MICU pt. TLC presep & aline placed.\n R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx bottles from\n OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o flu &\n legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 23.less bleeding from mouth,lines,ett secretions blood tinged\n ,platelets increasing ,ptt decreasing by holding sc heparin .bp tol\n levo wean ,no bradycardia ,ci 6 ,tol tf ,no stool,rectal exam showed\n soft brown guiac neg stool,ng aspirate guiac neg also\n Action:\n Triple abx ,vanco level 15.4, dose to be adjusted\n Levo weaned\n Sedation dc\n Response:\n Tol levo wean,abgs good\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo wean goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleedingno\n Continue Xigris til 07:30\ncheck coags/CBC \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since noon No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n ARDSnet vent settings\n VAP protocol, HOB elevated\n Response:\n Stable ABGs. Sedation re-started at 06:30 desynchrony w/ vent. PF\n ratios 210-214\n Plan:\n Wean vent as tol, ? PS today\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596611, "text": "y/o w/ limited PMH including DM, COPD & Schizophrenia, hypothyroidism.\n P/w severe septic shock, ARF & resp failure. Per fam, pt taken to\n for unresponsiveness at home (persisted from evening prior to\n day of admission into the AM of admission), w/ SBPs reportedly in the\n 40s, hypothermic & bradycardic. Intubated, given IVF, abx & mult\n pressors. to CCU as MICU pt. TLC presep & aline placed.\n R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx bottles from\n OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o flu &\n legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 23.less bleeding from mouth,lines,ett secretions blood tinged\n ,platelets increasing ,ptt decreasing by holding sc heparin .bp tol\n levo wean ,no bradycardia ,ci 6 ,tol tf ,no stool,rectal exam showed\n soft brown guiac neg stool,ng aspirate guiac neg also\n Action:\n Triple abx ,vanco level 15.4, dose to be adjusted\n Levo weaned\n Sedation dc\n Response:\n Tol levo wean,abgs good\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo wean goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleedingno\n Continue Xigris til 07:30\ncheck coags/CBC \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since noon No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n Weaned peep to 11\n VAP protocol, HOB elevated\n Response:\n ABGs. 7.39/38/97/24\n Plan:\n Wean vent as tol,\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Nursing", "chartdate": "2121-09-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596682, "text": "Shock, septic\n Assessment:\n HCT 22.3 (23). Afebrile. MAPs >65 on Levo. HR 60-70s SR w/o ectopy.\n Gross general body edema.\n Action:\n Triple abx\n Levo weaned\n Response:\n Unable to wean Levo off\nMAPs fall below 65. Adequate UOP. BUN/Cr\n 100/4.5 (94/4.2). PLT 73(76). Random vanco level this AM 18.0\n Plan:\n Monitor hemodynamics\nvigileo\n ? Transfusion PRBC today\n Continue levo for goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleeding\n Continue Xigris til 07:30\ncheck coags/CBC \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96% on AC 50% 420x24 11 PEEP. Overbreathing 4 breaths,\n appearing desynchronous. PF ratio 184\n Action:\n VAP care per protocol, HOB up 45 degrees\n Placed on CPAP at 04:30\n Response:\n Appearing more comfortable. Sats 97% on CPAP, ABG:\n Plan:\n Wean vent as tol, follow ABGs\n Hyperglycemia\n Assessment:\n TF @ goal rate 45cc/hr w/ mod amts residuals. On Steroids Q6hrs. FSGB\n high 100s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Constipation (Obstipation, FOS)\n Assessment:\n No BM since at least admission \n Action:\n Aggressive bowel regimen\n Response:\n X-lg amt formed stool, then lg amts loose stool. Guiac POS\n Plan:\n Hold Bowel meds for now\n Altered mental status (not Delirium)\n Assessment:\n Sedation off since noon . No spontaneous mvmts. No corneals.\n Action:\n Neuro assessment monitored\n Response:\n + corneal reflexes in AM, resisting eye exam. Rare RUE mvmts. BUN 100\n (94)\n Plan:\n Continue to monitor neuron exam\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid. R radial aline site w/ blisters from\n ? tegaderm\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Thin duoderm to\n protect site from friction intact (placed )\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed at 00:00\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF. Incontinent care\n" }, { "category": "Physician ", "chartdate": "2121-09-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596417, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n - TTE: extremely poor image windows. LV systolic function is probably\n normal LVEF > 55 %. Other structures of the heart are not well\n visualized.\n - Cx from ED: 2/4 bottles with GPC in clusters - f/u speciation\n and sensitivities \n - Weaned off Dopamine and vasopressin, still on max levophed\n - Potassium persistently elevated > 5.5 treated with Kayexalate but did\n not have BM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Norepinephrine - 0.5 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Famotidine (Pepcid) - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 72 (62 - 85) bpm\n BP: 109/74(90) {90/50(64) - 142/5,955(162)} mmHg\n RR: 24 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (11 - 18)mmHg\n Total In:\n 21,885 mL\n 1,316 mL\n PO:\n 120 mL\n TF:\n IVF:\n 13,885 mL\n 1,136 mL\n Blood products:\n Total out:\n 842 mL\n 415 mL\n Urine:\n 842 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 21,043 mL\n 903 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 13 cmH2O\n FiO2: 80%\n PIP: 30 cmH2O\n Plateau: 25 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 97%\n ABG: 7.33/41/168/20/-4\n Ve: 9.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n Cardiovascular: gen: intubated, sedated\n cv: RRR\n resp: reduced breath sounds anteriorly\n abd: soft, hypoactive bowel sounds\n ext: edematous diffusely\n Labs / Radiology\n 88 K/uL\n 9.0 g/dL\n 176 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 5.5 mEq/L\n 82 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.4 %\n 10.4 K/uL\n [image002.jpg]\n 05:13 AM\n 06:26 AM\n 06:43 AM\n 11:49 AM\n 12:19 PM\n 05:51 PM\n 06:16 PM\n 11:58 PM\n 12:33 AM\n 06:22 AM\n WBC\n 2.1\n 6.1\n 9.4\n 10.4\n Hct\n 31\n 30.2\n 29.9\n 28.6\n 27.4\n Plt\n 115\n 100\n 103\n 88\n Cr\n 3.2\n 3.3\n 3.5\n 3.4\n TropT\n 0.09\n TCO2\n 23\n 19\n 21\n 23\n 23\n Glucose\n 76\n Other labs: PT / PTT / INR:14.7/96.0/1.3, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:57/63, Alk Phos / T Bili:43/0.2,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:661 mg/dL, LDH:259 IU/L, Ca++:6.8 mg/dL, Mg++:1.4\n mg/dL, PO4:3.1 mg/dL\n Microbiology: GPCs in clusters from \n legionella neg\n flu neg\n cultures pending\n sputum gram stain:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n TTE: Extreemly poor image windows. The left atrium is normal in size.\n Due to suboptimal technical quality, a focal wall motion abnormality\n cannot be fully excluded. Overall left ventricular systolic function is\n probably normal (LVEF>55%). RV not well seen. The aortic valve is not\n well seen. There is no aortic valve stenosis. The mitral valve leaflets\n are not well seen. There is no pericardial effusion.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Pt was transferred from ED to on 3 pressors, able to\n be weaned down to 2 pressors of Dopamine following 8 litres of fluid.\n Pt is currently is hypothermic on examination. Pt noted to have\n positive U/A as well as large PNA on left lung. Suspect sources to be\n pulmonary versus urine. Pt's CVP currently , MAP noted to be 76,\n with a mixed venous sat of 83%. Pt also was reportedly on Dexamethasone\n at home and thus was given stress dose steroids in the ED. Per family\n pt has a history of PNA versus aspiration PNA, hospitalizaed three\n times over the past year\n - influenza antigen and legionella negative\n - will try to wean DA first and then levophed to maintain MAP >65\n - will continue on broad coverage with Zosyn, Cipro for coverage of\n Gram+, Gram -, atypicals and double coverage for Pseudomonas.\n Vancomycin for MRSA. Blood cx from OSH growing GPCs in clusters\n - f/u panculture results, continue surveillance blood cultures\n - will continue on IV Hydrocortisone\n - pt on xygris high apache score\n .\n #hyperkalemia: could be to renal failure, but pt is making urine.\n Also ? hypoaldo as pmh and home meds. Most likely to comb\n of renal insuff plus repletion c LR. Will call PCP today Dr \n today to get better sense of pmh.\n -f/u am K\n -may need additional kayexelate\n .\n # : baseline.\n -Consider urine sediment.\n -Check urine lytes to diff bet prerenal v atn, most likely atn\n -ask pcp about baseline GFR\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring Atropine in the\n field for HR in the 40s. Bradycardia is likely due to his hypothermia.\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol.\n - continue ardsnet\n - wean FiO2 prn\n - will sedate with Fentanyl and Midazolam\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine.\n .\n #housekeeping: home meds\n .\n # FEN: replete electrolytes, consider OGT and tube feeds\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2121-09-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596600, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\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: Insp Wheeze\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Insp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / 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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596604, "text": "y/o w/ limited PMH including DM, COPD & Schizophrenia, hypothyroidism.\n P/w severe septic shock, ARF & resp failure. Per fam, pt taken to\n for unresponsiveness at home (persisted from evening prior to\n day of admission into the AM of admission), w/ SBPs reportedly in the\n 40s, hypothermic & bradycardic. Intubated, given IVF, abx & mult\n pressors. to CCU as MICU pt. TLC presep & aline placed.\n R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx bottles from\n OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o flu &\n legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 23.less bleeding from mouth,lines,ett secretions blood tinged\n ,platelets increasing ,ptt decreasing by holding sc heparin .bp tol\n levo wean ,no bradycardia ,ci 6 ,tol tf ,no stool,rectal exam showed\n soft brown guiac neg stool,ng aspirate guiac neg also\n Action:\n Triple abx ,vanco level 15.4, dose to be adjusted\n Levo weaned\n Sedation dc\n Response:\n Tol levo wean,abgs good\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo wean goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleedingno\n Continue Xigris til 07:30\ncheck coags/CBC \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since :00 . No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n ARDSnet vent settings\n VAP care per protocol, HOB up 45 degrees\n Response:\n Stable ABGs. Sedation re-started at 06:30 desynchrony w/ vent. PF\n ratios 210-214\n Plan:\n Wean vent as tol, ? PS today\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Respiratory ", "chartdate": "2121-09-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597116, "text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 78\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: 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: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596402, "text": "74 yo with known PMH, adult onset DM, COPD & Schizophrenia,\n hypothyroidism, nephrectomy, asp pna req hospitalizations (intubated),\n ?adrenal insufficiency who presents to OSH unresponsive w/ sbp\n 40\ns marked hypothermia and bradycardia. Pt w/ severe septic shock,\n acute renal failure, and respiratory failure. Pt was Intubated, given\n fluids, ABX, and multiple vasopressors. Transferred to via\n . TLC presep cath & arterial line placed in ED. Transferred\n to CCU as MICU border.\n Shock, septic\n Assessment:\n Rec\nd pt on triple pressors including dopamine 20mcg/kg/min,\n vasopressin 2.4units/hr and levophed 0.5mcg/kg/min. BP\n 90-110/50-60\ns. HR 70-80\ns nsr w/ rare apc. Temp normothermic 99.6.\n CVP\ns 15 down to 11.\n CR/BUN 3.3/81. Approx 20L positive.\n Action:\n Triple pressors cont, but dopamine has been decreased throught day.\n Triple abx continue.\n 1000cc LR administered for low CVP@ 11am.\n Xigris restarted 20mg/hr. H/H, coags and lytes monitoring q6hrs\n Vigileo monitoring\n CO 5.5-5.3. SVV .\n IV steriods conintue.\n Insulin gtt started.\n Response:\n Culture results are pending\n Tolerating Dopa wean, maintaining SBP >110.\n No significant CVP response to IVF bolus.\n Patient now with worsening edema, periorbital, facial, bilateral upper\n & lower extremities\n BG now controlled w/ insulin gtt.\n H/H 29.9/9.3, and 28.6/9.2. WBC 9.2 INR 1.2.\n u/o 0-70cc/hr.\n Plan:\n Continue septic shock management with MICU team. Attempt to wean dopa\n as tolerated, Close monitoring of labs on xigris, cont insulin gtt as\n necessary, close monitoring i/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont intubated and ventilated 80%/420/24/13peep. Breathing in synch\n w/ vent.\n Pt sedated 200mcgs/hr fentanyl, Versed 5mg/hr.\n Action:\n ABG\ns q4-6hr, 7.25/41/106/- and 7.31/40/93/-\n Aggressive pulmonary toileting\n VAP care per protocol\n Sedation unchanged.\n Response:\n Sx for sm amts thick tan, blood tinged secretions via ETT. Copious\n clear oral secretions noted.\n Comfortable on current fent/versed regime.\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Cont fent and\n versed for comfort.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement. Blister noted r ac area\n underneath tegaderm iv dsg, becoming deroofed and is oozing lg amts\n clear.\n Action:\n Turned and positioned q2-4 hrs. Barrier cream to sacrum, elbows and\n heels\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment w/ close monitoring elbows\n and knees.\n Social\n lives w/ son and daughter in MA. Family met at length w/\n Dr. and this RN. Have been thoroughly updated on POC. Pt is DNR\n (no CPR or shock), but will continue aggressive management for septic\n shock.\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596403, "text": "74 yo with known PMH, adult onset DM, COPD & Schizophrenia,\n hypothyroidism, nephrectomy, asp pna req hospitalizations (intubated),\n ?adrenal insufficiency who presents to OSH unresponsive w/ sbp\n 40\ns marked hypothermia and bradycardia. Pt w/ severe septic shock,\n acute renal failure, and respiratory failure. Pt was Intubated, given\n fluids, ABX, and multiple vasopressors. Transferred to via\n . TLC presep cath & arterial line placed in ED. Transferred\n to CCU as MICU border.\n Shock, septic\n Assessment:\n Rec\nd pt on triple pressors including dopamine 20mcg/kg/min,\n vasopressin 2.4units/hr and levophed 0.5mcg/kg/min. BP\n 90-110/50-60\ns. HR 70-80\ns nsr w/ rare apc. Temp normothermic 99.6.\n CVP\ns 15 down to 11.\n CR/BUN 3.3/81. Approx 20L positive.\n Action:\n Triple pressors cont, but dopamine has been decreased throught day.\n Triple abx continue.\n 1000cc LR administered for low CVP@ 11am.\n Xigris restarted 20mg/hr. H/H, coags and lytes monitoring q6hrs\n Vigileo monitoring\n CO 5.5-5.3. SVV .\n IV steriods conintue.\n Insulin gtt started.\n Response:\n Culture results are pending\n Tolerating Dopa wean, maintaining SBP >110.\n No significant CVP response to IVF bolus.\n Patient now with worsening edema, periorbital, facial, bilateral upper\n & lower extremities\n BG now controlled w/ insulin gtt.\n H/H 29.9/9.3, and 28.6/9.2. WBC 9.2 INR 1.2.\n u/o 0-70cc/hr.\n Plan:\n Continue septic shock management with MICU team. Attempt to wean dopa\n as tolerated, Close monitoring of labs on xigris, cont insulin gtt as\n necessary, close monitoring i/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont intubated and ventilated 80%/420/24/13peep. Breathing in synch\n w/ vent.\n Pt sedated 200mcgs/hr fentanyl, Versed 5mg/hr.\n Action:\n ABG\ns q4-6hr, 7.25/41/106/- and 7.31/40/93/-\n Aggressive pulmonary toileting\n VAP care per protocol\n Sedation unchanged.\n Response:\n Sx for sm amts thick tan, blood tinged secretions via ETT. Copious\n clear oral secretions noted.\n Comfortable on current fent/versed regime.\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Cont fent and\n versed for comfort.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement. Blister noted r ac area\n underneath tegaderm iv dsg, becoming deroofed and is oozing lg amts\n clear.\n Action:\n Turned and positioned q2-4 hrs. Barrier cream to sacrum, elbows and\n heels\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment w/ close monitoring elbows\n and knees.\n Social\n lives w/ son and daughter in MA. Family met at length w/\n Dr. and this RN. Have been thoroughly updated on POC. Pt is DNR\n (no CPR or shock), but will continue aggressive management for septic\n shock.\n ------ Protected Section ------\n Above note written by , RN on \n ------ Protected Section Addendum Entered By: , RN\n on: 06:59 ------\n" }, { "category": "Physician ", "chartdate": "2121-09-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596405, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n - TTE: extremely poor image windows. LV systolic function is probably\n normal LVEF > 55 %. Other structures of the heart are not well\n visualized.\n - Cx from ED: 2/4 bottles with GPC in clusters - f/u speciation\n and sensitivities \n - Weaned off Dopamine - attempting to wean off Vasopressin\n - Potassium persistently elevated > 5.5 treated with Kayexalate\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Norepinephrine - 0.5 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Famotidine (Pepcid) - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 72 (62 - 85) bpm\n BP: 109/74(90) {90/50(64) - 142/5,955(162)} mmHg\n RR: 24 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (11 - 18)mmHg\n Total In:\n 21,885 mL\n 1,316 mL\n PO:\n 120 mL\n TF:\n IVF:\n 13,885 mL\n 1,136 mL\n Blood products:\n Total out:\n 842 mL\n 415 mL\n Urine:\n 842 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 21,043 mL\n 903 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 13 cmH2O\n FiO2: 80%\n PIP: 30 cmH2O\n Plateau: 25 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 97%\n ABG: 7.33/41/168/20/-4\n Ve: 9.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n Cardiovascular: gen: intubated, sedated\n cv: RRR\n resp: rhonchorous b/l\n abd: soft, +BS\n ext: edematous\n Labs / Radiology\n 88 K/uL\n 9.0 g/dL\n 176 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 5.5 mEq/L\n 82 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.4 %\n 10.4 K/uL\n [image002.jpg]\n 05:13 AM\n 06:26 AM\n 06:43 AM\n 11:49 AM\n 12:19 PM\n 05:51 PM\n 06:16 PM\n 11:58 PM\n 12:33 AM\n 06:22 AM\n WBC\n 2.1\n 6.1\n 9.4\n 10.4\n Hct\n 31\n 30.2\n 29.9\n 28.6\n 27.4\n Plt\n 115\n 100\n 103\n 88\n Cr\n 3.2\n 3.3\n 3.5\n 3.4\n TropT\n 0.09\n TCO2\n 23\n 19\n 21\n 23\n 23\n Glucose\n 76\n Other labs: PT / PTT / INR:14.7/96.0/1.3, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:57/63, Alk Phos / T Bili:43/0.2,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:661 mg/dL, LDH:259 IU/L, Ca++:6.8 mg/dL, Mg++:1.4\n mg/dL, PO4:3.1 mg/dL\n Microbiology: GPCs in clusters from \n legionella neg\n flu neg\n cultures pending\n sputum gram stain:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Pt was transferred from ED to on 3 pressors, able to\n be weaned down to 2 pressors of Dopamine following 8 litres of fluid.\n Pt is currently is hypothermic on examination. Pt noted to have\n positive U/A as well as large PNA on left lung. Suspect sources to be\n pulmonary versus urine. Pt's CVP currently , MAP noted to be 76,\n with a mixed venous sat of 83%. Pt also was reportedly on Dexamethasone\n at home and thus was given stress dose steroids in the ED. Per family\n pt has a history of PNA versus aspiration PNA, hospitalizaed three\n times over the past year\n - influenza antigen and legionella negative\n - will try to wean DA first and then levophed to maintain MAP >65\n - will continue on broad coverage with Zosyn, Cipro for coverage of\n Gram+, Gram -, atypicals and double coverage for Pseudomonas.\n Vancomycin for MRSA. Blood cx from OSH growing GPCs in clusters\n - f/u panculture results, continue surveillance blood cultures\n - will continue on IV Hydrocortisone\n - pt on xygris high apache score\n .\n #hyperkalemia: could be to renal failure. Also ? hypoaldo\n .\n # : baseline. Figure out baseline. Consider urine sediment.\n Check urine lytes to diff bet prerenal v atn. Most likely atn\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring Atropine in the\n field for HR in the 40s. Bradycardia is likely due to his hypothermia.\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol.\n - continue ardsnet\n - wean FiO2 prn\n - will sedate with Fentanyl and Midazolam\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine.\n .\n #housekeeping: home meds\n .\n # FEN: replete electrolytes, ? OGT ?tube feeds\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596412, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n - TTE: extremely poor image windows. LV systolic function is probably\n normal LVEF > 55 %. Other structures of the heart are not well\n visualized.\n - Cx from ED: 2/4 bottles with GPC in clusters - f/u speciation\n and sensitivities \n - Weaned off Dopamine and vasopressin, still on max levophed\n - Potassium persistently elevated > 5.5 treated with Kayexalate but did\n not have BM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Norepinephrine - 0.5 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Famotidine (Pepcid) - 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.8\n HR: 72 (62 - 85) bpm\n BP: 109/74(90) {90/50(64) - 142/5,955(162)} mmHg\n RR: 24 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 18 (11 - 18)mmHg\n Total In:\n 21,885 mL\n 1,316 mL\n PO:\n 120 mL\n TF:\n IVF:\n 13,885 mL\n 1,136 mL\n Blood products:\n Total out:\n 842 mL\n 415 mL\n Urine:\n 842 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 21,043 mL\n 903 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 13 cmH2O\n FiO2: 80%\n PIP: 30 cmH2O\n Plateau: 25 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 97%\n ABG: 7.33/41/168/20/-4\n Ve: 9.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n Cardiovascular: gen: intubated, sedated\n cv: RRR\n resp: reduced breath sounds anteriorly\n abd: soft, hypoactive bowel sounds\n ext: edematous diffusely\n Labs / Radiology\n 88 K/uL\n 9.0 g/dL\n 176 mg/dL\n 3.4 mg/dL\n 20 mEq/L\n 5.5 mEq/L\n 82 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.4 %\n 10.4 K/uL\n [image002.jpg]\n 05:13 AM\n 06:26 AM\n 06:43 AM\n 11:49 AM\n 12:19 PM\n 05:51 PM\n 06:16 PM\n 11:58 PM\n 12:33 AM\n 06:22 AM\n WBC\n 2.1\n 6.1\n 9.4\n 10.4\n Hct\n 31\n 30.2\n 29.9\n 28.6\n 27.4\n Plt\n 115\n 100\n 103\n 88\n Cr\n 3.2\n 3.3\n 3.5\n 3.4\n TropT\n 0.09\n TCO2\n 23\n 19\n 21\n 23\n 23\n Glucose\n 76\n Other labs: PT / PTT / INR:14.7/96.0/1.3, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:57/63, Alk Phos / T Bili:43/0.2,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:661 mg/dL, LDH:259 IU/L, Ca++:6.8 mg/dL, Mg++:1.4\n mg/dL, PO4:3.1 mg/dL\n Microbiology: GPCs in clusters from \n legionella neg\n flu neg\n cultures pending\n sputum gram stain:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n TTE: Extreemly poor image windows. The left atrium is normal in size.\n Due to suboptimal technical quality, a focal wall motion abnormality\n cannot be fully excluded. Overall left ventricular systolic function is\n probably normal (LVEF>55%). RV not well seen. The aortic valve is not\n well seen. There is no aortic valve stenosis. The mitral valve leaflets\n are not well seen. There is no pericardial effusion.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Pt was transferred from ED to on 3 pressors, able to\n be weaned down to 2 pressors of Dopamine following 8 litres of fluid.\n Pt is currently is hypothermic on examination. Pt noted to have\n positive U/A as well as large PNA on left lung. Suspect sources to be\n pulmonary versus urine. Pt's CVP currently , MAP noted to be 76,\n with a mixed venous sat of 83%. Pt also was reportedly on Dexamethasone\n at home and thus was given stress dose steroids in the ED. Per family\n pt has a history of PNA versus aspiration PNA, hospitalizaed three\n times over the past year\n - influenza antigen and legionella negative\n - will try to wean DA first and then levophed to maintain MAP >65\n - will continue on broad coverage with Zosyn, Cipro for coverage of\n Gram+, Gram -, atypicals and double coverage for Pseudomonas.\n Vancomycin for MRSA. Blood cx from OSH growing GPCs in clusters\n - f/u panculture results, continue surveillance blood cultures\n - will continue on IV Hydrocortisone\n - pt on xygris high apache score\n .\n #hyperkalemia: could be to renal failure. Also ? hypoaldo as \n pmh and home meds. Will call PCP today Dr .\n -f/u am K\n -likely will need additional kayexelate\n .\n # : baseline.\n -Consider urine sediment.\n -Check urine lytes to diff bet prerenal v atn, most likely atn\n -ask pcp about baseline GFR\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring Atropine in the\n field for HR in the 40s. Bradycardia is likely due to his hypothermia.\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol.\n - continue ardsnet\n - wean FiO2 prn\n - will sedate with Fentanyl and Midazolam\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine.\n .\n #housekeeping: home meds\n .\n # FEN: replete electrolytes, consider OGT and tube feeds\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2121-09-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596668, "text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 24 cm at lip\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: Insp/Exp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / 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 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: Reduce PEEP as tolerated; Comments: no rsbi due to ^\n peep\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved; Comments: abg 7.37/40/184 on\n a/c. Weaned to psv with additional abg pending.\n" }, { "category": "Physician ", "chartdate": "2121-09-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596860, "text": "Chief Complaint:\n 24 Hour Events:\n -discontinued vancomycin and weaned hydrocortisone to 25 mg q 6hr\n -xigris discontinued\n -insulin drip changed from gtt to SQ\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 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 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96\n HR: 56 (55 - 68) bpm\n BP: 138/55(83) {104/47(65) - 142/93(102)} mmHg\n RR: 14 (7 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 115.7 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 7 (6 - 12)mmHg\n Total In:\n 2,410 mL\n 751 mL\n PO:\n TF:\n 1,083 mL\n 327 mL\n IVF:\n 1,327 mL\n 424 mL\n Blood products:\n Total out:\n 2,025 mL\n 590 mL\n Urine:\n 2,025 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n 161 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 860 (755 - 910) mL\n PS : 15 cmH2O\n RR (Spontaneous): 7\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n SpO2: 100%\n ABG: 7.36/47/161/24/0\n Ve: 5.5 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: , Rhonchorous: )\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 7.5 g/dL\n 201 mg/dL\n 4.2 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 97 mg/dL\n 109 mEq/L\n 143 mEq/L\n 22.8 %\n 7.9 K/uL\n [image002.jpg]\n 09:39 PM\n 04:00 AM\n 04:12 AM\n 06:12 AM\n 03:32 PM\n 03:55 PM\n 09:11 PM\n 10:35 PM\n 04:28 AM\n 05:01 AM\n WBC\n 7.0\n 7.9\n Hct\n 22.3\n 21.7\n 23.0\n 22.8\n Plt\n 73\n 67\n Cr\n 4.5\n 4.2\n TCO2\n 24\n 24\n 24\n 25\n 24\n 28\n Glucose\n 125\n 201\n Other labs: PT / PTT / INR:11.6/32.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:5.4 mg/dL\n Imaging: Single AP chest radiograph compared to shows\n unchanged left\n mid lower lung consolidation. Right lower lobe airspace opacity and\n perihilar\n hazziness continues to improve compatible with decreased fluid\n overload. The\n cardiomediastinal contour is stable. There is no pneumothorax. Right IJ\n central venous catheter tip overlies the proximal SVC. NG tube tip is\n in the\n stomach. ET tube terminates 3 cm above the carina.\n Microbiology: STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B\n TEST-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY\n {YEAST, GRAM NEGATIVE ROD(S)} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n URINE URINE CULTURE-FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST,\n GRAM NEGATIVE ROD(S)} INPATIENT\n URINE Legionella Urinary Antigen -FINAL INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT\n Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL;\n DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT\n MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN\n RESISTANT STAPH AUREUS} INPATIENT\n URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.} INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro. currently growing\n vre sensitive to amp, gnrs from sputum gram stain x2 and coag neg staph\n from blood (likely contaminant) from . dc'ed vancomycin\n yesterday\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 25q6h (=3.75 daily\n of decadron, pt on 2 daily of decadron at home) will wean today\n - pt finished course of xygris yesterday.\n .\n ##. Respiratory Failure:\n - will aim to wean PSV today, will try (was unsuccessful\n yesterday)\n - off sedation\n .\n # : baseline 1.8-2, current Cr is 4.2 down from 4.5 yesterday.\n Likely this is ATN. UOP has gone from low to high so perhaps renal\n function is in process of improving.\n -will trend\n -no acute indications for HD at this point\n -pt is on lasix at home, could consider giving lasix gtt once off\n pressors\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - consider add bblocker and ace if improves clinically and off pressors\n -consider starting ASA now that xigris is off\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -on PPI\n -stool guiac negative\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med now that sedation off\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: switched to insulin SQ yesterday b/c labile BS. If BS not well\n controlled, can switch back to gtt (? if edema will limit absorption).\n .\n .# SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, tube feeds at goal\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (chemical code ok)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:36 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\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: DNR (do not resuscitate)\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2121-09-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596779, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 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: Insp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Insp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / 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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596844, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR; now on 1 pressor, 2 IV abx:\n xigris & insulin gtt d/c\n Shock, septic\n Assessment:\n Pneumonia/urosepsis c/b septic shock. Patient with MRSA + nasal swab,\n +VRE from OSH lab reports. Received patient on levophed gtt only. s/p\n multiple liters of fluid this admission- generalized body edema. Now on\n 2 antibiotic therapy including ciprofloxacin & zosyn. WBC 7, Continues\n to require vent support. Aline waveform dampening at intervals.\n Action:\n Hemodynamics:\n Attempted to wean levophed gtt @ intervals overnight.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 2 antibiotic therapy: Cipro & zosyn\n Given IV steroids as ordered q 6 hours (now 25 ml q 6 hours)\n Xigris discontinued prior shift decreasing HCT level &\n oozing from lines\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact precautions\n Response:\n Levophed remains at 0.03 mcg/kg/min- MAP\ns <65 when gtt\n d/c\n CVP range 7-10; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Insulin gtt d/c\nd at 1 am.\n Re-peat labs show HCT improving to 23 (21.7) no blood\n administered.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CPAP/PS 50% on , initially rate 5-8\n bpm. Lungs diminished with some fine crackles at intervals, partially\n diminished body habitus. Suctioned for small amounts bloody\n secretions. Clear oral secretions draining from mouth. Sedation off >\n 12 hours.\n Action:\n ABG monitoring\n PS changed from 10 to 15 to improve patient spontaneous RR\n Neuro exam monitored\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Am ABG 7.36/47/161/28\n Patient appears more comfortable with slightly higher RR on\n 15 PS\n Patient continues to be synchronous with the vent off\n sedation\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. ? diuresis today\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 4.2/97. Likely hypotension & sepsis MD. Also with\n elevated CE\ns at start of admission. Adequate hourly urine output.\n Action:\n Electrolyte monitoring, especially potassium level.\n No IVF administered this shift\n Monitored UO\n Making liquid stool contained in flexiseal\n Response:\n Am K+ 3.7- given 20 meq K+ up at 0600\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, ecchymotic abdomen, reddened\n sacral area, hematoma in left s/p aline removal, right AC site of\n old PIV opened blister that is oozing clear fluid; swollen testes with\n petechia-type spots that are oozing intermittently. Patient fluid\n balance grossly positive LOS- generalized body & scrotal edema.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right & left groin site: cleansed with wound cleanser:\n applied criticaid clear & fanned gauze\n Sacral area- mepilex dressing\n Right AC- adaptic wrapped in kerlix\n Scrotum- elevated on sling\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597210, "text": "74M with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism. Presents to MICU with severe septic shock, acute renal\n failure, and respiratory failure. Per family, patient was taken to OSH\n for unresponsiveness at home, with SBPs reportedly in the 40s.\n Hypothermic and bradycardic, intubated for airway protection, given\n fluids, ABX, and multiple vasopressors. Transferred to via\n , then to CCU from ED as MICU border. Received approx 16L\n during fluid resuscitation, eventually weaned off pressors and is now\n in the MICU with acute on chronic renal failure.\n Hypernatremia (high sodium)\n Assessment:\n Pt\ns AM Na 146.\n Action:\n Free water increased to 250cc q4h.\n Response:\n Plan:\n Repeat labs due at 2100.\n Altered mental status (not Delirium)\n Assessment:\n Pt off sedation for >24 hours, pt easily arousable to voice,\n intermittently following commands, withdraws to pain, PERRL, denies\n pain.\n Action:\n Mental status evaluated q4h, pt oriented to time, place, situation as\n needed.\n Response:\n Pt\ns mental status continues to clear however per ICU team no plans of\n extubation until fluid balance is negative.\n Plan:\n Continue to assess mental status frequently, question need for sedation\n for comfort if no plans for extubation any time soon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute on chronic renal failure, pt\ns baseline Cr around 2.5,\n currently 4.5. UOP adequate on lasix drip, putting out >200cc q2h.\n Action:\n Lasix drip increased in order to achieve negative fluid balance, per\n team goal is to have pt 1-2L negative by MN.\n Response:\n Slight increase noted in UOP after increase in dose, currently lasix\n drip is at 9mg/hr and pt is -450cc since MN.\n Plan:\n Will continue diuresis for another few days in order to take off fluid,\n if fluid balance continues to be high pt will be consulted by renal for\n CRRT. Labs due at 2100.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV 50%/420*20/+10, pt rarely overbreathing vent, lung sounds\n rhonchorous throughout.\n Action:\n Turned to left side only as pt drops sat on right side. Suctioned for\n small to copious amounts of thick, blood tinged secretions, chest PT\n done with excellent effects. Lasix drip for fluid overload and\n pulmonary edema.\n Response:\n Lung sounds slightly improved post suctioning. UOP >200cc q2h.\n Plan:\n Continue pulmonary toilet, lasix drip, chest PT.\n" }, { "category": "Nursing", "chartdate": "2121-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596203, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia\n Admit: Evening of the day prior to admit patient was put to bed by\n son/daugh after appearing weak and being unable to talk, the following\n morning patient still not speaking; they gave him a nebulizer and juice\n & sent him by ambulance to his day care program. The ambulance instead\n transported the patient to where he was found to be\n unresponsive, bradycardic, hypotensive & hypothermic. Given atropine x\n 2 & medflighted to . In the ED hypotensive on levo/dopa& neo,\n given 8 liters IVF, hypothermic 31.5 Rectally, given warm IVF, bair\n hugger. Given vanco & levaquin & cultures obtained. Transferred to CCU\n as MICU border.\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Action:\n Hemodynamic monitoring\n IVF (s/p 8 liters in ED)\n Dopamine gtt at 20 mcg/kg/min\n Levophed gtt at 0.24 mcg/kg/min\n Response:\n Plan:\n Hypothermia\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-09-09 00:00:00.000", "description": "ICU Attending", "row_id": 596206, "text": "CRITICAL CARE ATTENDING\n 00:25\n I saw and examined Mr. with Dr. , whose note reflects my\n input. I would add/emphasize that this desperately ill 74-year-old man\n presents with severe septic shock, acute renal failure, and respiratory\n failure. Background history is limited (from family; records limited\n and patient unable to discuss): COPD, schizophrenia, diabetes,\n hypothyroidism, and ?adrenal insufficiency are noted. Limited prodrome\n per family; taken to for unresponsiveness, with SBPs reportedly\n in the 40s. Markedly hypothermic and quite bradycardic. Intubated,\n given fluids, ABX, and multiple vasopressors. Transferred to .\n CVL and art line placed in ED.\n Now:\n T 91.8\n 94.6. HR 63. BP 112/51 on dopa @ 20 and Levophed @ 0.24.\n CVP 8\n A/C 420, RR20, PEEP 10, FiO2 0\n 7.20 / 33 / 99\n Distant heart\n Decreased BS on left\n Soft abdomen\n Labs reviewed. EKG reviewed, Imaging reviewed and esp notable for cr\n 3.7, CK 1836, MB 230, trop .06, UA with 21-50 WBC, leucopenia, 29%\n bands.\n Assessment and Plan\n 74-year-old man with\n Septic shock\n Respiratory failure\n Acute renal failure\n Acute MI\n Acidosis\n By history from the family, there was no meningitic prodrome, no\n diarrhea, and no abdominal symptoms. Suspect that initial event is\n either UTI and PNA, or UTI\n encephalopathy\n aspiration. At present,\n identified sources include urine and lung. Syndrome could be influenza\n staphylococcal pneumonia, but influenza-like prodrome not compelling.\n We will plan:\n Septic shock\n ABX/source control\n o Cover HCAP (recent hospitalizations), CAP (including\n Legionella), and UTI: vanco, zosyn, and quinolone are adequate.\n o Fully cult ue, including influenza DFA\n Hemodynamics\n o Currently on substantial doses of dopa and Levophed\n o Although his respiratory status is tenuous, will try to trade\n fluids for vasopressors until CVP in the 13-15 range or off pressors.\n Will need close monitoring for increased hypoxemia, etc.\n o Continue to follow EGDT protocol\n Steroids (at sepsis doses) given history of adrenal\n insufficiency and receipt of steroids\n Drotrecogin: given multiple organ failures, APACHE II >> 24\n (~37 by my calculation, depending on how one treats GCS), and absence\n of contraindications, we will proceed with drotrecogin.\n Respiratory failure\n 6cc/kg/breath (PBW)\n Sedate further to improve synchrony\n Increase PEEP to ARDSnet ladder\n If difficulty, consider esophageal balloon\n Acute renal failure\n Likely hemodynamic and sepsis-related.\n Check urine lytes\n Acidosis\n Mostly metabolic: suspect mixed lactic and non-anion gap\n from saline\n However, need repeat lytes\n Follow closely\n SQH / H2B / VAP prophylaxis / etc.\n Discussed by our team with his family.\n He is critically ill: 80 minutes\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596219, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: aspiration PNA/UTI or a\n combination.\n Recievied patient hypotensive: on 2 pressors ( dopamine at\n 20 mcg/kg/min & levophed @ 0.24 mcg/kg/min) s/p 8 liters NS given in ED\n Received patient hypothermic: temp 91.8\n Urine culture from ED with WBC\n ED had sent BC x 1, urine culture\n Action:\n Continued to culture patient to attempt to identify source:\n BC x1, RRT sent influenza DFA, MRSA nasal swab, urine\n specimen for legionella\n Maitnained & increased doses of dopamine and levophed to\n support hemodynamics\n CVP monitoring, goal 13-15; Given total of 4 liters LR for\n fluid resuscitation\n Vigileo in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score\n Response:\n Results cultures are pending\n Dopamine now at 20 mcg/kg/min, Levophed now @ 0.4 mcg/kg/min\n CVP remains ; 5^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n 4 am ABG:\n Plan:\n Potential for placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06)\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 4 liters\n Response:\n Am CR/BUN\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium level:\n Re-peat K+ level:\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596310, "text": "74 yo with known PMH, adult onset DM, COPD & Schizophrenia,\n hypothyroidism, ?adrenal insufficiency who presents to OSH \n unresponsive w/ sbp 40\ns marked hypothermia and bradycardia. Pt w/\n severe septic shock, acute renal failure, and respiratory failure. Pt\n was Intubated, given fluids, ABX, and multiple vasopressors.\n Transferred to via . TLC presep cath & arterial line\n placed in ED. Transferred to CCU as MICU border.\n Shock, septic\n Assessment:\n Rec\nd pt on triple pressors including dopamine 20mcg/kg/min,\n vasopressin 2.4units/hr and levophed 0.5mcg/kg/min. BP\n 90-110/50-60\ns. HR 70-80\ns nsr w/ rare apc. Temp normothermic 99.6.\n CVP\ns 15 down to 11.\n CR/BUN 3.3/81. Approx 20L positive.\n Action:\n Triple pressors cont, but dopamine has been decreased throught day.\n Triple abx continue.\n 1000cc LR administered for low CVP@ 11am.\n Xigris restarted 20mg/hr. H/H, coags and lytes monitoring q6hrs\n Vigileo monitoring\n CO 5.5-5.3. SVV .\n IV steriods conintue.\n Insulin gtt started.\n Response:\n Culture results are pending\n Tolerating Dopa wean, maintaining SBP >110.\n No significant CVP response to IVF bolus.\n Patient now with worsening edema, periorbital, facial, bilateral upper\n & lower extremities\n BG now controlled w/ insulin gtt.\n H/H 29.9/9.3, INR 1.2.\n u/o 0-70cc/hr.\n Plan:\n Continue septic shock management with MICU team. Attempt to wean dopa\n as tolerated, Close monitoring of labs on xigris, cont insulin gtt as\n necessary, close monitoring i/o\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cont intubated and ventilated 80%/420/24/13peep. Breathing in synch\n w/ vent.\n Pt sedated 200mcgs/hr fentanyl, Versed 5mg/hr.\n Action:\n ABG\ns q4-6hr, 7.25/41/106/-.\n Aggressive pulmonary toileting\n VAP care per protocol\n Sedation unchanged.\n Response:\n Sx for sm amts thick tan, blood tinged secretions via ETT. Copious\n clear oral secretions noted.\n Comfortable on current fent/versed regime.\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Cont fent and\n versed for comfort.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement. Blister noted r ac area\n underneath tegaderm iv dsg, becoming deroofed and is oozing lg amts\n clear.\n Action:\n Turned and positioned q2-4 hrs. Barrier cream to sacrum, elbows and\n heels\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment w/ close monitoring elbows\n and knees.\n Social\n lives w/ son and daughter in MA. Family met at length w/\n Dr. and this RN. Have been thoroughly updated on POC. Pt is DNR\n (no CPR or shock), but will continue aggressive management for septic\n shock.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596312, "text": "Day of mechanical ventilation: 2\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: Crackles\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant - moderate\n Comments:\n No vent changes this shift with acceptable ABG\ns in view of continued\n metabolic acidosis. Continues on pressors for septic shock. Wean as\n possible. Wean FiO2 and/or PEEP as appropriate. Possible candidate for\n esophageal balloon.\n" }, { "category": "Respiratory ", "chartdate": "2121-09-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596394, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26cmH2O\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: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt remains intubated, fully vent supported. No changes made\n overnight. See flowsheet for further pt data.\n 06:32\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596396, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely cause is PNA seen on Cxray; however also ruling out for\n influenza & legionella, some WBC\ns in urine. Received patient on 3\n pressors (dopamine, levophed & vasopressin) s/p total of 8 liters NS\n given in ED & 9 liters LR in CCU (patient with generalized body edema).\n On 3 antibiotic regimen & steroids. Patient now normothermic off\n warming blanket, WBC 10.4, Continues to require vent support. Aline\n waveform dampening at intervals.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin gtt off.\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT/INR monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Vanco level sent 6 am.\n Goal BG level 150-200, maintained with insulin gtt ranging\n 0.5-2 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CMV 80%, rate set at 24, PEEP 13. ABG at\n start of shift: 7.31/40/93. patient synchronous with the vent, no\n overbreathing noted. Lungs diminished with some fine crackles at\n intervals, partially diminished body habitus. Suctioned for small\n amounts bloody secretions. Clear oral secretions draining from mouth.\n Patient sedated to .\n Action:\n ABG monitoring\n Maintained sedation to keep patient synchronous with the\n vent.\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Versed @ 5 mg/hr\n Fentanyl @ 200 mcg/hr\n Patient continues to be synchronous with the vent on current\n sedation\n Re-peat ABG\ns 7.34/41/170 & 7.33/41/168\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. Potential for placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.4/82. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06), likely r/u in for an MI- Cards\n consulted. Adequate hourly urine output. Elevated K+ level 5.8.\n Action:\n Electrolyte monitoring, especially potassium level\n given\n kayexelate at 1 am.\n No IVF administered this shift\n Monitored UO\n Response:\n Am CR/BUN; pending\n Am K+ 5.5, no stool output following kayexelate\n administration\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal, right AC site of old PIV\n opened blister that is oozing clear fluid & is at risk for skin\n breakdown given fluid status & pressor requirement.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear\n Sacral area- applied aloe vesta lotion\n Right AC- mepilex dressing placed & re-inforced with pink\n hy-tape\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596845, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR; now on 1 pressor, 2 IV abx:\n xigris & insulin gtt d/c\nd overnight.\n Shock, septic\n Assessment:\n Pneumonia/urosepsis c/b septic shock. Patient with MRSA + nasal swab,\n +VRE from OSH lab reports. Received patient on levophed gtt only. s/p\n multiple liters of fluid this admission- generalized body edema. Now on\n 2 antibiotic therapy including ciprofloxacin & zosyn. WBC 7, Continues\n to require vent support. Aline waveform dampening at intervals.\n Action:\n Hemodynamics:\n Attempted to wean levophed gtt @ intervals overnight.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 2 antibiotic therapy: Cipro & zosyn\n Given IV steroids as ordered q 6 hours (now 25 ml q 6 hours)\n Xigris discontinued prior shift decreasing HCT level &\n oozing from lines\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact precautions\n Response:\n Levophed remains at 0.03 mcg/kg/min- MAP\ns <65 when gtt\n d/c\n CVP range 7-10; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Insulin gtt d/c\nd at 1 am.\n Re-peat labs show HCT improving to 23 (21.7) no blood\n administered.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CPAP/PS 50% on , initially rate 5-8\n bpm. Lungs diminished with some fine crackles at intervals, partially\n diminished body habitus. Suctioned for small amounts bloody\n secretions. Clear oral secretions draining from mouth. Sedation off >\n 12 hours.\n Action:\n ABG monitoring\n PS changed from 10 to 15 to improve patient spontaneous RR\n Neuro exam monitored\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Am ABG 7.36/47/161/28\n Patient appears more comfortable with slightly higher RR on\n 15 PS\n Patient continues to be synchronous with the vent off\n sedation\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. ? diuresis today\n Hyperglycemia\n Assessment:\n TF continues @ goal rate 45cc/hr w/ small amts residuals. On Steroids\n Q6hrs. Rec\nd patient on insulin gtt\n Action:\n Insulin gtt titrated for goal <200\n Insulin gtt d/c\nd at 0100 by MICU team\n Response:\n 4 AM Bg of 222 treated with 4 units Humalog\n TF remain at goal with little residual\n Plan:\n Q 4 hour BG monitoring with HISS coverage. Continue to monitor TF &\n residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 4.2/97. Likely hypotension & sepsis MD. Also with\n elevated CE\ns at start of admission. Adequate hourly urine output.\n Action:\n Electrolyte monitoring, especially potassium level.\n No IVF administered this shift\n Monitored UO\n Making liquid stool contained in flexiseal\n Response:\n Am K+ 3.7- given 20 meq K+ up at 0600\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, ecchymotic abdomen, reddened\n sacral area, hematoma in left s/p aline removal, right AC site of\n old PIV opened blister that is oozing clear fluid; swollen testes with\n petechia-type spots that are oozing intermittently. Patient fluid\n balance grossly positive LOS- generalized body & scrotal edema.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right & left groin site: cleansed with wound cleanser:\n applied criticaid clear & fanned gauze\n Sacral area- mepilex dressing\n Right AC- adaptic wrapped in kerlix\n Scrotum- elevated on sling\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596847, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR; now on 1 pressor, 2 IV abx:\n xigris & insulin gtt d/c\nd overnight.\n Shock, septic\n Assessment:\n Pneumonia/urosepsis c/b septic shock. Patient with MRSA + nasal swab,\n +VRE from OSH lab reports. Received patient on levophed gtt only. s/p\n multiple liters of fluid this admission- generalized body edema. Now on\n 2 antibiotic therapy including ciprofloxacin & zosyn. WBC 7, Continues\n to require vent support. Aline waveform dampening at intervals.\n Action:\n Hemodynamics:\n Attempted to wean levophed gtt @ intervals overnight.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 2 antibiotic therapy: Cipro & zosyn\n Given IV steroids as ordered q 6 hours (now 25 ml q 6 hours)\n Xigris discontinued prior shift decreasing HCT level &\n oozing from lines\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact precautions\n Response:\n Levophed remains at 0.03 mcg/kg/min- MAP\ns <65 when gtt\n d/c\n CVP range 7-10; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Insulin gtt d/c\nd at 1 am.\n Re-peat labs show HCT improving to 23 (21.7) no blood\n administered.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CPAP/PS 50% on , initially rate 5-8\n bpm. Lungs diminished with some fine crackles at intervals, partially\n diminished body habitus. Suctioned for small amounts bloody\n secretions. Clear oral secretions draining from mouth. Sedation off >\n 24 hours.\n Action:\n ABG monitoring\n PS changed from 10 to 15 to improve patient spontaneous RR\n Neuro exam monitored\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Am ABG 7.36/47/161/28\n Patient appears more comfortable with slightly higher RR on\n 15 PS\n Patient continues to be synchronous with the vent off\n sedation\n Neuro exam- withdrawing from mouth care & nursing\n stimulation, moving bilateral LE\ns on bed\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. ? diuresis today\n Constipation (Obstipation, FOS)\n Assessment:\n Rec\nd patient with flexiseal in place draining liquid golden-brown\n stool.\n Action:\n Held bowel meds\n Maintained flexiseal\n TF at goal\n Response:\n Continues to have golden/brown liquid stool\n Flexiseal without leakage\n Plan:\n Continue to hold bowel meds for now\n Hyperglycemia\n Assessment:\n TF continues @ goal rate 45cc/hr w/ small amts residuals. On Steroids\n Q6hrs. Rec\nd patient on insulin gtt\n Action:\n Insulin gtt titrated for goal <200\n Insulin gtt d/c\nd at 0100 by MICU team\n Response:\n 4 AM Bg of 222 treated with 4 units Humalog\n TF remain at goal with little residual\n Plan:\n Q 4 hour BG monitoring with HISS coverage. Continue to monitor TF &\n residuals.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 4.2/97. Likely hypotension & sepsis MD. Also with\n elevated CE\ns at start of admission. Adequate hourly urine output.\n Action:\n Electrolyte monitoring, especially potassium level.\n No IVF administered this shift\n Monitored UO\n Making liquid stool contained in flexiseal\n Response:\n Am K+ 3.7- given 20 meq K+ up at 0600\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, ecchymotic abdomen, reddened\n sacral area, hematoma in left s/p aline removal, right AC site of\n old PIV opened blister that is oozing clear fluid; swollen testes with\n petechia-type spots that are oozing intermittently. Patient fluid\n balance grossly positive LOS- generalized body & scrotal edema.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right & left groin site: cleansed with wound cleanser:\n applied criticaid clear & fanned gauze\n Sacral area- mepilex dressing\n Right AC- adaptic wrapped in kerlix\n Scrotum- elevated on sling\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597046, "text": "Altered mental status (not Delirium)\n Assessment:\n Opens eyes when name\n\n called. Nods head to indicate that he isn\n having pain. Moving arms and legs on the bed. Midazolam and Fentanyl\n gtts off over 48hrs.\n Action:\n No sedation given for over 48hrs\n Response:\n Plan:\n Continue to allow sedating drugs to wear off\n resume antipsychotic medication on \n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact over coccyx intact. General edema continues with\n weight 14.5kg above noted dry weight. Seeping serous fluid from\n edematous scrotum.\n Action:\n Transferred patient to KCI air bed\n Response:\n Plan:\n Bradycardia\n Assessment:\n Some brief episodes of bradycardia to 47. Pt napping at the time\n bradycardia noted. Sbp as high as 151.\n Action:\n Requested prn antihypertensive medication\n Response:\n No prn antihypertensive to be given at this time\n Plan:\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Rhonchi bilaterally. Diminished breathsounds at bases. SPO2 to 89-90%\n during CPAP trial with peep to 5. Many episodes of endotracheal\n suctioning required. No gag reflex noted with subglotal suctioning.\n ETT suctioned for blood tinged white/tan secretions.\n Hydrocortisone weaning. Hct to 21.6 overnight\n Action:\n Hydrocortisone from qid to tid\n Response:\n Failed wean attempt today around 0700\n Plan:\n Additional diuresis using Lasix bolus and gtt with 24hour negative\n balance goal of 2 liters\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596211, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for\n unresponsiveness, with SBPs reportedly in the 40s. Hypothermic &\n bradycardic; intubated, given fluids, ABX, and multiple vasopressors.\n Transferred to via . CVL and art line placed in ED.\n Transferred to CCU as MICU border.\n Labs reviewed. EKG reviewed, Imaging reviewed and esp notable for cr\n 3.7, CK 1836, MB 230, trop .06, UA with 21-50 WBC, leucopenia, 29%\n bands.\n Septic shock\n Respiratory failure\n Acute renal failure\n Acute MI\n Acidosis\n By history from the family, there was no meningitic prodrome, no\n diarrhea, and no abdominal symptoms. Suspect that initial event is\n either UTI and PNA, or UTI\n encephalopathy\n aspiration. At present,\n identified sources include urine and lung. Syndrome could be influenza\n staphylococcal pneumonia, but influenza-like prodrome not compelling.\n We will plan:\n Septic shock\n ABX/source control\n o Cover HCAP (recent hospitalizations), CAP (including\n Legionella), and UTI: vanco, zosyn, and quinolone are adequate.\n o Fully cult ue, including influenza DFA\n Hemodynamics\n o Currently on substantial doses of dopa and Levophed\n o Although his respiratory status is tenuous, will try to trade\n fluids for vasopressors until CVP in the 13-15 range or off pressors.\n Will need close monitoring for increased hypoxemia, etc.\n o Continue to follow EGDT protocol\n Steroids (at sepsis doses) given history of adrenal\n insufficiency and receipt of steroids\n Drotrecogin: given multiple organ failures, APACHE II >> 24\n (~37 by my calculation, depending on how one treats GCS), and absence\n of contraindications, we will proceed with drotrecogin.\n Respiratory failure\n 6cc/kg/breath (PBW)\n Sedate further to improve synchrony\n Increase PEEP to ARDSnet ladder\n If difficulty, consider esophageal balloon\n Acute renal failure\n Likely hemodynamic and sepsis-related.\n Check urine lytes\n Acidosis\n Mostly metabolic: suspect mixed lactic and non-anion gap\n from saline\n However, need repeat lytes\n Follow closely\n" }, { "category": "Respiratory ", "chartdate": "2121-09-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 596943, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 78 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 24 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Weaned on PSV from 15/10 to . ABG was acceptable.\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 ? Elective extubation.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2121-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596202, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia\n Admit: Evening of the day prior to admit patient was put to bed by\n son/daugh after appearing weak and being unable to talk, the following\n morning patient continued to not speak, they gave him a nebulizer &\n sent him by ambulance to his day care program. The ambulance instead\n transported the patient to where he was found to be\n unresponsive, bradycardic, hypotensive & hypothermic. Given atropine x\n 2 & medflighted to . In the ED hypotensive on levo/dopa& neo,\n given 8 liters IVF, hypothermic 31.5 Rectally, given warm IVF, bair\n hugger. Given vanco & levaquin & cultures obtained. Transferred to CCU\n as MICU border.\n" }, { "category": "Nursing", "chartdate": "2121-09-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596292, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: aspiration PNA/UTI or a\n combination.\n Recievied patient hypotensive: on 2 pressors ( dopamine at\n 20 mcg/kg/min & levophed @ 0.24 mcg/kg/min) s/p 8 liters NS given in ED\n Received patient hypothermic: temp 91.8\n Urine culture from ED with WBC\n ED had sent BC x 1, urine culture\n Action:\n Continued to culture patient to attempt to identify source:\n BC x1, RRT sent influenza DFA, MRSA nasal swab, urine\n specimen for legionella\n Increased doses of dopamine and levophed to support\n hemodynamics\n CVP monitoring, goal 13-15; Given total of 8 liters LR for\n fluid resuscitation\n Vigileo in place\n Given IV steroids as ordered\n Xigris (Drotrecogin) administered given APACHE II score\n Type & cross specimen sent\n Response:\n Results cultures are pending\n Dopamine now at 20 mcg/kg/min, Levophed now @ 0.4\n mcg/kg/min; required addition of vasopressin at 2.4 units/hour; patient\n BP appears most responsive to fluid resusication ; patient now with\n worsening edema, periorbital, facial, bilateral upper & lower\n extremities\n CVP now 13-15; 9^th & 10^th bag LR available\n SCVO2 by vigileo ranging 78-86%\n BG monitoring with steroid administration; levels elevated 1\n x dose 12 units humalog administered\n Xigris on hold at 0500 given potentially low Hgb level-\n re-peat level sent for confirmation\n MICU team in contact with primary contact family members\n regarding patient\ns tenuous status; they plan to travel in today to\n visit with patient.\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring. Potentially re-start\n Xigris gtt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Mixed\n Assessment:\n Action:\n Response:\n Plan:\n Hypothermia\n Assessment:\n Action:\n Response:\n Plan:\n Shock, hypovolemic or hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Social Work", "chartdate": "2121-09-10 00:00:00.000", "description": "Social Work Progress Note", "row_id": 596481, "text": "SOCIAL WORK: Pt referred to SW in POE re: concerns raised by pt\ns PCP\n that he is unable to care for self and in unsafe living situation\n leading to frequent hospitalizations. Medical record reviewed, case\n discussed briefly with RN yesterday and today. Pt is currently\n intubated and sedated on CCU. SW met with pt\n in family\n waiting area. reports pt lives in his own home, and pt\n son live with him. reports pt has a PCA for 1 hour 3\n days/week through Minuteman Elder Services, and attends as adult day\n health program 2 days/ week. reports pt requires assist with\n bathing, but independent with toileting, dressing and feeding. \n reports pt has hx of Paranoid Schizophrenia and sees a psychiatrist\n every few months. Pt\ns psych illness stable, has not required psych\n admission in 15 years . Pt was widowed 5 years ago. states\n pt has no HCP or guardian, but she and brother have acted as surrogate\n decision makers when pt is unable. Pt has 2 other , and\n , who live out of state. reports pt has always expressed\n desire to remain in his own home, and family has been committed to\n keeping him at home. She expresses understanding that pt is very ill\n at this time, and that he may not have long to live. She reports\n family would consider rehab in a local if pt is unable to return\n home after hospitalization. SW educated about SW role, and she is\n receptive to ongoing SW support while pt is in hospital. SW will\n collaborate with Minuteman Elder Services as needed to obtain\n additional information about pt\ns baseline functioning and home\n situation. Will continue to follow with team.\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596488, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR\nCPR not indicated, but would\n use pressors. SW in to assess and provide support to pt\ns family.\n Shock, septic\n Assessment:\n Ruled out for influenza and legionella, blood cultures from OSH\n with GPC . Urine sample from OSH + for VRE. MRSA +. Received pt on\n levophed, dopamine and vasopressin had been weaned off over night.\n Action/Response:\n Hemodynamics monitored: CVP 10-12, Vigileo monitoring in\n place: CO 4.7-5.3, CI 2.1-2.4, Scvo2 low 80\ns high 70\n No further fluid boluses\n Levophed weaned from 0.5 mcg/kg/min to 0.16 maintaining\n goal MAP >65\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn. Vanco dose\n given late awaiting trough level\ntrough 8 on q 48 hour dosing. Vanco\n to q 24 hours.\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) @ 20 mcg/kg/min, H/H, PLTS & PT/INR\n monitored . 1600 values returned with decreased Hct/Hgb/plt/WBC--?\n Lab error. MICU team notified and sample repeated\nsimilar to earlier\n values, though with a more significant fall in plts. MICU team\n notifed.\n Assessed for bleeding\nno expansion of L groin hematoma (site\n soft and ecchymotic), GI asps bilious, ETS\nold bloody secretions.\n Insulin gtt remains @ 0.5 unit/hour with BS 150\ns-160\n (goal 150-200)\n Droplet precautions d/c\nd, remains on contact precautions\n d/t VRE and MRSA\n Blood cultures X2 sent, urine culture repeated, sputum\n culture sent.\n T 96.8-98 po\n U/O 40-80cc/hour, Cr 3.5 (3.4)\n Pt in sinus rhythm rate 60-70 all day. 1800 while changing\n pt\ns IV lines, HR slowing very transiently to 40\ns SB, lasted only\n seconds. MICU team notified and came into to assess pt.\n Plan:\n Continue with contact precautions. Follow Temp, antibiotics as\n ordered. Please note that pt is to have trough Vanco drawn \nplease\n draw at 1100. Continue with hemodynamic monitoring. Wean levo as able\n to keep MAP >65. Monitor HR/Rhythm. Plan as per team is to let pt\n autodiurese for now and monitor Cr. Steroids IV q 6 hours with plan to\n decrease dose tomorrow as per team. Monitor BS hourly on insulin\n gtt\nmay need to ^ dose as TF is advanced. Monitor labs with Xigris\n infusion, assess for bleeding, guiac stool. To receive 1 unit\n PRBC\ns. Team would like to remove sepsis cath as possible and change\n to PICC.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 420/ 24, PEEP 13. Not overbreathing vent.\n Fentanyl @ 200mcg/hour, Versed @ 5mg/hour. Lungs with diminished\n breath sounds, occ rhonchi. 1.\n Action/Response:\n Sedation weaned q 2 hours while following neuro assessment.\n Breathing breathes over vent. Sedation turned to off at 1815 as\n not awakening. MICU team aware.\n Fi O2 weaned to 50%\ns stable.\n PEEP weaned to 10 with stable ABG and O2 sat until turned on\n L side. Then sat decreased to 90%. ABG sent , RT notifed, MDI\n given. ABG\nhypoxemia. MICU team notified and PEEP ^ back to 12.\n Sats 92-94%, ABG repeated, greatly improved.\n VAP prevention including HOB > 40, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n ETS\nscant old bldy secretions.\n Plan:\n Continue sedation weaned to off\nwill need to be cautious of mental\n status given history of schizophrenia and not currently on his\n medications. ? attempting weaning PEEP down to 11 and reassess.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.5 (3.4 )\n Action:\n K 5.1 following K exalate last night.\n ? Cr falsely low given Vanco trough levels.\n Mg replaced. Calcium replaced X2 as per sliding scale\n orders.\n Response:\n Plan:\n Cotninue to monitor urine output & labs. Monitor ionized Calcium, esp\n given bleeding risk.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, sacral area pink, blanchable\n with central flakey area which resembles Seborrheic Keratosis (pt has\n many on his back). L groin with soft ecchymotic area s/p aline\n removal, right AC site of old PIV opened blister that is oozing clear\n with dressing in place.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear, fanned 4X4 gauze over site to prevent skin from\n touching skin.\n L Panus with criticaid and fanned 4X4 gauze over pinkened\n area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- mepilex dressing with pink hy-tape intact.\n Nutren 2.0 TF begun, to titrate up to 40 cc/hour goal.\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\nstopped oozing.\n Plan:\n Continue careful skin assessment. Reposition q 2 hours, avoid back.\n Advance TF towards goal.\n" }, { "category": "Nutrition", "chartdate": "2121-09-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 596575, "text": "Subjective\n intub/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 100 kg\n 118 kg ( 02:00 PM)\n up due to fluid\n 30.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 78 kg\n 128%\n 83.5 kg\n not available\n Diagnosis: SEPSIS;TELEMETRY\n PMHx:\n Food allergies and intolerances: not available\n Pertinent medications: Norepinephrine, Fentanyl Citrate, Vasopressin,\n Midazolam, Vancomycin, Hydrocortisone, Ciprofloxacin,\n Piperacillin-Tazobactam, DOPamine, Levothyroxine Sodium, Pantoprazole,\n others noted\n Labs:\n Value\n Date\n Glucose\n 110 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 73\n 09:00 AM\n BUN\n 88 mg/dL\n 04:00 AM\n Creatinine\n 4.1 mg/dL\n 04:00 AM\n Sodium\n 137 mEq/L\n 04:00 AM\n Potassium\n 4.0 mEq/L\n 04:00 AM\n Chloride\n 103 mEq/L\n 04:00 AM\n TCO2\n 21 mEq/L\n 04:00 AM\n PO2 (arterial)\n 108 mm Hg\n 04:09 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:09 AM\n pH (arterial)\n 7.37 units\n 04:09 AM\n pH (urine)\n 5.0 units\n 02:38 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 04:09 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:00 AM\n Phosphorus\n 5.0 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.19 mmol/L\n 12:08 AM\n Magnesium\n 2.1 mg/dL\n 04:00 AM\n ALT\n 45 IU/L\n 04:00 AM\n Alkaline Phosphate\n 42 IU/L\n 04:00 AM\n AST\n 30 IU/L\n 04:00 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:00 AM\n WBC\n 5.5 K/uL\n 04:00 AM\n Hgb\n 7.7 g/dL\n 04:00 AM\n Hematocrit\n 23.2 %\n 04:00 AM\n Current diet order / nutrition support: Nutren 2.0 Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 40 ml/hr\n (1920kcal/77g protein)\n Residual Check: q4h Hold feeding for residual >= : 150 ml\n GI: abd: obese, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: 1837-2087 (BEE x or / 22-25 cal/kg)\n Protein: 83-100 (1-1.2 g/kg)\n Fluid: min\n Calculations based on: Adjusted weight\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n 74 year old male in septic shock on admission to the ED, found to have\n pneumonia and equivocal urinalysis. Patient noted to have elevated\n cardiac enzymes, being monitor closely but patient is not a candidate\n for cath given his instability at this time. Tube feed ordered\n yesterday, patient currently tolerating tube feed at 40ml/hr without\n problem, currently tube feed order slightly underfeeding patient.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: change tube feed to Nutren 2.0\n goal 45ml/hr (2160kcal/86.4g protein)\n Monitor tube feed tolerance\n Check chemistry 10 panel daily, replete prn\n Continue BS management\n Other: if has question\n ------ Protected Section ------\n PMHX:\n h.o. nephrectomy in ?\n Paranoid Schizophrenia\n HTN\n DM II\n COPD\n ?h.o. PNA requiring hospitalization\n ------ Protected Section Addendum Entered By: , RD, \n on: 12:09 ------\n" }, { "category": "Physician ", "chartdate": "2121-09-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596587, "text": "Chief Complaint:\n 24 Hour Events:\n -from : growing coag neg staph of 2 morphologies out of blood\n and growing >100,000 VRE from urine. the VRE is sensitive to ampicillin\n in addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n -also growing enterococcus from urine on admission here\n -got more blood cultures and urine culture and sputum culture today\n -got records from pt's pcp ( #)\n -Dr reports that pt's home living situation is very poor. In past\n has had vna and they feel unsafe their for health reasons (in\n disarray, dirty). Pt not able to care for self and sister also very\n debilitated by psych issues. Dr feels strongly that pt belongs in\n , but sister has been reluctant to pursue in the past. Will consult\n sw.\n -consider picc tomorrow or friday\n -does have mild chronic cri s/p nephrectomy for hematoma\n -weaned sedation down, weaned levo\n -tried to wean peep down from 12 to 10, but patient later desaturated\n when turned, and PaO2 of 64. turned peep back up to 12\n -HCT of 22.5, gave one unit PRBC\n -6pm, called for brady to 40's, but then spontaneously resolved.\n happened while nurse lines, but doesnt seem vagal. On\n tele, was sinus. By the time we got there he was back in the 60's\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:30 AM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 50 mcg/hour\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Insulin - Regular - 1.5 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Famotidine (Pepcid) - 03:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.2\nC (97.1\n HR: 66 (42 - 71) bpm\n BP: 103/50(66) {103/50(66) - 160/73(95)} mmHg\n RR: 19 (18 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (10 - 14)mmHg\n Total In:\n 3,981 mL\n 934 mL\n PO:\n 120 mL\n TF:\n 170 mL\n 294 mL\n IVF:\n 3,211 mL\n 640 mL\n Blood products:\n 350 mL\n Total out:\n 1,740 mL\n 590 mL\n Urine:\n 1,740 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,241 mL\n 344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 32.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/40/108/21/-1\n Ve: 10.5 L/min\n PaO2 / FiO2: 216\n Physical Examination\n gen: intubated, sedated\n cv: RRR\n resp: clear anteriorly\n abd: obese, hypoactive bowel sounds\n ext: edematous\n Labs / Radiology\n 55 K/uL\n 7.7 g/dL\n 110 mg/dL\n 4.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 88 mg/dL\n 103 mEq/L\n 137 mEq/L\n 23.2 %\n 5.5 K/uL\n [image002.jpg]\n 12:32 PM\n 03:49 PM\n 04:03 PM\n 04:41 PM\n 05:22 PM\n 05:35 PM\n 12:00 AM\n 12:08 AM\n 04:00 AM\n 04:09 AM\n WBC\n 6.7\n 6.9\n 5.5\n Hct\n 22.9\n 22.5\n 23.7\n 23.2\n Plt\n 72\n 58\n 55\n Cr\n 4.1\n TCO2\n 22\n 21\n 22\n 22\n 23\n 24\n Glucose\n 110\n Other labs: PT / PTT / INR:13.8/86.9/1.2, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:45/30, Alk Phos / T Bili:42/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:644 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Microbiology: 8:52 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n RESPIRATORY CULTURE (Preliminary):\n HEAVY GROWTH Commensal Respiratory Flora.\n YEAST. HEAVY GROWTH.\n GRAM NEGATIVE ROD(S). SPARSE GROWTH.\n from : growing coag neg staph of 2 morphologies out of blood and\n growing >100,000 VRE from urine. the VRE is sensitive to ampicillin in\n addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n also growing enterococcus from blood cultures from here, sensitivities\n pending\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro and vancomycin.\n currently growing vre sensitive to amp, gnrs from sputum and coag neg\n staph from blood (likely contaminant). Likely dc vancomycin tomorrow\n - f/u panculture results\n - will continue on IV Hydrocortisone, weaned to 50q6h (=7.5 daily of\n decadron, pt on 2 daily of decadron at home)\n - pt on xygris high apache score, check coags\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - continue ardsnet\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n # : baseline.\n -Consider urine sediment.\n -Check urine lytes to diff bet prerenal v atn, most likely atn\n -pt does have some chronic renal insufficiency\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult for ? sick sinus syndrome, seems less c/w vagal\n - will continue to monitor heart rate on tele, not bradycardic since\n admission\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration\n -keep active type and screen\n -increase H2B to \n -guiac stool\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine\n (home dose is 50 and pt on 25, will increase to 50)\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych meds\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n .\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin\n .\n # SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, f/u tube feed recs\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:38 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596589, "text": "Chief Complaint:\n 24 Hour Events:\n -from : growing coag neg staph of 2 morphologies out of blood\n and growing >100,000 VRE from urine. the VRE is sensitive to ampicillin\n in addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n -also growing enterococcus from urine on admission here\n -got more blood cultures and urine culture and sputum culture today\n -got records from pt's pcp ( #)\n -Dr reports that pt's home living situation is very poor. In past\n has had vna and they feel unsafe their for health reasons (in\n disarray, dirty). Pt not able to care for self and sister also very\n debilitated by psych issues. Dr feels strongly that pt belongs in\n , but sister has been reluctant to pursue in the past. Will consult\n sw.\n -consider picc tomorrow or friday\n -does have mild chronic cri s/p nephrectomy for hematoma\n -weaned sedation down, weaned levo\n -tried to wean peep down from 12 to 10, but patient later desaturated\n when turned, and PaO2 of 64. turned peep back up to 12\n -HCT of 22.5, gave one unit PRBC\n -6pm, called for brady to 40's, but then spontaneously resolved.\n happened while nurse lines, but doesnt seem vagal. On\n tele, was sinus. By the time we got there he was back in the 60's\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 11:30 AM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 50 mcg/hour\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Insulin - Regular - 1.5 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Famotidine (Pepcid) - 03:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.2\nC (97.1\n HR: 66 (42 - 71) bpm\n BP: 103/50(66) {103/50(66) - 160/73(95)} mmHg\n RR: 19 (18 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (10 - 14)mmHg\n Total In:\n 3,981 mL\n 934 mL\n PO:\n 120 mL\n TF:\n 170 mL\n 294 mL\n IVF:\n 3,211 mL\n 640 mL\n Blood products:\n 350 mL\n Total out:\n 1,740 mL\n 590 mL\n Urine:\n 1,740 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,241 mL\n 344 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 32.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/40/108/21/-1\n Ve: 10.5 L/min\n PaO2 / FiO2: 216\n Physical Examination\n gen: intubated, sedated\n cv: RRR\n resp: clear anteriorly\n abd: obese, hypoactive bowel sounds\n ext: edematous\n Labs / Radiology\n 55 K/uL\n 7.7 g/dL\n 110 mg/dL\n 4.1 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 88 mg/dL\n 103 mEq/L\n 137 mEq/L\n 23.2 %\n 5.5 K/uL\n [image002.jpg]\n 12:32 PM\n 03:49 PM\n 04:03 PM\n 04:41 PM\n 05:22 PM\n 05:35 PM\n 12:00 AM\n 12:08 AM\n 04:00 AM\n 04:09 AM\n WBC\n 6.7\n 6.9\n 5.5\n Hct\n 22.9\n 22.5\n 23.7\n 23.2\n Plt\n 72\n 58\n 55\n Cr\n 4.1\n TCO2\n 22\n 21\n 22\n 22\n 23\n 24\n Glucose\n 110\n Other labs: PT / PTT / INR:13.8/86.9/1.2, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:45/30, Alk Phos / T Bili:42/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:644 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Microbiology: 8:52 am SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n RESPIRATORY CULTURE (Preliminary):\n HEAVY GROWTH Commensal Respiratory Flora.\n YEAST. HEAVY GROWTH.\n GRAM NEGATIVE ROD(S). SPARSE GROWTH.\n from : growing coag neg staph of 2 morphologies out of blood and\n growing >100,000 VRE from urine. the VRE is sensitive to ampicillin in\n addition to linezolid and daptomycin. D/w Dr and we will keep\n him on his current meds for now (zosyn covering enterococcus).\n also growing enterococcus from blood cultures from here, sensitivities\n pending\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have pna and equivocal urinalysis. Per family pt has a\n history of PNA versus aspiration PNA, hospitalizaed three times over\n the past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro and vancomycin.\n currently growing vre sensitive to amp, gnrs from sputum and coag neg\n staph from blood (likely contaminant). Likely dc vancomycin tomorrow\n - f/u panculture results\n - will continue on IV Hydrocortisone, weaned to 50q6h (=7.5 daily of\n decadron, pt on 2 daily of decadron at home)\n - pt on xygris high apache score, check coags. Will dc xygris\n today if PTT stays high this afternoon.\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol, however\n overall status seems to be improved\n - will aim to wean today possibly try PSV\n - lighten Fentanyl and Midazolam\n .\n # : baseline 1.8-2, current Cr is 4. Likely this is ATN. UOP\n has gone from low to high so likely renal function is in process of\n improving.\n -will trend\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers.\n -keep active type and screen\n -increase H2B to \n -guiac stool\n -likely dc xygris given falling hct\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych meds\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n .\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin\n .\n # SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, f/u tube feed recs\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (? chemical code)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:38 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n 18 Gauge - 10:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2121-09-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596933, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n Received briefly opening eyes to voice. Pearl. Not following\n commands. Mae. Hypothermic temp 94.8. sb->nsr w/rare pvc\ns noted.\n Low dose levo gtt. Sbp 130-140 this am. Vigileo sqi 4. Lungs clear\n w/crackles in bases->rhonchi throughout this afternoon. Received on\n cpap 50% 10/10. abd obese +bs. Tf at goal. Flexiseal in place\n w/mod amt liquid stool. Foley patent w/clear yellow urine. +weak but\n palp pp bilat. K+ 3.8. cont on zosyn & cipro.\n Action:\n Increased movement of extremities through out the day, lifting &\n holding bue, moving ble on bed. Bair hugger applied. Levo drip off.\n Team aware of sqi 4 on vigileo, no intervention at this time.\n Suctioned for thick blood tinged sputum. Tf off, SBT done this am.\n Restarted asa & heparin. Lasix 40mg iv x1 given. Team aware of k+ do\n not treat at this time.\n Response:\n Temp improved to 96.9 po w/bair hugger on. Maintaining sbp>100 off\n levo. Abg\ns acceptable. Suctioned frequently. To redraw abg. Fair\n effect after lasix.\n Plan:\n Cont to assess neuro status, hemodynamics, resp status, i&o, labs.\n Repeat abg. Suction prn. Cont ivabx.\n Impaired Skin Integrity\n Assessment:\n Multiple areas of skin breakdown. See flowsheet for details.\n Action:\n Skin care done. T&r q2h.\n Response:\n Skin breakdown unchanged.\n Plan:\n Cont current skin care plan.\n" }, { "category": "Physician ", "chartdate": "2121-09-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597003, "text": "Chief Complaint:\n 24 Hour Events:\n - all pressors off\n - patient did OK on 0/5 trial. Will attempt to wean vent today.\n - started subQ heparin and restarted ASA\n - some bloody secretions\n - holding Bblocker and ACEi b/c of bradycardia and renal function\n respectively\n - on lasix 40mg PO BID at home; goal of 1.5 liters diuresis today, gave\n 40mg IV lasix in AM only 250 cc negative by 7pm. Gave additional 40mg\n IV lasix\n -RSBI 33; lots of secretions and poor mental status. will try SBT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Piperacillin/Tazobactam (Zosyn) - 01:10 AM\n Ciprofloxacin - 02:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:27 PM\n Heparin Sodium (Prophylaxis) - 09:27 PM\n Furosemide (Lasix) - 10:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 61 (53 - 82) bpm\n BP: 136/58(82) {104/41(58) - 146/62(88)} mmHg\n RR: 14 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.5 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 14 (4 - 15)mmHg\n Total In:\n 1,438 mL\n 418 mL\n PO:\n TF:\n 557 mL\n 49 mL\n IVF:\n 832 mL\n 369 mL\n Blood products:\n Total out:\n 1,960 mL\n 365 mL\n Urine:\n 1,960 mL\n 365 mL\n NG:\n Stool:\n Drains:\n Balance:\n -522 mL\n 53 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 735 (537 - 735) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 93%\n ABG: 7.40/45/81./26/1\n Ve: 7.1 L/min\n PaO2 / FiO2: 162\n Physical Examination\n gen: intubated\n cv: rrr\n resp: cta anteriorly\n abd: obese, +BS\n ext: pitting edema\n Labs / Radiology\n 91 K/uL\n 7.3 g/dL\n 105 mg/dL\n 4.6 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 103 mg/dL\n 107 mEq/L\n 149 mEq/L\n 21.6 %\n 5.4 K/uL\n [image002.jpg]\n 03:55 PM\n 09:11 PM\n 10:35 PM\n 04:28 AM\n 05:01 AM\n 12:17 PM\n 03:31 PM\n 06:38 PM\n 12:03 AM\n 04:32 AM\n WBC\n 7.9\n 6.5\n 5.4\n Hct\n 23.0\n 22.8\n 22.4\n 21.6\n Plt\n 67\n 79\n 91\n Cr\n 4.2\n 4.4\n 4.6\n TCO2\n 25\n 24\n 28\n 25\n 25\n 29\n Glucose\n \n Other labs: PT / PTT / INR:12.0/34.6/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.7 mg/dL, PO4:5.0 mg/dL\n Microbiology: GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT\n WITH\n OROPHARYNGEAL FLORA.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n RESPIRATORY CULTURE (Preliminary):\n Further incubation required to determine the presence or absence\n of\n commensal respiratory flora.\n YEAST. MODERATE GROWTH.\n ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ACINETOBACTER BAUMANNII COMPLEX\n |\n AMPICILLIN/SULBACTAM-- =>32 R\n CEFEPIME-------------- 32 R\n CEFTAZIDIME----------- =>64 R\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ 8 I\n IMIPENEM-------------- 2 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- =>16 R\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - off pressors since this AM\n - currently on zosyn/, broaden zosyn to given\n acinetobacter in sputum s to imi and tobra only. currently growing vre\n sensitive to amp, gnrs from sputum gram stain x2 and coag neg staph\n from blood (likely contaminant) from . dc'ed vancomycin\n yesterday\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 25q6h, will space to\n 25q8 today (=2.8 daily of decadron, pt on 2 daily of decadron at home)\n - pt completed xygris course\n .\n ##. Respiratory Failure:\n - will aim for SBT today\n - off sedation\n .\n # : baseline 1.8-2, current Cr is 4.6, was 4.2 yesterday prior to\n diuresis but increased slightly over course of the day.\n -will trend\n -no acute indications for HD at this point\n -pt is on 40mg lasix PO BID at home; will continue gentle diuresis\n -if renal function does not improve, will consult renal\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension.\n - consider add bblocker and ace pending improvement of bradycardia and\n RF respectively\n - restart ASA now that xigris is off\n .\n #hypernatremia: hypernatremic to 149 this am. will increase free water\n in tube feeds.\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady 2\n nights ago\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -on PPI\n -stool guiac negative\n .\n #. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med now that sedation off\n -consider psych consult when extubated.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will continue\n to wean hydrocort slowly and restart dexamethasone at home dose.\n .\n # DM: now back on insulin SQ, may need to tighten ss\n .\n # SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, tube feeds at goal\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Right IJ, A-line\n .\n # Code: DNR (chemical code ok)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (chemical code ok)\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-14 00:00:00.000", "description": "ICU attending", "row_id": 597037, "text": "CRITICAL CARE ATTENDING ADDENDUM\n I saw and examined Mr. with the ICU team, whose note reflects my\n input. I would add/emphasize that he did not tolerate SBT today.\n -500cc with two boluses of Lasix yesterday. PSV 5/5 /.5\n ABG\n pending. Remains off pressors.\n Labs notable for escalating creatinine, Hct 21.6, Plt 91, Na 149, Cr\n 4.6. ABG: 7.40 / 45 / 81\n Sputum:\n ACINETOBACTER BAUMANNII COMPLEX\n |\n AMPICILLIN/SULBACTAM-- =>32 R\n CEFEPIME-------------- 32 R\n CEFTAZIDIME----------- =>64 R\n CIPROFLOXACIN--------- =>4 R\n GENTAMICIN------------ 8 I\n IMIPENEM-------------- 2 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- =>16 R\n Meds: synthroid, pip/tazo, cipro, PPI, hydrocort 25 q6, CHG, MDIs, SQH,\n PPI\n 74-year-old man with respiratory failure, septic shock (now off\n pressors), NSTEMI related to demand, anemia, thrombocytopenia, and\n acute renal failure. He has made substantial progress.\n Respiratory failure\n has made substantial progress, but still\n substantial secretions and intermittent desaturations. Sputum culture\n with Acinetobacter, but not completely clear if this represents\n colonization. Given inability to extubate, substantial secretions,\n abnormal CXR, we will change to meropenem given new (+) cultures. 15\n day course. Diuresis today goal about negative 1500\n .\n Shock\n resolved. Taper steroids (hx of adrenal insufficiency)\n UTI with VRE\n confirm clearance with UA today. If still abnormal\n consider linezolid or dapto.\n Acute renal failure\n likely due to ATN on baseline of about 2.\n Non-oliguric. Recheck urine lytes and eos today. Transfuse.\n Anemia\n Transfuse now. On PPI given prior hx of ulcers.\n Psych\n resume home meds if UA negative\n Hypernatremia\n replete free water. PM lytes\n NSTEMI\n ASA; diuresis today; potential beta blockade after diuresis.\n Other issues as per ICU team note.\n 40 minutes\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596374, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely cause is PNA seen on Cxray; however also ruling out for\n influenza & legionella, some WBC\ns in urine. Received patient on 3\n pressors (dopamine, levophed & vasopressin) s/p total of 8 liters NS\n given in ED & 9 liters LR in CCU (patient with generalized body edema).\n On 3 antibiotic regimen & steroids. Patient now normothermic off\n warming blanket, WBC 10.4, Continues to require vent support. Aline\n waveform dampening.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin gtt off.\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT/INR monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Vanco level sent 6 am.\n Goal BG level 150-200, maintained with insulin gtt ranging\n 0.5-2 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CMV 80%, rate set at 24, PEEP 13. ABG at\n start of shift: 7.31/40/93. patient synchronous with the vent, no\n overbreathing noted. Lungs diminished with some fine crackles at\n intervals, partially diminished body habitus. Suctioned for small\n amounts bloody secretions. Clear oral secretions draining from mouth.\n Patient sedated to .\n Action:\n ABG monitoring\n Maintained sedation to keep patient synchronous with the\n vent.\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Versed @ 5 mg/hr\n Fentanyl @ 200 mcg/hr\n Patient continues to be synchronous with the vent on current\n sedation\n Re-peat ABG 7.34/41/170\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. Potential for placement of esophageal balloon.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.4/82. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06), likely r/u in for an MI- Cards\n consulted. Adequate hourly urine output. Elevated K+ level 5.8.\n Action:\n Electrolyte monitoring, especially potassium level\n given\n kayexelate at 1 am.\n No IVF administered this shift\n Monitored UO\n Response:\n Am CR/BUN;\n Am K+ 5.5, no stool output following kayexelate\n administration\n Making > 50\n 100 ml urine hourly\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned q 2 hours. Oral care.\n Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596530, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 22.5 (26.2). Bloody oral secretions, ? tongue. RIJ TLC oozing.\n Hypothermic T 95.4 PO. MAPs >65 on Levo. HR 60-70s SR w/o ectopy. SVV\n , Scv02 78-80%. CVP 11-14. Gross general body edema.\n Action:\n 1 unit PRBC transfused\n Triple abx\n Serveillance Bcx drawn from Aline w/ AM labs\n Levo weaned\n Response:\n HCT 4hrs post transfusion 23.2. Unable to wean Levo off\nMAPs fall below\n 65. +23L LOS. UOP 40-170cc/hr. BUN/Cr 88/4.1 (81/3.5). PLT 55(58)\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo for goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleeding, Guiac stool when able. (of note: pt\n dtr states pt easily become constipated--> no BM since admit . ?\n Supp today\n ? another unit PRBC\n Draw vanc trough level prior to 11:00 dose\n Continue Xigris til 07:30\ncheck coags \n Wean Steriods today\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since :00 . No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n ARDSnet vent settings\n VAP care per protocol, HOB up 45 degrees\n Response:\n Stable ABGs. PF ratios\n Plan:\n Wean vent as , need sedation for comfort high PEEP when\n wakes up.\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596477, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR\nCPR not indicated, but would\n use pressors.\n Shock, septic\n Assessment:\n Ruled out for influenza and legionella, blood cultures from OSH\n with GPC . Urine sample from OSH + for VRE. MRSA +. Received pt on\n levophed, dopamine and vasopressin had been weaned off over night.\n Action/Response:\n Hemodynamics monitored: CVP 10-12, Vigileo monitoring in\n place: CO 4.7-5.3, CI 2.1-2.4, Scvo2 low 80\ns high 70\n No further fluid boluses\n Levophed weaned from 0.5 mcg/kg/min to 0.16 maintaining\n goal MAP >65\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn. Vanco dose\n given late awaiting trough level\ntrough 8 on q 48 hour dosing. Vanco\n to q 24 hours.\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) @ 20 mcg/kg/min, H/H, PLTS & PT/INR\n monitored . 1600 values returned with decreased Hct/Hgb/plt/WBC--?\n Lab error. MICU team notified and sample repeated.\n Assessed for bleeding\nno expansion of L groin hematoma (site\n soft and ecchymotic), GI asps bilious, ETS\nold bloody secretions.\n Insulin gtt remains @ 0.5 unit/hour with BS 150\ns-160\n (goal 150-200)\n Droplet precautions d/c\nd, remains on contact precautions\n d/t VRE and MRSA\n Blood cultures X2 sent, urine culture repeated, sputum\n culture sent.\n T 96.8-98 po\n U/O 40-80cc/hour, Cr 3.5 (3.4)\n Plan:\n Continue with contact precautions. Follow Temp, antibiotics as\n ordered. Please note that pt is to have trough Vanco drawn \nplease\n draw at 1100. Continue with hemodynamic monitoring. Wean levo as able\n to keep MAP >65. Plan as per team is to let pt autodiurese for now and\n monitor Cr. Steroids IV q 6 hours with plan to decrease dose tomorrow\n as per team. Monitor BS hourly on insulin gtt\nmay need to ^ dose as\n TF is advanced. Monitor labs with Xigris infusion, assess for bleeding,\n guiac stool. Team would like to remove sepsis cath as possible and\n change to PICC.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 420/ 24, PEEP 13. Not overbreathing vent.\n Fentanyl @ 200mcg/hour, Versed @ 5mg/hour. Lungs with diminished\n breath sounds, occ rhonchi. 1.\n Action/Response:\n Sedation weaned q 2 hours while following neuro assessment.\n Breathing breathes over vent.\n Fi O2 weaned to 50%\ns stable.\n PEEP weaned to 10 with stable ABG and O2 sat until turned on\n L side. Then sat decreased to 90%. ABG sent , RT notifed, MDI\n given. ABG\nhypoxemia. MICU team notified and PEEP ^ back to 12.\n Sats 92-93%, ABG\n VAP prevention including HOB > 40, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n ETS\nscant old bldy secretions.\n Plan:\n Continue sedation weaning to allow for further spontaneous resps.\n Will need to be cautious of mental status given history of\n schizophrenia and not currently on his medications. Wean PEEP down to\n 10, and then ? begin CPAP if pt with enough spontaneous resps.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.5 (3.4 )\n Action:\n K 5.1 following K exalate last night.\n ? Cr falsely low given Vanco trough levels.\n Mg and Calcium replaced as per sliding scale orders.\n Response:\n Plan:\n Cotninue to monitor urine output & labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, sacral area pink, blanchable\n with central flakey area which resembles Seborrheic Keratosis (pt has\n many on his back). L groin with soft ecchymotic area s/p aline\n removal, right AC site of old PIV opened blister that is oozing clear\n with dressing in place.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear, fanned 4X4 gauze over site to prevent skin from\n touching skin.\n L Panus with criticaid and fanned 4X4 gauze over pinkened\n area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- mepilex dressing with pink hy-tape intact.\n Nutren 2.0 TF begun, to titrate up to 40 cc/hour goal.\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\nstopped oozing.\n Plan:\n Continue careful skin assessment. Reposition q 2 hours, avoid back.\n Advance TF towards goal.\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596484, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR\nCPR not indicated, but would\n use pressors.\n Shock, septic\n Assessment:\n Ruled out for influenza and legionella, blood cultures from OSH\n with GPC . Urine sample from OSH + for VRE. MRSA +. Received pt on\n levophed, dopamine and vasopressin had been weaned off over night.\n Action/Response:\n Hemodynamics monitored: CVP 10-12, Vigileo monitoring in\n place: CO 4.7-5.3, CI 2.1-2.4, Scvo2 low 80\ns high 70\n No further fluid boluses\n Levophed weaned from 0.5 mcg/kg/min to 0.16 maintaining\n goal MAP >65\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn. Vanco dose\n given late awaiting trough level\ntrough 8 on q 48 hour dosing. Vanco\n to q 24 hours.\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) @ 20 mcg/kg/min, H/H, PLTS & PT/INR\n monitored . 1600 values returned with decreased Hct/Hgb/plt/WBC--?\n Lab error. MICU team notified and sample repeated\nsimilar to earlier\n values, though with a more significant fall in plts. MICU team\n notifed.\n Assessed for bleeding\nno expansion of L groin hematoma (site\n soft and ecchymotic), GI asps bilious, ETS\nold bloody secretions.\n Insulin gtt remains @ 0.5 unit/hour with BS 150\ns-160\n (goal 150-200)\n Droplet precautions d/c\nd, remains on contact precautions\n d/t VRE and MRSA\n Blood cultures X2 sent, urine culture repeated, sputum\n culture sent.\n T 96.8-98 po\n U/O 40-80cc/hour, Cr 3.5 (3.4)\n Plan:\n Continue with contact precautions. Follow Temp, antibiotics as\n ordered. Please note that pt is to have trough Vanco drawn \nplease\n draw at 1100. Continue with hemodynamic monitoring. Wean levo as able\n to keep MAP >65. Plan as per team is to let pt autodiurese for now and\n monitor Cr. Steroids IV q 6 hours with plan to decrease dose tomorrow\n as per team. Monitor BS hourly on insulin gtt\nmay need to ^ dose as\n TF is advanced. Monitor labs with Xigris infusion, assess for bleeding,\n guiac stool. Team would like to remove sepsis cath as possible and\n change to PICC.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 420/ 24, PEEP 13. Not overbreathing vent.\n Fentanyl @ 200mcg/hour, Versed @ 5mg/hour. Lungs with diminished\n breath sounds, occ rhonchi. 1.\n Action/Response:\n Sedation weaned q 2 hours while following neuro assessment.\n Breathing breathes over vent.\n Fi O2 weaned to 50%\ns stable.\n PEEP weaned to 10 with stable ABG and O2 sat until turned on\n L side. Then sat decreased to 90%. ABG sent , RT notifed, MDI\n given. ABG\nhypoxemia. MICU team notified and PEEP ^ back to 12.\n Sats 92-94%, ABG repeated, greatly improved.\n VAP prevention including HOB > 40, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n ETS\nscant old bldy secretions.\n Plan:\n Continue sedation weaning to allow for further spontaneous resps.\n Will need to be cautious of mental status given history of\n schizophrenia and not currently on his medications. Wean PEEP down to\n 10, and then ? begin CPAP if pt with enough spontaneous resps.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.5 (3.4 )\n Action:\n K 5.1 following K exalate last night.\n ? Cr falsely low given Vanco trough levels.\n Mg replaced. Calcium replaced X2 as per sliding scale\n orders.\n Response:\n Plan:\n Cotninue to monitor urine output & labs. Monitor ionized Calcium, esp\n given bleeding risk.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, sacral area pink, blanchable\n with central flakey area which resembles Seborrheic Keratosis (pt has\n many on his back). L groin with soft ecchymotic area s/p aline\n removal, right AC site of old PIV opened blister that is oozing clear\n with dressing in place.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear, fanned 4X4 gauze over site to prevent skin from\n touching skin.\n L Panus with criticaid and fanned 4X4 gauze over pinkened\n area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- mepilex dressing with pink hy-tape intact.\n Nutren 2.0 TF begun, to titrate up to 40 cc/hour goal.\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\nstopped oozing.\n Plan:\n Continue careful skin assessment. Reposition q 2 hours, avoid back.\n Advance TF towards goal.\n" }, { "category": "Nutrition", "chartdate": "2121-09-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 596565, "text": "Subjective\n intub/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 100 kg\n 118 kg ( 02:00 PM)\n up due to fluid\n 30.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 78 kg\n 128%\n 83.5 kg\n not available\n Diagnosis: SEPSIS;TELEMETRY\n PMHx:\n Food allergies and intolerances: not available\n Pertinent medications: Norepinephrine, Fentanyl Citrate, Vasopressin,\n Midazolam, Vancomycin, Hydrocortisone, Ciprofloxacin,\n Piperacillin-Tazobactam, DOPamine, Levothyroxine Sodium, Pantoprazole,\n others noted\n Labs:\n Value\n Date\n Glucose\n 110 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 73\n 09:00 AM\n BUN\n 88 mg/dL\n 04:00 AM\n Creatinine\n 4.1 mg/dL\n 04:00 AM\n Sodium\n 137 mEq/L\n 04:00 AM\n Potassium\n 4.0 mEq/L\n 04:00 AM\n Chloride\n 103 mEq/L\n 04:00 AM\n TCO2\n 21 mEq/L\n 04:00 AM\n PO2 (arterial)\n 108 mm Hg\n 04:09 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:09 AM\n pH (arterial)\n 7.37 units\n 04:09 AM\n pH (urine)\n 5.0 units\n 02:38 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 04:09 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:00 AM\n Phosphorus\n 5.0 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.19 mmol/L\n 12:08 AM\n Magnesium\n 2.1 mg/dL\n 04:00 AM\n ALT\n 45 IU/L\n 04:00 AM\n Alkaline Phosphate\n 42 IU/L\n 04:00 AM\n AST\n 30 IU/L\n 04:00 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:00 AM\n WBC\n 5.5 K/uL\n 04:00 AM\n Hgb\n 7.7 g/dL\n 04:00 AM\n Hematocrit\n 23.2 %\n 04:00 AM\n Current diet order / nutrition support: Nutren 2.0 Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 40 ml/hr\n (1920kcal/77g protein)\n Residual Check: q4h Hold feeding for residual >= : 150 ml\n GI: abd: obese, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: 1837-2087 (BEE x or / 22-25 cal/kg)\n Protein: 83-100 (1-1.2 g/kg)\n Fluid: min\n Calculations based on: Adjusted weight\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n 74 year old male in septic shock on admission to the ED, found to have\n pneumonia and equivocal urinalysis. Patient noted to have elevated\n cardiac enzymes, being monitor closely but patient is not a candidate\n for cath given his instability at this time. Tube feed ordered\n yesterday, patient currently tolerating tube feed at 40ml/hr without\n problem, currently tube feed order slightly underfeeding patient.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: change tube feed to Nutren 2.0\n goal 45ml/hr (2160kcal/86.4g protein)\n Monitor tube feed tolerance\n Check chemistry 10 panel daily, replete prn\n Continue BS management\n Other: if has question\n" }, { "category": "Nursing", "chartdate": "2121-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597101, "text": "Altered mental status (not Delirium)\n Assessment:\n Off fent/versed gtt over\n Action:\n No sedation given for over 48hrs\n Response:\n Staff members who have assessed him over the last few days note that he\n is more awake.\n Plan:\n Continue to allow sedating drugs to wear off\n possibley resume antipsychotic medication on (Clonazine,\n Profenazide)\n Impaired Skin Integrity\n Assessment:\n Mepilex dsg intact over coccyx intact. General edema continues with\n weight 14.5kg above noted dry weight. Seeping serous fluid from\n edematous scrotum. Stage II skin breakdown noted R antecubital space,\n underneath panus.\n Action:\n Transferred patient to KCI air bed\n Open skin cleansed with wound cleanser and gauze placed to\n absorb serous fluid\n Response:\n No new skin breakdown noted\n Mepilex dressing over coccyx intact\n Plan:\n Continue to keep skin dry and clean.\n Turn side to side but patient not tolerating positioning on right side\n (drops SPO2)\n Bradycardia\n Assessment:\n Some brief episodes of bradycardia to 47. SBP > 120 at the time of\n bradycardia. When patient HR down, patient noted to appear to be\n napping. SBP as high as 151.\n Action:\n Requested prn antihypertensive medication\n Response:\n No betablockers or ace inhibitors to be given at this time\n Plan:\n Continue to monitor closely.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Rhonchi bilaterally. Diminished breathsounds at bases. SPO2 to 89-90%\n during CPAP trial with peep to 5. Many episodes of endotracheal\n suctioning required. No gag reflex noted with subglotal suctioning.\n ETT suctioned for blood tinged white/tan secretions. Agonal appearing\n respirations at times with use of accessory muscles noted. ABG sent\n late this shift (7.26-61-65-0-29-89%) on CPAP 50% 5/5.\n Hydrocortisone weaning. Hct to 21.6 overnight.\n Action:\n Attempted to keep patient at minimum of 45 degree angle\n Attempted to suction ett as often as needed\n Dr. (#) called to bedside to evaluate respiratory\n status\n Response:\n Failed wean attempt today around 0700\n Respiratory acidosis\n Plan:\n Additional diuresis using Lasix bolus and gtt with 24hour negative\n balance goal of 1.5-2 liters\n Return patient to SIMV ventilation\n Possible need for sedation with SIMV per respiratory therapist\n use fentanyl boluses per Dr. if patient appears\n uncomfortable\n Repeat CXR\n Hypernatremia (high sodium)\n Assessment:\n Na to 149 this A.M.\n Action:\n Free water boluses of 200cc ordered every 4hrs via sump tube\n 400cc total boluses given\n Response:\n Na to 138\n Plan:\n Plan to check on need to continue free water\n" }, { "category": "Nursing", "chartdate": "2121-09-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597102, "text": "Altered mental status (not Delirium)\n Assessment:\n Off fent/versed gtt over 60 hrs.Pt responsive to voice and obeys\n command.\n Action:\n No sedation.Cont to orient pt.Soft restraints on.\n Response:\n Pt seem to be more awake.\n Plan:\n Continue to allow sedating drugs to wear off, frequent reorientation\n and neuro checks.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) without acute exacerbation\n Assessment:\n Received the pt on CMV 50%/peep 10/RR20.LS rhonchorous.Suctioned for\n small amount of bloody secretions.Had SBT yesterday with poor results.\n Pt with GNR in sputum and VRE in urine.\n Action:\n Conts to be on CMV.Will try RSBI in am.Started to diuresis with\n frusemide,aiming for 1.5-2lit neg.On Linezolid and meropeem.\n Response:\n Pt is neg 1.2 lit for 24hrs at MN.\n Plan:\n Cont ot diuresis.Monitor Cr.?try SBT this am.\n Hypernatremia (high sodium)\n Assessment:\n Na to\n Action:\n Free water boluses of 200cc ordered every 4hrs via sump tube\n Response:\n Na to 138\n Plan:\n Plan to check on need to continue free water\n" }, { "category": "Physician ", "chartdate": "2121-09-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 596273, "text": "TITLE:\n Chief Complaint:\n HPI:\n 74 y.o. Male w/ h.o. ?adrenal insufficiency, hypothyroidism, paranoid\n schizophrenia, DM II p/w septic source likely pulmonary versus\n urine.\n .\n Per family they noted yesterday afternoon he had decreased PO intake as\n well as congestion symptoms. Last night his family noted that he was a\n little weak and put him to bed. Although he did not complain of any\n fevers his family noted that he was extremely cold to the touch and\n gave him several blankets and heating blankets to help him stay warm.\n The next day they noted that he was awake but was not verbal. Given\n this he was taken to ED. At he was noted to be very\n hypotensive to 40s-50s. He was given Solumedrol 125mng x 1, he was also\n noted to be bradycardic to 40s and received Atropine. Azithromycin,\n Zosyn were initiated and a HeadCT was performed which was negative. He\n was also intubated and started on Dopamine, Levophed and Neo.\n .\n In the , pt was given 2gm of Vancomycin and 750mg of Levofloxacin. He\n was also given stress dose steroids of Hydrocortisone 100mg IV x 1,\n PEEP was increased to 10 and pt was set on ARDSnet protocol. He also\n received a total of 8L of NS. His labs were notable for leukopenia,\n thrombocytopenia 116, creatinine 3.7, BUN 93. Troponin was noted to be\n 0.06 with a CK of 1836 and CK-MB that was pending. Urine and serum tox\n were negative. ABG obtained after intubation noted to be pH 7.28, pCO2,\n 43, O2 60, HCO3 21 on PEEP of 5 that was increased to 10.\n .\n Review of systems:\n unable to obtain ROS intubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 01:00 AM\n Piperacillin/Tazobactam (Zosyn) - 01:42 AM\n Infusions:\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Vasopressin - 2.4 units/hour\n Dopamine - 20 mcg/Kg/min\n Drotrecogin (Xigris) - 24 mcg/Kg/hour\n Norepinephrine - 0.5 mcg/Kg/min\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Fentanyl - 01:00 AM\n Famotidine (Pepcid) - 03:11 AM\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n h.o. nephrectomy in ?\n Paranoid Schizophrenia\n HTN\n DM II\n COPD\n ?h.o. PNA requiring hospitalization\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 12:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 83 (60 - 91) bpm\n BP: 142/72(94) {68/43(53) - 142/72(94)} mmHg\n RR: 22 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n CVP: 12 (6 - 17)mmHg\n Total In:\n 240 mL\n 19,613 mL\n PO:\n TF:\n IVF:\n 240 mL\n 11,613 mL\n Blood products:\n Total out:\n 140 mL\n 119 mL\n Urine:\n 10 mL\n 119 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n 19,494 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 420 (420 - 420) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 13 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 46.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.27/48/75/22/-4\n Ve: 9.8 L/min\n PaO2 / FiO2: 94\n Physical Examination\n General: Elderly Caucasian Male intubated in NARD.\n Psych: Localizes to pain, opens eyes to verbal stimuli\n HEENT: Sclera anicteric, MMM\n Neck: difficult to eval JVP given IJ\n Lungs: Crackles noted diffusely on anterior exam with diminished\n crackles over left lung field.\n CV: Borderline bradycardic (50), S1 + S2, no murmurs, rubs, gallops\n Abdomen: no grimacing noted on abdominal palpation, non-distended,\n obese, + bowel sounds present, no rebound tenderness or guarding\n Left Groin: Hematoma noted from femoral line placement, appears better\n RN from ED after warm compress\n Ext: 2+ edema noted in all extremities.\n Labs / Radiology\n 115 K/uL\n 9.7 g/dL\n 250 mg/dL\n 3.2 mg/dL\n 80 mg/dL\n 22 mEq/L\n 106 mEq/L\n 6.1 mEq/L\n 137 mEq/L\n 30.2 %\n 2.1 K/uL\n [image002.jpg]\n \n 2:33 A9/22/ 12:14 AM\n \n 10:20 P9/22/ 12:30 AM\n \n 1:20 P9/22/ 02:10 AM\n \n 11:50 P9/22/ 02:26 AM\n \n 1:20 A9/22/ 04:11 AM\n \n 7:20 P9/22/ 04:28 AM\n 1//11/006\n 1:23 P9/22/ 05:09 AM\n \n 1:20 P9/22/ 05:13 AM\n \n 11:20 P9/22/ 06:26 AM\n \n 4:20 P9/22/ 06:43 AM\n WBC\n 1.4\n 2.1\n Hct\n 34\n 27.2\n 31\n 30.2\n Plt\n 85\n 115\n Cr\n 3.2\n 3.2\n 3.2\n TropT\n 0.07\n 0.09\n TC02\n 23\n 18\n 23\n Glucose\n 395\n 334\n 250\n Other labs: PT / PTT / INR:13.3/46.3/1.1, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:57/63, Alk Phos / T Bili:43/0.2,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:661 mg/dL, LDH:259 IU/L, Ca++:7.3 mg/dL, Mg++:1.5\n mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n HYPOTHERMIA\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ICU Care\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Pt was transferred from ED to on 3 pressors, able to\n be weaned down to 2 pressors of Dopamine following 8 litres of fluid.\n Pt is currently is hypothermic on examination. Pt noted to have\n positive U/A as well as large PNA on left lung. Suspect sources to be\n pulmonary versus urine. Pt's CVP currently , MAP noted to be 76,\n with a mixed venous sat of 83%. Pt also was reportedly on Dexamethasone\n at home and thus was given stress dose steroids in the ED. Per family\n pt has a history of PNA versus aspiration PNA, hospitalizaed three\n times over the past year\n - will check for influenza\n - will try to wean DA first and then levophed to maintain MAP >65\n - will continue on broad coverage with Zosyn, Cipro for coverage of\n Gram+, Gram -, atypicals and double coverage for Pseudomonas.\n Vancomycin for MRSA\n - f/u panculture results, will add urine culture, collect blood\n culture, urine legionella\n - will continue on IV Hydrocortisone\n - Pt's APACHE score noted to be very high, pt would benefit from Xigris\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n Troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Hepari due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - cycles enzymes\n .\n ##. Bradycardic: Pt noted to be bradycardic, requiring Atropine in the\n field for HR in the 40s. Bradycardia is likely due to his hypothermia.\n - will continue to monitor heart rate on tele\n .\n ##. Respiratory Failure: Pt currently on ARDSnet protocol. ABG showed\n pO2 of 60 on a PEEP of 5. PEEP was increased to 10. Tidal volumes noted\n to be 500s. MV 12, Ppeak 26, set at rate of 20, currently 27.\n - will repeat an ABG\n - wean attempt to wean FiO2\n - will sedate with Fentanyl and Midazolam\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine.\n .\n # FEN: replete electrolytes, NPO\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: FULL CODE\n .\n # Disposition: pending above\n .\n , PGY-2\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596364, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: PNA/UTI or a combination;\n however also ruling out for influenza.\n Recievied patient on 3 pressors (dopamine, levophed &vasopressin) s/p\n total of 8 liters NS given in ED 7 9 liters LR (patient with\n generalized body edema). On 3 antibiotic regimen & steroids. Patient\n now normothermic off warming blanket, WBC now 10.4, Continues to\n require vent support.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin to 1.2 units/hour (from 2.4).\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight\n Vigileo monitoring in place\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Goal BG level <200, maintained with insulin gtt ranging\n 0.5-2.5 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n Agree with plan to manage shock with IVF based on SVV / CVP / ScvO2,\n will check CO / echo and try to wean dopa. Will continue HC 50 q6h for\n ? adrenal insufficiency. Will check sputum cx, legionella ag, and flu\n swab while continuing zosyn / cipro / vanco and APC. Resp failure /\n ARDS - continue VAC 420 x24, place , tolerate elevated\n pCO2. AMI is stable, check echo, confirm LB3 is old, asa. Evolving ARF\n - continue IVF support, RD meds, check lytes and sediment while\n monitoring K+ closely. Will start insulin drip for goal <200, NPO for\n now. Will meet with family, very poor prognosis. Remainder of plan as\n outlined above\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596365, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: PNA/UTI or a combination;\n however also ruling out for influenza.\n Recievied patient on 3 pressors (dopamine, levophed &vasopressin) s/p\n total of 8 liters NS given in ED 7 9 liters LR (patient with\n generalized body edema). On 3 antibiotic regimen & steroids. Patient\n now normothermic off warming blanket, WBC now 10.4, Continues to\n require vent support.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin to 1.2 units/hour (from 2.4).\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight\n Vigileo monitoring in place\n 3 antibiotic therapy: Vanco, Cipro & Zosyn\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Vanco level sent 6 am.\n Goal BG level <200, maintained with insulin gtt ranging\n 0.5-2.5 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient overbreathing the vent by approx 5-10 bpm\ns. ABG on arrival:\n 7.20/33/99\n Action:\n Q 2hour ABG monitoring\n Re-peat ABG 7.27/47/100\n Sedation increased to improve synchrony with vent\n PEEP increased to 15 (per ARDSnet protocol)\n Response:\n Versed- 5 mg/hr\n Fentanyl 200 mcg/hr\n Patient no longer overbreathing the vent on current doses of\n fentanyl/versed\n PEEP decreased to 13 in setting of hypotension\n Plan:\n Continue to titrate vent settings with RRT & ABG\ns. Potential for\n placement of esophageal .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n Agree with plan to manage shock with IVF based on SVV / CVP / ScvO2,\n will check CO / echo and try to wean dopa. Will continue HC 50 q6h for\n ? adrenal insufficiency. Will check sputum cx, legionella ag, and flu\n swab while continuing zosyn / cipro / vanco and APC. Resp failure /\n ARDS - continue VAC 420 x24, place , tolerate elevated\n pCO2. AMI is stable, check echo, confirm LB3 is old, asa. Evolving ARF\n - continue IVF support, RD meds, check lytes and sediment while\n monitoring K+ closely. Will start insulin drip for goal <200, NPO for\n now. Will meet with family, very poor prognosis. Remainder of plan as\n outlined above\n" }, { "category": "Nursing", "chartdate": "2121-09-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596366, "text": "74 yo with limited known PMH, including DM, COPD & Schizophrenia,\n hypothyroidism\n Presents with severe septic shock, acute renal failure, and respiratory\n failure. Per family, patient was taken to for unresponsiveness\n at home (persisted from evening prior to day of admission into the\n morning of the day of admission), with SBPs reportedly in the 40s.\n Hypothermic & bradycardic; intubated, given fluids, ABX, and multiple\n vasopressors. Transferred to via . TLC presep cath &\n arterial line placed in ED. Transferred to CCU as MICU border.\n CCU Course including titration of pressors, 3 abx therapy, fluid\n administration; code status changed to DNR.\n Shock, septic\n Assessment:\n MD\ns likely causes are potentially: PNA/UTI or a combination;\n however also ruling out for influenza.\n Recievied patient on 3 pressors (dopamine, levophed &vasopressin) s/p\n total of 8 liters NS given in ED 7 9 liters LR (patient with\n generalized body edema). On 3 antibiotic regimen & steroids. Patient\n now normothermic off warming blanket, WBC now 10.4, Continues to\n require vent support.\n Action:\n Hemodynamics:\n Weaned dopamine gtt to off.\n Weaned vasopressin gtt off.\n Maintained levophed gtt at 0.5 mcg/kg/min.\n CVP monitoring, goal 13-15; required no further IVF boluses\n overnight.\n Vigileo monitoring in place\n 3 antibiotic IV therapy: Vanco, Cipro & Zosyn\n Given IV steroids as ordered q 6 hours\n Xigris (Drotrecogin) administered given APACHE II score-\n H/H, PLTS & PT/INR monitored\n Tight BG control with insulin gtt, hourly BG monitoring &\n gtt titration\n Maintained contact & droplet precautions for influenza r/o\n Response:\n Dopamine gtt remains off.\n Vasopressin gtt remains off\n Levophed remains at 0.5 mcg/kg/min\n CVP range 13-18; no fluid overnight\n ScVO2 by vigileo ranging 72-82%, CO range 5.7-7, CI approx.\n 3, SVV , SVR 900-1100.\n Vanco level sent 6 am.\n Goal BG level <200, maintained with insulin gtt ranging\n 0.5-2.5 units/hour.\n Xigris infusing, team aware of lab results including HCT\n 27.4,HGB 9, PLTS 88, PT 14.7 INR 1.3\n Plan:\n Continue septic shock management with MICU team. Pressors, fluid, Blood\n products as ordered. Steroids IV w/ BG monitoring on insulin gtt.\n Monitor labs with Xigris infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated on CMV 80%, rate set at 24, PEEP 13. ABG at\n start of shift: 7.31/40/93. patient synchronous with the vent, not\n overbreathing. Lungs diminished with some fine crackles at intervals,\n partially diminished body habitus. Suctioned for small amounts\n bloody secretions. Clear oral secretions draining from mouth.\n Action:\n ABG monitoring\n Maintained sedation to keep patient synchronous with the\n vent.\n VAP prevention including HOB > 30, mouth care &\n repositioning\n ABX therapy to treat PNA & sepsis management as above\n Response:\n Versed @ 5 mg/hr\n Fentanyl @ 200 mcg/hr\n Patient continues to be synchronous with the vent on current\n sedation\n Re-peat ABG 7.34/41/170\n Continues to have large amount clear oral secretions\n Plan:\n Continue to titrate vent settings with RRT & MICU input. ABGs as\n ordered. Potential for placement of esophageal .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CR/BUN 3.2/87. Likely hypotension & sepsis MD. Also with\n elevated CE\ns (CK 1836, Trop 0.06). Patient pupils equal & react to\n light; he is responding to sternal rub, although slow to open eyes to\n command, hands now too edematous to check for strength. With the\n addition of sedation, patient no longer moving extremities; prior to\n sedation patient twitching/moving bilateral upper and lower extremities\n in the bed.\n Action:\n Patient making < 10 ml urine /hour.\n Administering IVF\ns- total 8 liters\n Response:\n Am CR/BUN; 3.2/80.\n Plan:\n Cotninue to monitor urine output & labs with MICU.\n Acidosis, Mixed\n Assessment:\n Mostly metabolic acidosis. MD- mixed lactic & non-anion gap from 8\n liters NS in ED.\n Action:\n Monitored electrolytes\n K+= 5.5\n Repleted Ionized Calcium of 1.08 with 2 gm calcium gluconate\n Since CCU admission given LR as fluid v. NS\n Response:\n Re-peat ionized calcium & K+ level: pending\n Plan:\n Continue to closely follow electrolyes; replete K+ and Ionized calcium\n by sliding scale. Follow ABG\ns & all labs.\n Impaired Skin Integrity\n Assessment:\n Patient with excoriated right groin site, reddened sacral area,\n hematoma in left s/p aline removal & is at risk for skin breakdown\n given fluid status & pressor requirement.\n Action:\n Please see MV for site treatments. Repositioned slightly in bed given\n hemodynamic stability q 2 hours. Aloe vesta application. T& S sent.\n Response:\n No signs of new skin breakdown.\n Plan:\n Continue supportive skin care & treatment.\n Agree with plan to manage shock with IVF based on SVV / CVP / ScvO2,\n will check CO / echo and try to wean dopa. Will continue HC 50 q6h for\n ? adrenal insufficiency. Will check sputum cx, legionella ag, and flu\n swab while continuing zosyn / cipro / vanco and APC. Resp failure /\n ARDS - continue VAC 420 x24, place , tolerate elevated\n pCO2. AMI is stable, check echo, confirm LB3 is old, asa. Evolving ARF\n - continue IVF support, RD meds, check lytes and sediment while\n monitoring K+ closely. Will start insulin drip for goal <200, NPO for\n now. Will meet with family, very poor prognosis. Remainder of plan as\n outlined above\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596532, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 22.5 (26.2). Bloody oral secretions, ? tongue. RIJ TLC oozing.\n Hypothermic T 95.4 PO. MAPs >65 on Levo. HR 60-70s SR w/o ectopy. SVV\n , Scv02 78-80%. CVP 11-14. Gross general body edema.\n Action:\n 1 unit PRBC transfused\n Triple abx\n Serveillance Bcx drawn from Aline w/ AM labs\n Levo weaned\n Response:\n HCT 4hrs post transfusion 23.2. Unable to wean Levo off\nMAPs fall below\n 65. +23L LOS. UOP 40-170cc/hr. BUN/Cr 88/4.1 (81/3.5). PLT 55(58)\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo for goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleeding, Guiac stool when able. (of note: pt\n dtr states pt easily become constipated--> no BM since admit . ?\n Supp today\n ? another unit PRBC\n Draw vanc trough level prior to 11:00 dose\n Continue Xigris til 07:30\ncheck coags \n Wean Steriods today\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since :00 . No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n ARDSnet vent settings\n VAP care per protocol, HOB up 45 degrees\n Response:\n Stable ABGs. PF ratios\n Plan:\n Wean vent as , need sedation for comfort high PEEP when\n wakes up.\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable w/ central flakey\n area which resembles Seborrheic Keratosis (pt has many on his back).\n L groin with soft ecchymotic area s/p aline removal, right AC site of\n old PIV opened blister that is oozing clear with dressing in\n place.\n Action:\n Repositioned q 2 hours.\n Aloe vesta application.\n Right groin site: cleansed with wound cleanser: applied\n criticaid clear, fanned 4X4 gauze over site to prevent skin from\n touching skin.\n L Panus with criticaid and fanned 4X4 gauze over pinkened\n area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- mepilex dressing with pink hy-tape intact.\n Nutren 2.0 TF begun, to titrate up to 40 cc/hour goal.\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\nstopped oozing.\n Plan:\n Continue careful skin assessment. Reposition q 2 hours, avoid back.\n Advance TF towards goal.\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596535, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 22.5 (26.2). Bloody oral secretions, ? tongue. RIJ TLC oozing.\n Hypothermic T 95.4 PO. MAPs >65 on Levo. HR 60-70s SR w/o ectopy. SVV\n , Scv02 76-80%. CVP 11-14. Gross general body edema.\n Action:\n 1 unit PRBC transfused\n Triple abx\n Serveillance Bcx drawn from Aline w/ AM labs\n Levo weaned\n Response:\n HCT 4hrs post transfusion 23.2. Unable to wean Levo off\nMAPs fall below\n 65. +23L LOS. UOP 40-170cc/hr. BUN/Cr 88/4.1 (81/3.5). PLT 55(58)\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo for goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleeding, Guiac stool when able. (of note: pt\n dtr states pt easily become constipated--> no BM since admit . ?\n Supp today\n ? another unit PRBC\n Draw vanc trough level prior to 11:00 dose\n Continue Xigris til 07:30\ncheck coags/CBC \n Wean Steriods today\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since :00 . No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n ARDSnet vent settings\n VAP care per protocol, HOB up 45 degrees\n Response:\n Stable ABGs. PF ratios\n Plan:\n Wean vent as , need sedation for comfort high PEEP when\n wakes up.\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Nursing", "chartdate": "2121-09-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596543, "text": "74 y/o w/ limited PMH including DM, COPD & Schizophrenia,\n hypothyroidism. P/w severe septic shock, ARF & resp failure. Per fam,\n pt taken to for unresponsiveness at home (persisted from\n evening prior to day of admission into the AM of admission), w/ SBPs\n reportedly in the 40s, hypothermic & bradycardic. Intubated, given IVF,\n abx & mult pressors. to CCU as MICU pt. TLC presep &\n aline placed. R/I MI w/ CK 1833, mb 230, trop 0.06. PNA L>R &. BCx\n bottles from OSH w/ GPC in clusters. Urine sample from OSH (+ )VRE. R/o\n flu & legionella. (+) MRSA via nasal swab.\n Shock, septic\n Assessment:\n HCT 22.5 (26.2). Bloody oral secretions, ? tongue. RIJ TLC oozing. ETS-\n blood tinged. Hypothermic T 95.4 PO. MAPs >65 on Levo. HR 60-70s SR w/o\n ectopy. SVV , Scv02 76-80%. CVP 11-14. Gross general body edema.\n Action:\n 1 unit PRBC transfused\n Triple abx\n Serveillance Bcx drawn from Aline w/ AM labs\n Levo weaned\n Response:\n HCT 4hrs post transfusion 23.2. Unable to wean Levo off\nMAPs fall below\n 65. +23L LOS. UOP 40-170cc/hr. BUN/Cr 88/4.1 (81/3.5). PLT 55(58)\n Plan:\n Monitor hemodynamics\nvigileo\n Continue levo for goal MAP >65, monitor UOP/renal fxn\n Monitor s/sx bleeding, Guiac stool when able. (of note: pt\n dtr states pt easily become constipated--> no BM since admit . ?\n Supp today\n ? another unit PRBC\n Draw vanc trough level prior to 11:00 dose\n Continue Xigris til 07:30\ncheck coags/CBC \n Wean Steriods today\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sats 94-96%. Sedation off since :00 . No spontaneous mvmts. Occas\n overbreathing 1-4 breaths.\n Action:\n ARDSnet vent settings\n VAP care per protocol, HOB up 45 degrees\n Response:\n Stable ABGs. Sedation re-started at 06:30 desynchrony w/ vent. PF\n ratios 210-214\n Plan:\n Wean vent as tol, ? PS today\n Hyperglycemia\n Assessment:\n TF ^d to goal rate 40cc/hr w/ minimal residuals. On Steroids Q6hrs.\n FSGB 100-200s\n Action:\n Insulin gtt titrated for goal <200\n Response:\n FSBG <200\n Plan:\n Continue present management\n Impaired Skin Integrity\n Assessment:\n Excoriated right groin, sacral area pink-blanchable. L groin soft\n ecchymotic area s/p aline removal. R AC site of old PIV opened blister\n --oozing copius amts serous fluid\n Action:\n Repositioned q 2 hours. Aloe vesta applied\n Right groin site: cleansed w/ wound cleanser, criticaid\n clear, fanned kerlix over site to prevent skin from touching skin.\n L Panus with criticaid and fanned kerlix over pinkened area.\n Sacral area- applied aloe vesta lotion. Also applied thin\n duoderm to protect site from friction.\n Right AC- aqualcel w/ DSD, wrapped in kerlix\n R IJ TLC oozing\ndressing changed and surgi-foam dressing\n over site\n Response:\n Stable\n Plan:\n Continue careful skin assessment. Reposition q 2 hours,\n avoid back. Continue TF\n" }, { "category": "Nutrition", "chartdate": "2121-09-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 596574, "text": "Subjective\n intub/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 100 kg\n 118 kg ( 02:00 PM)\n up due to fluid\n 30.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 78 kg\n 128%\n 83.5 kg\n not available\n Diagnosis: SEPSIS;TELEMETRY\n PMHx:\n Food allergies and intolerances: not available\n Pertinent medications: Norepinephrine, Fentanyl Citrate, Vasopressin,\n Midazolam, Vancomycin, Hydrocortisone, Ciprofloxacin,\n Piperacillin-Tazobactam, DOPamine, Levothyroxine Sodium, Pantoprazole,\n others noted\n Labs:\n Value\n Date\n Glucose\n 110 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 73\n 09:00 AM\n BUN\n 88 mg/dL\n 04:00 AM\n Creatinine\n 4.1 mg/dL\n 04:00 AM\n Sodium\n 137 mEq/L\n 04:00 AM\n Potassium\n 4.0 mEq/L\n 04:00 AM\n Chloride\n 103 mEq/L\n 04:00 AM\n TCO2\n 21 mEq/L\n 04:00 AM\n PO2 (arterial)\n 108 mm Hg\n 04:09 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:09 AM\n pH (arterial)\n 7.37 units\n 04:09 AM\n pH (urine)\n 5.0 units\n 02:38 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 04:09 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:00 AM\n Phosphorus\n 5.0 mg/dL\n 04:00 AM\n Ionized Calcium\n 1.19 mmol/L\n 12:08 AM\n Magnesium\n 2.1 mg/dL\n 04:00 AM\n ALT\n 45 IU/L\n 04:00 AM\n Alkaline Phosphate\n 42 IU/L\n 04:00 AM\n AST\n 30 IU/L\n 04:00 AM\n Total Bilirubin\n 0.3 mg/dL\n 04:00 AM\n WBC\n 5.5 K/uL\n 04:00 AM\n Hgb\n 7.7 g/dL\n 04:00 AM\n Hematocrit\n 23.2 %\n 04:00 AM\n Current diet order / nutrition support: Nutren 2.0 Full strength;\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 40 ml/hr\n (1920kcal/77g protein)\n Residual Check: q4h Hold feeding for residual >= : 150 ml\n GI: abd: obese, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: 1837-2087 (BEE x or / 22-25 cal/kg)\n Protein: 83-100 (1-1.2 g/kg)\n Fluid: min\n Calculations based on: Adjusted weight\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n 74 year old male in septic shock on admission to the ED, found to have\n pneumonia and equivocal urinalysis. Patient noted to have elevated\n cardiac enzymes, being monitor closely but patient is not a candidate\n for cath given his instability at this time. Tube feed ordered\n yesterday, patient currently tolerating tube feed at 40ml/hr without\n problem, currently tube feed order slightly underfeeding patient.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: change tube feed to Nutren 2.0\n goal 45ml/hr (2160kcal/86.4g protein)\n Monitor tube feed tolerance\n Check chemistry 10 panel daily, replete prn\n Continue BS management\n Other: if has question\n" }, { "category": "Physician ", "chartdate": "2121-09-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596742, "text": "Chief Complaint:\n 24 Hour Events:\n -got 500mg of vanc for trough of 15\n -continued on just levophed, weaning\n -did have bm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ciprofloxacin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Drotrecogin (Xigris) - 20 mcg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 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 07:50 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: 35.8\nC (96.5\n HR: 67 (62 - 73) bpm\n BP: 120/54(75) {104/47(65) - 150/70(92)} mmHg\n RR: 9 (6 - 28) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 117.6 kg (admission): 100 kg\n Height: 71 Inch\n CVP: 12 (8 - 14)mmHg\n Total In:\n 2,792 mL\n 996 mL\n PO:\n TF:\n 1,005 mL\n 337 mL\n IVF:\n 1,697 mL\n 658 mL\n Blood products:\n Total out:\n 1,890 mL\n 635 mL\n Urine:\n 1,890 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 902 mL\n 361 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 420 (420 - 420) mL\n Vt (Spontaneous): 582 (582 - 582) mL\n PS : 15 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 11 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.36/40/177/21/-2\n Ve: 11.1 L/min\n PaO2 / FiO2: 354\n Physical Examination\n Cardiovascular: gen: intubated, sedated, can open eyes\n cv: RRR\n resp: CTA anteriorly\n abd: soft, +BS, obese\n ext: sig b/l edema\n Labs / Radiology\n 73 K/uL\n 7.5 g/dL\n 125 mg/dL\n 4.5 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 100 mg/dL\n 106 mEq/L\n 141 mEq/L\n 22.3 %\n 7.0 K/uL\n [image002.jpg]\n 12:08 AM\n 04:00 AM\n 04:09 AM\n 03:43 PM\n 03:54 PM\n 09:19 PM\n 09:39 PM\n 04:00 AM\n 04:12 AM\n 06:12 AM\n WBC\n 5.5\n 7.8\n 7.3\n 7.0\n Hct\n 23.2\n 23.9\n 23.0\n 22.3\n Plt\n 55\n 64\n 76\n 73\n Cr\n 4.1\n 4.2\n 4.5\n TCO2\n 23\n 24\n 24\n 24\n 24\n 24\n Glucose\n 110\n 125\n Other labs: PT / PTT / INR:12.3/56.2/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:65.0 %, Band:21.0 %, Lymph:5.0 %, Mono:0.0 %,\n Eos:0.0 %, Fibrinogen:626 mg/dL, Lactic Acid:1.4 mmol/L, LDH:275 IU/L,\n Ca++:7.6 mg/dL, Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ACIDOSIS, METABOLIC\n ACIDOSIS, MIXED\n SHOCK, HYPOVOLEMIC OR HEMORRHAGIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n SHOCK, SEPTIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock,\n NSTEMI, hypothermia with suspected pulmonary versus urine source.\n .\n ##. Septic Shock: Pt noted to be in septic shock on admission to the\n ED. Found to have GNRs in sputum and VRE in urine. Per family pt has a\n history of PNA versus aspiration PNA, hospitalized three times over the\n past year\n - influenza antigen and legionella negative\n - weaning pressors, now just on levophed\n - will continue on broad coverage with Zosyn, Cipro. currently growing\n vre sensitive to amp, gnrs from sputum gram stain x2 and coag neg staph\n from blood (likely contaminant) from . dc vancomycin today\n - f/u panculture results\n - will continue on IV Hydrocortisone, currently on 50q6h (=7.5 daily of\n decadron, pt on 2 daily of decadron at home) will switch to 25q6h\n - pt on xygris high apache score, check coags. low threshold to\n dc xygris if any coag abnormalities. Xygris course done tomorrow.\n .\n ##. Respiratory Failure:\n - will aim to wean PSV today, will try \n - lighten Fentanyl and Midazolam\n .\n # : baseline 1.8-2, current Cr is 4.5 up from 4 yesterday. Likely\n this is ATN. UOP has gone from low to high so perhaps renal\n function is in process of improving.\n -will trend\n -no acute indications for HD at this point\n -pt is on lasix at home, could consider giving lasix gtt once off\n pressors\n .\n ##. MI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes\n were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5,\n troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF\n inferiorly. Pt ruled in, likely ischemic from his prolonged episode of\n hypotension. Pt currently on Xigris so would not give IV Heparin due to\n bleeding risk, pt also not a candidate for cath given his instability.\n - consider add bblocker and ace if improves clinically and off pressors\n and asa once xygris off\n .\n ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the\n field for HR in the 40s. Bradycardia initially thought to likely be due\n to his hypothermia. However, had additional episode of sinus brady last\n night\n -consider cards consult when pt clinically improved for ? sick sinus\n syndrome if pt has recurrent bradycardia\n - will continue to monitor heart rate on tele\n .\n # Anemia: pt\ns crit trending down throughout admission. Likely \n aggressive fluid hydration. Pt does also have h/o peptic ulcers, hct\n stable.\n -keep active type and screen\n -switched to PPI\n -stool guiac negative\n .\n ##. Hypothyroidism: Will continue on home regimen of levothyroxine,\n switch back to po as pt improves\n .\n #Schizophrenia: holding clozaril and perphenazine while intubated and\n sedated\n -consider restart home psych med\n -consider psych consult.\n .\n #COPD: continue atrovent and albuterol prn, usually on nebs but will\n switch to inh while intubated.\n #? adrenal insufficiency: on dexamethasone 2mg at home, will wean\n hydrocort and restart dexamethasone at home dose.\n .\n # DM: will continue insulin gtt as pt too edematous to absorb sc\n insulin. Will switch to subcutaneous once off pressors\n .\n .# SW: will consult sw re concerns about pt's home situation\n .\n # FEN: replete electrolytes, tube feeds at goal\n .\n # Prophylaxis: Subcutaneous heparin , bowel reg\n .\n # Access: Peripherals, Right IJ, A-line\n .\n # Code: DNR (chemical code ok)\n .\n # Disposition: ICU for now\n PCP Dr \n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:28 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Arterial Line - 10:11 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2121-09-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 597953, "text": "Chief Complaint: 74 yom w/ paranoid schizophrenia, hypothyroidism,\n hypoadrenalism a/w pneumo vs. urosepsis, now with sputum cultures\n positive for MRSA and acinetobacter.\n 24 Hour Events:\n - continued thick secretions with high oxygen requirements\n - continued lasix gtt at 10 mcg, even yesterday and neg. 19,059 ml for\n LOS\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:00 PM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 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: 78 (54 - 78) bpm\n BP: 124/50(68) {108/41(57) - 153/58(80)} mmHg\n RR: 22 (9 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 107.3 kg (admission): 100 kg\n Height: 71 Inch\n Total In:\n 2,705 mL\n 758 mL\n PO:\n TF:\n 1,080 mL\n 315 mL\n IVF:\n 405 mL\n 98 mL\n Blood products:\n Total out:\n 2,670 mL\n 675 mL\n Urine:\n 2,370 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 35 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///36/\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 316 K/uL\n 8.0 g/dL\n 191 mg/dL\n 3.1 mg/dL\n 36 mEq/L\n 3.9 mEq/L\n 90 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.8 %\n 7.6 K/uL\n [image002.jpg]\n 10:25 PM\n 01:29 AM\n 08:54 AM\n 12:59 PM\n 03:56 PM\n 11:09 PM\n 03:44 AM\n 04:33 PM\n 04:07 AM\n 03:36 AM\n WBC\n 9.9\n 9.4\n 8.7\n 7.6\n 7.6\n Hct\n 28.2\n 26.6\n 25.4\n 28.0\n 26.2\n 25.8\n Plt\n 247\n 284\n 271\n 298\n 316\n Cr\n 3.5\n 3.2\n 3.3\n 3.2\n 3.2\n 3.1\n TCO2\n 37\n 38\n 38\n Glucose\n 184\n 153\n 188\n 178\n 167\n 191\n Other labs: PT / PTT / INR:11.8/42.4/1.0, CK / CKMB /\n Troponin-T:739/98/0.09, ALT / AST:48/25, Alk Phos / T Bili:50/0.3,\n Differential-Neuts:86.2 %, Band:21.0 %, Lymph:8.1 %, Mono:4.9 %,\n Eos:0.6 %, Fibrinogen:626 mg/dL, Lactic Acid:0.9 mmol/L, LDH:275 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.1 mg/dL\n Microbiology\n - none\n Imaging\n - none\n Assessment and Plan\n 74 yom w/ paranoid schizophrenia, hypothyroidism, hypoadrenalism a/w\n pneumosepsis vs, urosepsis c/b by NSTEMI and acinetobacter MRSA PNA,\n now extubated but with continued elevated oxygen requirements.\n ##. Respiratory Failure/PNA: most recent cultures from showing\n Acinetobacter and MRSA pneumonia in setting of fluid overload and\n pulmonary edema.\n - continue meropenum (8 of 14) and linezolid (8 of 14)\n - increase lasix gtt (titrated as low as possible) for continued\n diuresis as patient was positive yesterday + 19 for f/u cultures and CXR\n - continue face mask with down titration as oxygen requirement permits\n # Hypertension\n patient with occasional HTN but has remained in the\n 120\ns for the past day. His home dose ACE-I and BB are being held for\n his RF and bradycardia and he is currently being treated with\n hydralazine and amlodipine.\n - continue to up-titrate Amlodipine and down titrate Hydralazine\n # : likely resulting from ATN in septic shock state with normal\n baseline 1.8-2, now trending down from peak to 3.1 from peak of 4.6\n - continue to trend Cr and UOP\n - limit daily fluid intake and continue minimal lasix gtt to achieve -\n 1.5L per day\n # Schizophrenia: will hold clozaril until linezolid course complete\n for risk of pancyotopenia. On home dose of perphenzine.\n - contact family concerning baseline mental status and interactions\n - consider psychiatry consult\n # Urinary infection\n only urine Cx from positive for VRE,\n completed 7 day course of Linezolid. Most recent cultures from \n negative.\n - continue to follow with periodic surveillance cultures\n # Hypernatremia: likely combination of pre-renal azotemia in setting of\n hypertonic tube feeds.\n - continue to monitor with daily electrolytes and titrate free water\n flushes in tube feeds PRN\n # Anemia: continued slow drop of HCT from 28 to 26.2 to 25.8 in the\n setting of known PUD\n - re-guiac stool to r/o slow GIB\n - avoid transfusion if possible to avoid contributing to volume\n overload\n threshold is 23\n #.Hypothyroidism: continue levothyroxine\n # COPD: continue atrovent and albuterol\n # Adrenal insufficiency: continue home decadron dose\n # DM: continue insulin SQ with ISS\n # FEN: replete electrolytes, tube feeds at goal, monitor hypernatremia\n # Prophylaxis: Subcutaneous heparin , bowel reg\n # Access: PICC line\n # Code: FULL\n # Disposition: possible to floor in PM\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:19 PM 45 mL/hour\n Glycemic Control:\n Lines:\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": "Echo", "chartdate": "2121-09-24 00:00:00.000", "description": "Report", "row_id": 88362, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 78\nWeight (lb): 220\nBSA (m2): 2.35 m2\nBP (mm Hg): 162/70\nHR (bpm): 59\nStatus: Inpatient\nDate/Time: at 15:21\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\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 systolic function.\n\nAORTA: Moderately dilated aortic sinus.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). with normal\nfree wall contractility. The aortic root is moderately dilated at the sinus\nlevel. The aortic valve leaflets (3) are mildly thickened. There is no aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. There is a trivial/physiologic\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the appears is\nsimilar. Regional systolic function is probably normal in both studies\nalthough views are suboptimal.\n\n\n" }, { "category": "Echo", "chartdate": "2121-09-17 00:00:00.000", "description": "Report", "row_id": 88363, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 78\nWeight (lb): 220\nBSA (m2): 2.35 m2\nBP (mm Hg): 175/64\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 15:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function.\n\nAORTA: Moderately dilated aortic sinus.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] 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 as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\nventilator.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded in addition\nto mild basal to mid inferoseptal and inferior hypokinesis. Overall left\nventricular systolic function is low normal (LVEF 50-55%). The right\nventricular cavity is moderately dilated with normal free wall contractility.\nThe aortic root is moderately dilated at the sinus level. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The left ventricular inflow pattern suggests\nimpaired relaxation. There is an anterior space which most likely represents a\nfat pad.\n\nCompared with the prior study (images reviewed) of , the image\nquality is slightly better. The findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2121-09-09 00:00:00.000", "description": "Report", "row_id": 88364, "text": "PATIENT/TEST INFORMATION:\nIndication: possible ACS, sepsis of unknown etiology, intubated\nHeight: (in) 78\nWeight (lb): 220\nBSA (m2): 2.35 m2\nBP (mm Hg): 141/71\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 11:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Aortic valve not well seen. No AS.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Suboptimal image quality - ventilator.\n\nConclusions:\nExtreemly poor image windows. The left atrium is normal in size. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is probably normal\n(LVEF>55%). RV not well seen. The aortic valve is not well seen. There is no\naortic valve stenosis. The mitral valve leaflets are not well seen. There is\nno pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2121-09-13 00:00:00.000", "description": "Report", "row_id": 235930, "text": "Rhythm is probably sinus rhythm with ventricular premature beats, atrial\npremature beats and a long P-R interval. Inferior ST-T wave changes suggest\nmyocardi8al injury/infarction. Overall low QRS voltages. Compared to the\nprevious tracing the QRS complex is much narrower. The rhythm is slower and\nappears to be at least partly sinus. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2121-09-13 00:00:00.000", "description": "Report", "row_id": 235931, "text": "Undetermined rhythm. Wide complex tachycarfdia which appears to degenerate to a\nfaster tachycardia at the end of the tracing. Concern is for ventricular\ntachycardia or diffuse metabolic process causing extensive widening of the\nQRS complexes. Clinical correlation is suggested. Compared to the previous\ntracing of there is a widened complex tachycardia which is radically\ndifferent from prior tracing.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2121-09-09 00:00:00.000", "description": "Report", "row_id": 235932, "text": "Probable sinus rhythm. Left axis deviation. Intraventricular conduction delay.\nSince the previous tracing the rate is faster and QRS width is wider.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2121-09-08 00:00:00.000", "description": "Report", "row_id": 235933, "text": "Baseline artifact. Sinus rhythm. Leftward axis. Late R wave progression. Since\nthe previous tracing T wave abnormalities may be less.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2121-09-08 00:00:00.000", "description": "Report", "row_id": 235934, "text": "Sinus bradycardia with atrial premature beats. Leftward axis. Low voltage\nthroughout. Mild Q-T interval prolongation. No previous tracing available for\ncomparison.\nTRACING #1\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-17 00:00:00.000", "description": "P CHEST (PA & LAT) PORT", "row_id": 1100391, "text": " 3:19 AM\n CHEST (PA & LAT) PORT Clip # \n Reason: interval change?\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA, poor respiratory status\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Pneumonia, poor respiratory status.\n\n Comparison is made with prior study performed a day earlier.\n\n Bilateral large pleural effusions have increased. Multifocal extensive\n diffuse lung consolidations have worsened. Cardiac silhouette is obscured by\n the pleural parenchymal opacity. Lines and tubes remain in place in unchanged\n position.\n\n IMPRESSION: Worsened bilateral pleural effusions and diffuse lung\n consolidations. Lung consolidations are due to superimposed pulmonary edema\n on a background of multifocal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1100622, "text": ", MED MICU 2:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 50 cm Picc placed in left basilic vein need Picc tip placeme\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 50 cm Picc placed in left basilic vein need Picc tip placement\n ______________________________________________________________________________\n PFI REPORT\n TYPE OF EXAMINATION: Chest, AP portable, single view.\n\n INDICATION: New PICC line placed, check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi upright position. Comparison is made with the next preceding\n similar study obtained 12 hours earlier during the same day. Previously\n described ETT, NG tube and right internal jugular approach central venous\n lines unchanged. A new line consists of a left-sided PICC line, which is seen\n to terminate in the lower SVC and rather close to the expected entrance into\n the right atrium. As this termination points projects almost 6 cm below the\n carina, a withdrawal of the line by about 3 cm is recommended to avoid\n unintentional contact. pneumothorax has developed. As before, marked\n perivascular haze and central parenchymal densities are consistent with\n pulmonary edema. Lateral lower densities indicative of bilateral pleural\n effusions.\n\n IMPRESSION: Uncomplicated placement of PICC line, withdrawal by about 3 cm is\n recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100525, "text": " 2:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval progression of pul edema/PNA.\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA, poor respiratory status\n REASON FOR THIS EXAMINATION:\n Eval progression of pul edema/PNA.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, evaluation of progression.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. The extent of the ventilated lung areas\n has increased, there is substantially improved transparency of the upper and\n middle lung regions in both hemithoraces. Subsequent reduction of\n pre-existing opacities in the middle and lower parts of the lung. Persisting\n retrocardiac atelectasis with sparse air bronchograms. The left heart border\n can now be completely seen. The presence of small pleural effusions cannot be\n excluded. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101903, "text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with recent trach and pneumonia\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Evaluate for interval change from the recent\n tracheostomy and pneumonia.\n\n Comparison is made to the prior study from .\n\n FINDINGS:\n Tracheostomy is in the midline. There is a small right-sided pleural effusion\n with atelectasis. There is a small left-sided pleural effusion with\n atelectasis as well. There is mild congestive failure. Heart and mediastinum\n within normal limits.\n\n IMPRESSION:\n Mild interval increase in bilateral pleural effusions and atelectasis.\n Continued mild congestive failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1100621, "text": " 2:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 50 cm Picc placed in left basilic vein need Picc tip placeme\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 50 cm Picc placed in left basilic vein need Picc tip placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 5:36 PM\n TYPE OF EXAMINATION: Chest, AP portable, single view.\n\n INDICATION: New PICC line placed, check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi upright position. Comparison is made with the next preceding\n similar study obtained 12 hours earlier during the same day. Previously\n described ETT, NG tube and right internal jugular approach central venous\n lines unchanged. A new line consists of a left-sided PICC line, which is seen\n to terminate in the lower SVC and rather close to the expected entrance into\n the right atrium. As this termination points projects almost 6 cm below the\n carina, a withdrawal of the line by about 3 cm is recommended to avoid\n unintentional contact. pneumothorax has developed. As before, marked\n perivascular haze and central parenchymal densities are consistent with\n pulmonary edema. Lateral lower densities indicative of bilateral pleural\n effusions.\n\n IMPRESSION: Uncomplicated placement of PICC line, withdrawal by about 3 cm is\n recommended.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable, single view.\n\n INDICATION: New PICC line placed, check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi upright position. Comparison is made with the next preceding\n similar study obtained 12 hours earlier during the same day. The previously\n described ETT, NG tube and right internal jugular approach central venous line\n unchanged. A new line consists of a left-sided PICC line, which is seen to\n terminate in the lower SVC and rather close to the expected entrance into the\n right atrium. As this termination point projects almost 6 cm below the\n carina, a withdrawal of the line by about 3 cm is recommended to avoid\n unintentional contact. pneumothorax has developed. As before, marked\n perivascular haze and central parenchymal densities are consistent with\n pulmonary edema. Lateral lower densities indicative of bilateral pleural\n effusions.\n\n IMPRESSION: Uncomplicated placement of PICC line, withdrawal by about 3 cm is\n recommended.\n\n (Over)\n\n 2:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 50 cm Picc placed in left basilic vein need Picc tip placeme\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2121-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102271, "text": " 3:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with volume overload, intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:04 A.M., \n\n HISTORY: Volume overloaded intubated.\n\n IMPRESSION: AP chest compared to :\n\n Substantial bibasilar atelectasis has improved minimally since .\n Upper lungs clear. Small bilateral pleural effusions are presumed. Heart\n size normal. No pneumothorax. Tracheostomy tube in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100853, "text": " 1:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pneumonia and UTI\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:36 A.M., \n\n HISTORY: Pneumonia and UTI.\n\n IMPRESSION: AP chest compared to at 3:20 a.m.:\n\n The trachea has been extubated, but lung volumes have improved. Left\n perihilar consolidation probably pneumonia, and moderate bilateral pleural\n effusions have all improved. Left lower lobe remains severely atelectatic.\n Heart size is normal. Nasogastric tube passes below the diaphragm and out of\n view. No pneumothorax. Left PIC line tip projects over the mid SVC.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100205, "text": " 3:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval changes\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n please evaluate interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 74-year-old male with pneumonia. Evaluate for interval change.\n\n Single AP chest radiograph compared to show increased\n widespread bilateral airspace consolidation and atelectasis with\n associated small bilateral pleural effusions. The cardiomediastinal contour\n is unchanged. ET tube terminates 4.1 cm above the carina. NG tube enters the\n stomach, the tip has been excluded. There is no pneumothorax. Right IJ\n central venous catheter tip overlies the SVC.\n\n IMPRESSION: Increased bilateral airspace consolidation and atelectasis with\n small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101716, "text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with PNA and pulmonary edema\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: Pneumonia and pulmonary edema.\n\n Comparison is made with prior study .\n\n New tracheostomy tube is in the standard position. NG tube tip is in the\n stomach. Cardiac size is top normal. This study is slightly limited, the\n left lateral CP angle was not included on the film. Small bilateral pleural\n effusions greater on the right side are unchanged, are associated with\n bibasilar opacities likely atelectasis. Pneumonia cannot be totally excluded.\n Interstitial peribronchial abnormalities in the left hilum are new,\n could be infectios or aspiration and attention in this area in the\n followup studies is recommended. Mild vascular congestion has improved.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100253, "text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: 74-year-old man with pneumonia.\n\n FINDINGS: The tip of the ET tube is satisfactory just below the thoracic\n inlet and 43 mm above the carina. The NG tube passes below the diaphragm into\n the stomach, right internal jugular central venous line is unchanged.\n\n Diffuse dense bilateral air space consolidation persists and has worsened in\n some areas particularly in the apices and perihilar regions which given the\n short interval suggests superimposed pulmonary edema. Left lower lobe\n atelectasis is stable and bilateral small pleural effusions are unchanged. The\n right costophrenic angle and lateral chest has not been included in the study.\n\n No pneumothorax, cardiomediastinal silhouette is unchanged, degenerative\n changes in the thoracic spine are moderate-to-severe unchanged.\n\n IMPRESSION: Worsening diffuse bilateral air space opacities are most likely\n due to superimposed pulmonary edema on a background of multifocal\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101193, "text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pneumonia, volume overload\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Pneumonia and fluid overload.\n\n FINDINGS: Since the previous study, bilateral pleural effusions are moderate\n and stable. Perihilar haziness and upper lobe vascular congestion has\n improved and is now mild with no new consolidation or pneumothorax.\n Cardiomediastinal silhouette is unchanged and normal.\n\n The NG tube passes into the stomach and could be advanced by 2-3 cm to a more\n optimal position.\n\n IMPRESSION:\n\n Stable bilateral moderately large pleural effusions with improved pulmonary\n edema which is now mild. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100689, "text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pneumonia and fluid overload\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:20 A.M., :\n\n HISTORY: Pneumonia and volume overload.\n\n IMPRESSION: AP chest compared to :\n\n Moderate pulmonary edema, moderate right pleural effusion. Left perihilar\n consolidation, probably pneumonia, unchanged over 12 hours. Cuff of the\n endotracheal tube is wider than the diameter of the native trachea and the\n sharp definition of the upper margin suggests retained secretions in the upper\n airway. Tip position is standard. Nasogastric tube ends in the region of the\n pylorus. Heart size is top normal. Left PIC catheter tip ends just above the\n superior cavoatrial junction. Small left pleural effusion is stable. No\n pneumothorax. Dr. has been paged.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102116, "text": " 1:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with hx of pneumonia, now diuresing\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Pneumonia and CHF after diuresing.\n\n Comparison is made with prior study of .\n\n Cardiac size is top normal. Mild pulmonary edema has improved. Small\n bilateral pleural effusions, right greater than left, have decreased in\n amount. Tracheostomy tube is in standard position. Left catheter tip remains\n in place. Bibasilar consolidations are minimally increased in the right base.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101312, "text": " 4:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pneumonia and CHF\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n WET READ: DLrc TUE 6:05 PM\n ETT in good postion 4.3cm above the level of the carina. Stable appearance\n of pulmonary edema and bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:15 P.M., \n\n HISTORY: Pneumonia and CHF. Check ET tube.\n\n IMPRESSION: AP chest compared to , 3:13 p.m. and :\n\n ET tube in standard placement. Nasogastric tube passes into the stomach and\n out of view. Upper lungs show vascular congestion. Lower lungs, particularly\n the right, probably atelectasis, worsened on the right, improved on the left.\n Small-to-moderate right and small left pleural effusion, not appreciably\n changed. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101358, "text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pna and pulm edema\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with pulmonary edema and\n pneumonia.\n\n Portable AP chest radiograph was compared to obtained at 5:14\n p.m.\n\n The ET tube tip is 5 cm above the carina. The NG tube tip is in the proximal\n stomach and should be advanced about 10 to 15 cm. Bibasilar atelectasis is\n present, although infection might be underlying. The mild pulmonary edema is\n unchanged. There is bilateral pleural effusion, small; but there is no\n evidence of pneumothorax within the limitations of this study technique.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-24 00:00:00.000", "description": "CT NECK W/O CONTRAST (EG: PAROTIDS)", "row_id": 1101509, "text": " 9:03 PM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: SWOLLEN LEFT SUBMANDIBULAT GLAND\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with swollen left submandibular gland\n REASON FOR THIS EXAMINATION:\n evaluate for sialolith\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n WET READ: DLrc WED 11:23 PM\n No calcifications that would be concerning for sialolithiasis. Prominent 9\n x16mm intraparotid lymph node. Two 13mm in short axis submandibular lymph\n nodes in the with associated surrounding inflammation located between the\n parotid and submandibular glands with associated asymmetric enlargement of\n both the parotid and submandibular glands as compared to the right compatible\n with inflammatory changes, and it is unclear whether the submandibular or\n parotid gland, or a cellulitis involving this region is the origin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 74-year-old male with swollen left mandibular gland.\n Please evaluate for sialolithiasis.\n\n EXAMINATION: Non-contrast CT of the neck.\n\n COMPARISONS: No prior studies are available for direct comparison.\n\n TECHNIQUE: Helically acquired axial images were obtained through the neck. No\n intravenous contrast was administered secondary to elevated creatinine.\n Coronal and sagittal reformations were obtained.\n\n FINDINGS:\n\n There is enlargement of the left parotid and submandibular glands. The left\n parotid enlargement can best be appreciated on (2:19) and asymmetric\n enlargement of the submandibular gland can best be appreciated on (2:28). In\n addition, there are left-sided prominent lymph nodes with an intraparotid\n lymph node best seen on (2:15) measuring 16 x 9 mm, and two subjacent\n submandibular lymph nodes best seen on (2:24) each measuring 13 mm in their\n short axis. These lymph nodes are likely reactive in nature, with associated\n surrounding fat stranding suggestive of an inflammatory process. Given the\n proximity of the fat stranding and lymphadenopathy to both the parotid and\n submandibular glands and given the asymmetric enlargement of both, the origin\n of this inflammatory process is not clear and could be either related to the\n submandibular or parotid gland, or also may be related to a cellulitis within\n this area.\n\n No fluid collections are seen in this area that would be concerning for\n abscess, however evaluation is limited with lack of intravenous contrast.\n There are no high-density calcifications that would be concerning for\n sialolithiasis. There is a small calcification in the floor of the mouth\n (Over)\n\n 9:03 PM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: SWOLLEN LEFT SUBMANDIBULAT GLAND\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in the midline that is not along the course of a major salivary duct. The\n patient is status post intubation, a nasogastric tube placement. In addition,\n the patient is status post central venous catheter placement with catheter\n seen coursing through the left subclavian vein. There are bilateral right\n greater than left pleural effusions. In addition, there is nonspecific\n ground-glass opacity seen within both lung apices. There is mucosal\n thickening involving the ethmoid, sphenoid and maxillary sinuses, and the\n mastoid air cells are opacified. No other areas of lymphadenopathy are\n identified. Evaluation of the parapharyngeal soft tissues is limited in the\n presence of the endotracheal tube.\n\n BONE WINDOWS: The visualized osseous structures are unremarkable with no\n fractures identified.\n\n IMPRESSION:\n\n 1. Inflammatory changes with enlargement of the left submandibular and parotid\n glands. Reactive adjacent left-sided adenopathy with associated fat\n stranding. The inflammation can either originate from the parotid or\n submandibular gland, or may be associated with overlying cellulitis. No\n associated fluid collection that would be concerning for abscess formation.\n\n 2. Mucosal thickening involving all of the paranasal sinuses.\n\n 3. Bilateral right greater than left pleural effusions and apical ground\n glass opacification.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1099076, "text": " 5:51 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ij placement\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n Comparison made with a study performed approximately 20 minutes earlier.\n\n CLINICAL HISTORY: Line placement, evaluate for catheter position.\n\n FINDINGS: Single AP supine portable chest radiograph is obtained. There has\n been interval placement of a right IJ central venous catheter with its tip in\n the expected position of the superior vena cava. There is no pneumothorax.\n Endotracheal tube is unchanged. The tip of the nasogastric tube remains\n positioned at the expected location of the GE junction. Bilateral lung\n opacities persist, which are more prominent on the left side.\n Cardiomediastinal silhouette is unchanged.\n\n IMPRESSION: Adequate position of the right IJ central venous catheter. No\n pneumothorax. Otherwise, unchanged.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2121-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099547, "text": " 7:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with respiratory failure, intubated, PNA\n REASON FOR THIS EXAMINATION:\n please assess for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with respiratory failure, intubated and\n pneumonia. Evaluate for change.\n\n AP chest radiograph compared to shows mildly improved right\n lower lobe airspace opacity and pleural effusion. Left mid and lower lung\n consolidations persist. There is no pneumothorax. ET tube terminates 4.7 cm\n above the carina. Feeding tube tip is in the stomach. Right IJ central\n venous catheter overlies the mid proximal SVC.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099158, "text": " 9:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate OGT placement\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new OGT placement\n REASON FOR THIS EXAMINATION:\n please evaluate OGT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE 12:49 PM\n Right central line and endogastric tube placement without complication;\n interval improvement of left lung aeration.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old male with new OG tube placed, please evaluate placement.\n\n STUDY: AP semi-upright portable chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube is 5 cm above the carina. There has been\n interval placement of a right-sided central catheter with its tip in the mid\n SVC. The endogastric tube courses inferiorly and curls in the stomach below\n the GE junction. The heart and mediastinal contours are unchanged. There is\n interval improvement of the left lung patchy opacities. Left pleural effusion\n persists. There is no pneumothorax.\n\n IMPRESSION: Right central line and endogastric tube placement without\n complication; interval improvement of left lung aeration.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099159, "text": ", F. MED CCU 9:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate OGT placement\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new OGT placement\n REASON FOR THIS EXAMINATION:\n please evaluate OGT placement\n ______________________________________________________________________________\n PFI REPORT\n Right central line and endogastric tube placement without complication;\n interval improvement of left lung aeration.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-08 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1099074, "text": " 5:36 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: Trauma.\n\n FINDINGS: Supine portable AP view of the chest is obtained. An endotracheal\n tube is seen with its tip approximately 2.7 cm above the carina. NG tube tip\n projects over the expected location of the distal esophagus. Confluent\n opacities are noted in the left mid and lower lung, which may reflect\n aspiration or extensive contusion. There is hilar prominence and pulmonary\n vascular prominence, likely reflecting mild congestive heart failure.\n Cardiomediastinal silhouette is unremarkable. No pneumothorax or large\n pleural effusion is seen. Left sixth posterior rib appears fractured. Ribs\n may be fractured, though suboptimally assessed given the extensive\n opacification in the left lung. Ovoid calcific densities projecting over the\n left axilla may be external to the patient.\n\n IMPRESSION:\n\n 1. ET tube positioned adequately. NG tube should be advanced for more optimal\n position.\n 2. Mild congestive heart failure with confluent opacity in the left mid and\n lower lung concerning for contusion or aspiration. CT may be performed to\n further assess.\n 3. Apparent left sixth posterior rib fracture. Consider CT or rib series to\n further assess.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2121-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099387, "text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for any change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with severe sepsis, left lung PNA, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for any change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Radiograph of one day earlier.\n\n INDICATION: Sepsis. Pneumonia.\n\n FINDINGS: Asymmetrically distributed perihilar and basilar lung opacities\n affecting the left lung to a greater degree than the right has slightly\n worsened in the interval, some of the left opacities appear slightly nodular.\n There is also a new area of ill-defined opacity at the right base. Observed\n findings likely reflect a combination of pulmonary edema and infection.\n Moderate left effusion is unchanged, but small right pleural effusion has\n increased. Indwelling support devices are unchanged in position.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099895, "text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with septic shock\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n FINDINGS:\n\n Portable, semi-erect radiograph of the chest is somewhat degraded due to\n motion artifact.\n\n Tubes and lines are stable. The tip of the nasogastric tube is at least below\n the cardiac silhouette; however, the tip is not included in the field of view.\n There is persistent pulmonary edema, bilateral pleural fluid, and compressive\n bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2121-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099733, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 74-year-old male with respiratory failure and pneumonia.\n\n Single AP chest radiograph compared to shows unchanged left\n mid lower lung consolidation. Right lower lobe airspace opacity and perihilar\n hazziness continues to improve compatible with decreased fluid overload. The\n cardiomediastinal contour is stable. There is no pneumothorax. Right IJ\n central venous catheter tip overlies the proximal SVC. NG tube tip is in the\n stomach. ET tube terminates 3 cm above the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100079, "text": " 6:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval for fluid overload\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with w/ h.o. ?adrenal insufficiency, hypothyroidism, paranoid\n schizophrenia, DM II p/w septic source likely pulmonary versus urine.\n Hypoxic\n REASON FOR THIS EXAMINATION:\n Eval for fluid overload\n ______________________________________________________________________________\n WET READ: PXDb SUN 8:05 PM\n Bilateral patchy air space opacities with improved aeration at the RLL and\n more confluent opacity in the left perihilar region. Unchanged bilateral\n pleural effusions. Stable lines and tubes. ( )\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Radiograph of earlier the same date.\n\n INDICATION: Hypoxia. Clinical suspicion for fluid overload.\n\n FINDINGS: Slight interval improvement in asymmetrically distributed bilateral\n perihilar and basilar alveolar opacities, worse on the right than the left.\n Moderate right and small left pleural effusion are also unchanged as well as\n left retrocardiac atelectasis. Continued radiographic followup after diuresis\n is suggested to exclude the possibility of a coexisting infection.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100060, "text": " 2:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval placement of central line\n Admitting Diagnosis: SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with w/ h.o. ?adrenal insufficiency, hypothyroidism, paranoid\n schizophrenia, DM II p/w septic source likely pulmonary versus urine.\n REASON FOR THIS EXAMINATION:\n Please eval placement of central line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Study of one day earlier.\n\n INDICATION: Line placement.\n\n FINDINGS: Right internal jugular central venous catheter terminates within\n the mid superior vena cava, with no pneumothorax. Worsening of bilateral\n asymmetric perihilar airspace opacities, right greater than left, most likely\n due to asymmetrical pulmonary edema. Persistent moderate bilateral pleural\n effusions with adjacent basilar atelectasis.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2101-07-07 00:00:00.000", "description": "CT LUMBAR W&W/O CONTRAST", "row_id": 1245173, "text": " 9:17 AM\n CT LUMBAR W&W/O CONTRAST Clip # \n Reason: please evaluate for fluid collections of L-spine (also T12 r\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58yoW h/o morbid obesity, COPD, lumbosacral radiculopathy, DM c/b peripheral\n neuropathy and recent T12-L4 fusion c/b wound dehissence/infection now s/p I&D\n w/ wound vac placement.\n REASON FOR THIS EXAMINATION:\n please evaluate for fluid collections of L-spine (also T12 region)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post recent T12-L4 fusion complicated by wound dehiscence\n and infection. Evaluate for fluid collections.\n\n COMPARISONS: Preoperative CT of the lumbar spine, . Preoperative\n MRI of the lumbar spine, . Postoperative radiograph of the lumbar\n spine .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the lumbar\n spine with and without the administration of intravenous contrast. Sagittal\n and coronal reformatted images were obtained and reviewed.\n\n FINDINGS: The exam is severely limited by the patient's body habitus, motion,\n and metallic artifact from the recent fusion hardware.\n\n Within the limitations, the fusion hardware appears intact. There are pedicle\n screws in the vertebral bodies of T12 through L4. There is no evidence of\n screw fractures or loosening. The screws do not extend through the anterior\n cortex. Rods are in place without evidence of fracture. The patient is\n extremely osteopenic. Again seen is a widely distracted horizontal fracture\n through the L2 vertebral body. Compression deformities are present in the T12\n and L1 vertebral bodies. These are unchanged from the prior preoperative CT,\n as well as the postoperative radiograph. There is severe subluxation of the\n anterior L2 fracture fragment, but is stable in appearance from the\n preoperative and postoperative exams. There is no evidence of new fractures\n or new malalignment. Significant degenerative changes are noted with flowing\n anterior osteophytes and facet hypertrophy.\n\n There is a defect in the skin posterior to the levels of T12 through L3. It\n measures approximately 3.8 cm in depth (7, 57). Within the wound, there is\n dressing material and a drain, consistent with a vacuum dressing. Surrounding\n the skin defect, there is ill-defined, non-enhancing edema, without an\n identified fluid collection. There is no rim ehancement. More anterior to\n this skin defect, no large fluid collection is noted, although a small fluid\n collection cannot be excluded given the extensive artifact. The epidural\n space, thecal sac and the spinal canal cannot be evaluated due to artifact.\n\n To the right of the vertebral bodies, the psoas muscle has abnormal low\n density and is enlarged when compared to the left. This was present on the\n preoperative MRI, and it is of unclear significance. It may represent\n (Over)\n\n 9:17 AM\n CT LUMBAR W&W/O CONTRAST Clip # \n Reason: please evaluate for fluid collections of L-spine (also T12 r\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemorrhage or a postoperative fluid collection. Infection of this region\n cannot be excluded. The left psoas muscle is atrophied, but has normal\n density.\n\n There is a moderate left nonhemorrhagic pleural effusion and a trace right\n nonhemorrhagic pleural effusion. There is a small amount of consolidation\n associated with the left effusion, likely atelectasis. A small right adrenal\n nodule measures approximately 8 mm (3, 27), and is unchanged from the prior\n exams. It is not completely evaluated due to motion and artifact. An IVC\n filter is noted. Atherosclerotic disease of the aorta and common iliac\n arteries is present.\n\n IMPRESSION:\n 1. Skin defect extending from the level of T12 through L2 without definite\n associated fluid collection. Evaluation is very limited due to patient\n motion, body habitus, and metallic artifact. A small fluid collection, or any\n abnormality within the spinal canal, could not be appreciated. MRI may help\n better evaluate the soft tissues for fluid collections.\n 2. Abnormal hypodensity within the right psoas muscle appears stable from the\n preoperative MRI. It is of unclear significance, and may represent a hematoma\n or seroma. Superinfection cannot be excluded. MRI could further evaluate\n this muscle.\n 3. Bilateral pleural effusions, larger on the left than the right, with\n associated atelectasis.\n 4. Incompletely characterized right adrenal nodule.\n 5. No new fractures or evidence of hardware complications.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1245031, "text": " 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? position of ET tube and NG tube placement\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with COPD, morbid obesity, seizures now s/p I&D of lumbar\n wound who remains intubated/sedated.\n REASON FOR THIS EXAMINATION:\n ? position of ET tube and NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:52 A.M., \n\n HISTORY: Check line and tube positions.\n\n IMPRESSION: AP chest compared to and 8:\n\n Endotracheal tube is in standard placement. Right subclavian infusion port\n can be traced to the right heart, but the tip cannot be seen. Subject to the\n technical limitations of bedside radiography of a morbidly obese patient, the\n major change since is new, relative elevation of the base of the right\n lung, but whether this is due to pleural effusion, lobar collapse, or\n elevation of the diaphragm is radiographically indeterminate. Moderate\n cardiomegaly may have worsened. Moderate left pleural effusion is stable.\n Nasogastric tube passes below the diaphragm and out of view. There is no\n radiographic evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1245949, "text": " 4:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: location of 52 cm left basilic picc tip\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with infectiom\n REASON FOR THIS EXAMINATION:\n location of 52 cm left basilic picc tip\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Infection, location of 62 cm left basilic PICC line.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. The right pectoral\n Port-A-Cath is in unchanged position. However, the patient has received a\n left PICC line. The course of the line is unremarkable, the tip of the line\n projects over the mid SVC. The vertebral stabilization devices are in\n constant position. No evidence of complications, notably no pneumothorax.\n\n Multiple nodular sclerotic abnormalities projecting over the left humeral head\n are better visible than on the previous examination.\n\n\n" }, { "category": "ECG", "chartdate": "2101-07-05 00:00:00.000", "description": "Report", "row_id": 181284, "text": "Sinus rhythm. Right bundle-branch block. Diffuse non-specific ST segment\nchanges. Compared to the previous tracing of the QRS width in the\nleads V2-V3 is markedly less wide but the ventricular rate is faster.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2182-12-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 705366, "text": "Chief Complaint: Confusion, rigidity\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Sedated overnight with diazepam\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 04:15 PM\n History obtained from Patient, Family / Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 01:30 AM\n Heparin Sodium (Prophylaxis) - 08:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, Delirious, No(t) Daytime\n somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:31 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: 36.3\nC (97.3\n HR: 62 (58 - 131) bpm\n BP: 143/75(92) {129/62(82) - 171/92(105)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,460 mL\n 62 mL\n PO:\n TF:\n 499 mL\n IVF:\n 661 mL\n 62 mL\n Blood products:\n Total out:\n 2,930 mL\n 1,300 mL\n Urine:\n 2,930 mL\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,470 mL\n -1,238 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 324 (324 - 324) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Anxious, No(t) Diaphoretic, Frail\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, 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), 2/6 SEM\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, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , Crackles : few mid insp, No(t) Bronchial: ,\n 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: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: 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): x2, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 298 K/uL\n 76 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 103 mEq/L\n 143 mEq/L\n 29.0 %\n 13.1 K/uL\n [image002.jpg]\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n 02:57 PM\n 08:44 PM\n 03:22 AM\n WBC\n 19.2\n 16.6\n 14.9\n 13.1\n Hct\n 25.8\n 21.9\n 26.3\n 29.6\n 29.0\n Plt\n 98\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n 102\n 96\n 76\n Other labs: PT / PTT / INR:12.7/32.1/1.1, CK / CKMB /\n Troponin-T:422/6/, ALT / AST:44/80, Alk Phos / T Bili:191/0.6, Amylase\n / Lipase:/39, Differential-Neuts:84.1 %, Lymph:12.3 %, Mono:2.7 %,\n Eos:0.7 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n She is slowly improving. We will continue to taper Sinemet per Neuro's\n reqs. Continue to treat agitation with Valium per CIWA but she is\n gradually improving. Seems likely her cognitive fxn is not completely\n normal at baseline due to her chronic EtOH. WBC continues to trend\n down and all cx have been neg except for sputum pos for Staph. We will\n image her liver. BUN/Creat are normal.\n ICU Care\n Nutrition:\n Comments: will begin soft solids\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:43 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2182-12-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 704978, "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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / 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 Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n" }, { "category": "General", "chartdate": "2182-12-08 00:00:00.000", "description": "Generic Note", "row_id": 705166, "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. Sedated this morning, but\n arousable. Abx d/c\n 100.0 71 117/60\n Chest\n few crackles\n CV w/o m\n Abd\n soft w/o tenderness\n WBC\n 16.6\n Hct 26\n CXR bilat basilar atelectasis\n We still do not know what has caused her delirium/ encephalopathy. Now\n still febrile but tachy and HTN have improved on midazolam gtt\n tapering gtt with goal of reinstituting something equivalent to her\n home oxazepam. Hct of 21 this am appears to be spurious\n continuing\n to monitor. RSBI this am 27\n we will try SBT and hopefully move to\n extubation if her mental status permits\n Time spent 40 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2182-12-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705168, "text": "Chief Complaint:\n 24 Hour Events:\n - antibiotics stopped\n - will hold on extubation given that she is requiring large doses of\n benzos for aggitation and presummed withdrawal\n - high IV midazolam requirement therefore started on a gtt, propofol\n gtt weaned\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Midazolam (Versed) - 15 mg/hour\n Other ICU medications:\n Propofol - 01:32 PM\n Midazolam (Versed) - 12:13 AM\n Heparin Sodium (Prophylaxis) - 07:52 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 08:17 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: 38.1\nC (100.6\n HR: 65 (62 - 103) bpm\n BP: 112/76(84) {112/60(76) - 166/90(119)} mmHg\n RR: 24 (0 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 4,512 mL\n 953 mL\n PO:\n TF:\n 474 mL\n 324 mL\n IVF:\n 3,469 mL\n 329 mL\n Blood products:\n Total out:\n 4,020 mL\n 950 mL\n Urine:\n 4,020 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 492 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 444 (274 - 450) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 21\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 5.4 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 283 K/uL\n 7.4 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 105 mEq/L\n 143 mEq/L\n 26.3 %\n 16.6 K/uL\n [image002.jpg]\n 05:52 AM\n 07:40 AM\n 12:58 PM\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n WBC\n 19.2\n 16.6\n Hct\n 26.7\n 25.8\n 21.9\n 26.3\n Plt\n 217\n 283\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 23\n 24\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n Other labs: PT / PTT / INR:13.3/40.3/1.1, CK / CKMB /\n Troponin-T:861/6/, ALT / AST:72/128, Alk Phos / T Bili:213/0.7, Amylase\n / Lipase:/39, Differential-Neuts:79.0 %, Lymph:19.6 %, Mono:1.0 %,\n Eos:0.3 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.5 mg/dL, Mg++:1.5 mg/dL,\n PO4:4.1 mg/dL\n Microbiology: Sputum Cx: Coag + STAPH AUREUS, same as previous with\n colonization from two colonies\n Assessment and Plan\n 61 yo with hx of parkinson's presented to OSH with possible delirium\n and concern for NMS.\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n also contribution of alcohol withdrawal. LP was bland, though many\n cultures are pending. Propofol weaned off, high midazolam gtt more\n calm overnight. Able to follow commands.\n - Sinemet 25/100 two tabs Q6H and amantadine 100mg \n - wean bzd gtt\n - Continue thiamine\n # Fever: Likely due to NMS as the patient has no signs of infection and\n with sputum culture with coag + staph, all other cultures are negative\n to date. Abx stopped yesterday.\n - wait for speciation prior to restarting abx\n - avoid antipsychotics\n - f/u cultures\n # Elevated transaminases: There has been some report from her husband\n that the transaminitis may be chronic. Her numbers are suggestive of\n chronic alcoholism.\n - discuss with family about history of liver disease.\n - continue to trend LFTs.\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS. Hemolysis\n labs negative, reticulocyte count low and iron studies suggestive of\n severe anemia of chronic disease. Decreased Hct to 21, but repeat 26,\n likely error.\n - Trend hct with goal >21% or avoid end-organ symptoms.\n - was given 1 UPRC prior to transfer\n #. hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and give 150mg free water flushes Q6hrs.\n - Continue to monitor qdaily.\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration. CK trending down, Cr\n normalized.\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n #. FEN: IVF, tube feed\n #. PPX:\n -DVT ppx with SC heparin and pneumoboots\n -bowel regimen with colace and senna\n -PPI: start if cannot extubate today\n #. ACCESS: PIV's\n #. CODE STATUS: Presumed full\n #. EMERGENCY CONTACT: Partner : , son :\n \n #. DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:19 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:43 AM\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": "General", "chartdate": "2182-12-07 00:00:00.000", "description": "Generic Note", "row_id": 704959, "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. Alert\n answering questions\n 99.8 80 117/87\n Alert, intermit agitated\n Chest\n few mid insp crackles\n CV w/o m\n Abd soft w/o tenderness\n Extrem\n now nl tone\n WBC\n 19.2\n Temp trending down, less rigid, more alert. Seems likely she has had\n NMS that is now resolving. Still seems likely this was in part a\n consequence of Sinemet withdrawal. Now treating her for EtOH\n withdrawal in addition with diazepam and midaz. Continuing Sinemet.\n She is adequately controlled on these meds, CK coming down. Will start\n to wean ventilator, d/c propofol, d/c abx and reassess MS. \nIWA scale for EtOH withdrawal.\n Time spent 40 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2182-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705269, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2-week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n Electrolyte & fluid disorder, other\n Assessment:\n Pm labs sent\n Action:\n Pm labs stable\n Response:\n Plan:\n Await results and replete per S/S,\n Altered mental status (not Delirium)\n Assessment:\n Very agitated, wants to go home and getting out of bed and trying pull\n iv/tubing. Bilateral wrist restraints in place for safety, patient\n alert, oriented x2, following commands. No tremors , on po cinamet 4\n times/day\n Action:\n Patient received iv diazepam 10mg q 2hrs PRN and 10mg x2 as single\n dose. Also receiving oxazepam PO\n Response:\n Patient was agitated and OOB, received diazepam . .mg\n Plan:\n Diazepam IV for anxiety/agitation, continue to follow neuro exam\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp,?temp related to NMS [ potentially can be hyper-febrile]\n Action:\n All cxs taken neg, all antibiotics stopped\n Response:\n Stable at this time\n Plan:\n Continue to follow temp curve, and Tylenol,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on O2 50% via face tent, O2 sats 98-100%. Bilateral\n lung sounds clear.\n Action:\n Continued o2 50% via face tent, encouraged cough and deep breathing\n Response:\n Doing well RR 15-20 sats 100% on 50% face tent\n Plan:\n Encourage cough/deep breath, pulmonary toilet, wean fio2 as tolerated\n" }, { "category": "General", "chartdate": "2182-12-06 00:00:00.000", "description": "Generic Note", "row_id": 704750, "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. BC pos from OSH\n coccobacillus\n and GPC\n 100.3 75 115/61\n Tremulous, flows simple commands, tone increased\n Chest\n quiet w/o crackles/ wheezes\n CV w/o m\n Abd\n soft + BS\n Extrem w/o edema\n WBC 21.1\n INR 1.5\n Remains confusing. Story difficult to synthesize but fever, rigidity,\n elevated CK all c/w NMS or Parkinsonian NMS. CK is actually down\n slightly this morning and WBC is trending down. She is still somewhat\n volume depleted and is also dehydrated so we are increasing IVF,\n placing CVL, removing a-line from OSH, repeating cx, performing LP.\n Need to have better handle on EtOH use but suspect she is at signif\n risk for alcohol withdrawal so will cover with a low dose of diazepam.\n Time spent\n 45 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2182-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 704962, "text": "Chief Complaint: Rigidity\n 24 Hour Events:\n ARTERIAL LINE - START 08:04 AM\n SPUTUM CULTURE - At 10:40 AM\n MULTI LUMEN - START 11:43 AM\n LUMBAR PUNCTURE - At 02:48 PM\n \n - LP done - 0 WBC and 0 RBC with normal protein and glucose.\n - Central line placed.\n - f/u blood cultures from OSH\n - 8pm lytes show improving CK and Cr, low phos repleted.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:38 AM\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 PM\n Midazolam (Versed) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 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: 37.7\nC (99.9\n HR: 75 (63 - 94) bpm\n BP: 126/74(86) {121/72(83) - 129/84(94)} mmHg\n RR: 18 (6 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,587 mL\n 2,014 mL\n PO:\n TF:\n 159 mL\n 169 mL\n IVF:\n 6,869 mL\n 1,635 mL\n Blood products:\n Total out:\n 1,380 mL\n 540 mL\n Urine:\n 1,380 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,207 mL\n 1,474 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (468 - 487) mL\n PS : 10 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 62\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.51/29/106/23/1\n Ve: 7.8 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Calm shortly after receiving Propofol bolus for agitation and\n scheduled sinemet\n HEENT: No scleral icterus. PERRL, MMM. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2.\n LUNGS: CTAB, good air movement bilaterally with central rhonchi.\n ABDOMEN: Soft, +BS, NTND\n EXTREMITIES: No edema or calf pain, 2+ radial/ dorsalis pedis/\n posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Less rigid today with improved relaxation. Has a prominent\n resting tremor when Sinemet and ativan wearing off.\n Labs / Radiology\n 217 K/uL\n 111 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 14 mg/dL\n 117 mEq/L\n 142 mEq/L\n 25.8 %\n 19.2 K/uL\n [image002.jpg]\n 10:41 PM\n 11:56 PM\n 05:28 AM\n 05:52 AM\n 07:40 AM\n 12:58 PM\n 01:03 PM\n 06:02 AM\n WBC\n 23.6\n 21.1\n Hct\n 29.9\n 27.4\n 26.7\n Plt\n 213\n 182\n Cr\n 1.2\n 1.0\n 0.8\n TCO2\n 23\n 23\n 24\n 24\n Glucose\n 224\n 106\n 87\n Other labs: PT / PTT / INR:13.4/33.4/1.1, CK / CKMB /\n Troponin-T:2797/6/, ALT / AST:99/234, Alk Phos / T Bili:195/0.7,\n Amylase / Lipase:/39, Differential-Neuts:79.0 %, Lymph:19.6 %, Mono:1.0\n %, Eos:0.3 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:987 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.5 mg/dL,\n Vanco: 13.7\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n ASSESSMENT AND PLAN: 61 yo with hx of parkinson's presented to OSH with\n possible delirium and concern for NMS.\n .\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n though there is question of whether alcohol withdrawal is also\n contributing. LP was bland, though many cultures are pending. She is\n now alert on minimal sedation and able to follow basic commands. She\n can likely be extubated today as she is on minimal vent settings and\n following commands.\n - Sinemet 25/100 two tabs Q6H and amantadine 100mg \n - Continue diazepam 5mg with midazolam boluses for agitation,\n assuming that alcohol withdrawal is playing a role. We can reassess\n her benzodiazepine requirement and switch her over to only PO diazepam.\n - Continue thiamine\n - We can ease off of the aggressive hydration, but should still verify\n electrolytes today as she as at risk for hypokalemia,\n hypophosphatemia and hypernatremia.\n .\n # Fever: Likely due to NMS as the patient has no signs of infection and\n all cultures are negative to date.\n - On vancomycin, meropenem and acyclovir day 2 for empiric meningitis\n coverage. These antibiotics can be stopped given given the patient\n improvement and normal LP.\n - avoid antipsychotics\n - f/u cultures\n .\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration. After being 6L positive\n yesterday we may need to begin gently diuresis today.\n .\n # elevated transaminbases: There has been some report from her husband\n that the transaminitis may be chronic. Her numbers today or less\n suggestive of chronic alcoholism.\n - discuss with family about history of liver disease.\n - continue to trend LFTs.\n .\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS. Hemolysis\n labs negative, reticulocyte count low and iron studies suggestive of\n severe anemia of chronic disease.\n - Trend hct with goal >21% or avoid end-organ symptoms.\n - was given 1 UPRC prior to transfer\n .\n # coagulopathy: was concerning for chronic liver dz, the the\n coagulopathy has now resolved.\n .\n # hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and give 150mg free water flushes Q6hrs.\n - Continue to monitor qdaily.\n .\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n .\n FEN: IVF, tube feed\n .\n PPX:\n -DVT ppx with SC heparin and pneumoboots\n -bowel regimen with colace and senna\n -PPI: No indication for ulcer prevention as she is being extubated\n today.\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: Partner : , son :\n \n .\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:08 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:04 AM\n Multi Lumen - 11:43 AM\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: ICU pending extubation and stabilization.\n" }, { "category": "Nutrition", "chartdate": "2182-12-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 705380, "text": "Subjective: patient off floor, did not speak with her.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 51.4 kg\n 22.1\n Pertinent medications: Senna, Colace, Thimine, Protonix, others noted\n Labs:\n Value\n Date\n Glucose\n 76 mg/dL\n 03:22 AM\n Glucose Finger Stick\n 83\n 10:00 AM\n BUN\n 8 mg/dL\n 03:22 AM\n Creatinine\n 0.5 mg/dL\n 03:22 AM\n Sodium\n 143 mEq/L\n 03:22 AM\n Potassium\n 3.8 mEq/L\n 03:22 AM\n Chloride\n 103 mEq/L\n 03:22 AM\n TCO2\n 33 mEq/L\n 03:22 AM\n PO2 (arterial)\n 106 mm Hg\n 06:02 AM\n PCO2 (arterial)\n 29 mm Hg\n 06:02 AM\n pH (arterial)\n 7.51 units\n 06:02 AM\n pH (urine)\n 5.0 units\n 11:22 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 06:02 AM\n Albumin\n 2.9 g/dL\n 05:23 AM\n Calcium non-ionized\n 8.8 mg/dL\n 03:22 AM\n Phosphorus\n 4.1 mg/dL\n 03:22 AM\n Ionized Calcium\n 1.11 mmol/L\n 06:02 AM\n Magnesium\n 1.7 mg/dL\n 03:22 AM\n ALT\n 44 IU/L\n 03:22 AM\n Alkaline Phosphate\n 191 IU/L\n 03:22 AM\n AST\n 80 IU/L\n 03:22 AM\n Total Bilirubin\n 0.6 mg/dL\n 03:22 AM\n WBC\n 13.1 K/uL\n 03:22 AM\n Hgb\n 10.4 g/dL\n 03:22 AM\n Hematocrit\n 29.0 %\n 03:22 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds (not running); Replete with Fiber @ 40ml/hr\n Assessment of Nutritional Status\n 61 yo Female with hx of parkinson's presented to OSH with possible\n delirium and concern for NMS, now extubated with signs of possible\n alcohol withdrawal. A tube feed consult was entered last night,\n however, per discussion with MD, there is no plan to start tube feeds\n at this time as patient is more awake. Patient tolerated liquid po\n trials today, so plan is to advance diet when able. Will follow up\n with diet advancement and po tolerance. Recommend continuing with\n Thiamine supplementation and recommend starting a multivitamin.\n Following\n #\n" }, { "category": "Physician ", "chartdate": "2182-12-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705133, "text": "Chief Complaint:\n 24 Hour Events:\n - antibiotics stopped\n - will hold on extubation given that she is requiring large doses of\n benzos for aggitation and presummed withdrawal\n - high IV midazolam requirement therefore started on a gtt, propofol\n gtt weaned\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Midazolam (Versed) - 15 mg/hour\n Other ICU medications:\n Propofol - 01:32 PM\n Midazolam (Versed) - 12:13 AM\n Heparin Sodium (Prophylaxis) - 07:52 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 08:17 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: 38.1\nC (100.6\n HR: 65 (62 - 103) bpm\n BP: 112/76(84) {112/60(76) - 166/90(119)} mmHg\n RR: 24 (0 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 4,512 mL\n 953 mL\n PO:\n TF:\n 474 mL\n 324 mL\n IVF:\n 3,469 mL\n 329 mL\n Blood products:\n Total out:\n 4,020 mL\n 950 mL\n Urine:\n 4,020 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 492 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 444 (274 - 450) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 21\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 5.4 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 283 K/uL\n 7.4 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 105 mEq/L\n 143 mEq/L\n 26.3 %\n 16.6 K/uL\n [image002.jpg]\n 05:52 AM\n 07:40 AM\n 12:58 PM\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n WBC\n 19.2\n 16.6\n Hct\n 26.7\n 25.8\n 21.9\n 26.3\n Plt\n 217\n 283\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 23\n 24\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n Other labs: PT / PTT / INR:13.3/40.3/1.1, CK / CKMB /\n Troponin-T:861/6/, ALT / AST:72/128, Alk Phos / T Bili:213/0.7, Amylase\n / Lipase:/39, Differential-Neuts:79.0 %, Lymph:19.6 %, Mono:1.0 %,\n Eos:0.3 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.5 mg/dL, Mg++:1.5 mg/dL,\n PO4:4.1 mg/dL\n Microbiology: Sputum Cx: Coag + STAPH AUREUS, same as previous with\n colonization from two colonies\n Assessment and Plan\n 61 yo with hx of parkinson's presented to OSH with possible delirium\n and concern for NMS.\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n also contribution of alcohol withdrawal. LP was bland, though many\n cultures are pending. Propofol weaned off, high midazolam gtt more\n calm overnight. Able to follow commands.\n - Sinemet 25/100 two tabs Q6H and amantadine 100mg \n - wean bzd gtt\n - Continue thiamine\n - We can ease off of the aggressive hydration, but should still verify\n electrolytes today as she as at risk for hypokalemia,\n hypophosphatemia and hypernatremia.\n # Fever: Likely due to NMS as the patient has no signs of infection and\n all cultures are negative to date.\n - On vancomycin, meropenem and acyclovir day 2 for empiric meningitis\n coverage. These antibiotics can be stopped given given the patient\n improvement and normal LP.\n - avoid antipsychotics\n - f/u cultures\n # Elevated transaminases: There has been some report from her husband\n that the transaminitis may be chronic. Her numbers today or less\n suggestive of chronic alcoholism.\n - discuss with family about history of liver disease.\n - continue to trend LFTs.\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS. Hemolysis\n labs negative, reticulocyte count low and iron studies suggestive of\n severe anemia of chronic disease. Decreased Hct to 21, but repeat 26,\n likely error.\n - Trend hct with goal >21% or avoid end-organ symptoms.\n - was given 1 UPRC prior to transfer\n #. coagulopathy: was concerning for chronic liver dz, the the\n coagulopathy has now resolved.\n #. hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and give 150mg free water flushes Q6hrs.\n - Continue to monitor qdaily.\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration. CK trending down, Cr\n normalized.\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n #. FEN: IVF, tube feed\n #. PPX:\n -DVT ppx with SC heparin and pneumoboots\n -bowel regimen with colace and senna\n -PPI: start if cannot extubate today\n #. ACCESS: PIV's\n #. CODE STATUS: Presumed full\n #. EMERGENCY CONTACT: Partner : , son :\n \n #. DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:19 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:43 AM\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": "2182-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705311, "text": "Chief Complaint: NMS and alcohol withdrawal\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 04:15 PM\n --Versed gtt weaned with Valium bridge, and Oxazepam standing\n --Agitated in the pm, pulling at lines, trying to get out of bed,\n oriented to place not time, started on Valium IV q2. Took 30mg IV\n b/t 7-10pm.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Diazepam (Valium) - 01:30 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.6\nC (97.8\n HR: 58 (58 - 131) bpm\n BP: 140/64(82) {112/60(74) - 171/92(105)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,460 mL\n 33 mL\n PO:\n TF:\n 499 mL\n IVF:\n 661 mL\n 33 mL\n Blood products:\n Total out:\n 2,930 mL\n 920 mL\n Urine:\n 2,930 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,470 mL\n -887 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 324 (324 - 469) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 9.6 L/min\n Physical Examination\n GENERAL: Calm shortly after receiving Propofol bolus for agitation and\n scheduled sinemet\n HEENT: No scleral icterus. PERRL, MMM. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2.\n LUNGS: CTAB, good air movement bilaterally with central rhonchi.\n ABDOMEN: Soft, +BS, NTND\n EXTREMITIES: No edema or calf pain, 2+ radial/ dorsalis pedis/\n posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Less rigid today with improved relaxation. Has a prominent\n resting tremor when Sinemet and ativan wearing off.\n Labs / Radiology\n 298 K/uL\n 10.4 g/dL\n 76 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 103 mEq/L\n 143 mEq/L\n 29.0 %\n 13.1 K/uL\n [image002.jpg]\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n 02:57 PM\n 08:44 PM\n 03:22 AM\n WBC\n 19.2\n 16.6\n 14.9\n 13.1\n Hct\n 25.8\n 21.9\n 26.3\n 29.6\n 29.0\n Plt\n 98\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n 102\n 96\n 76\n Other labs: PT / PTT / INR:12.7/32.1/1.1, CK / CKMB /\n Troponin-T:422/6/, ALT / AST:44/80, Alk Phos / T Bili:191/0.6, Amylase\n / Lipase:/39, Differential-Neuts:84.1 %, Lymph:12.3 %, Mono:2.7 %,\n Eos:0.7 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n 61 yo with hx of parkinson's presented to OSH with possible delirium\n and concern for NMS, now extubated with signs of possible alcohol\n withdrawal.\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n also contribution of alcohol withdrawal. LP was bland, though many\n cultures are pending. Propofol weaned off, high midazolam gtt more\n calm overnight. Able to follow commands.\n - Sinemet 25/100 two tabs Q6H and amantadine 100mg \n - wean bzd gtt\n - Continue thiamine\n # Fever: Likely due to NMS as the patient has no signs of infection and\n with sputum culture with coag + staph, all other cultures are negative\n to date. Abx stopped yesterday.\n - wait for speciation prior to restarting abx\n - avoid antipsychotics\n - f/u cultures\n # Elevated transaminases: There has been some report from her husband\n that the transaminitis may be chronic. Her numbers are suggestive of\n chronic alcoholism.\n - discuss with family about history of liver disease.\n - continue to trend LFTs.\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS. Hemolysis\n labs negative, reticulocyte count low and iron studies suggestive of\n severe anemia of chronic disease. Decreased Hct to 21, but repeat 26,\n likely error.\n - Trend hct with goal >21% or avoid end-organ symptoms.\n - was given 1 UPRC prior to transfer\n #. hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and give 150mg free water flushes Q6hrs.\n - Continue to monitor qdaily.\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration. CK trending down, Cr\n normalized.\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n #. FEN: IVF, tube feed\n #. PPX:\n -DVT ppx with SC heparin and pneumoboots\n -bowel regimen with colace and senna\n -PPI: start if cannot extubate today\n #. ACCESS: PIV's\n #. CODE STATUS: Presumed full\n #. EMERGENCY CONTACT: Partner : , son :\n \n #. DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:43 AM\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": "2182-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705313, "text": "Chief Complaint: NMS and alcohol withdrawal\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 04:15 PM\n --Versed gtt weaned with Valium bridge, and Oxazepam standing\n --Agitated in the pm, pulling at lines, trying to get out of bed,\n oriented to place not time, started on Valium IV q2. Took 30mg IV\n b/t 7-10pm.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Diazepam (Valium) - 01:30 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.6\nC (97.8\n HR: 58 (58 - 131) bpm\n BP: 140/64(82) {112/60(74) - 171/92(105)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,460 mL\n 33 mL\n PO:\n TF:\n 499 mL\n IVF:\n 661 mL\n 33 mL\n Blood products:\n Total out:\n 2,930 mL\n 920 mL\n Urine:\n 2,930 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,470 mL\n -887 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 324 (324 - 469) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 9.6 L/min\n Physical Examination\n GENERAL: Calm, oriented to person and year, asking when she can get out\n of here, breathing easily.\n HEENT: No scleral icterus. PERRL, MMM. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2.\n LUNGS: CTAB, good air movement bilaterally.\n ABDOMEN: Soft, +BS, NTND\n EXTREMITIES: No edema or calf pain, 2+ radial/ dorsalis pedis/\n posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Continues to have some residual rigidity.\n Labs / Radiology\n 298 K/uL\n 10.4 g/dL\n 76 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 103 mEq/L\n 143 mEq/L\n 29.0 %\n 13.1 K/uL\n [image002.jpg]\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n 02:57 PM\n 08:44 PM\n 03:22 AM\n WBC\n 19.2\n 16.6\n 14.9\n 13.1\n Hct\n 25.8\n 21.9\n 26.3\n 29.6\n 29.0\n Plt\n 98\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n 102\n 96\n 76\n Other labs: PT / PTT / INR:12.7/32.1/1.1, CK / CKMB /\n Troponin-T:422/6/, ALT / AST:44/80, Alk Phos / T Bili:191/0.6, Amylase\n / Lipase:/39, Differential-Neuts:84.1 %, Lymph:12.3 %, Mono:2.7 %,\n Eos:0.7 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n 61 yo with hx of parkinson's presented to OSH with possible delirium\n and concern for NMS, now extubated with signs of possible alcohol\n withdrawal.\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n also contribution of alcohol withdrawal. LP was bland, though many\n cultures are pending. Propofol weaned off, high midazolam gtt more\n calm overnight. Able to follow commands.\n - Sinemet 25/100 two tabs Q6H and amantadine 100mg \n - weaned off of midazolam gtt, but still requiring doses of valium\n (40mg yesterday evening and 20mg since midnight). Goal is to get back\n to home doses of oxazepam.\n - Continue thiamine\n # Fever/leukocytosis: Likely due to NMS as the patient has no signs of\n infection and with sputum culture with coag + staph, all other cultures\n are negative to date. Abx stopped yesterday. Leukocytosis improving,\n afebrile.\n - wait for speciation prior to restarting abx\n - avoid antipsychotics\n - f/u cultures\n # Elevated transaminases: There has been some report from her husband\n that the transaminitis may be chronic. Her numbers are suggestive of\n chronic alcoholism.\n - discuss with family about history of liver disease.\n - continue to trend LFTs.\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS. Hemolysis\n labs negative, reticulocyte count low and iron studies suggestive of\n severe anemia of chronic disease. Decreased Hct to 21, but repeat 26,\n likely error.\n - Trend hct with goal >21% or avoid end-organ symptoms.\n - was given 1 UPRC prior to transfer\n #. hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and give 150mg free water flushes Q6hrs.\n - Continue to monitor qdaily.\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration. CK trending down, Cr\n normalized.\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n #. FEN: IVF, tube feed\n #. PPX:\n -DVT ppx with SC heparin and pneumoboots\n -bowel regimen with colace and senna\n -PPI: start if cannot extubate today\n #. ACCESS: PIV's\n #. CODE STATUS: Presumed full\n #. EMERGENCY CONTACT: Partner : , son :\n \n #. DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:43 AM\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": "2182-12-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 705354, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2-week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n Altered mental status (not Delirium)\n Assessment:\n Very agitated, wants to go .asking for ice chips.Bilateral wrist\n restraints in place for safety, patient alert, oriented x2 confused\n abor date, following commands. No tremors ,\n Action:\n Patient received 50 mg Diazepam last night. Changed her sine met from\n QID to TID.Also receiving oxazepam PO. Neuro following.\n Response:\n Patient was agitated and OOB, received diazepam . .mg\n Plan:\n Diazepam IV for anxiety/agitation, continue to follow neuro exam Cont\n follow up with Neurology.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n NEUROLEPTIC MALIGNANT SYNDROME\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.4 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH: Asthma, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:75\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 59 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:22 AM\n Potassium:\n 3.8 mEq/L\n 03:22 AM\n Chloride:\n 103 mEq/L\n 03:22 AM\n CO2:\n 33 mEq/L\n 03:22 AM\n BUN:\n 8 mg/dL\n 03:22 AM\n Creatinine:\n 0.5 mg/dL\n 03:22 AM\n Glucose:\n 76 mg/dL\n 03:22 AM\n Hematocrit:\n 29.0 %\n 03:22 AM\n Finger Stick Glucose:\n 83\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: MICU 682\n Transferred to:\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2182-12-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 705371, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2-week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n Altered mental status (not Delirium)\n Assessment:\n Very agitated, wants to go .asking for ice chips.Bilateral wrist\n restraints in place for safety, patient alert, oriented x3,following\n commands. No tremors ,\n Action:\n Patient received 50 mg Diazepam last night. Changed her sine met from\n QID to TID.Also receiving oxazepam PO. Neuro following. CIWAL within\n normal .changed her IV meds to PO,Tolerating Drinks. C/O floor .\n Response:\n Patient looks comfortable,Restraints off.\n Plan:\n Diazepam IV for anxiety/agitation, continue to follow neuro exam and\n slowly taper Senemet. Cont follow up with Neurology.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n NEUROLEPTIC MALIGNANT SYNDROME\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.4 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH: Asthma, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:75\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 59 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:22 AM\n Potassium:\n 3.8 mEq/L\n 03:22 AM\n Chloride:\n 103 mEq/L\n 03:22 AM\n CO2:\n 33 mEq/L\n 03:22 AM\n BUN:\n 8 mg/dL\n 03:22 AM\n Creatinine:\n 0.5 mg/dL\n 03:22 AM\n Glucose:\n 76 mg/dL\n 03:22 AM\n Hematocrit:\n 29.0 %\n 03:22 AM\n Finger Stick Glucose:\n 83\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: MICU 682\n Transferred to: CC728\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2182-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705374, "text": "Chief Complaint: NMS and alcohol withdrawal\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 04:15 PM\n --Versed gtt weaned with Valium bridge, and Oxazepam standing\n --Agitated in the pm, pulling at lines, trying to get out of bed,\n oriented to place not time, started on Valium IV q2. Took 30mg IV\n b/t 7-10pm.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Diazepam (Valium) - 01:30 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.6\nC (97.8\n HR: 58 (58 - 131) bpm\n BP: 140/64(82) {112/60(74) - 171/92(105)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,460 mL\n 33 mL\n PO:\n TF:\n 499 mL\n IVF:\n 661 mL\n 33 mL\n Blood products:\n Total out:\n 2,930 mL\n 920 mL\n Urine:\n 2,930 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,470 mL\n -887 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 324 (324 - 469) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///33/\n Ve: 9.6 L/min\n Physical Examination\n GENERAL: Calm, oriented to person and year, asking when she can get out\n of here, breathing easily.\n HEENT: No scleral icterus. PERRL, MMM. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2.\n LUNGS: CTAB, good air movement bilaterally.\n ABDOMEN: Soft, +BS, NTND\n EXTREMITIES: No edema or calf pain, 2+ radial/ dorsalis pedis/\n posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Continues to have some residual rigidity.\n Labs / Radiology\n 298 K/uL\n 10.4 g/dL\n 76 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 103 mEq/L\n 143 mEq/L\n 29.0 %\n 13.1 K/uL\n [image002.jpg]\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n 02:57 PM\n 08:44 PM\n 03:22 AM\n WBC\n 19.2\n 16.6\n 14.9\n 13.1\n Hct\n 25.8\n 21.9\n 26.3\n 29.6\n 29.0\n Plt\n 98\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n 102\n 96\n 76\n Other labs: PT / PTT / INR:12.7/32.1/1.1, CK / CKMB /\n Troponin-T:422/6/, ALT / AST:44/80, Alk Phos / T Bili:191/0.6, Amylase\n / Lipase:/39, Differential-Neuts:84.1 %, Lymph:12.3 %, Mono:2.7 %,\n Eos:0.7 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n 61 yo with hx of parkinson's presented to OSH with possible delirium\n and concern for NMS, now extubated with signs of possible alcohol\n withdrawal.\n # Acute MS change: Cause of her altered mental status was likely NMS,\n alcohol withdrawal and delirium. It seems that she may have had some\n baseline dementia as well. LP was bland, though viral cultures are\n pending. Off of sedation except for PO valium on CIWA scale. Able to\n follow commands. Now swallowing as well.\n - Sinemet 25/100 two tabs Q6H and amantadine 100mg \n - weaned off of midazolam gtt, but still requiring doses of valium\n (40mg yesterday evening and 20mg since midnight). Goal is to get back\n to home doses of oxazepam. For now we will use a CIWA scale with PRN\n valium with scores>10.\n - Can d/c NG tube if she can swallow PO meds without difficulty (did\n drink juice without difficulty). Then she can come out of restraints\n as well.\n - Continue thiamine\n # Fever/leukocytosis: Likely due to NMS as the patient has no signs of\n infection. Except for an asymptomatic sputum culture with coag +\n staph, all other cultures are negative to date. Of antibiotics,\n leukocytosis improving, afebrile.\n - avoid antipsychotics\n - f/u cultures\n # Elevated transaminases: There has been some report from her partner\n that the transaminitis may be chronic. Her numbers are suggestive of\n chronic alcoholism.\n - RUQ ultrasound today.\n - discuss with family about history of liver disease.\n - continue to trend LFTs.\n # Anemia: Yesterday had a spurious hematocrit of 21%, repeat was 26\n which is near her baseline, but otherwise has had a stable anemia with\n MCV\ns on the high side of normal.\n #. hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and give 150mg free water flushes Q6hrs.\n - Continue to monitor qdaily.\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration. CK trending down, Cr\n normalized.\n # EtOH abuse: has a history of EtOH, unclear exact amount. Has been\n getting significant amounts of benzodiazepenes for agitation which were\n being interpreted as possible withdrawal.\n - Q2hr CIWA scale with valium 5-10mg for CIWA>10.\n #. FEN: tube feeds off, and is now tolerating some clears. If she can\n tolerate PO meds, we will d/c NG tube and start her on a clear fluid\n diet.\n #. PPX:\n -DVT ppx with SC heparin and pneumoboots\n -bowel regimen with colace and senna\n -PPI: not required\n #. ACCESS: PIV's and Right IJ. Can pull right IJ today before going to\n the floor.\n #. CODE STATUS: Presumed full\n #. EMERGENCY CONTACT: Partner : , son :\n \n #. DISPOSITION: Call out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:43 AM\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: To the floor.\n" }, { "category": "Nursing", "chartdate": "2182-12-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 705378, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2-week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n Altered mental status (not Delirium)\n Assessment:\n Slightly agitated at times, wants to go .asking for food.Bilateral\n wrist restraints in place for safety, patient alert, oriented x3,\n following commands. No tremors ,\n Action:\n Patient received 50 mg Diazepam last night. Changed her sine met from\n QID to TID.Also receiving oxazepam PO. Neuro following. CIWAL within\n normal .changed her IV meds to PO, Tolerating Drinks. C/O floor. Pt had\n Liver ultrasound ^ transaminase.\n Response:\n Patient looks comfortable,Restraints off.\n Plan:\n Diazepam PO for anxiety/agitation and CIWAL > 10, continue to follow\n neuro exam and slowly taper Senemet. Cont follow up with Neurology.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n NEUROLEPTIC MALIGNANT SYNDROME\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.4 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH: Asthma, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:75\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 59 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:22 AM\n Potassium:\n 3.8 mEq/L\n 03:22 AM\n Chloride:\n 103 mEq/L\n 03:22 AM\n CO2:\n 33 mEq/L\n 03:22 AM\n BUN:\n 8 mg/dL\n 03:22 AM\n Creatinine:\n 0.5 mg/dL\n 03:22 AM\n Glucose:\n 76 mg/dL\n 03:22 AM\n Hematocrit:\n 29.0 %\n 03:22 AM\n Finger Stick Glucose:\n 83\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: MICU 682\n Transferred to: CC728\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2182-12-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 705388, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2-week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH fr MS changes/airway protection.\n Events; Pt has Liver ultrasound this afternoon, waiting for result.\n DCd NGT and IJ.\n Altered mental status (not Delirium)\n Assessment:\n Slightly agitated at times, wants to go home,Asking for food.\n Bilateral wrist restraints in place for safety, patient alert, oriented\n x3, following commands. Slight tremors with arm extended\n Action:\n Patient received 50 mg Diazepam last night. Changed her sine met from\n QID to TID.Also receiving oxazepam PO. Neuro following. CIWAL within\n normal .changed her IV meds to PO, Tolerating PO meds and Drinks. C/O\n floor. Pt had Liver ultrasound ^ transaminase.\n Response:\n Patient looks comfortable, Restraints off. DCd NGT and Left IJ.\n Plan:\n Diazepam PO for anxiety/agitation and CIWAL > 10, continue to follow\n neuro exam and slowly taper Senemet. Cont follow up with Neurology.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n NEUROLEPTIC MALIGNANT SYNDROME\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.4 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH: Asthma, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:75\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 62 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 59 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:22 AM\n Potassium:\n 3.8 mEq/L\n 03:22 AM\n Chloride:\n 103 mEq/L\n 03:22 AM\n CO2:\n 33 mEq/L\n 03:22 AM\n BUN:\n 8 mg/dL\n 03:22 AM\n Creatinine:\n 0.5 mg/dL\n 03:22 AM\n Glucose:\n 76 mg/dL\n 03:22 AM\n Hematocrit:\n 29.0 %\n 03:22 AM\n Finger Stick Glucose:\n 83\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: MICU 682\n Transferred to: CC728\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2182-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705317, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2-week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n Altered mental status (not Delirium)\n Assessment:\n Very agitated, wants to go home and getting out of bed and trying pull\n iv/tubing. Bilateral wrist restraints in place for safety, patient\n alert, oriented x2, following commands. No tremors , on po cinamet 4\n times/day\n Action:\n Patient received iv diazepam 10mg q 2hrs PRN and 10mg x2 as single\n dose. Also receiving oxazepam PO\n Response:\n Patient was agitated and OOB, received diazepam . .mg\n Plan:\n Diazepam IV for anxiety/agitation, continue to follow neuro exam\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on O2 50% via face tent, O2 sats 98-100%. Bilateral\n lung sounds clear.\n Action:\n Continued o2 50% via face tent, encouraged cough and deep breathing\n Response:\n Doing well RR 15-20 sats 100% on 50% face tent\n Plan:\n Encourage cough/deep breath, pulmonary toilet, wean fio2 as tolerated\n" }, { "category": "Nursing", "chartdate": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704933, "text": "Events: PT alert, can track anf follow, follows commands off Propofol\n and on low dose propofol- currently comfortable on 30mcg/kg. PT cont\n to be tremulous with stimulation, although less over shift- PM\n hypertensive 160\ns/ HR low 100\ns with fine tremor and agitation- given\n 1x dose 2mg IVP Versed and episode resolving. LS clear though cont\n copious thick yellow suctioning from ETT, large amount oral secretions,\n + gag and cough. Tolerating increase in TF, sm BM x 2. Good UOP\n 60-120cc/hr- given 2 L\n NS @ 200cc/hr for rhabdo with enzymes trending\n down. Multiple electrolyte repletion. Am ABG 7.41/\n Electrolyte & fluid disorder, other\n Assessment:\n 200 labs repleted mg 1.7, Ca 7.7, phos 2.1, K 4.2\n Action:\n 30mmol Kphos on 500cc NS, 2 mg Mag Sulfate, 2mg Calcium\n Response:\n Awaiting AM labs\n Plan:\n Cont electrolyte repletion, TF as tolerated with free water flush, IVF\n @ 200cc/hr with 2^nd bag up- likely recheck multiple lab values and\n need for additional hydration\n Altered mental status (not Delirium)\n Assessment:\n Off Propofol alert, interactive, nods/shakes head approp, + tremors,\n able to MAE in bed, + rigidity\n Action:\n Neuro checks, titrating Propofol and need for additional\n benzodiazepines, frequent re-orientation and emotional support\n Response:\n Cont to be tremulous, easily woken on Propofol\n Plan:\n Cont to monitor neuro status, neuro checks, cont Propofol for light\n sedation, PRN versed if needed, PO Valium \n" }, { "category": "Nursing", "chartdate": "2182-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705107, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\nNo significant events overnoc, sedation increased, pm lytes\n stable\n Electrolyte & fluid disorder, other\n Assessment:\n Lytes checked at 8 pm\n Action:\n Continued free water via nutrition, pm lytes stable\n Response:\n AM labs results awaiting\n Plan:\n Check lytes and replete per order\n Altered mental status (not Delirium)\n Assessment:\n Received on propofol @ 20mcg/kg/min and versed at 5mg/hr, patient\n following commands\nmoving all extrimities, but agitated , attempting to\n pull at tubes and get OOB, ? alcohol withdrawl, hypertensive to 160\n tachy to 100. Requiring increasing amounts of benzos for agitation,\n Bilateral soft restraints in place for safety\n Action:\n Numerous boluses of IV benzos, IV drip of versed increased, unable to\n wean propofol gtt. Less tremulous, on sinemet qid,\n Response:\n Versed dwn to 15mg/hr and Propofol down to 15mcg/kg/min,\n Plan:\n Wean prop to assess benzo need, titrate up as needed for calm\n respsonse. Neuro following\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp,?temp related to NMS [ potentially can be hyper-febrile]\n Action:\n All cxs taken neg, ?all antibiotics stopped\n Response:\n Am temp 100.7, Tylenol given\n Plan:\n Continue to follow temp curve, Tylenol, cooling blanket as required\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received intubated, orally vented, on PSV 10 peep @ 5 40%, RR\n 15-30 , TV @ 400-500, sat > 95%. Bilateral lung sounds clear.\n Action:\n Increased sedation to keep her comfortable with vent\n Response:\n RSBI 22 this am, minimal secretion\n Plan:\n Plan for extubation if less agitated, wean Propofol as tolerated\n" }, { "category": "Nursing", "chartdate": "2182-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705041, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\ncontinue to follow CK\ns [ raised CKS on admission related to\n rabdo], NA and replete per S/S , calcium /phos/mag /k closely, check\n again @ 2000hrs\n Electrolyte & fluid disorder, other\n Assessment:\n Lytes checked at 8 pm\n Action:\n Continued free water via nutrition,\n Response:\n AM labs\n Plan:\n Check lytes and replete per order\n Altered mental status (not Delirium)\n Assessment:\n Received on propofol @ 20mcg/kg/min and versed at 5mg/hr, patient\n following commands\nmoving all extrimities, but agitated , attempting to\n pull at tubes and get OOB, ? alcohol withdrawl, hypertensive to 160\n tachy to 100. Requiring increasing amounts of benzos for agitation,\n Bilateral soft restraints in place for safety\n Action:\n Numerous boluses of IV benzos, IV drip of versed increased, unable to\n wean propofol gtt. Less tremulous, on sinemet qid,\n Response:\n Plan:\n Wean prop to assess benzo need, titrate up as needed for calm\n respsonse. Neuro following\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp,?temp related to NMS [ potentially can be hyper-febrile]\n Action:\n All cxs taken neg, ?all antibiotics stopped\n Response:\n Plan:\n Continue to follow temp curve, Tylenol, cooling blanket as required\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received intubated, orally vented, on PSV 10 peep @ 5 40%, RR\n 15-30 , TV @ 400-500, sat > 95%. Bilateral lung sounds clear.\n Action:\n Increased sedation to keep her comfortable with vent\n Response:\n With anxiety/agitation,\n Plan:\n Plan for extubation if less agitated\n" }, { "category": "Respiratory ", "chartdate": "2182-12-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 705109, "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: Unknown\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: initially, copious amt thick creamy yellow\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n 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": "Respiratory ", "chartdate": "2182-12-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 705236, "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 Tube Type\n ETT:\n Type: Standard\n Size: 7mm\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: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Pt received on PSV 10/5 as noted. PS weaned to 5cm - pt tolerated well.\n Pt placed on SBT 5/0 - pt tolerated SBT well with VT 522 and RR 22.\n Subglottic suctioning done prior to extubation. Pt has a positive cuff\n leak test. Pt extubated to cool aerosol without incident.\n" }, { "category": "Physician ", "chartdate": "2182-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 705308, "text": "Chief Complaint: NMS and alcohol withdrawal\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 04:15 PM\n --Versed gtt weaned with Valium bridge, and Oxazepam standing\n --Agitated in the pm, pulling at lines, trying to get out of bed,\n oriented to place not time, started on Valium IV q2. Took 30mg IV\n b/t 7-10pm.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Vancomycin - 08:05 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Diazepam (Valium) - 01:30 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.6\nC (97.8\n HR: 58 (58 - 131) bpm\n BP: 140/64(82) {112/60(74) - 171/92(105)} mmHg\n RR: 22 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,460 mL\n 33 mL\n PO:\n TF:\n 499 mL\n IVF:\n 661 mL\n 33 mL\n Blood products:\n Total out:\n 2,930 mL\n 920 mL\n Urine:\n 2,930 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,470 mL\n -887 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 324 (324 - 469) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 99%\n ABG: ///33/\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 298 K/uL\n 10.4 g/dL\n 76 mg/dL\n 0.5 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 103 mEq/L\n 143 mEq/L\n 29.0 %\n 13.1 K/uL\n [image002.jpg]\n 01:03 PM\n 05:23 AM\n 06:02 AM\n 12:01 PM\n 09:07 PM\n 06:05 AM\n 07:09 AM\n 02:57 PM\n 08:44 PM\n 03:22 AM\n WBC\n 19.2\n 16.6\n 14.9\n 13.1\n Hct\n 25.8\n 21.9\n 26.3\n 29.6\n 29.0\n Plt\n 98\n Cr\n 0.8\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 24\n Glucose\n 87\n 111\n 100\n 104\n 120\n 102\n 96\n 76\n Other labs: PT / PTT / INR:12.7/32.1/1.1, CK / CKMB /\n Troponin-T:422/6/, ALT / AST:44/80, Alk Phos / T Bili:191/0.6, Amylase\n / Lipase:/39, Differential-Neuts:84.1 %, Lymph:12.3 %, Mono:2.7 %,\n Eos:0.7 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:2.9 g/dL, LDH:482 IU/L, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:43 AM\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": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704704, "text": "61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n Events: Arrived via @ 2300- vented on Propofol and Neo\n gtt. PT arrived very tremulous, intermittently interactive- BP and MS\n labile.\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 Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2182-12-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 704783, "text": "Subjective\n Patient intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 51.4 kg\n 22.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 113%\n Diagnosis: neuroleptic malignant syndrome\n PMHx:\n HTN\n Parkinson's\n Alcohol abuse (3 glass of vodca or whiskey)\n Asthma\n Depression\n Food allergies and intolerances: NKFA\n Pertinent medications: propofol drip, thiamin, heparin, bowel meds,\n abx, others noted\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 05:28 AM\n Glucose Finger Stick\n 90\n 08:00 AM\n BUN\n 25 mg/dL\n 05:28 AM\n Creatinine\n 1.0 mg/dL\n 05:28 AM\n Sodium\n 148 mEq/L\n 05:28 AM\n Potassium\n 3.3 mEq/L\n 05:28 AM\n Chloride\n 116 mEq/L\n 05:28 AM\n TCO2\n 23 mEq/L\n 05:28 AM\n PO2 (arterial)\n 163 mm Hg\n 07:40 AM\n PCO2 (arterial)\n 39 mm Hg\n 07:40 AM\n pH (arterial)\n 7.42 units\n 01:37 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 07:40 AM\n Albumin\n 3.4 g/dL\n 10:41 PM\n Calcium non-ionized\n 7.3 mg/dL\n 05:28 AM\n Phosphorus\n 1.4 mg/dL\n 05:28 AM\n Ionized Calcium\n 1.10 mmol/L\n 01:37 PM\n Magnesium\n 1.9 mg/dL\n 05:28 AM\n ALT\n 55 IU/L\n 05:28 AM\n Alkaline Phosphate\n 181 IU/L\n 05:28 AM\n AST\n 367 IU/L\n 05:28 AM\n WBC\n 21.1 K/uL\n 05:28 AM\n Hgb\n 9.3 g/dL\n 05:28 AM\n Hematocrit\n 26.7 %\n 12:58 PM\n Current diet order / nutrition support: replete c/ fiber @ 40mL/hr\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Patient at risk due to: NPO status\n Estimated Nutritional Needs\n Calories: 1285-1542 (25-30 cal/kg)\n Protein: 52-68 (1-1.3 g/kg)\n Calculations based on: Admit weight\n Specifics:\n 61 year old female transferred from outside hospital c/ likely\n parkinson\ns crisis infection- work up ongoing. Nutrition consulted\n for tube feeds recommendations, currently replete c/ fiber infusing @\n 10mL/hr. Will need to change tube feed as current feed will provide\n excess nitrogen at goal rate.\n K, Mag, Ca, and PO4 repletion noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feed\n Tube feeding recommendations: change feeds to Fibersource\n HN @ 25 mL hr to increase 10 mL q 4 hr, to goal of 45mL/hr (1296\n kcals/57 gr protein)\n residual checks q4 hr, hold if >200mL\n Replete lytes prn\n glucose management as you are\n Following #\n ------ Protected Section ------\n Error in above recommendations as patient is currently on propfol drip\n providing 1.1 kcals/kg, which was not take into account. Can continue\n c/ current feed until propfol of, then will need to change to above\n feed- Fibersource HN @45mL/hr.\n ------ Protected Section Addendum Entered By: , RD, \n on: 15:02 ------\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704787, "text": "EVENTS\n Electrolyte & fluid disorder, other\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" }, { "category": "Respiratory ", "chartdate": "2182-12-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 704790, "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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\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 Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n" }, { "category": "Respiratory ", "chartdate": "2182-12-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 704855, "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 Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position:20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Rusty / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: basic secretions thick creamy yellow/green. Occasionally\n blood tinged to rusty\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: rapid and erratic on occasion\n when stimulated\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: synchronous\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n :\n" }, { "category": "Nutrition", "chartdate": "2182-12-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 704772, "text": "Subjective\n Patient intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 51.4 kg\n 22.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 113%\n Diagnosis: neuroleptic malignant syndrome\n PMHx:\n Food allergies and intolerances: NKFA\n Pertinent medications: propofol drip, thiamin, heparin, bowel meds,\n abx, others noted\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 05:28 AM\n Glucose Finger Stick\n 90\n 08:00 AM\n BUN\n 25 mg/dL\n 05:28 AM\n Creatinine\n 1.0 mg/dL\n 05:28 AM\n Sodium\n 148 mEq/L\n 05:28 AM\n Potassium\n 3.3 mEq/L\n 05:28 AM\n Chloride\n 116 mEq/L\n 05:28 AM\n TCO2\n 23 mEq/L\n 05:28 AM\n PO2 (arterial)\n 163 mm Hg\n 07:40 AM\n PCO2 (arterial)\n 39 mm Hg\n 07:40 AM\n pH (arterial)\n 7.42 units\n 01:37 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 07:40 AM\n Albumin\n 3.4 g/dL\n 10:41 PM\n Calcium non-ionized\n 7.3 mg/dL\n 05:28 AM\n Phosphorus\n 1.4 mg/dL\n 05:28 AM\n Ionized Calcium\n 1.10 mmol/L\n 01:37 PM\n Magnesium\n 1.9 mg/dL\n 05:28 AM\n ALT\n 55 IU/L\n 05:28 AM\n Alkaline Phosphate\n 181 IU/L\n 05:28 AM\n AST\n 367 IU/L\n 05:28 AM\n WBC\n 21.1 K/uL\n 05:28 AM\n Hgb\n 9.3 g/dL\n 05:28 AM\n Hematocrit\n 26.7 %\n 12:58 PM\n Current diet order / nutrition support: replete c/ fiber @ 40mL/hr\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Patient at risk due to:\n Estimated Nutritional Needs\n Calories: 1285-1542 (BEE x or / 25-30 cal/kg)\n Protein: 52-68 (1-1.3 g/kg)\n Calculations based on: Admit weight\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feed\n Tube feeding recommendations: change feeds to Fibersource\n HN @ 25 mL hr to increase 10 mL q 4 hr, to goal of 45mL/hr gr\n protein)\n residual checks q4 hr, hold if >200mL\n Replete lytes prn\n glucose management as you are\n Following #\n" }, { "category": "Nutrition", "chartdate": "2182-12-06 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 704774, "text": "Subjective\n Patient intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 51.4 kg\n 22.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 113%\n Diagnosis: neuroleptic malignant syndrome\n PMHx:\n HTN\n Parkinson's\n Alcohol abuse (3 glass of vodca or whiskey)\n Asthma\n Depression\n Food allergies and intolerances: NKFA\n Pertinent medications: propofol drip, thiamin, heparin, bowel meds,\n abx, others noted\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 05:28 AM\n Glucose Finger Stick\n 90\n 08:00 AM\n BUN\n 25 mg/dL\n 05:28 AM\n Creatinine\n 1.0 mg/dL\n 05:28 AM\n Sodium\n 148 mEq/L\n 05:28 AM\n Potassium\n 3.3 mEq/L\n 05:28 AM\n Chloride\n 116 mEq/L\n 05:28 AM\n TCO2\n 23 mEq/L\n 05:28 AM\n PO2 (arterial)\n 163 mm Hg\n 07:40 AM\n PCO2 (arterial)\n 39 mm Hg\n 07:40 AM\n pH (arterial)\n 7.42 units\n 01:37 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 07:40 AM\n Albumin\n 3.4 g/dL\n 10:41 PM\n Calcium non-ionized\n 7.3 mg/dL\n 05:28 AM\n Phosphorus\n 1.4 mg/dL\n 05:28 AM\n Ionized Calcium\n 1.10 mmol/L\n 01:37 PM\n Magnesium\n 1.9 mg/dL\n 05:28 AM\n ALT\n 55 IU/L\n 05:28 AM\n Alkaline Phosphate\n 181 IU/L\n 05:28 AM\n AST\n 367 IU/L\n 05:28 AM\n WBC\n 21.1 K/uL\n 05:28 AM\n Hgb\n 9.3 g/dL\n 05:28 AM\n Hematocrit\n 26.7 %\n 12:58 PM\n Current diet order / nutrition support: replete c/ fiber @ 40mL/hr\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Patient at risk due to: NPO status\n Estimated Nutritional Needs\n Calories: 1285-1542 (25-30 cal/kg)\n Protein: 52-68 (1-1.3 g/kg)\n Calculations based on: Admit weight\n Specifics:\n 61 year old female transferred from outside hospital c/ likely\n parkinson\ns crisis infection- work up ongoing. Nutrition consulted\n for tube feeds recommendations, currently replete c/ fiber infusing @\n 10mL/hr. Will need to change tube feed as current feed will provide\n excess nitrogen at goal rate.\n K, Mag, Ca, and PO4 repletion noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feed\n Tube feeding recommendations: change feeds to Fibersource\n HN @ 25 mL hr to increase 10 mL q 4 hr, to goal of 45mL/hr (1296\n kcals/57 gr protein)\n residual checks q4 hr, hold if >200mL\n Replete lytes prn\n glucose management as you are\n Following #\n" }, { "category": "Physician ", "chartdate": "2182-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 704901, "text": "Chief Complaint: Rigidity\n 24 Hour Events:\n ARTERIAL LINE - START 08:04 AM\n SPUTUM CULTURE - At 10:40 AM\n MULTI LUMEN - START 11:43 AM\n LUMBAR PUNCTURE - At 02:48 PM\n \n - LP done - 0 WBC and 0 RBC with normal protein and glucose.\n - Central line placed.\n - f/u blood cultures from OSH\n - 8pm lytes show improving CK and Cr, low phos repleted.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:38 AM\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 PM\n Midazolam (Versed) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 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: 37.7\nC (99.9\n HR: 75 (63 - 94) bpm\n BP: 126/74(86) {121/72(83) - 129/84(94)} mmHg\n RR: 18 (6 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,587 mL\n 2,014 mL\n PO:\n TF:\n 159 mL\n 169 mL\n IVF:\n 6,869 mL\n 1,635 mL\n Blood products:\n Total out:\n 1,380 mL\n 540 mL\n Urine:\n 1,380 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,207 mL\n 1,474 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (468 - 487) mL\n PS : 10 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 62\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.51/29/106/23/1\n Ve: 7.8 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: sedated\n HEENT: conjunctival pallor. No scleral icterus. PERRL, MMM. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2.\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Soft, +BS\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: 1+ reflexes, equal BL. clockwheel rigidity.\n Labs / Radiology\n 182 K/uL\n 9.3 g/dL\n 87 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 22 mg/dL\n 117 mEq/L\n 147 mEq/L\n 26.7 %\n 21.1 K/uL\n [image002.jpg]\n 10:41 PM\n 11:56 PM\n 05:28 AM\n 05:52 AM\n 07:40 AM\n 12:58 PM\n 01:03 PM\n 06:02 AM\n WBC\n 23.6\n 21.1\n Hct\n 29.9\n 27.4\n 26.7\n Plt\n 213\n 182\n Cr\n 1.2\n 1.0\n 0.8\n TCO2\n 23\n 23\n 24\n 24\n Glucose\n 224\n 106\n 87\n Other labs: PT / PTT / INR:15.2/41.1/1.3, CK / CKMB /\n Troponin-T:2797/6/, ALT / AST:55/367, Alk Phos / T Bili:181/1.0,\n Amylase / Lipase:/39, Differential-Neuts:79.0 %, Lymph:19.6 %, Mono:1.0\n %, Eos:0.3 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:3.4 g/dL, LDH:987 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n ASSESSMENT AND PLAN: 61 yo with hx of parkinson's presented to OSH with\n possible delirium and concern for NMS.\n .\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n though there is question of whether alcohol withdrawal is also\n contributing. LP was bland, though many cultures are pending.\n - Sinemt 25/100 two tabs Q6H\n - if ongoing tremor and fever: dandrolen\n - IVF\n - monitor CK, WBC, lytes, and BP/HR\n - LP after reversal of coagulopathy and CT\n .\n # Fever: infectious vs. NMS\n - On vancomycin, meropenem and acyclovir day 2 for empiric meningitis\n coverage. These antibiotics can be stopped given given the patient\n improvement and normal LP.\n - symptomatic treatment of NMS (?dandrolen)\n - no antipsychotics\n - IVF\n - empiric meningitis coverage\n - cultures\n .\n # Acute renal failure: prerenal due to sepsis/dehydration vs, ATN in\n the setting of possible hypotension. unlikely due to rhabdo as CK not\n significanlty high\n - obrtain baseline renal function\n - renal lytes\n - monitor UOP\n - IVF\n .\n # elevated transaminbases: suggestive of alcoholic hepatitis. possibly\n AST elevated due to rhabdo.\n - monitor and treat symptomatically\n - rule out infectious cholecystitis/ angitis by RUQ US\n .\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS\n - iron sudies, retic count, smear, hemolysis labs\n - was given 1 UPRC prior to transfer\n .\n # coagulopathy: concerning for DIC vs. chronic liver dz\n - check PTT\n - LFT, Albumin, daily coags\n - FFP for LP\n - DIC labs\n .\n # hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and replace gently free water\n .\n # leucocytosis: indicative for SIRS, unclear if due to infection or NMS\n - empiric treatment for both\n - moniotor daily\n - f/u cultures\n - c-diff as hospitalized and treated with clinda/levofloxacine\n .\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n .\n FEN: IVF, tube feed\n .\n PPX:\n -DVT ppx with SC heparin and pneumoboots\n -Bowel regimen,\n -PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: Partner : , son :\n \n .\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:08 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:04 AM\n Multi Lumen - 11:43 AM\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": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704675, "text": "61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n Events: Arrived via @ 2300- vented on Propofol and Neo\n gtt. PT arrived very tremulous, intermittently interactive- BP and MS\n labile.\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 Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704732, "text": "61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n Events: Arrived via @ 2300- vented on Propofol and Neo\n gtt. PT arrived very tremulous, intermittently interactive and able to\n nod/shake head but not follow additional commands- BP and MS labile.\n PERRLA and followed by neuro- per neuro cranial nerves intact, hyper\n reflective- difficult to asses of ? alcohol WD- 1 AM last drink\n s/p Ativan gtt and Valium @ OSH. Remains of low dose Propofol with\n total 4 mg IVP Versed given for agitation and CT scan. Ct head benign\n but ? slight sinusitis. Resumed home anti-parkinsonian medication \n ? neuroleptic syndrome. + BS , no BM. NGT pulled and OG placed. Pt to\n have LP in AM repeat INR 1.5 (1.6) and likely will need 1 unit FFP.\n T&S sent on admission with 1 unit RBC type and crossed. PT Initially\n on mod dose Neo gtt and all extremities mottled- mottling abated but\n remains cechetic and pale. Given total 2 L IVF. Pt t max 100.9 PO on\n admission- multiple ABX and anti-viral medications. Pan cultured. BC\n x 2. PT appears severely malnourished- order to start TF, to start\n after LP. Multiple electrolyte repletion- 2 gm Mag Sulfate, 2 packet\n neutral phos, 400mg IV Thiamine. LS clear but can suction copious\n thick yellow secretions- sputum culture sent. Accepted on AC but\n tolerating CPAP 10/+5/30% with ABG within normal limits, sat 94-100%.\n Hypoactive BS. UOP adequate and increased post IVF bolus.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.9 PO\n Action:\n See multiple ABX and anti-viral coverage, pan cultures\n Response:\n T current 99.7 PO\n Plan:\n F/U cultures, cont IV and anti-viral\n Impaired Skin Integrity\n Assessment:\n Multiple bruises noted, back bilat knees, pale thin skin\n Action:\n Barrier cream, pressure relief\n Response:\n No acute change\n Plan:\n Support electrolyte repletion, nutrition, pressure relief, barrier\n cream\n Ineffective Coping\n Assessment:\n s/p failing at home, ETOH abuse\n Action:\n Emotional support to family, social work consult ordered\n Response:\n No acute change for pt, awaiting multiple family members in AM\n Plan:\n Family support, emotional support to pt- pt with multiple medical\n problems\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704820, "text": "EVENTS\n Central line placed and PIVS from OSH removed\n LP performed\n IV fluids for CKS > 3000 [ rabdo]/NA @ 148\n IV abs for possible infection process[ received vanc this am ? needs\n level again this eve]\n Neuro following closely for possible NMS, on sinemt, observe closely\n for alcohol withdrawl\n Aggressively replete lytes [ next due at 2000hrs], now ordered s/s for\n cal/mag /k\n Electrolyte & fluid disorder, other\n Assessment:\n Patient received with low k/mag/cal phos\nNA @ 148 CKS > 3000\n Action:\n Lytes repleted, IV fluids for CKS, free water/IV fluid for NA level\n Response:\n Improved this pm\n Plan:\n Continue to follow closely and treat per S/S, inform team of any\n changes and liase regarding fluid repletion\n Altered mental status (not Delirium)\n Assessment:\n Patient received on propofol drip at 10..easily stimulated,\n shaking/tremours in all 4 limbs,? attempting to follow simple\n commands, appears to be traking/focusing, pupils equal but sluggish to\n react\n..borderline temp\n Action:\n Propofol switched of for neuro exam by neuro team, now receiving BD\n dose of diazepam [ patient on benzos at home and could well be\n withdrawing from alcohol] sinemet QID\n Response:\n Less tremulous as the day has progressed, responded well for neuro exam\n following simple commands, less rigid in all limbs, borderline temp\n continues at this time, responding to family memebers\n Plan:\n Re-sedated with propfol, received further IV dose of benzos this pm for\n agitation ? withdrawl\n.continue close observation of mental status for\n NMS/ alcohol withdrawl\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Borderline temp @ 100.3\n Action:\n All ABS as ordered, vanc given despite level @ 24, sputum spec sent [\n thick yellow secretions], LP performed\n Response:\n Remains borderline temp but not spiked\n Plan:\n ? needs futher vanc level this eve, continue ab therapy await LP\n results\n" }, { "category": "Physician ", "chartdate": "2182-12-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 704668, "text": "Chief Complaint: transfer from OSH for management of possible NMS\n HPI:\n 61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n .\n Other medications included a course of levofloxacin, Clindamycin,\n librium, klonipin, ativan drip, valium, trazadone, amanatadine 100 ,\n bupropion 100 mg .\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n home meds:\n V B12\n Vit C\n Centrum\n HCTZ 25 daily\n Oxacepam 30 mg \n bupropion 10 po bid\n Percocet 1tab \n atenolol 50 \n simvastatin 20 daily\n Prilosec\n clonidin 0.1 \n cabidopa/levodopa 25/100 tid\n amantadine 100 \n trazadone 50 qhs\n loratadine 10 daily\n singulair 10 daily\n -\n on transfer: neosynephrine, s/p 2xFFP, 1 UPRBC\n on OSH:\n Bactrim IV Q12H\n Zovirax 500 mg iv BID\n Azactam 2g IV BID\n Vanco 1g IV BID\n Lactulose 30 ml \n PPI\n Combivent\n Propofol drip\n Symmetrel/Amantadine 100mg daily\n Tenormin 50 mg \n Sinemet 25/100 2 tabs q6h\n librium 20 mg q6h prn\n Clondine 0.1 \n Valium tid\n Past medical history:\n Family history:\n Social History:\n HTN\n Parkinson's\n Alcohol abuse (3 glass of vodca or whiskey)\n Asthma\n Depression\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol: hx of abuse\n Other:\n Review of systems:\n Flowsheet Data as of 01:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.5\n HR: 65 (65 - 83) bpm\n RR: 19 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 14 mL\n PO:\n TF:\n IVF:\n 14 mL\n Blood products:\n Total out:\n 210 mL\n 5 mL\n Urine:\n 210 mL\n 5 mL\n NG:\n Stool:\n Drains:\n Balance:\n -210 mL\n 9 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.39/37/123/28/-1\n Ve: 8 L/min\n PaO2 / FiO2: 410\n Physical Examination\n General Appearance: sedated, spontaneous movements\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, 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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Cool, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 213 K/uL\n 9.7 g/dL\n 224 mg/dL\n 1.2 mg/dL\n 29 mg/dL\n 28 mEq/L\n 109 mEq/L\n 4.1 mEq/L\n 147 mEq/L\n 29.9 %\n 23.6 K/uL\n [image002.jpg]\n \n 2:33 A10/29/ 10:41 PM\n \n 10:20 P10/29/ 11:56 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 23.6\n Hct\n 29.9\n Plt\n 213\n Cr\n 1.2\n TC02\n 23\n Glucose\n 224\n Other labs: PT / PTT / INR:17.6/50.7/1.6, CK / CKMB /\n Troponin-T:3714/6/, ALT / AST:70/723, Alk Phos / T Bili:214/1.0,\n Amylase / Lipase:/39, Differential-Neuts:82.4 %, Lymph:15.9 %, Mono:1.4\n %, Eos:0.1 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:3.4 g/dL, LDH:987 IU/L, Ca++:7.2 mg/dL, Mg++:1.4 mg/dL,\n PO4:1.9 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 61 yo with hx of parkinson's presented to OSH with\n possible delirium and now concern of NMS.\n .\n # acute MS change: most likely medication effect due to escalating dose\n of antiparkinsons, and subsequent decrease with supperimposed\n antipsychotics, delirium unliky given no response to benzo. Acute\n parkinson's crisis due to infection likely and of concern including CNS\n infection.\n - Sinemt 25/100 two tabs Q6H\n - if ongoing tremor and fever: dandrolen\n - IVF\n - monitor CK, WBC, lytes, and BP/HR\n - LP after reversal of coagulopathy and CT\n .\n # Fever: infectious vs. NMS\n - symptomatic treatment of NMS (?dandrolen)\n - no antipsychotics\n - IVF\n - empiric meningitis coverage\n - cultures\n .\n # Acute renal failure: prerenal due to sepsis/dehydration vs, ATN in\n the setting of possible hypotension. unlikely due to rhabdo as CK not\n significanlty high\n - obrtain baseline renal function\n - renal lytes\n - monitor UOP\n - IVF\n .\n # elevated transaminbases: suggestive of alcoholic hepatitis. possibly\n AST elevated due to rhabdo.\n - monitor and treat symptomatically\n - rule out infectious cholecystitis/ angitis by RUQ US\n .\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS\n - iron sudies, retic count, smear, hemolysis labs\n - was given 1 UPRC prior to transfer\n .\n # coagulopathy: concerning for DIC vs. chronic liver dz\n - check PTT\n - LFT, Albumin, daily coags\n - FFP for LP\n - DIC labs\n .\n # hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and replace gently free water\n .\n # leucocytosis: indicative for SIRS, unclear if due to infection or NMS\n - empiric treatment for both\n - moniotor daily\n - f/u cultures\n - c-diff as hospitalized and treated with clinda/levofloxacine\n .\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n .\n FEN: IVF, tube feed\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen,\n -PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: Partner : , son :\n \n .\n DISPOSITION:\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2182-12-06 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 704669, "text": "Chief Complaint: transfer from OSH for management of possible NMS\n HPI:\n 61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n .\n Other medications included a course of levofloxacin, Clindamycin,\n librium, klonipin, ativan drip, valium, trazadone, amanatadine 100 ,\n bupropion 100 mg .\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n home meds:\n V B12\n Vit C\n Centrum\n HCTZ 25 daily\n Oxacepam 30 mg \n bupropion 10 po bid\n Percocet 1tab \n atenolol 50 \n simvastatin 20 daily\n Prilosec\n clonidin 0.1 \n cabidopa/levodopa 25/100 tid\n amantadine 100 \n trazadone 50 qhs\n loratadine 10 daily\n singulair 10 daily\n -\n on transfer: neosynephrine, s/p 2xFFP, 1 UPRBC\n on OSH:\n Bactrim IV Q12H\n Zovirax 500 mg iv BID\n Azactam 2g IV BID\n Vanco 1g IV BID\n Lactulose 30 ml \n PPI\n Combivent\n Propofol drip\n Symmetrel/Amantadine 100mg daily\n Tenormin 50 mg \n Sinemet 25/100 2 tabs q6h\n librium 20 mg q6h prn\n Clondine 0.1 \n Valium tid\n Past medical history:\n Family history:\n Social History:\n HTN\n Parkinson's\n Alcohol abuse (3 glass of vodca or whiskey)\n Asthma\n Depression\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol: hx of abuse\n Other:\n Review of systems:\n Flowsheet Data as of 01:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.5\n HR: 65 (65 - 83) bpm\n RR: 19 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 14 mL\n PO:\n TF:\n IVF:\n 14 mL\n Blood products:\n Total out:\n 210 mL\n 5 mL\n Urine:\n 210 mL\n 5 mL\n NG:\n Stool:\n Drains:\n Balance:\n -210 mL\n 9 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 360 (360 - 360) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.39/37/123/28/-1\n Ve: 8 L/min\n PaO2 / FiO2: 410\n Physical Examination\n General Appearance: sedated, spontaneous movements\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, 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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Cool, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 213 K/uL\n 9.7 g/dL\n 224 mg/dL\n 1.2 mg/dL\n 29 mg/dL\n 28 mEq/L\n 109 mEq/L\n 4.1 mEq/L\n 147 mEq/L\n 29.9 %\n 23.6 K/uL\n [image002.jpg]\n \n 2:33 A10/29/ 10:41 PM\n \n 10:20 P10/29/ 11:56 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 23.6\n Hct\n 29.9\n Plt\n 213\n Cr\n 1.2\n TC02\n 23\n Glucose\n 224\n Other labs: PT / PTT / INR:17.6/50.7/1.6, CK / CKMB /\n Troponin-T:3714/6/, ALT / AST:70/723, Alk Phos / T Bili:214/1.0,\n Amylase / Lipase:/39, Differential-Neuts:82.4 %, Lymph:15.9 %, Mono:1.4\n %, Eos:0.1 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:3.4 g/dL, LDH:987 IU/L, Ca++:7.2 mg/dL, Mg++:1.4 mg/dL,\n PO4:1.9 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 61 yo with hx of parkinson's presented to OSH with\n possible delirium and now concern of NMS.\n .\n # acute MS change: most likely medication effect due to escalating dose\n of antiparkinsons, and subsequent decrease with supperimposed\n antipsychotics, delirium unliky given no response to benzo. Acute\n parkinson's crisis due to infection likely and of concern including CNS\n infection.\n - Sinemt 25/100 two tabs Q6H\n - if ongoing tremor and fever: dandrolen\n - IVF\n - monitor CK, WBC, lytes, and BP/HR\n - LP after reversal of coagulopathy and CT\n .\n # Fever: infectious vs. NMS\n - symptomatic treatment of NMS (?dandrolen)\n - no antipsychotics\n - IVF\n - empiric meningitis coverage\n - cultures\n .\n # Acute renal failure: prerenal due to sepsis/dehydration vs, ATN in\n the setting of possible hypotension. unlikely due to rhabdo as CK not\n significanlty high\n - obrtain baseline renal function\n - renal lytes\n - monitor UOP\n - IVF\n .\n # elevated transaminbases: suggestive of alcoholic hepatitis. possibly\n AST elevated due to rhabdo.\n - monitor and treat symptomatically\n - rule out infectious cholecystitis/ angitis by RUQ US\n .\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS\n - iron sudies, retic count, smear, hemolysis labs\n - was given 1 UPRC prior to transfer\n .\n # coagulopathy: concerning for DIC vs. chronic liver dz\n - check PTT\n - LFT, Albumin, daily coags\n - FFP for LP\n - DIC labs\n .\n # hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and replace gently free water\n .\n # leucocytosis: indicative for SIRS, unclear if due to infection or NMS\n - empiric treatment for both\n - moniotor daily\n - f/u cultures\n - c-diff as hospitalized and treated with clinda/levofloxacine\n .\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n .\n FEN: IVF, tube feed\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen,\n -PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: Partner : , son :\n \n .\n DISPOSITION:\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: 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: 61F EtOH abuse, recent dx Parkinson's at OSH\n - started sinemet and amantadine for falls and cognitive decline. Admit\n to OSH with tremors and delirium, discovered to have been\n doubling her anti-Parkinson's meds, dose decreased with worsening\n hallucinosis. Admitted, started on ativan gtt and haldol, eventually\n developed tremors, rigidity, fevers to 104. Sinemet increased, haldol\n d/c'ed. Concern for infection at OSH, BCx neg, UA +, rx with levo /\n clinda but no LP d/t INR 2.0.\n Exam notable for Tm 100.9 BP 100/50 HR 60 RR 18 with sat 100 on VAC\n 550x12 0.3 5 c ABG 7.39/37/123. Cog-wheel rigidity, rigid, CN intact.\n Withdraws to pain. RLE >LLE clonus. Coarse BS B. RRR s1s2. Soft +BS. No\n edema / cord / rash. Labs notable for WBC 23K, HCT 29, K+ 4.1, Cr 1.2,\n lactate 1.3, PTT 50, INR 1.6. CXR with ?LLL infiltrate / atlectasis.\n 61F EtOH, subacute decline, possible Parkinson's with fevers, rigidity,\n and encephalopathy. Unclear how much is med-induced vs ethanol\n withdrawal vs CNS infection vs thiamine deficiency or another primary\n CNS process; however, I suspect this is primarily due to NMS from\n combination of sinemet withdrawal and haldol adminstration. Agree with\n plan to consult neuro, continue sinemet and amatadine, start IV\n thiamine 200mg now and follow exam. Will give dantrolene if Tm >101 and\n d/w toxicology in AM. For now, will continue aggressive IVF repletion\n given insensible losses, phos repletion, serial CK monitoring, cycle\n CEs. Will check head CT, follow coags / DIC labs off sc heparin and\n obtain LP once these have normalized and intracranial pathology\n excluded. For now, will pan culture, f/u OSH cultures and continue\n broad abx coverage with vanco / for now, though I doubt fevers are\n infectious in origin. Will support with vent for now, transition to\n PSV, propofol for sedation. For ARF, hydrate aggressively, RD meds.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:29 ------\n" }, { "category": "Nursing", "chartdate": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704878, "text": "Events: PT alert, can track anf follow, follows commands off Propofol\n and on low dose propofol- currently comfortable on 30mcg/kg. PT cont\n to be tremulous with stimulation, although less over shift- PM\n hypertensive 160\ns/ HR low 100\ns with fine tremor and agitation- given\n 1x dose 2mg IVP Versed and episode resolving. LS clear though cont\n copious thick yellow suctioning from ETT, large amount oral secretions,\n + gag and cough. Tolerating increase in TF, sm BM x 2. Good UOP\n 60-120cc/hr- given 2 L\n NS @ 200cc/hr for rhabdo with enzymes trending\n down. Multiple electrolyte repletion.\n Electrolyte & fluid disorder, other\n Assessment:\n 200 labs repleted mg 1.7, Ca 7.7, phos 2.1, K 4.2\n Action:\n 30mmol Kphos on 55cc ND, 2 mg Mag Sulfate, 2mg Calcium\n Response:\n Awaiting AM labs\n Plan:\n Cont electrolyte repletion, TF as tolerated with free water flush, IVF\n @ 200cc/hr with 2^nd bag up- likely recheck multiple lab values and\n need for additional hydration\n Altered mental status (not Delirium)\n Assessment:\n Off Propofol alert, interactive, nods/shakes head approp, + tremors,\n able to MAE in bed, + rigidity\n Action:\n Neuro checks, titrating Propofol and need for additional\n benzodiazepines, frequent re-orientation and emotional support\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704720, "text": "61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n Events: Arrived via @ 2300- vented on Propofol and Neo\n gtt. PT arrived very tremulous, intermittently interactive and able to\n nod/shake head but not follow additional commands- BP and MS labile.\n PERRLA and followed by neuro- per neuro cranial nerves intact,\n hyperreflective- difficult to asses of ? alcohol WD- 1 AM last\n drink s/p Ativan gtt and Valium @ OSH. Remains of low dose Propofol\n with total 4 mg IVP Versed given for agitation and CT scan. Ct head\n benign but ? slight sinusitis. NGT pulled and OG placed. Pt to have\n LP in AM repeat INR 1.5 (1.6) and likely will need 1 unit FFP. T&S\n sent on admission with 1 unit RBC type and crossed. PT Initially on\n mod dose Neo gtt and all extremities mottled- mottling abated but\n remains cechetic and pale. Given total 2 L IVF. PT appears neverly\n malnutished- order to start TF, to start after LP. Multiple\n electrolyte repletion- 2 gm Mag Sulfate, 2 packet neutral phosl,\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 Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704722, "text": "61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n Events: Arrived via @ 2300- vented on Propofol and Neo\n gtt. PT arrived very tremulous, intermittently interactive and able to\n nod/shake head but not follow additional commands- BP and MS labile.\n PERRLA and followed by neuro- per neuro cranial nerves intact, hyper\n reflective- difficult to asses of ? alcohol WD- 1 AM last drink\n s/p Ativan gtt and Valium @ OSH. Remains of low dose Propofol with\n total 4 mg IVP Versed given for agitation and CT scan. Ct head benign\n but ? slight sinusitis. Resumed home anti-[arkinsonian medication \n ? neuroleptic syndrome. + BS , no BM. NGT pulled and OG placed. Pt to\n have LP in AM repeat INR 1.5 (1.6) and likely will need 1 unit FFP.\n T&S sent on admission with 1 unit RBC type and crossed. PT Initially\n on mod dose Neo gtt and all extremities mottled- mottling abated but\n remains cechetic and pale. Given total 2 L IVF. Pt t max 100.9 PO on\n admission- multiple ABX and anti-viral medications. Pan cultured. BC\n x 2. PT appears severely malnourished- order to start TF, to start\n after LP. Multiple electrolyte repletion- 2 gm Mag Sulfate, 2 packet\n neutral phos, 400mg IV Thiamine. LS clear but can suction copious\n thick yellow secretions- sputum culture sent.\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 Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704713, "text": "61 yo female with recent diagnosis of parkinsonism, who was admitted to\n OSH on . Her initial presentation was documented as\n \"semi-responsive state with significant tremor and delirium\". Patient\n has long history of depression and alcohol abuse. She also was\n progressively declining with regard of her cognitive function, and\n coordination over the past several months. Months ago she was diagnosed\n with parkinsonism an prescribed Maintained 100 mg and Sinemet\n 25/100 tid. Over the past month she was found to significantly\n overdosing her self on these medication (one month supply used within 2\n wks). He over all presentation of confusion, tremorness, Hallucinations\n and MS . He neurologist was called by her partner and\n eval was recommended.\n In the OSH she was admitted and given empiric Abx (elevated WBC) and\n Benzodiazepines for concern of EtOH withdrawal or infection. She did\n not respond to Benzodiazepines but her presentation rather worsened.\n She was seen by psych, thought to be in delirium, and given Haldol as\n well as Zyprexa in high doses. Again her clinical presentation\n deteriorated (fever, tremeor, obtundation), and requiring intubation\n for airway protection. Neurology consult expressed concern for NMS in\n the setting of sudden decrease in antiparkinsons as well as\n antipsychotic use with fevers to 104, elevated CK, ARF, and\n leucocytosis. Transfer to care center was recommended.\n She was found to have gram negative UTI.\n Events: Arrived via @ 2300- vented on Propofol and Neo\n gtt. PT arrived very tremulous, intermittently interactive and able to\n nod/shake head but not follow additional commands- BP and MS labile.\n PERRLA and followed by neuro- per neuro cranial nerves intact,\n hyperreflective- difficult to asses of ? alcohol WD- 1 AM last\n drink s/p Ativan gtt and Valium @ OSH. Remains of low dose Propofol\n with total 4 mg IVP Versed given for agitation and CT scan. Ct head\n benign but ? slight sinusitis. NGT pulled and OG placed. Pt to have\n LP in AM repeat INR 1.5 (1.6) and likely will need 1 unit FFP. T&S\n sent on admission with 1 unit RBC type and crossed. PT Initially on\n mod dose Neo gtt and all extremities mottled- mottling abated but\n remains cechetic and pale. Given total 2 L IVF. PT appears neverly\n malnutished- order to start TF, to start after LP. Multiple\n electrolyte repletion- 2 gm Mag Sulfate, 2 packet neutral phosl,\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 Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2182-12-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 704714, "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: Unknown\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\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: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: underlying illness\n not resolved.\n Travel to CT tolerated well\n" }, { "category": "Nursing", "chartdate": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705035, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\ncontinue to follow CK\ns [ raised CKS on admission related to\n rabdo], NA and replete per S/S , calcium /phos/mag /k closely, check\n again @ 2000hrs\n All ABS stopped , , continue to closely observe\n New NG placed in prep for extubation [ ? tomorrow]\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Checked @ 1200hrs, mag replaced, receiving free water via nutrition, iv\n replacement stopped\n Response:\n Stable, for re-check @ 2000hrs\n Plan:\n Check and replete per order\n Altered mental status (not Delirium)\n Assessment:\n Received on propofol @ 20mcg/kg/min and versed at 5mg/hr, patient\n following commands\nmoving all extrimities, but agitated , attempting to\n pull at tubes and get OOB, ? alcohol withdrawl, hypertensive to 160\n tachy to 100. Requiring increasing amounts of benzos for agitation,\n Bilateral soft restraints in place for safety\n Action:\n Numerous boluses of IV benzos, IV drip of versed increased, unable to\n wean propofol gtt. Less tremulous, on sinemet qid,\n Response:\n Plan:\n Wean prop to assess benzo need, titrate up as needed for calm\n respsonse. Neuro following\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n temp related to NMS [ potentially can be hyper-febrile]\n Action:\n All cxs taken neg, ?all antibiotics stopped\n Response:\n Plan:\n Continue to follow temp curve, Tylenol, cooling blanket as required\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received intubated, orally vented, on PSV 10 peep @ 5 40%, RR 15-30 ,\n TV @ 400-500, sat > 95%. Bilateral lung sounds clear.\n Action:\n Increased sedation to keep her comfortable with vent\n Response:\n With anxiety/agitation,\n Plan:\n Plan for extubation if less agitated\n" }, { "category": "Nursing", "chartdate": "2182-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704805, "text": "EVENTS\n Electrolyte & fluid disorder, other\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" }, { "category": "Nursing", "chartdate": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705018, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\ncontinue to follow CK\ns [ raised CKS on admission related to\n rabdo], NA and replete per S/S , calcium /phos/mag /k closely, check\n again @ 2000hrs\n All ABS stopped , temp related to NMS [ potentially can be\n hyper-febrile], continue to closely observe\n New NG placed in prep for extubation [ ? tomorrow]\n Far less tremoulous, on sinemet qid, neuro following\n ? alcohol withdrawl, requiring increasing amounts of benzos for\n agitation, drip commenced this eve, attempt to wean propofol to assess\n extent of withdrawl\n Electrolyte & fluid disorder, other\n Assessment:\n Patient received having receivind supplementation overnight per S/S\n with improving NA and CEs trending down\n Action:\n Checked @ 1200hrs, mag replaced, receiving free water via nutrition, iv\n replacement stopped\n Response:\n Stable, for re-check @ 2000hrs\n Plan:\n Check and replete per order\n Altered mental status (not Delirium)\n Assessment:\n Received on propofol @ 30, far less tremoulous, following\n commands\nagitated many times attempting to pull at tubes and get OOB,\n shakes head yes to feeling anxious, movement in all 4 limbs, ? alcohol\n withdrawl, hypertensive to 160 tachy to 100\n Action:\n Numerous boluses of IV benzos plus PO dose, IV drip of versed commenced\n , attempting to wean propofol\n Response:\n Continues agitated at this time attempting to get oob, denies pain\n admits to anxiety, titrating versed weaning prop as able\n Plan:\n Wean prop to assess benzo need, titrate up as needed for calm respsonse\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Patient was previously febrile\nLP performed and many BCS taken..t max\n today 100\n Action:\n All cxs taken neg, ?temp related to NMS, all abs stopped\n Response:\n Stable at this time\n Plan:\n Continue to follow temp curve, Tylenol, cooling blanket as required\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received intubated PS 10 peep @ 5 40% RR 15-30 [ depending on anxiety],\n TV @ 400-500, sat > 95%, sx for thick yellow secretions\n Action:\n Weaned to p/s 5\n Response:\n With anxiety/agitation, RR mid 30\n,S therefore re-increased to 10\n Plan:\n Continue vent support at this time, ?? extubate in the am once stable\n agitation\n" }, { "category": "Nursing", "chartdate": "2182-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705223, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\nversed drip weaned and extubated at 1600hrs, diazepam for\n agitataion\n Electrolyte & fluid disorder, other\n Assessment:\n Am labs showed mag low, all other labs stable\n Action:\n Pm labs taken\n Response:\n Pm labs pending\n Plan:\n Await results and replete per S/S, next set due at 2000hrs\n Altered mental status (not Delirium)\n Assessment:\n Received of propofol versed at 15mg/hr, patient following\n commands\nmoving all extremities, Bilateral soft restraints in place\n for safety, calm/co\noperative, no tremour noted, sinemet QID , neuro\n following\n Action:\n Received stat dose IV diazepam and po dose of home benzos, IV versed\n weaned, of by 1400hrs\n Response:\n Calm, co-operative at this time, consistently follows commands, denies\n pain/anxiety, confused in conversation but knows family, orientated x1\n Plan:\n for diazepam IV for anxiety/agitation, continue to follow neuro exam\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp,?temp related to NMS [ potentially can be hyper-febrile]\n Action:\n All cxs taken neg, all antibiotics stopped\n Response:\n Stable at this time\n Plan:\n Continue to follow temp curve, Tylenol, cooling blanket as required\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received intubated, orally vented, on PSV 10 peep @ 5 40%, RR\n 15-30 , TV @ 400-500, sat > 95%. Bilateral lung sounds clear.\n Action:\n Placed on and then 5/0 good TV and sat > 95%, rr 20, extubated at\n 1600hrs\n Response:\n Doing well RR 15-20 sats 100% on 50% face tent\n Plan:\n Encourage cough/deep breath, pulmonary toilet, wean fio2 as tolerated\n" }, { "category": "Physician ", "chartdate": "2182-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 704914, "text": "Chief Complaint: Rigidity\n 24 Hour Events:\n ARTERIAL LINE - START 08:04 AM\n SPUTUM CULTURE - At 10:40 AM\n MULTI LUMEN - START 11:43 AM\n LUMBAR PUNCTURE - At 02:48 PM\n \n - LP done - 0 WBC and 0 RBC with normal protein and glucose.\n - Central line placed.\n - f/u blood cultures from OSH\n - 8pm lytes show improving CK and Cr, low phos repleted.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:38 AM\n Acyclovir - 02:02 AM\n Meropenem - 02:02 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 PM\n Midazolam (Versed) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 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: 37.7\nC (99.9\n HR: 75 (63 - 94) bpm\n BP: 126/74(86) {121/72(83) - 129/84(94)} mmHg\n RR: 18 (6 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,587 mL\n 2,014 mL\n PO:\n TF:\n 159 mL\n 169 mL\n IVF:\n 6,869 mL\n 1,635 mL\n Blood products:\n Total out:\n 1,380 mL\n 540 mL\n Urine:\n 1,380 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,207 mL\n 1,474 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (468 - 487) mL\n PS : 10 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 62\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.51/29/106/23/1\n Ve: 7.8 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Calm shortly after receiving Propofol bolus for agitation and\n scheduled sinemet\n HEENT: No scleral icterus. PERRL, MMM. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2.\n LUNGS: CTAB, good air movement bilaterally with central rhonchi.\n ABDOMEN: Soft, +BS, NTND\n EXTREMITIES: No edema or calf pain, 2+ radial/ dorsalis pedis/\n posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Cogwheel rigidity with a prominent resting tremor\n Labs / Radiology\n 182 K/uL\n 9.3 g/dL\n 87 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 22 mg/dL\n 117 mEq/L\n 147 mEq/L\n 26.7 %\n 21.1 K/uL\n [image002.jpg]\n 10:41 PM\n 11:56 PM\n 05:28 AM\n 05:52 AM\n 07:40 AM\n 12:58 PM\n 01:03 PM\n 06:02 AM\n WBC\n 23.6\n 21.1\n Hct\n 29.9\n 27.4\n 26.7\n Plt\n 213\n 182\n Cr\n 1.2\n 1.0\n 0.8\n TCO2\n 23\n 23\n 24\n 24\n Glucose\n 224\n 106\n 87\n Other labs: PT / PTT / INR:15.2/41.1/1.3, CK / CKMB /\n Troponin-T:2797/6/, ALT / AST:55/367, Alk Phos / T Bili:181/1.0,\n Amylase / Lipase:/39, Differential-Neuts:79.0 %, Lymph:19.6 %, Mono:1.0\n %, Eos:0.3 %, D-dimer:637 ng/mL, Fibrinogen:511 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:3.4 g/dL, LDH:987 IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n IMPAIRED SKIN INTEGRITY\n INEFFECTIVE COPING\n ASSESSMENT AND PLAN: 61 yo with hx of parkinson's presented to OSH with\n possible delirium and concern for NMS.\n .\n # Acute MS change: Likely NMS caused by abrupt stop of high doses of\n anti-parkinosonian drugs combined with high doses of Haldol at the OSH,\n though there is question of whether alcohol withdrawal is also\n contributing. LP was bland, though many cultures are pending. She is\n now alert on minimal sedation and able to follow basic commands.\n - Sinemt 25/100 two tabs Q6H\n - if ongoing tremor and fever: dandrolen\n - IVF\n - monitor CK, WBC, lytes, and BP/HR\n .\n # Fever: infectious vs. NMS\n - On vancomycin, meropenem and acyclovir day 2 for empiric meningitis\n coverage. These antibiotics can be stopped given given the patient\n improvement and normal LP.\n - symptomatic treatment of NMS (?dandrolen)\n - no antipsychotics\n - IVF\n - empiric meningitis coverage\n - cultures\n .\n # Acute renal failure: improved with aggressive hydration, suggesting\n cause was mild rhabdomyolysis and dehydration.\n - Continue IVF as needed.\n .\n # elevated transaminbases: suggestive of alcoholic hepatitis. possibly\n AST elevated due to rhabdo.\n - monitor and treat symptomatically\n - rule out infectious cholecystitis/ angitis by RUQ US\n .\n # Anemia: no signs of bleed. elevated LDH suggestive of hemolysis but\n also could be due to rhabdo, concerning would be TTP/HUS\n - iron sudies, retic count, smear, hemolysis labs\n - was given 1 UPRC prior to transfer\n .\n # coagulopathy: concerning for DIC vs. chronic liver dz\n - check PTT\n - LFT, Albumin, daily coags\n - FFP for LP\n - DIC labs\n .\n # hypernatremia: appears to be hypovolemic hypernatremia. was\n significantly elevated in OSH and rapidly corrected\n - monitor daily and replace gently free water\n .\n # leucocytosis: indicative for SIRS, unclear if due to infection or NMS\n - empiric treatment for both\n - moniotor daily\n - f/u cultures\n - c-diff as hospitalized and treated with clinda/levofloxacine\n .\n # EtOH abuse: history until recent admission. given significant benzo\n administration, will hold further dose administration. withdrawal could\n possibly represent. will monitor and consider valium if indicated.\n .\n FEN: IVF, tube feed\n .\n PPX:\n -DVT ppx with SC heparin and pneumoboots\n -Bowel regimen,\n -PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT: Partner : , son :\n \n .\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:08 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:04 AM\n Multi Lumen - 11:43 AM\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": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 704917, "text": "Events: PT alert, can track anf follow, follows commands off Propofol\n and on low dose propofol- currently comfortable on 30mcg/kg. PT cont\n to be tremulous with stimulation, although less over shift- PM\n hypertensive 160\ns/ HR low 100\ns with fine tremor and agitation- given\n 1x dose 2mg IVP Versed and episode resolving. LS clear though cont\n copious thick yellow suctioning from ETT, large amount oral secretions,\n + gag and cough. Tolerating increase in TF, sm BM x 2. Good UOP\n 60-120cc/hr- given 2 L\n NS @ 200cc/hr for rhabdo with enzymes trending\n down. Multiple electrolyte repletion.\n Electrolyte & fluid disorder, other\n Assessment:\n 200 labs repleted mg 1.7, Ca 7.7, phos 2.1, K 4.2\n Action:\n 30mmol Kphos on 55cc ND, 2 mg Mag Sulfate, 2mg Calcium\n Response:\n Awaiting AM labs\n Plan:\n Cont electrolyte repletion, TF as tolerated with free water flush, IVF\n @ 200cc/hr with 2^nd bag up- likely recheck multiple lab values and\n need for additional hydration\n Altered mental status (not Delirium)\n Assessment:\n Off Propofol alert, interactive, nods/shakes head approp, + tremors,\n able to MAE in bed, + rigidity\n Action:\n Neuro checks, titrating Propofol and need for additional\n benzodiazepines, frequent re-orientation and emotional support\n Response:\n Cont to be tremulous, easily woken on Propofol\n Plan:\n Cont to monitor neuro status, neuro checks, cont Propofol for light\n sedation, PRN versed if needed, PO Valium \n" }, { "category": "Nursing", "chartdate": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705010, "text": "Electrolyte & fluid disorder, other\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" }, { "category": "Nursing", "chartdate": "2182-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705013, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\ncontinue to follow CK\ns [ raised CKS on admission related to\n rabdo], NA and replete per S/S , calcium /phos/mag /k closely, check\n again @ 2000hrs\n All ABS stopped , temp related to NMS [ potentially can be\n hyper-febrile], continue to closely observe\n New NG placed in prep for extubation [ ? tomorrow]\n Far less tremoulous, on sinemet qid, neuro following\n ? alcohol withdrawl, requiring increasing amounts of benzos for\n agitation, drip commenced this eve, attempt to wean propofol to assess\n extent of withdrawl\n Electrolyte & fluid disorder, other\n Assessment:\n Patient received having receivind supplementation overnight per S/S\n with improving NA and CEs trending down\n Action:\n Checked @ 1200hrs, mag replaced, receiving free water via nutrition, iv\n replacement stopped\n Response:\n Stable, for re-check @ 2000hrs\n Plan:\n Check and replete per order\n Altered mental status (not Delirium)\n Assessment:\n Received on propofol @ 30, far less tremoulous, following\n commands\nagitated many times attempting to pull at tubes and get OOB,\n shakes head yes to feeling anxious, movement in all 4 limbs\n Action:\n Numerous boluses of IV benzos plus PO dose, IV drip of ve\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" }, { "category": "Nursing", "chartdate": "2182-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 705195, "text": "Patient transferred from OSH with possible neuroleptc malignant\n syndrome\n.she has Parkinson @ baseline, took all her meds in a 2 week\n period, then went without for 2 weeks, finally admitted to Osh with\n extensive/uncontrolled tremors\n? NMS ?? component of alcohol\n withdrawal\n..she received haldol at OSH which may have exacerbated the\n NMS..patient was intubated at OSH for MS changes/airway protection\n EVENTS\n Electrolyte & fluid disorder, other\n Assessment:\n Am labs showed mag low, all other labs stable\n Action:\n Pm labs taken\n Response:\n Pm labs pending\n Plan:\n Await results and replete per S/S, next set due at 2000hrs\n Altered mental status (not Delirium)\n Assessment:\n Received of propofol versed at 15mg/hr, patient following\n commands\nmoving all extremities, Bilateral soft restraints in place\n for safety, calm/co\noperative, no tremour noted, sinemet QID , neuro\n following\n Action:\n Received stat dose IV diazepam and po dose of home benzos, IV versed\n weaned, of by 1400hrs\n Response:\n Calm, co-operative at this time, consistently follows commands, denies\n pain/anxiety\n Plan:\n for diazepam IV for anxiety/agitation, continue to follow neuro exam\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp,?temp related to NMS [ potentially can be hyper-febrile]\n Action:\n All cxs taken neg, all antibiotics stopped\n Response:\n Stable at this time\n Plan:\n Continue to follow temp curve, Tylenol, cooling blanket as required\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received intubated, orally vented, on PSV 10 peep @ 5 40%, RR\n 15-30 , TV @ 400-500, sat > 95%. Bilateral lung sounds clear.\n Action:\n Increased sedation to keep her comfortable with vent\n Response:\n RSBI 22 this am, minimal secretion\n Plan:\n Plan for extubation if less agitated, wean Propofol as tolerated\n" }, { "category": "Radiology", "chartdate": "2182-12-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1105191, "text": " 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MS CHANGES. EVAL.\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with acute mental status change\n REASON FOR THIS EXAMINATION:\n pls eval for pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 4:26 AM\n IMPRESSION:\n\n No acute intracranial process and paranasal sinus disease bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute mental status change.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial CT images were acquired through the head in the\n absence of intravenous contrast.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular\n territorial infarction. The ventricles and sulci are normal in size and in\n configuration. Included osseous structures reveal no fracture. The\n visualized paranasal sinuses are notable for circumferential mucosal\n thickening at the left maxillary sinus, at the ethmoid air cells bilaterally\n as well as secretions layering dependently in the sphenoid sinus. The\n maxillary sinuses appear hypoplastic bilaterally.\n\n IMPRESSION: No acute intracranial process\n\n" }, { "category": "Radiology", "chartdate": "2182-12-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1105192, "text": ", MED MICU 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MS CHANGES. EVAL.\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with acute mental status change\n REASON FOR THIS EXAMINATION:\n pls eval for pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n\n No acute intracranial process and paranasal sinus disease bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1105275, "text": " 12:16 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Placement of CVL\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n Placement of CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Altered mental status.\n\n Portable AP chest radiograph was compared to .\n\n The tracheostomy is at the midline with its tip approximately 5 cm above the\n carina. The left internal jugular line tip is at the level of mid SVC. The\n NG tube tip passes below the diaphragm, terminating in the stomach. There is\n no change in the cardiomediastinal appearance. There is presumably\n new/worsening left retrocardiac opacity, but giving its rapid change, it is\n worrisome for aspiration and should be further closely followed. There is\n also opacity at the right lung base that might represent area of aspiration as\n well. There is no evidence of failure. There is no pleural effusion or\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105453, "text": " 2:27 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with new NGT\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: New NG tube.\n\n NG tube tip is out of view below the diaphragm. Bibasilar opacities are\n persistent but stable from 10 hours earlier. ET tube, left IJ catheter remain\n in place. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105392, "text": " 3:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with ams and intubation\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: AMS and intubated.\n\n Comparison is made to prior study .\n\n Bibasilar opacities have worsened in the left side concerning for\n pneumonia.Opacity on the right base is likely atelectasis. There is no\n pneumothorax or enlarging pleural effusions. Cardiomediastinal contours are\n unchanged. Lines and tubes are in unchanged standard position.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105211, "text": " 6:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with MS changes\n REASON FOR THIS EXAMINATION:\n OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mental status changes, for OG tube placement.\n\n FINDINGS: In comparison with study of , the endotracheal tube tip lies\n approximately 5 cm above the carina. Nasogastric tube extends well into the\n stomach as it crosses the bottom edge of the image, with the side hole below\n the cardioesophageal junction.\n\n No evidence of acute pneumonia, vascular congestion, or pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-12-09 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1105696, "text": " 1:44 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED LFTS, ? INTRAHEPATIC, INTRA DUCTAL PROCESS\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with alcoholism, elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? intrahepatic, intra ductal process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf MON 4:26 PM\n PFI: Normal son appearance of the liver.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL SON\n\n INDICATION: 61-year-old woman with alcohol use, elevated liver function\n tests.\n\n COMPARISON: Not available at the .\n\n FINDINGS: The liver is normal in size, echogenicity, and architecture. The\n gallbladder is decompressed, accounting for prominence of the gallbladder\n wall. There is no cholelithiasis, gallbladder wall edema, or pericholecystic\n fluid. There is no intra- or extra-hepatic biliary ductal dilatation, and the\n common duct measures 4 mm at the porta hepatis. The main portal vein is\n patent with normal hepatopetal flow.\n\n There is no ascites. The spleen is not enlarged, and measures 8.3 cm.\n\n The left kidney measures 9.7 cm, and the right kidney measures 11 cm. There\n is a simple cyst arising from the interpolar region of the right kidney and\n measures 2.5 x 1.8 x 1.6 cm. The aorta is not visualized due to overlying\n bowel gas. The head and the neck of the pancreas are unremarkable, the body\n and the tail are not visualized due to overlying bowel gas.\n\n IMPRESSION:\n 1. Normal appearance of the liver.\n 2. Simple right renal cyst.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-09 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1105697, "text": ", MED MICU 1:44 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED LFTS, ? INTRAHEPATIC, INTRA DUCTAL PROCESS\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with alcoholism, elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? intrahepatic, intra ductal process\n ______________________________________________________________________________\n PFI REPORT\n PFI: Normal son appearance of the liver.\n\n" }, { "category": "Radiology", "chartdate": "2182-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1105183, "text": " 10:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval lines, ET tube and lung fiels\n Admitting Diagnosis: NEUROLEPTIC MALIGNANT SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with respiratory failure OSH transfer\n REASON FOR THIS EXAMINATION:\n please eval lines, ET tube and lung fiels\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Outside hospital transfer with respiratory failure, to evaluate for\n tubes and lines.\n\n FINDINGS: No previous images. The cardiac silhouette is within normal limits\n and there is no evidence of vascular congestion, pleural effusion, or acute\n pneumonia, though some respiratory motion degrades the image. Endotracheal\n tube tip lies approximately 3.5 cm above the carina. Nasogastric tube extends\n well into the stomach. The cardiac silhouette is at the upper limits of\n normal in size on this frontal radiograph.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2135-07-04 00:00:00.000", "description": "Report", "row_id": 1588488, "text": "See carevue for objective data.\n\nMore alert as NA level decreasing. Intermittingly appropriate as well as oriented.\nAFIB-received 12.5 mg lopressor po with good rate response. BP non-labile. Maintaining sats on RA. Crackles at bases.\nTaking diet fair. Needs soft diet-dietary notified. SSRI per FSBS after insulin gtt dc'd. Taking free water by mouth without difficulty.\nD5W IV at KVO presently until 1600 lytes are posted. NA at 0800 158/\nNA at 1200 146 after taking free water PO and receiving 1/2 NS IV.\nUrine output has improved. See flowsheet for objective data.\nOOB to chair X6 hours. Tolerated well.\n(3) LG black BM's-guiac +. HCT stable.\nWBC-20. Survelliance BCX1 sent.\n Needs lytes drawn at and 2400.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-07-05 00:00:00.000", "description": "Report", "row_id": 1588489, "text": "NPN 0700-1900\n\nNeuro: Alert, pleasantly confused; MAE's except L arm which is contracted. Slept poorly due to being awakened every hour for FSBG.\nCV: NBP 96-138/39-50, map 58-79; HR 69-82, a-fib; Given last of 3 doses of digoxin .125mcg IV. Tolerated well; hematocrit @ 0400 25.2.\nNo peripheral edema, peripheral pulses are difficult to palpate\nResp: O2 sat 97-100% on RA. RR 13-31, regular unlabored; Lung sounds are clear upper lobes, crackles lower lobes. Ocassional non-productive cough especially after drinking.\nGI/FEN: Abdomen soft, ND, NT, +BS; incontinent of 2 medium black stools with +guiac. Taking sips of apple juice and water during the night. AM labs showed NA 149, K 4.7, no supplemments needed.\nGU:Foley catheer draining 60-200cc clear yellow urine with sediment; 24hr balance is +270, LOS +3L.\nEndo: FSBG at 2200 was 26! at the time pt was diaphoretic and lethargic; given 1amp D50 with subsequent BS q 1hr 66-149 D5W increased to 80cc/hr.\nID: Afebrile, wbc 16; remains on vanco q 48hrs and ceftriaxone q 24hrs.\nPlan: Monitor serum Na and BS; encourage po intake of free water and food; monitor crit, transfuse as ordered; turn frequently.\n" }, { "category": "Nursing/other", "chartdate": "2135-07-04 00:00:00.000", "description": "Report", "row_id": 1588487, "text": "ADMISSION NOTE 7P-7A\n\nPT Y/O FAMALE ADMIT TO THE ED FROM REHAB, SECONDARY TO LETHARGY. SHE WAS FOUND LETHARGIC AT NSG HOME. AT THE NSG HOME THEY GAVE HER D5( NO HX OF DM). AN ADMISSION TO THE ED HER BS 800. INSULIN GTT WAS STARTED. NA 156. 1L NS W/ 40 KCL. CEFTAZ GIVEN IN ED. HEAD CT AND CHEST X-RAY NEG.\n\nPMH: CHF,EF 35%,CVA ( L HEMIPARESIS), HTN,PVD,DEMENTIA,S/P ENDOCARDITIS( VANC IS DONE),C- DIFF,\n\nALLERGIES: NKDA\n\n\nNEURO: ON ADMISSION PT LETHARGIC. A/OX2. NOW SHE HAS HER EYES OPEN, AND TRACKING RN IN TE ROOM. ABLE TO FOLLOW COMMANDS.ABLE TO WIGGLE THE FEET. I HAVE NOT NOTED HER MOVE HER ARMS.\n\nCV: AF HR 102-118. NO ECTOPY NOTED. B/P 140/53.\n\nRESP: LS DIMINSHED BILAT UPPER LOBES. CRACKLES BILAT LOWER LOBES. O2 SAT ON 2L VIA NC 100%. RR 98.\n\nGI/GU: NPO. ABD SOFT NON TENDER. + BS. NO BM. FOLEY CATH WITH CLEAR YELLOW URINE. 30CC/HR.\n\nSKIN: LEFT HEEL WITH OLD HEALING WOUND. NOT OPEN. LIGHT BLUE IN COLOR.\n\nPOC: MENTAL STATUS CHANGE SECONDARY TO NA 161. HEAD CT NEG. NOW ON D5 1/2 NS @ 200CC/HR. INSULIN GTT. ? NEW ON SET OF AF. IN ED SHE DIGOXIN LOADING DOSE. NOW DIG ON HOLD.\n" }, { "category": "Radiology", "chartdate": "2135-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873134, "text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with Short of breath\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: None.\n\n SINGLE VIEW CHEST, AP: The visualized lungs are clear. There is a marked\n kyphoscoliosis to the thoracolumbar spine. There is unfolding of the aorta\n with wall calcifications. The pulmonary vasculature appears within normal\n limits. No pleural effusions are identified.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-07-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 873135, "text": " 6:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich, sdh\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with change in mental status\n REASON FOR THIS EXAMINATION:\n ich, sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb SUN 7:57 PM\n No intracranial hemorrhage. Chronic changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of change in mental status. Evaluate for intracranial\n hemorrhage or subdural hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: No intraparenchymal, subarachnoid or subdural\n hemorrhage is identified. There is prominence of ventricles and sulci, which\n are symmetric, consistent with age related atrophic change. There is no shift\n of normally midline structures. There is decreased attenuation in the\n periventricular white matter consistent with chronic small vessel ischemic\n infarct. The -white matter differentiation is preserved. Several focal\n areas of decreased attenuation are seen in the subcortical white matter,\n consistent with chronic microvascular ischemic infarct. The soft tissue and\n osseous structures are within normal limits. A focal area of increased\n density in the posterior portion of the orbit on the left, which may represent\n a focal calcification. Mucosal thickening is noted within the left maxillary\n sinus.\n\n IMPRESSION: No intracranial hemorrhage or mass effect identified.\n\n\n" }, { "category": "ECG", "chartdate": "2135-07-03 00:00:00.000", "description": "Report", "row_id": 135613, "text": "Atrial flutter with rapid ventricular response\nLeft axis deviation - possible in part left anterior fascicular block\nLeft ventricular hypertrophy with ST-T abnormalities\nQS configuration in leads V1 and V2 - could be in part left ventricular\nhypertrophy but consider also Anteroseptal myocardial infarct, age\nindeterminate\nST-T wave abnormalities are diffuse and nonspecific\nClinical correlation is suggested\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Radiology", "chartdate": "2139-05-03 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1238603, "text": " 2:03 AM\n PORTABLE ABDOMEN Clip # \n Reason: please shoot upright KUB, please assess for pneumatosis, fre\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman cdiff positive, rising lactate\n REASON FOR THIS EXAMINATION:\n please shoot upright KUB, please assess for pneumatosis, free air\n ______________________________________________________________________________\n WET READ: MDAg SUN 5:38 AM\n Limited study. Paucity of bowel gas is nonspecific. Pt has open abdomen (going\n to OR today). No obvious free air. NGT ends in stomach. drains and sponges in\n place.\n -MAgarwal d/w Dr. in person at 5:38am .\n ______________________________________________________________________________\n FINAL REPORT\n UPRIGHT ABDOMEN ON \n\n HISTORY: C. diff positive. Upright KUB, to assess for pneumatosis or free\n air.\n\n FINDINGS: Erect portable abdomen demonstrates radiopaque drains in the left\n upper quadrant and the retrocardiac infiltrate that has been described on\n prior x-rays. Tubing overlies the abdomen. No free air is identified on this\n study or on the chest x-ray. There is paucity of bowel gas. Hardware\n overlies abdomen, limiting assessment. If further evaluation of the abdomen is\n desired, this would best be performed by CT.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1238532, "text": " 4:23 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for ileus, stool in colon\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p traumatic aortic injury, open abdomen, prolonged\n ventilatory requirement\n REASON FOR THIS EXAMINATION:\n Please evaluate for ileus, stool in colon\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ON \n\n HISTORY: Evaluate for ileus, status post aortic injury, prolonged ventilatory\n requirement.\n\n FINDINGS: Multiple radiopaque markers are seen, likely from drains. A\n prominent loop of gas-filled bowel is seen in the left mid abdomen measuring\n up to 3.2 cm with suggestion of a thick wall. There are other scattered areas\n of gas but no overtly distended bowel. These are supine films. Free air\n cannot be assessed.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239275, "text": " 3:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interim change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan failure\n REASON FOR THIS EXAMINATION:\n eval for interim change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Multiple organ failure, followup.\n\n COMPARISON: .\n\n The ET tube tip is 5 cm above the carina. Left subclavian line, right PICC\n line and right internal jugular line are in unchanged appropriate position.\n The NG tube tip is in the stomach. Heart size and mediastinum are unchanged.\n Bibasilar pleural effusions and bibasilar atelectasis are unchanged. Slight\n interval improvement of pulmonary edema is present.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240239, "text": " 3:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p aortic repair\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman status post aortic repair.\n\n COMPARISONS: to .\n\n FINDINGS: A single supine portable chest radiograph was obtained. The exam\n is limited by patient rotation. A tracheostomy tube ends in unchanged\n position. Left subclavian and right internal jugular catheter tip terminate\n within the superior right atrium. No focal consolidation, effusion, or\n pneumothorax is present.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1240654, "text": " 6:35 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new R HD catheter\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure\n REASON FOR THIS EXAMINATION:\n new R HD catheter\n ______________________________________________________________________________\n WET READ: SHSf MON 8:24 PM\n Low lung volumes. New Right IJ HD Catheter is at superior cavoatrial junction.\n No pneutmothorax. Left SC and ET tube stable.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with multiorgan system failure, status post new\n right HD catheter.\n\n COMPARISON: to .\n\n FINDINGS: Endotracheal tube tip ends in the mid clavicular heads. A right\n internal jugular dialysis catheter ends in the right atrium. A left-sided\n subclavian central catheter also ends in the right atrium. Lung volumes are\n low. There is decreased prominence of a right hilar opacity consistent\n improvement of mild central pulmonary vascular congestion. No effusion or\n pneumothorax is present. A left upper quadrant abdominal drain is unchanged.\n\n IMPRESSION: Slight improvement in central pulmonary vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238019, "text": " 8:41 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate position of ET tube\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with malpositioned ETT\n REASON FOR THIS EXAMINATION:\n evaluate position of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:25 PM ON \n\n HISTORY: ET tube malpositioned.\n\n IMPRESSION: AP chest compared to 8:09 p.m.:\n\n ET tube ends above the upper margin of the clavicles, no less than 5.5 cm from\n the carina, since the chin is not elevated, tube could be advanced 2.5 cm for\n more appropriate and secure positioning. Bilateral internal jugular lines\n meet at the junction of the brachiocephalic veins. Nasogastric tube passes\n into the stomach and out of view. Lung volumes are very low, which would\n explain bronchovascular crowding around the upper pole of the right hilus,\n though I cannot exclude consolidation. Similarly, longstanding opacification\n of the left lower lobe could be either atelectasis or less likely pneumonia,\n accompanied by increasing moderate left pleural effusion. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-09 00:00:00.000", "description": "PO HIP 1 VIEW PORT IN O.R.", "row_id": 1239462, "text": " 3:22 PM\n HIP 1 VIEW PORT IN O.R. Clip # \n Reason: PT. W/ EXTERN ROTATION OF BILAT LE. R/O HIP FX. PT. IN OR 16 .\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: External rotation of bilateral lower extremities, rule out hip\n fracture.\n\n RIGHT AND LEFT HIP, SINGLE AP VIEW OF EACH OBTAINED PORTABLY IN THE OR.\n\n Limited assessment shows that the right and left femoral heads are\n superimposed over their respective acetabulae, in anatomic alignment. No\n proximal femur fracture is identified. The pelvis itself is not included on\n these views. No pubic symphysis diastasis. Multiple lower pelvis phleboliths\n noted.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-05 00:00:00.000", "description": "PELVIS, NON-OBSTETRIC", "row_id": 1238858, "text": " 9:01 AM\n PELVIS, NON-OBSTETRIC; PELVIS U.S., TRANSVAGINAL Clip # \n Reason: rule out GU cause for persistent sepsis.\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure s/p attempted lap chole. persistent\n vaginal bleeding, known coagulopathy.\n REASON FOR THIS EXAMINATION:\n rule out GU cause for persistent sepsis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female with multiorgan failure status post attempted\n lap chole, persistent vaginal bleeding, rule out GU cause for persistent\n sepsis.\n\n COMPARISON: The report of the pelvic ultrasound of and liver\n ultrasound .\n\n FINDINGS: Transabdominal visualization of the pelvis was attempted however\n the visualization is severely limited due to the limited son window.\n An endovaginal exam was performed for better visualization of the uterus and\n ovaries. In the lower uterine segment there are at least two large fibroids.\n The largest fibroid is in the left lower uterine segment measuring 5.5 x 3.6 x\n 4.7 cm. A large right fibroid is also noted measuring 4.9 x 3.1 x 4.7 cm.\n Visualization of the body and fundus of the uterus is limited by the presence\n of these fibroids. The cervix is unremarkable in appearance. The endometrial\n stripe is visualized only in a short segment of the lower uterine segment.\n The remainder of the endometrium could not be visualized. No free fluid is\n identified within the pelvis. Limited views of the ovaries were obtained.\n The right ovary is about 1.5 x 2.9 x 2.2 cm. The left ovary is about 1.7 x\n 3.2 x 2.7 cm. No ovarian mass is identified. No suspicious adnexal mass is\n visualized.\n\n There is no hydronephrosis seen on limited views of the right kidney. The\n right kidney measures 12.0 cm in length. The left kidney could not be\n visualized. Several small shadowing gallstones are also incidentally noted\n within the gallbladder unchanged in appearance from the prior ultrasound.\n\n IMPRESSION:\n 1. Fibroid uterus. Visualization of the uterus and endometrium is very\n limited due to the presence of these fibroids.\n 2. No suspicious adnexal or ovarian mass is identified. Visualization of the\n ovaries is limited due to the patient's body habitus. No free fluid is seen\n in the pelvis.\n 3. No hydronephrosis in the right kidney. The left kidney is not visualized.\n 4. Cholelithiasis.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-04 00:00:00.000", "description": "PORTABLE HEAD CT W/O CONTRAST", "row_id": 1238710, "text": " 8:07 AM\n PORTABLE HEAD CT W/O CONTRAST Clip # \n Reason: r/o acute intracranial process - PORTABLE CT HEAD\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p aborted lap cholecystectomy, complicated by splenic and\n aortic injuries requiring splenectomy and aortic repair , now with new left\n gaze\n REASON FOR THIS EXAMINATION:\n r/o acute intracranial process - PORTABLE CT HEAD\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female status post aborted laparoscopic\n cholecystectomy complicated by splenic and aortic arterial injuries,\n necessitating splenectomy and aortic repair on , now with new leftward\n gaze, here to evaluate for acute intracranial process.\n\n COMPARISON: Non-contrast head CT last performed on .\n\n TECHNIQUE: Portable CT-acquired axial images were obtained through the head\n without intravenous contrast.\n\n FINDINGS: This study is limited by decreased resolution of a portable\n examination. Within these limitations, there is no evidence of intra-axial or\n extra-axial hemorrhage, edema, mass effect, or shift of normally midline\n structures. The -white matter differentiation is preserved without\n evidence of acute major vascular territorial infarct. The ventricles and\n sulci are normal in size and configuration for the patient's age. Mucosal\n thickening is noted within the bilateral maxillary sinuses and the left\n sphenoid sinus. The remainder of the visualized paranasal sinuses and middle\n ear cavities are clear. The mastoid air cells are partially opacified\n bilaterally. The bony calvaria appear intact.\n\n IMPRESSION:\n 1. No loss of -white matter differentiation by CT. If there is continued\n concern for hypoxic injury, MRI could be considered if clinically indicated.\n 2. Partial opacification of the bilateral mastoid air cells.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238593, "text": " 5:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for pna, atelectasis, effusion\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with MOF now with increased airway pressure\n REASON FOR THIS EXAMINATION:\n eval for pna, atelectasis, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Increased airway pressure, question pneumonia.\n\n REFERENCE EXAM: at 0500.\n\n FINDINGS: Compared to the study from earlier the same day, there is no\n significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239500, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure,\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST.\n\n COMPARISON: Chest x-ray of .\n\n FINDINGS: Indwelling support and monitoring devices are not substantially\n changed in position, and cardiomediastinal contours are stable. Persistent\n pulmonary vascular congestion, now accompanied by asymmetrical left perihilar\n haziness, probably reflecting asymmetrical mild edema. Previously present\n opacities in the right juxtahilar region have substantially improved, and may\n have been due to atelectasis or aspiration given the rapid improvement.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-08 00:00:00.000", "description": "LP UNILAT LOWER EXT VEINS LEFT PORT", "row_id": 1239299, "text": " 8:30 AM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: dvt?\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with left leg swelling\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female with left leg swelling. Evaluate for DVT.\n\n FINDINGS: -scale, color, and spectral Doppler evaluation was performed of\n the left lower extremity veins. There is normal phasicity of the common\n femoral veins bilaterally. There is normal compression and augmentation of\n the left common femoral, proximal femoral, mid femoral, distal femoral,\n popliteal, posterior tibial, and peroneal veins.\n\n IMPRESSION: No evidence of DVT in the left lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238147, "text": " 5:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check pot of ett and check for pna\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with ETT\n REASON FOR THIS EXAMINATION:\n check pot of ett and check for pna\n ______________________________________________________________________________\n WET READ: LLTc TUE 8:40 PM\n ET tube terminating 4.2 cm above the carina. Right and left IJ catheters\n terminating at the mid SVC. Orogastric tube within the stomach. No\n pneumothorax. Small left effusion is unchanged. Persistent severe left lower\n lobe atelelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:49 P.M., \n\n HISTORY: 31-year-old woman with an ET tube. Check position and possible\n pneumonia.\n\n IMPRESSION: AP chest compared to through at 4:18 a.m.:\n\n ET tube is at the thoracic inlet in standard placement. Bilateral jugular\n lines end at the junction of brachiocephalic veins and a nasogastric tube\n passes below the diaphragm and out of view. Lung volumes remain very small.\n Persistent consolidation at the left lung base is presumably atelectasis,\n which is mild at the right base. Small left pleural effusion presumed.\n Although there is definitely vascular crowding due to low lung volumes,\n engorgement of upper lobe pulmonary veins, has increased since earlier in the\n day. Whether this is due to supine positioning or increased pulmonary venous\n pressure is radiographically indeterminate.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238015, "text": " 7:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm ETT placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n confirm ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:09 P.M., \n\n HISTORY: Respiratory failure. Confirm ET tube placement.\n\n IMPRESSION: AP chest compared to 4:47 p.m.:\n\n Endotracheal tube has been partially withdrawn to the upper margin of the\n clavicles, although some of the apparent change in position may be due to\n difference in chin position, previously flexed, now neutral or extended. When\n the radiograph was performed, the tip of the endotracheal tube is no less than\n 6 cm from the carina. Advancing it 2 cm would be reasonable.\n\n Bilateral jugular lines end at the junction of brachiocephalic veins,\n nasogastric tube ends in the upper stomach. New right suprahilar\n opacification could be atelectasis and bronchovascular crowding, but raises\n concern for pneumonia. Chronic left lower lobe consolidation is probably,\n though not definitely atelectasis, accompanied by a small left pleural\n effusion, increased over the past week. Heart size normal. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-05 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1238890, "text": " 12:10 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p r 49cm picc\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with picc\n REASON FOR THIS EXAMINATION:\n s/p r 49cm picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with PICC 49 cm.\n\n COMPARISONS: Portable AP radiograph from .\n\n FINDINGS: Malpositioned right PICC catheter tip crosses midline and points\n towards the left IJ. Recommend pulling it back 8-9 cm and repeating film.\n Hazy opacity in the retrocardiac region likely represents atelectasis and\n there is likely a small left pleural effusion.\n There is increased opacificaiton in the right middle lobe which may be due to\n volume loss. The lung volumes remain low. The remainder of the support\n devices is unchanged.\n\n IMPRESSION:\n 1. Malpositioned right PICC catheter tip crosses midline, and points towards\n the left IJ. Recommend pulling back 8-9 cm and reimaging.\n 2. Possible left pleural effusion and atelectasis in the left lower and right\n middle lobes.\n\n These findings regarding the PICC line reported to , IV nurse, by Dr.\n via telephone at 12:30 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238177, "text": " 4:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for effusions/infiltrates\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with s/p injury to aorta\n REASON FOR THIS EXAMINATION:\n evaluate for effusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:02 A.M. ON \n\n HISTORY: A 31-year-old woman with aortic injury.\n\n IMPRESSION: AP chest compared to and 30:\n\n ET tube in standard placement. Bilateral jugular lines end at the junction of\n brachiocephalic veins and a nasogastric tube ends in the mid stomach. Right\n lung is low in volume but clear. Left lower lobe atelectasis is more than a\n week old, accompanied by small left pleural effusion. Heart size normal. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-12 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1239789, "text": " 7:43 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval NGT placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: As on the study of earlier in this date, the tip of the nasogastric\n tube extends only to the distal esophagus. Although no coiling within the\n mouth is seen on this limited study, this possibility should be considered if\n there has been an attempt to further advance the nasogastric tube since the\n previous study.\n\n Remainder of the examination is essentially unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1238898, "text": " 1:51 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please recheck PICC placement previous malpositioned\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with repo PICC\n REASON FOR THIS EXAMINATION:\n please recheck PICC placement previous malpositioned\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with PICC reposition.\n\n COMPARISONS: Portable AP radiograph from at 11:53 a.m.\n\n FINDINGS: A right PICC catheter tip is crossing midline. Recommend pulling\n back 2 cm, flushing and then reimaging. The remainder of the monitoring and\n support devices are unchanged. Again seen is haziness at the left base likely\n pleural effusion and right middle lobe opacity which may represent\n atelectasis. Lung volumes remain low\n\n IMPRESSION: Malpositioned PICC tip. Recommend pulling back 2 cm, flushing\n and then reimaging.\n\n These findings were discussed with , IV nurse by Dr. via\n telephone at 2:30 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238416, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure after aortic tear\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiorgan failure after aortic tear.\n\n Comparison is made to prior study .\n\n Lines and tubes are in unchanged standard position. There are persistent low\n lung volumes. Cardiomediastinal contours are unchanged. Left lower lobe\n opacity is persistent, is a combination of pleural effusion and a large area\n of atelectasis. Mild pulmonary edema have increased. Linear opacity in the\n right mid lung is a combination of small amount of fluid in the fissure and\n adjacent atelectasis. There is no new lung abnormality. There are bilateral\n upper lobe medial atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1239190, "text": " 12:34 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p wire exchange right IJ TLC for HD catheter\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p wire exchange right IJ TLC for HD catheter\n REASON FOR THIS EXAMINATION:\n s/p wire exchange right IJ TLC for HD catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman status post wire exchanged for a right IJ\n triple-lumen catheter.\n\n COMPARISON: Portable chest radiograph from .\n\n FINDINGS: A new right IJ dialysis catheter terminates in appropriate position\n in the lower SVC. The ET tube is 5.5 cm from the carina. Left subclavian\n line, right PICC line and NG tube are unchanged in position. There is\n increased haziness in the right lung likely due to worsening pleural effusion.\n Additionally, there is most likely collapse of the left lower lobe. Pulmonary\n vascular congestion has slightly increased.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238533, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure after aortic tear\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Multiorgan failure after aortic tear, question interval change.\n\n REFERENCE EXAM: .\n\n Compared to the study from the prior day there is no significant interval\n change.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240693, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assessment\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure s/p tracheostomy\n REASON FOR THIS EXAMINATION:\n interval assessment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with multisystem organ failure status post\n tracheostomy for interval change.\n\n TECHNIQUE: Semi-erect portable chest view was read in comparison with prior\n chest radiographs with most recent from .\n\n FINDINGS:\n\n Tracheostomy tube is in standard position. Left subclavian line extends till\n the right mid atrium. The tip of the right internal jugular catheter reaches\n till the right upper atrium. There is no pneumothorax or pleural effusion.\n Bilateral lung volumes are low. Right hemidiaphragm is persistently elevated.\n Ill-defined right perihilar opacity has been stable since . No\n new opacities or acute changes in the chest.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238762, "text": " 1:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure and ARDS, now with decreased\n oxygenation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:39 P.M., \n\n HISTORY: 31-year-old woman with multisystem organ failure and ARDS, decreased\n oxygenation.\n\n IMPRESSION: Left upper quadrant surgical material is still in place. ET\n tube, left and right internal jugular catheters are in standard placements,\n and a nasogastric tube passes into the stomach. Lung volumes remain quite\n low. Bibasilar consolidation, left greater than right, has improved on the\n left since and worsened slightly on the right. Upper lungs are grossly\n clear. These are not findings of ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238968, "text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiorgan failure.\n\n Comparison is made with prior study .\n\n There are low lung volumes. Cardiac size is top normal. Right upper and\n lower opacities have increased consistent with worsening atelectasis. Left\n lower lobe retrocardiac opacities are stable, a combination of atelectasis and\n pleural effusions. Lines and tubes are in standard position.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238641, "text": " 11:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ett s/p transfer\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 yoF s/p exploratory laparotomy, splenectomy, aortic bifurcation repair,\n re-exploration\n REASON FOR THIS EXAMINATION:\n eval ett s/p transfer\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Ex-lap splenectomy, aortic bifurcation repair, reexploration, status\n post transfer.\n\n FINDINGS: The ET tube is slightly high at the thoracic inlet, 7.6 cm above\n the carina. The left IJ line is slightly higher than on the film from earlier\n the same day with the tip not yet in the midline. The right IJ line tip is in\n the mid SVC. There is dense retrocardiac opacity with air bronchograms\n compatible with a combination of volume loss and consolidation. There is mild\n pulmonary vascular redistribution and mildly elevated right hemidiaphragm.\n One radiopaque drain marker is still seen in the left upper quadrant. The\n orogastric tube has been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238604, "text": " 2:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna, effusion\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with MOF\n REASON FOR THIS EXAMINATION:\n eval pna, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON AT 0200\n\n HISTORY: Evaluate pneumonia and effusion.\n\n FINDINGS: The ET tube is 5.3 cm above the carina. Bilateral IJ lines are in\n similar location. Radiopaque drain markers are seen in the left upper\n quadrant. There continues to be retrocardiac opacity consistent with volume\n loss/infiltrate/effusion. There is mild pulmonary vascular redistribution.\n Compared to the study from the prior day, the aeration is slightly improved;\n however, there is persistent retrocardiac infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239916, "text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interim change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure\n REASON FOR THIS EXAMINATION:\n eval for interim change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:14 A.M., .\n\n HISTORY: Multisystem organ failure.\n\n IMPRESSION: AP chest compared to through 15:\n\n Left subclavian line ends alongside the right internal jugular multichannel\n catheter in the region of the superior cavoatrial junction or upper right\n atrium. Nasogastric tube passes into the stomach and beyond. Tracheostomy\n tube in standard placement. Lungs grossly clear. Normal cardiomediastinal\n silhouette. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239116, "text": " 3:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: comparte to prior studies\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with aortic lac\n REASON FOR THIS EXAMINATION:\n comparte to prior studies\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with aortic laceration,\n followup.\n\n COMPARISON: Chest radiograph from .\n\n The ET tube tip remains high, 6 cm above the carina. The right internal\n jugular line tip is at the level of mid SVC. Heart size and mediastinum are\n stable. Bilateral pleural effusions and bibasilar areas of atelectasis are\n unchanged. Note is made that there is slight interval improvement of right\n upper lobe atelectasis as compared to prior examination.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1239162, "text": " 10:18 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p left subclavian TLC placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p left subclavian TLC placement\n REASON FOR THIS EXAMINATION:\n s/p left subclavian TLC placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New line placement.\n\n COMPARISON: , 3:53 a.m.\n\n FINDINGS: In the interval, the patient has received a left subclavian vein\n catheter. Catheter is malpositioned and crosses the midline to the right.\n Tip projects at the mid clavicular line on the right. There is no evidence of\n complications, notably no pneumothorax, but the line needs repositioning. The\n referring physician, . , was paged for notification at the time of\n observation, 11:03 a.m., on .\n\n\n" }, { "category": "Echo", "chartdate": "2139-05-15 00:00:00.000", "description": "Report", "row_id": 101548, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Right ventricular function.\nWeight (lb): 255\nBP (mm Hg): 106/49\nHR (bpm): 99\nStatus: Inpatient\nDate/Time: at 09:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\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 and cavity size are normal.\nRegional left ventricular wall motion is normal. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The diameters\nof aorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nThe pulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , no clear change.\n\n\n" }, { "category": "Echo", "chartdate": "2139-04-30 00:00:00.000", "description": "Report", "row_id": 101255, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 210\nBSA (m2): 2.07 m2\nBP (mm Hg): 105/50\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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 - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality - body habitus. Suboptimal image quality\n- ventilator. The patient appears to be in sinus rhythm.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Left ventricular\nsystolic function is hyperdynamic (EF>75%). Right ventricular chamber size and\nfree wall motion are normal. No aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. No mitral regurgitation is seen. There is an\nanterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Hyperdynamic left ventricle systolic\nfunction. Normal right ventricular function. Anterior fat pad. Cardiac output\ncalculated at roughly 8.4L/min.\n\nPRELIMINARY REPORT developed by an ICU Fellow. Not reviewed/approved by the\nAttending Echo Physician.\n\nCompared with the prior study (images reviewed) of \n\n" }, { "category": "Echo", "chartdate": "2139-05-04 00:00:00.000", "description": "Report", "row_id": 101568, "text": "PATIENT/TEST INFORMATION:\nIndication: ?Right heart strain/signs of pulmonary embolism or left ventricular wall motion abnormalities. Hx multi-system organ failure, SIRS/shock with hyperdynamic heart, now hypotensive.\nHeight: (in) 61\nWeight (lb): 244\nBSA (m2): 2.06 m2\nBP (mm Hg): 114/56\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 14:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\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\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No valvular AS.\nThe increased transaortic velocity is related to high cardiac output.\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: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. Regional left ventricular wall\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\nThe estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. The increased transaortic velocity is likely related to\nhigh cardiac output. The mitral valve appears structurally normal with trivial\nmitral regurgitation. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size with normal regional and\nhyperdynamic global systolic function.\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\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": "2139-04-22 00:00:00.000", "description": "Report", "row_id": 101569, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate right heart failure s/p ex-lap for aortic injury in multi organ system failure.\nHeight: (in) 61\nWeight (lb): 209\nBSA (m2): 1.93 m2\nBP (mm Hg): 100/56\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 16:38\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 and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size. Regional left\nventricular wall motion is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis or aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved reginoal and hyperdynamic global systolic function.\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": "2139-04-20 00:00:00.000", "description": "Report", "row_id": 101570, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nStatus: Inpatient\nDate/Time: at 15:27\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic 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: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3).\n\nMITRAL VALVE: Normal mitral valve leaflets. Physiologic MR (within normal\nlimits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPt transferred from BIDN with massive bleeding from adbominal surgery. TEE\nplaced to evaluate cardiac function and volume staus\n\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Regional left ventricular wall motion\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion. The\nmitral valve leaflets are structurally normal. Physiologic mitral\nregurgitation is seen (within normal limits).\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240938, "text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval failure\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ system failure\n REASON FOR THIS EXAMINATION:\n interval failure\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multiorgan system failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are constant. Constant size of the cardiac silhouette. Mildly\n increasing diameters of the pulmonary vasculature, potentially indicating\n early pulmonary edema. However, no overt pulmonary edema is present.\n Moderate cardiomegaly without pleural effusions. No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-18 00:00:00.000", "description": "O PORTABLE ABDOMEN IN O.R.", "row_id": 1240629, "text": " 2:40 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: WASHOUT/ R/O INSTRUMENTATION\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for foreign body prior to washout.\n\n COMPARISONS: CT .\n\n FINDINGS: Five intraoperative images of the abdomen were obtained. There is\n no radiopaque foreign object identified. Surgical clips overlying the left\n abdomen and a surgical drain in the left upper quadrant are noted as seen on\n prior CT. Phleboliths are in the pelvis. There is free intraperitoneal air.\n The imaged lung bases and heart are grossly unremarkable.\n\n IMPRESSION: No radiopaque foreign object.\n\n These findings were discussed with Dr. by Dr. at 14:45 on by telephone.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241378, "text": " 4:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema, infiltrate\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi system organ failure, prolonged ventilatory\n requirement, recent GI bleed\n REASON FOR THIS EXAMINATION:\n pulmonary edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 31-year-old woman with multisystem organ failure, prolonged\n ventilatory requirement.\n\n FINDINGS: Comparison is made to prior study from .\n\n The bilateral central venous catheters, tracheostomy tube, nasogastric tube\n are unchanged in position. There is again seen low lung volumes with\n elevation of the right hemidiaphragm and atelectasis of the right lung bases.\n No pneumothoraces are seen. There is no significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1239175, "text": " 11:06 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with sepsis\n REASON FOR THIS EXAMINATION:\n line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Sepsis, line placement.\n\n COMPARISON: , 10:26.\n\n FINDINGS: As compared to the previous radiograph, the previously\n malpositioned left subclavian catheter has been re-positioned. The catheter\n now shows a normal course, the tip of the catheter projects over the lower\n SVC, at the level of the cavoatrial junction.\n\n No evidence of complications, notably no pneumothorax. The other monitoring\n and support devices and the general appearance of the lung parenchyma are\n constant.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241467, "text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for changes\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ system failure\n REASON FOR THIS EXAMINATION:\n eval for changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:24 A.M. \n\n HISTORY: 31-year-old woman with multiorgan system failure.\n\n IMPRESSION: AP chest compared to through 28:\n\n Lung volumes are low but improved since , although there are still\n several areas of subsegmental atelectasis in the right lung. Left lung is\n grossly clear. Heart size normal. Dual-channel right jugular and left\n subclavian line both end at or just below the superior cavoatrial junction.\n Tracheostomy tube in standard placement. Pleural effusion is minimal on the\n left if any. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240384, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi system organ failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:36 A.M., \n\n HISTORY: 31-year-old woman with multisystem organ failure.\n\n IMPRESSION: AP chest compared to through 18:\n\n New right perihilar opacification suggests pneumonia. Heart size is normal.\n Pulmonary vascular engorgement is new but mild, and there is no pulmonary\n edema or appreciable pleural effusion. Tracheostomy tube in standard\n placement. Left subclavian and right jugular lines both end in the region of\n the superior cavoatrial junction. No pneumothorax or large pleural effusion.\n\n Findings were discussed by telephone with the house officer caring for this\n patient at 12:45, two minutes after discovery.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240468, "text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ARDS\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multisystem organ failure\n REASON FOR THIS EXAMINATION:\n ARDS\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:04 AM, \n\n HISTORY: 31-year-old woman with multiple organ failure and ARDS.\n\n IMPRESSION: AP chest compared to :\n\n Tracheostomy tube in position. Dual-channel right internal jugular and left\n subclavian lines both end in the upper right atrium, as before. Nasogastric\n tube has been removed. Left lung clear. Elevation of the right hemidiaphragm\n and reduced right lung volume are longstanding but there is a persistent acute\n right perihilar pulmonary abnormality, which could be pneumonia. No\n pneumothorax. Pleural effusions are small if any.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1239043, "text": " 3:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p left IJ central venous catheter placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p left IJ central venous catheter placement\n REASON FOR THIS EXAMINATION:\n s/p left IJ central venous catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Left internal jugular vein catheter.\n\n COMPARISON: , 3:40 a.m.\n\n FINDINGS: As compared to the previous radiograph, the left-sided central\n venous access line has been removed. The right-sided internal jugular vein\n catheter is unchanged. A right pre-existing PICC line is also unchanged.\n\n There is no evidence of complications, notably no pneumothorax. Unchanged\n aspect of the perihilar opacities on the right. A minimal pleural effusion\n might have newly occurred.\n\n The pre-existing drain is no longer visible.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238831, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi organ failure, increasing respiratory support\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiorgan failure with increasing respiratory support.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is extremely low lung volumes with retrocardiac\n opacification consists most likely reflecting atelectasis. In the appropriate\n clinical setting, supervening pneumonia would have to be considered.\n\n Monitoring and support devices remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1238911, "text": " 3:05 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PICC tip check pulled back 2 more cm \n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with repo additional 2 cm\n REASON FOR THIS EXAMINATION:\n PICC tip check pulled back 2 more cm \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with repo of PICC line.\n\n COMPARISONS: Prior radiograph from at 2 p.m.\n\n FINDINGS: Right PICC line tip is seen in the right brachicephalic vein.\n There is otherwise no significant change from the prior radiographs.\n\n IMPRESSION: Malpositioned right PICC catheter in the right brachicephalic\n vein.\n\n These findings were reported to , IV nurse, by Dr. via\n telephone at 3:15 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241314, "text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan system failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 31-year-old woman with multiorgan system failure.\n\n FINDINGS: Comparison is made to previous study from at 3:41 p.m.\n\n There is a large right-sided central venous line with the distal lead tip in\n the proximal right atrium. There is a left-sided subclavian catheter with the\n distal tip at the cavoatrial junction. Tracheostomy tube is seen. There is a\n feeding tube whose side port is at the GE junction and this could be advanced\n several centimeters for more optimal placement. There is elevation of the\n right hemidiaphragm. The heart size is within normal limits. There is\n improvement of the airspace opacities in lung bases since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238693, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure, intubated/sedated.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multiorgan failure, intubation, sedation, evaluation for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Monitoring and support devices are in constant position, except for\n the nasogastric tube that has now been advanced. Its tip projects over the\n middle parts of the stomach. The drain device projecting over the left upper\n quadrant is constant. There are bilateral areas of basal atelectasis, left\n more than right, at overall low lung volumes. Borderline size of the cardiac\n silhouette. No new parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241654, "text": " 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Trach tube placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with new trach tube #7\n REASON FOR THIS EXAMINATION:\n Trach tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: New tracheostomy.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Tracheostomy tip is 5.3 cm above the carina. Hemodialysis line tip is at the\n cavoatrial junction. Left subclavian line tip is at the cavoatrial junction.\n Heart size, mediastinal are unremarkable. Bibasilar atelectasis are\n unchanged. No pneumothorax is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241881, "text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi system organ failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Multisystem organ failure.\n\n Comparison is made with prior study .\n\n There are low lung volumes. Tracheostomy tube is in standard position. Right\n large-bore catheter is in the standard position. Bibasilar opacities are\n increased markedly on the left. This could be due to atelectasis. A\n superimposed infection cannot be excluded. Small right pleural effusion is\n newly appearing.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241277, "text": " 3:34 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval NGT placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31F s/p gastric bypass now w/ NGT placed in setting of GIB\n REASON FOR THIS EXAMINATION:\n Eval NGT placement\n ______________________________________________________________________________\n WET READ: LLTc SAT 7:48 PM\n NGT terminating with the stomach, with side port at the GE junction.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: Patient with nasogastric tube in the setting of GI bleed.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is a nasogastric tube whose side port is above the GE junction. This\n could be advanced several centimeters for more optimal placement. There are\n bilateral central venous catheters and tracheostomy which are unchanged.\n There are low lung volumes with elevation of the right hemidiaphragm and\n atelectasis at the right lung base, stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-14 00:00:00.000", "description": "CTA ABD & PELVIS", "row_id": 1240160, "text": " 1:49 PM\n CTA ABD & PELVIS Clip # \n Reason: new intra-abdominal bleeding\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure\n REASON FOR THIS EXAMINATION:\n new intra-abdominal bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:07 PM\n 1. No evidence for acute active bleeding.\n 2. Diminutive celiac trunk.\n 3. Esophageal catheter terminates in the distal esophagus. Advancing the\n catheter is recommended.\n 4. Enlargement of the left common iliac vein, unchanged; thrombus cannot be\n excluded.\n\n Findings discussed with Dr. by Dr. in person at 3:50 p.m.\n on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female status post aborted cholecystectomy due to\n aortic injury and splenic injury, now status post splenectomy, with\n multisystem organ failure and blood draining from wound VAC.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images through the abdomen and pelvis were acquired\n before and after administration of intravenous contrast in the arterial and\n venous phases. Coronal and sagittal reformatted images were reviewed.\n\n FINDINGS: There has been interval resolution of the right pleural effusion\n and decrease in the left pleural effusion which is now trace. There is\n improved but persistent bibasilar atelectasis. An esophageal catheter\n terminates in the distal esophagus. Central catheters terminate at the level\n of the cavoatrial junction.\n\n ABDOMEN: The liver is fatty. No focal lesions are detected. The patient is\n status post splenectomy. A drain terminates in the left upper quadrant in the\n region of the previously seen fluid collection, which is now much smaller. Two\n sponges are seen in the anterior upper abdomen with radiopaque tags. There is\n a small amount of perihepatic and pericholecystic ascites and small amount of\n mesenteric and retroperitoneal fluid. Hematoma anterior to the aorta appears\n similar. There is no evidence for acute or active bleeding at this time.\n Stones are seen in the gallbladder with mild gallbladder wall edema. The\n pancreas, adrenal glands, and kidneys are unremarkable. The patient is status\n post Roux-en-Y gastric bypass; there has been interval resolution of the\n dilation of the duodenal limb. There is persistent but improved dilation at\n the level of the jejunojejunal anastomosis. The remainder of the visualized\n bowel demonstrates no acute abnormalities.\n\n (Over)\n\n 1:49 PM\n CTA ABD & PELVIS Clip # \n Reason: new intra-abdominal bleeding\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The origin of the celiac axis is diminutive. The inferior vena cava is\n collapsed, suggesting depleted volume status. Diffuse anasarca is again seen.\n\n PELVIS: Calcified fibroids are again seen in the region of the uterus. A\n rectal catheter and Foley catheter are seen; air in the bladder is likely\n secondary to recent instrumentation. Enlargement of the left common iliac\n vein is unchanged.\n\n There is anterolisthesis of L5 on S1 with bilateral L5 spondylolysis.\n\n IMPRESSION:\n 1. No evidence for acute active bleeding.\n 2. Diminutive celiac trunk.\n 3. Esophageal catheter terminates in the distal esophagus. Advancing the\n catheter is recommended.\n 4. Enlargement of the left common iliac vein, unchanged; thrombus cannot be\n excluded.\n\n Findings discussed with Dr. by Dr. in person at 3:50 p.m.\n on .\n\n" }, { "category": "Radiology", "chartdate": "2139-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239364, "text": " 4:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate NGT position\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p NGT replacement\n REASON FOR THIS EXAMINATION:\n evaluate NGT position\n ______________________________________________________________________________\n WET READ: EHAd FRI 9:11 PM\n NGT terminates in the stomach. Stable position of ETT, right PICC, left\n subclavian central catheter, right IJ central catheter. Stable heart size and\n mediastinum. Stable low lung volumes and elevated right hemidiaphragm.\n Unchanged bibasilar atelectasis and pulmonary edema. - \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube replacement.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The tip of the NG tube terminates over the gastric fundus. Otherwise, little\n interval change compared with .\n\n" }, { "category": "Radiology", "chartdate": "2139-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241203, "text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ system failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 31-year-old woman with multiorgan system failure. Evaluate\n interval change.\n\n FINDINGS: Since the previous study, the nasogastric tube has been advanced\n and the distal tip is in the fundus of the stomach; however, the side port is\n at the GE junction. This could be advanced 6 to 10 cm for more optimal\n placement. Tracheostomy tube is appropriately sited. There are bilateral\n central venous lines which are unchanged in position. There are markedly low\n lung volumes and some atelectasis at the lung bases, right worse than left.\n There is some elevation of the left hemidiaphragm.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-23 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1241204, "text": " 3:42 AM\n PORTABLE ABDOMEN Clip # \n Reason: long-standing constipation\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ system failure, constipation\n REASON FOR THIS EXAMINATION:\n long-standing constipation\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable abdomen .\n\n CLINICAL HISTORY: 31-year-old woman with multiorgan system failure and\n constipation.\n\n FINDINGS: There is an infrarenal filter seen. Nonspecific bowel gas pattern\n with air seen throughout non-dilated loops of colon and mildly prominent loops\n of small bowel within the mid abdomen. There is a relative paucity of bowel\n gas within the descending colon and in the rectum. The nasogastric tube tip\n is in the fundus of the stomach. Multiple surgical clips are seen projecting\n over the abdominal midline.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-24 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1241315, "text": " 4:32 AM\n PORTABLE ABDOMEN Clip # \n Reason: interval change. Please ensure film is appropriately penetra\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with lower GIB, ileus\n REASON FOR THIS EXAMINATION:\n interval change. Please ensure film is appropriately penetrated as patient is\n large and films tend to be underpenetrated. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable abdomen .\n\n CLINICAL HISTORY: 31-year-old woman with lower GI bleed and ileus.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is an IVC filter. There are surgical clips projecting over the spine.\n There are catheter devices seen along the lower pelvis. The bowel gas pattern\n is nonspecific. There is some air seen throughout the non-dilated loops of\n small bowel and colon; however, no definite sign of small-bowel obstruction is\n seen. No free intra-abdominal gas is present.\n\n" }, { "category": "Radiology", "chartdate": "2139-06-01 00:00:00.000", "description": "REMOVE TUNNELED CENTRAL W/O PORT", "row_id": 1242296, "text": " 5:36 PM\n TUNNEL LINE REPLACEMENT Clip # \n Reason: Please d/c tunnel line\n Admitting Diagnosis: CHOLYCYSTITIS\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with R tunnel line\n REASON FOR THIS EXAMINATION:\n Please d/c tunnel line\n ______________________________________________________________________________\n FINAL REPORT\n TUNNELED HEMODIALYSIS CATHETER REMOVAL\n\n INDICATION: 31-year-old woman with existing right IJV tunneled hemodialysis\n catheter, not used. Requesting physician requested that the catheter tip be\n sent for culture.\n\n CONTRAST: None.\n\n SEDATION: None.\n\n PROCEDURE AND FINDINGS: Under aseptic conditions, the right IJV tunneled\n hemodialysis catheter was removed with gentle traction. The tip was sent for\n microbiology analysis. Patient tolerated the procedure well. Hemostasis was\n achieved by manual pressure at the venotomy site. No immediate post-procedure\n complication was seen.\n\n IMPRESSION: Uncomplicated removal of right IJV tunneled hemodialysis\n catheter. Tip sent for microbiology analysis.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241067, "text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assessment\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multisystem organ failure\n REASON FOR THIS EXAMINATION:\n interval assessment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with multisystem organ failure.\n\n COMPARISONS: to .\n\n FINDINGS: A single portable AP chest radiograph was obtained. A tracheostomy\n tube remains in the upper airway. Right internal jugular large bore catheter\n and left subclavian line terminate in the right atrium. A surgical drain\n remains in the left upper quadrant. Lung volumes remain low. Right middle\n and upper lobe atelectasis is similar. No new consolidation, effusion, or\n pneumothorax is present.\n\n IMPRESSION: Stable appearance of low lung volumes and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2139-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1242336, "text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rising wbc. pneumonia, pneumothorax?\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan system dysfunction s/p iatrogenic injury to\n aorta in \n REASON FOR THIS EXAMINATION:\n rising wbc. pneumonia, pneumothorax?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multiorgan system dysfunction, evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is slightly\n increasing loss of transparency at the lung bases, likely reflecting\n increasing atelectasis. Low lung volumes, moderate fluid overload, and\n moderate cardiomegaly. Tracheostomy tube in situ. The patient has received a\n new PICC line which is in correct position. The previously placed\n hemodialysis catheter has been removed in the interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-27 00:00:00.000", "description": "CTA ABD & PELVIS", "row_id": 1241675, "text": " 2:40 PM\n CTA ABD & PELVIS Clip # \n Reason: Localize bleed?\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with aortic injury which was fixed and with ongoing massive\n GI bleeding of unclear etiology. Bleed is likely from stomach or duodenum.\n REASON FOR THIS EXAMINATION:\n Localize bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SVMc WED 6:03 PM\n - no evidence of active extrav\n - previously dilated loop of jejunum near the j-j anastomosis is significantly\n less dilated and now fluid filled. previously it was thought to be blood\n filled.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 31-year-old woman with aortic injury with ongoing massive\n GI bleed. Question localization.\n\n COMPARISON: as well as more remote CTs.\n\n TECHNIQUE: Helical images of the abdomen and pelvis were acquired before and\n after administration of IV contrast. There were formatted into coronal and\n sagittal planes.\n\n TOTAL DLP: 3933.38 mGy-cm.\n\n CT OF THE ABDOMEN:\n\n LUNG BASES AND HEART APEX: There are small, layering, non-hemorrhagic\n bilateral pleural effusions along with compressive atelectasis at the lung\n bases. Imaged portion of the heart apex is unremarkable.\n\n LIVER: Liver enhances heterogeneously, however, shows no focal liver lesions\n (4a:45). There is also a subcapsular fluid collection which causes some\n indentation of the liver (4a:34 and 4a:31) which is not appreciably different\n from the prior study.\n\n GALLBLADDER: Multiple gallstones are seen within the gallbladder, unchanged.\n\n PANCREAS: The pancreas is unremarkable.\n\n SPLEEN: Spleen is absent. In the area of the splenic area, there is now a\n fluid collection with two drains in place without appreciable difference in\n the size of the collection from the study.\n\n KIDNEYS: Bilateral kidneys enhance and excrete contrast symmetrically without\n (Over)\n\n 2:40 PM\n CTA ABD & PELVIS Clip # \n Reason: Localize bleed?\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n any evidence of hydronephrosis. There is on the right a 2.6 x 1.5 cm\n subcapsular collection (4a: 75) again unchanged from the prior studies.\n\n VASCULAR STRUCTURES: Aorta and its major branches are all patent. There is\n an IVC filter in place. Portal, SMA and splenic veins are all patent.\n\n BOWEL: Patient is status post Roux-en-Y gastrectomy. Patient is also status\n post jejunojejunostomy (4a:135). While this loop of jejunum was dilated on\n the previous study and filled with high-density material, on today's study it\n is simply fluid filled substantially less dilated (4a:133).\n\n There is intraperitoneal free air, likely postoperative, along with diffuse\n stranding of the intra-abdominal fat and free fluid within the pelvis along\n the paracolic gutters as well as anterior and lateral to the liver. No active\n area of extravasation can be identified on this study. There is general small\n amount of free fluid within the abdomen itself.\n\n PELVIS: Again noted is a fibroid uterus. The colon is fluid filled without\n wall thickening. Two additional drains are seen entering into the pelvis and\n residing in the anterior abdominal wall.\n\n No suspicious bony lesions are noted.\n\n IMPRESSION:\n 1. Previously massively dilated loop of jejunum which previously contained\n dense contents now is now less dilated and fluid filled.\n\n 2. No areas of active extravasation noted.\n\n 3. Gallstones and fibroid uterus are stable.\n\n 4. Bilateral pleural effusions, stable.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-23 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1241188, "text": " 12:09 AM\n MESSENERTIC Clip # \n Reason: assess source of bleed and embolize if found\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OPTIRAY Amt: 160\n ********************************* CPT Codes ********************************\n * INITAL 3RD ORDER ABD/PEL/LOWER EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * VISERAL SEL/SUPERSEL A-GRAM VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with aortic injury, MOSF, now with new likely GI bleed\n REASON FOR THIS EXAMINATION:\n assess source of bleed and embolize if found\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman status post extensive surgery, now with a\n history of bloody output from her jejunal tube and melena, concerning for an\n upper GI bleed, including hematocrit drop and hemodynamic instability.\n\n PHYSICIANS: Dr. , the attending radiologist, performed the\n procedure. Dr. , fellow.\n\n MEDICATIONS: This procedure was performed under general anesthesia.\n\n CONTRAST: 160 mL Optiray.\n\n PROCEDURE:\n 1. Right common femoral artery access.\n 2. Celiac, SMA, right hepatic, and left gastric arterial angiography.\n\n PROCEDURE NOTE: Prior to initiation of the procedure, informed consent was\n obtained from the patient's mother over the phone. The patient was brought\n down to the procedure room and placed supine on the table. General anesthesia\n was administered by the anesthesiology team (see separate dictated note for\n that). A preprocedure timeout was performed. The right greater groin was\n prepped and draped in a sterile manner. Under ultrasound guidance, axial\n FLAIR, femoral artery film was obtained over the mid femoral head, and a 5\n French sheath was placed. A C2 glide catheter was advanced into the aorta\n used to select the SMA, and angiography was performed. Next, this was\n exchanged for catheter, which was used to select the celiac\n ostium, and additional angiography was performed. Following this, this was\n exchanged again for the C2 glide catheter which was used to select the right\n hepatic artery and left gastric artery, and selective angiography was\n performed. No active extravasation was seen. The catheter and sheath were\n removed, and manual compression was applied to hemostasis.\n\n FINDINGS:\n 1. Patent right common femoral artery, with normal anatomy over the common\n femoral head.\n (Over)\n\n 12:09 AM\n MESSENERTIC Clip # \n Reason: assess source of bleed and embolize if found\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OPTIRAY Amt: 160\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Celiac angiography demonstrates variant anatomy, with early bifurcation of\n the common hepatic artery, anterior right and left hepatic artery. Absence of\n the splenic artery is post-surgical. No GDA was identified on angiography. A\n smooth tapered narrowing of the origin of the right hepatic artery and left\n gastric artery at its bifurcation was noted, with brisk forward flow - this\n likely represents vasospasm. No active extravasation or pseudoaneurysms were\n identified. Selective right hepatic and left gastric angiography also\n demonstrated no active extravasation or pseudoaneurysms.\n 3. SMA angiography demonstrated diffuse vessel attenuation (may reflect\n vasoconstriction from hypovolemia or effects of vasopressin, which has been\n used as a pressor ). No active extravasation or pseudoaneurysm is seen.\n Additionally, no pancreaticoduodenal branches or retrograde filling of the GDA\n was identified.\n\n IMPRESSION: Celiac, SMA, and selective hepatic and left gastric angiography\n do not demonstrate any source of active extravasation.\n\n Findings were discussed with Dr. by Dr. , upon completion\n of the procedure. If the patient re-bleeds, they will contact IR for repeat\n angiography.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1242008, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: monitoring\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan failure after traumatic lap chole now trached\n REASON FOR THIS EXAMINATION:\n monitoring\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Multiorgan failure.\n\n REFERENCE EXAM: .\n\n FINDINGS: There continue to be low lung volumes with an elevated right\n hemidiaphragm and volume loss in the right lower lobe. There are small\n bilateral pleural effusions. Given the amount of volume loss in the lower\n lobe, infiltrates cannot be excluded. There is minimal pulmonary vascular\n re-distribution. Tracheostomy tube is again seen. Overall, there is no\n substantial change compared to prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239594, "text": " 4:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: 39-year-old woman with multiorgan failure, for evaluation.\n\n TECHNIQUE: Portable semi-erect chest view was read in comparison with prior\n radiograph from .\n\n FINDINGS: Tracheostomy tube is in standard position. Right internal jugular\n line ends at lower SVC and left subclavian line tip is in the lower SVC as\n well. Orogastric tube courses below the diaphragm and ends approximately at\n the level of the gastroesophageal junction. Considering advancing the\n orogastric tube by additional 7-8 cm for appropriate seating. Since , lung opacity in the left juxtahilar and the lower lung and retrocardiac\n density reflecting atelectasis and/or aspiration has significantly improved.\n In addition, previously appreciated mild pulmonary vascular congestion is\n better. Heart size is normal, mediastinal and hilar contours are unchanged.\n There is no pleural effusion or pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-06 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1238990, "text": " 8:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: r/o PE (PE protocol). Evaluate for hidden abdominal/pelvic f\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31F s/p aborted lap cholecystectomy, complicated by splenic and aortic injuries\n requiring splenectomy and aortic repair, now s/p multiple abdominal washouts\n and open abdomen, now with sepsis, tachycardic and hypoxic\n REASON FOR THIS EXAMINATION:\n r/o PE (PE protocol). Evaluate for hidden abdominal/pelvic fluid collections\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg WED 12:17 PM\n 1. suboptical opacification of pulmonary arterial vasculature. no pulmonary\n embolism identified.\n 2. complete LLL collpase. partial RLL collapse. adjacent heterogenous\n opacities are nonspecific in setting of respiratory motion, but infection is\n not excluded. small left nonhemorrhagic pleural effusion\n 3. fluid in the splenectomy bed with thin rim enhancement. superinfection is\n not excluded on imaging\n 4. early or partial SBO with transition point at the distal jejunojejunostomy\n site with reflux of fluid into the afferent loop.\n 5. anasarca\n\n -MAgarwal d/w (surgery) in person at 11:45am at time of\n initial review.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 31-year-old woman, status post aborted laparoscopic\n cholecystectomy complicated by splenic and aortic injuries, requiring\n splenectomy and aortic repair, now status post multiple abdominal washouts and\n open abdomen with sepsis, tachycardia, and hypoxia. Evaluate for pulmonary\n embolism or hidden abdominal or pelvic fluid collections.\n\n COMPARISON: CT ; ultrasounds and .\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n after the administration of 130 mL intravenous contrast. Images are presented\n for display at 5-mm collimation. Subsequently, images of the abdomen and\n pelvis were obtained with intravenous contrast and Gastrografin. Multiplanar\n reformation images were submitted for review.\n\n DLP: 1600.43 mGy-cm.\n\n CT CHEST: The patient is intubated, endotracheal tube ends 3.9cm above the\n carina. A nasogastric tube is within the esophagus. The thoracic aorta is\n normal in caliber without evidence of dissection. Contrast bolus timing in\n the pulmonary artery is suboptimal. Additionally, evaluation of the\n subsegmental pulmonary arteries is limited by atelectasis. Within these\n limitations, there is no filling defect to suggest pulmonary embolism. The\n heart, pericardium, and great vessels are within normal limits. No\n (Over)\n\n 8:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: r/o PE (PE protocol). Evaluate for hidden abdominal/pelvic f\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pathologically enlarged axillary, mediastinal, or hilar lymph nodes are\n identified, ranging up to 8 mm in the precarinal station (2B:30). There is no\n pericardial effusion. No right pleural effusion. There is a small left\n non-hemorrhagic pleural effusion with complete collapse of the left lower lobe\n and partial right lower lobe collapse. Heterogenous opacities adjacent to the\n collapsed parenchyma may be due to respiratory motion or atelectasis, but\n infection cannot be excluded. The upper lung zones are clear.\n\n CT ABDOMEN: The liver is diffusely hypodense compatible with fatty deposition\n without focal liver lesion identified. There is no intra- or extra-hepatic\n bile duct dilation. The gallbladder is distended with multiple small stones.\n Pericholecystic fluid is nonspecific in the setting of anasarca and small\n perihepatic ascites. Spleen is absent. Within the splenic bed, there is an\n approximately 12.6 x 4.1 cm curvilinear fluid collection with a thin enhancing\n rim. Superinfection of the collection cannot be excluded. The pancreas and\n right adrenal gland are normal. The left adrenal gland is not well\n visualized. There is no hydronephrosis bilaterally.\n\n The patient is status post Roux-en-Y bypass surgery. The Roux limb is dilated\n to the level of the jejunojejunostomy, with fluid within the dilated afferent\n loop. The small bowel becomes decompressed at the jejunojejunostomy\n anastomotic site (2A:141); however, there are dilated small bowel loops distal\n to the anastomotic site with collapse of the terminal ileum and large bowel.\n The findings are concerning for partial or early small bowel obstruction with\n a transition point at the jejunojejunostomy anastomotic site.\n\n The abdominal aorta is of normal caliber throughout. An ill-defined soft\n tissue density at the aortic bifurcation may represent a small hematoma after\n known aortic bifurcation injury. Main portal vein and SMV are patent. The\n abdomen is open with pneumoperitoneum.\n\n CT PELVIS: A rectal tube is within the rectum. The sigmoid is decompressed.\n A Foley catheter is in the decompressed bladder. A 3.5 x 5.8 cm calcified\n fibroid is seen in the left uterus as seen on pelvic ultrasound . An\n adjacent hypodensity in the uterus measuring 5.7 x 4.7cm is probably a second\n fibroid.\n\n There is diffuse anasarca throughout the body wall.\n\n BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.\n Grade 1 anterolisthesis of L5 on S1 is noted.\n\n IMPRESSION:\n 1. Suboptimal contrast bolus in the pulmonary arterial tree. No filling\n defect to suggest pulmonary embolism.\n 2. Left lower lobe collapse and partial right lower lobe collapse. Adjacent\n (Over)\n\n 8:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: r/o PE (PE protocol). Evaluate for hidden abdominal/pelvic f\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n heterogeneous opacities may be due to atelectasis or respiratory motion, but\n infection cannot be excluded. Small left nonhemorrhagic pleural effusion.\n 3. Thin rim-enhancing curvilinear collection in the splenectomy bed.\n Superinfection cannot excluded on imaging.\n 4. Early or partial small bowel obstruction with the transition point at the\n jejunojejunostomy site. More distal small bowel loops are intermittently\n dilated with a collapsed terminal ileum and large bowel. Reflux of fluid into\n the afferent loop of the gastric bypass.\n 5. Fibroid uterus.\n 6. Anasarca.\n 7. Fatty liver.\n\n Findings were discussed with Dr. (surgery) in person at 11:45am\n at time of initial review.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238041, "text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f interval progression\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p traumatic aortic injury with multi-organ dysfunction\n REASON FOR THIS EXAMINATION:\n e/f interval progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post traumatic aortic injury, evaluation for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is improved\n transparency of the lung parenchyma, notably at the right lung apex, likely\n reflecting improved ventilation. However, small pleural effusion on the left\n persists, as does an area of relatively extensive retrocardiac atelectasis.\n The lung volumes remain low, the size and shape of the cardiac silhouette is\n constant. Unchanged nasogastric tube, endotracheal tube, right internal\n jugular vein catheter and left internal jugular vein dialysis catheter.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1242473, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evolution\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan system dysfunction s/p iatrogenic injury to\n aorta in \n REASON FOR THIS EXAMINATION:\n evolution\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:45 \n\n HISTORY: 31-year-old woman with multiorgan system dysfunction after aortic\n injury.\n\n IMPRESSION: AP chest compared to through :\n\n Lung volumes remain exceedingly low. Nevertheless, there does appear to be\n new opacification in the right upper lung which could be asymmetric edema or\n alternatively pneumonia, and there is also greater consolidation in the\n infrahilar left lung now more substantially obscuring the left hemidiaphragm.\n This is probably atelectasis. Tracheostomy tube is in standard position.\n Right PIC line has migrated from the SVC to the left brachiocephalic vein.\n Withdrawing it 5.5 cm would return to the origin of the SVC. No pneumothorax.\n\n Dr. was paged at 11:19, 3 minutes following recognition of the\n radiographic findings which were discussed with a nurse on his\n behalf 5 minutes later.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240814, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assessment\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure. + tracheostomy\n REASON FOR THIS EXAMINATION:\n interval assessment\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Multisystem organ failure. Tracheostomy.\n\n There are low lung volumes. Cardiomediastinal contours are normal.\n Tracheostomy tube is in standard position. Right perihilar opacity has\n minimally improved, consistent with improving atelectasis. Right lower lobe\n atelectasis is unchanged. There are no new lung abnormalities, pneumothorax\n or pleural effusion. Bilateral central catheter tips are in the superior\n aspect of the right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238299, "text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-organ failure after aortic tear\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Multiorgan failure, status post aortic tear.\n\n TECHNIQUE: AP radiograph was obtained.\n\n COMPARISON: .\n\n REPORT:\n NG tube is identified coursing throughout the mediastinum. It terminates in\n the left hypochondrium. A right-sided central line is in good position. ET\n tube is in good position. A left-sided Swan sheath is in good position at the\n proximal SVC.\n\n There is patchy change in the left base, probably represents a small effusion.\n This is unchanged from prior study. Otherwise, no acute finding is seen.\n\n CONCLUSION:\n Support hardware in appropriate position. No interval change from prior\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239771, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: trach'd\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan failure,\n REASON FOR THIS EXAMINATION:\n trach'd\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiorgan failure with tracheostomy.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place with the tip of the nasogastric tube in the distal\n esophagus. The tube should be pushed forward about 8 cm for better seating.\n\n Continued low lung volumes. Mild atelectatic changes in the retrocardiac\n region. No appreciable vascular congestion or acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243248, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for aspiration in setting of restarting PO intake\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with complicated surgical history, cough, new fever\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration in setting of restarting PO intake\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with complicated surgical\n history and cough and new fever.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n No change in heart size and mediastinal contours is demonstrated. Patient\n continues to be in mild pulmonary edema. There is impression of new\n consolidation in the left lower lung, adjacent to the left cardiac border that\n potentially might reflect interval development of infectious process.\n Otherwise, no substantial change demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241179, "text": " 9:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess ngt placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with new ngt placement\n REASON FOR THIS EXAMINATION:\n assess ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest , .\n\n CLINICAL HISTORY: 31-year-old woman with new nasogastric tube placement.\n\n FINDINGS: There is a tracheostomy tube whose distal tip is at the level of\n clavicular heads. There is a bilateral central venous catheter whose distal\n lead tip is at the cavoatrial junction. There is mild elevation of the right\n hemidiaphragm. There is some atelectasis at the lung bases. Cardiac\n silhouette and mediastinum is within normal limits. There is placement of a\n nasogastric tube whose tip is too high and is several centimeters above the\n gastroesophageal junction. This could be advanced at least 15-20 cm for more\n optimal placement.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-30 00:00:00.000", "description": "GI BLEEDING STUDY", "row_id": 1242072, "text": "GI BLEEDING STUDY Clip # \n Reason: S/P EXPLORATORY LAPAROTOMY, SPLENECTOMY, AORTIC BIFURCATION REPAIR P/W MELENA DECREASED HCT/HYPOTENSION R/ GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 14.8 mCi Tc-m RBC ();\n HISTORY: Patient status post exploratory laparatomy with aortic injury and\n repair with melena, decreased hematocrit and hypotension; evaluate for GI\n bleed.\n\n TECHNIQUE: Following the in- labeling of autologous RBCs, blood flow images\n for 1 second per frame were obtained. Serial dynamic images at one minute per\n frame were then obtained for 90 minutes. A lateral static view of the pelvis was\n obtained following dynamic images.\n\n INTERPRETATION: Blood flow images show normal tracer flow through the large\n vessels of the abdominal and pelvic vasculature.\n\n Dynamic images of the abdomen show tracer accumulating over left mid abdomen\n over the expected region of the descending colon. The initial focus of\n accumulation faded with additional imaging. Due to the small amount of\n bleeding, the anatomy of the site of bleeding was not defined, and the exact\n location cannot be determined with certainty. During the last 30 minutes the\n focus, which had presumably stopped bleeding, was not identified.\n\n IMPRESSION: Small focus of tracer uptake in the left mid abdomen possibly over\n the region of the descending colon with no further bleed noted likely due to\n small GI bleed which stopped during the course of the study.\n\n Findings discussed with Dr. at the time of completion of the study at\n 7:30 pm via telephone on .\n\n\n\n , M.D.\n , M.D. Approved: TUE 3:31 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2139-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1242635, "text": " 4:42 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evolution\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan system dysfunction s/p iatrogenic injury to\n aorta in \n REASON FOR THIS EXAMINATION:\n evolution\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multiorgan system dysfunction, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the tracheostomy tube is in\n unchanged position. Lung volumes have minimally decreased. A drain is seen\n projecting over the left upper quadrant.\n\n The pre-existing retrocardiac atelectasis and minimal blunting of the left\n costophrenic sinus as well as moderate cardiomegaly are constant. Slightly\n increased is the atelectatic crowding of vascular structures at the right lung\n base. No other changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-06-04 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1242723, "text": " 3:22 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please reposition picc into central system\n Admitting Diagnosis: CHOLYCYSTITIS\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 31F s/p aborted lap cholecystectomy, complicated by splenic and aortic injuries\n requiring splenectomy and aortic repair . Has returned to OR multiple times\n for washouts. ex lap for perf'd J. Closed abdomen on . Pt most\n recently w/ GIB of unclear source, thus went for tagged RBC scan on which\n showed no active bleed. Now with herniated bowel through mesh.\n REASON FOR THIS EXAMINATION:\n Please reposition picc into central system\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31 y/o female with malposition of right sided indwelling PICC line\n into opposite side subclavian vein.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. (attending) and Dr (resident) performed the\n procedure.\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 then placed over the guidewire. A new double lumen PICC\n line measuring 42.5 cm in length was then placed through the peel-away sheath\n with its tip positioned in the SVC under fluoroscopic guidance. Position of\n the catheter was confirmed by a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied. The patient tolerated\n the procedure well. There were no immediate complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new\n double lumen PICC line. Final internal length is 42.5 cm, with the tip\n positioned in the SVC. The line is ready to use.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2139-06-01 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1242288, "text": " 4:20 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: 31 year old woman with mult attempts from IV team to place P\n Admitting Diagnosis: CHOLYCYSTITIS\n This is a power pick\n ********************************* CPT Codes ********************************\n * PICC W/O REMOVE TUNNELED CENTRAL W/O PO *\n * -59 DISTINCT PROCEDURAL SERVICE FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with mult attempts from IV team to place PICC line but\n unsuccessful.\n REASON FOR THIS EXAMINATION:\n 31 year old woman with mult attempts from IV team to place PICC line but\n unsuccessful.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT AND REMOVAL OF TUNNELED HEMODIALYSIS CATHETER\n\n INDICATION: 31-year-old woman with multiple attempts by IV team to place PICC\n but unsuccessful.\n\n OPERATORS: Drs. (fellow) and (attending\n physician). Dr. was present during key moments of the procedure.\n\n CONTRAST: None.\n\n SEDATION: None.\n\n PROCEDURE AND FINDINGS: Patient was placed supine on the imaging table in the\n interventional suite. Timeout was performed as per protocol.\n\n Under aseptic conditions, guidance, and after infiltrating the\n skin and subcutaneous tissues with 1% lidocaine, a micropuncture needle was\n placed in the patent right basilic vein. images were printed\n prior to and following needle placement. A 0.018 wire was advanced through\n the needle and eventually into the IVC. After making a small incision at the\n access site, the needle was removed to place a 5 French peel-away sheath.\n After appropriate measurements and removal of the inner cannula, a 5 French 40\n cm double-lumen PowerPICC was placed. Sheath was peeled away and wire was\n removed. Catheter tip was confirmed under fluoroscopy to be in the lower SVC.\n Lumens were aspirated and flushed. Catheter was secured by StatLock. Site\n was dressed in a sterile fashion. Patient tolerated the procedure well and no\n immediate post-procedure complication was seen.\n\n Incidental note of moderate right pleural effusion and tracheostomy tube was\n made.\n\n Under aseptic conditions, the right IJV tunneled hemodialysis catheter (tip in\n the right atrium) was removed by gentle traction after removing the securing\n sutures. Firm pressure was applied to the venotomy site for about 5 minutes\n (Over)\n\n 4:20 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: 31 year old woman with mult attempts from IV team to place P\n Admitting Diagnosis: CHOLYCYSTITIS\n This is a power pick\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to achieve complete hemostasis. Patient tolerated the procedure well and and\n no immediate post-procedure complication was seen.\n\n IMPRESSION:\n 1. Uncomplicated ultrasound and fluoroscopy-guided placement of a 5 French 40\n cm double-lumen PowerPICC via the patent right basilic vein, and with its tip\n in the lower SVC.\n 2. Uncomplicated removal of the right IJV tunneled hemodialysis catheter.\n Tip was sent for microbiology analysis.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-19 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1240773, "text": " 3:08 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place tunelled HD line in RIJ through a new stick (ha\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OPTIRAY Amt: OPT320=12,OMNI350=30\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O INS ENDOVAS VENA CAVA FILTER *\n * FLUORO GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with CVVH requirement, needs tunelled HD line.\n REASON FOR THIS EXAMINATION:\n Please place tunelled HD line in RIJ through a new stick (has a current\n temporary line through same area).\n ______________________________________________________________________________\n FINAL REPORT\n IVC-GRAM, IVC FILTER PLACEMENT AND TUNNELED HEMODIALYSIS CATHETER PLACEMENT.\n\n INDICATION: 31-year-old woman with renal insufficiency requiring tunneled\n hemodialysis catheter. Also, has contraindication to anticoagulation and\n hence needs IVC filter.\n\n OPERATORS: Drs. (fellow) and (attending\n physician). Dr. was present in the room and supervised throughout the\n procedure.\n\n SEDATION: Moderate sedation with divided doses of intravenous 200 mcg\n fentanyl and 7 mg of Versed over three hours, during which patient's\n hemodynamic status was continuously monitored by a trained radiology nurse.\n\n CONTRAST: Sterile 15 mL Optiray 320 and 30 mL Omnipaque 350.\n\n PROCEDURE AND FINDINGS: Consent was obtained from the healthcare\n proxy (mother) after explaining the benefits, risks, and alternatives.\n Patient was placed supine on the imaging table in the interventional suite.\n Timeout was performed as per protocol.\n\n Under aseptic conditions, guidance, and after inflating the skin\n and subcutaneous tissues with adequate amounts of 1% lidocaine, a\n micropuncture needle was placed in the patent right internal jugular vein,\n just above the level of clavicle. images were printed prior to\n and following needle placement. A 0.018 wire was advanced through the needle\n into the SVC. After making an incision at the access site, the needle was\n removed to place a 4.5 French microsheath. After removing the inner cannula\n and wire, a 0.035 wire was advanced through the microsheath and into the\n IVC. After removing the microsheath, a 6 French -Tip sheath was advanced\n over the wire and into the IVC. After removing the inner cannula, the sidearm\n was aspirated and flushed. A 5 French Omniflush catheter was placed over the\n wire and within the sheath, and advanced into the lower IVC to the level of\n its bifurcation. After removing the wire, an IVC-gram was performed. It\n demonstrated:\n (Over)\n\n 3:08 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place tunelled HD line in RIJ through a new stick (ha\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OPTIRAY Amt: OPT320=12,OMNI350=30\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Single patent IVC.\n 2. Infrarenal IVC measurement of 2.15 cm.\n 3. Lowermost renal vein (right) at L1-L2 level.\n\n Based on the IVC-gram findings, we proceeded to place an Option retrievable\n IVC filter. The 6 French -Tip sheath was then removed over the \n wire to place a 6.5 French sheath (packaged as a part of the filter kit).\n After removing the inner cannula, the sidearm was aspirated and flushed.\n After removing the wire, the filter was loaded and pushed tip-to-tip with the\n help of its pusher. The sheath, along with its contents, was repositioned\n appropriately. The filter was then deployed in the infrarenal IVC by\n unsheathing. The pusher was removed. After placing the wire, the sheath was\n then removed.\n\n The 6 French -Tip sheath was placed over the wire. After removing the\n inner cannula, appropriate measurements were made. A site was chosen on the\n right anterior chest wall. After infiltrating the skin with adequate amounts\n of 1% lidocaine, an incision was made. After infiltrating the subcutaneous\n tissues along the proposed tunnel, a 15.5 French x 19 cm (tip-to-cuff)\n hemodialysis catheter was tunneled from the skin incision to exit at the\n venotomy site with the help of a blunt metallic tunneler. After removing the\n sheath from the venotomy site, the tract was sequentially dilated under\n fluoroscopy with 12 and 14 French dilators. A 16 French peel-away sheath was\n then placed. After removing the wire and inner cannula, the tunneled catheter\n was placed via the sheath, which was then peeled away. Catheter tip was\n confirmed under fluoroscopy to be in the upper right atrium. Ports were\n aspirated and flushed. Catheter was secured by 0 silk sutures. A single 4-0\n Vicryl subcuticular suture was placed at the venotomy site. Sites were\n dressed in a sterile fashion. Patient tolerated the procedure well and no\n immediate post-procedure complication was seen.\n\n Incidental note of tracheostomy tube, and right IJV and left subclavian venous\n catheters with their tips projecting over the expected location of upper\n cavoatrial junction was made.\n\n IMPRESSION\n 1. Uncomplicated IVC-gram. Based on the findings, an Option retrievable\n filter was placed in the infrarenal IVC.\n\n 2. Uncomplicated ultrasound and fluoroscopy-guided placement of a 15.5 French\n x 19 cm (tip-to-cuff) tunneled hemodialysis catheter, with its tip in the\n right atrium. The catheter is ready for use.\n (Over)\n\n 3:08 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Please place tunelled HD line in RIJ through a new stick (ha\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OPTIRAY Amt: OPT320=12,OMNI350=30\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2139-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243107, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: monitor resp status\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with tracheostomy\n REASON FOR THIS EXAMINATION:\n monitor resp status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate respiratory status in patient with tracheostomy\n following iatrogenic aortic injury.\n\n COMPARISON: A series of chest radiographs from dating back to\n .\n\n SUPINE PORTABLE RADIOGRAPH OF THE CHEST: The tracheostomy tube is no longer\n present. There is marked improvement in lung volumes and aeration when\n compared to the prior study. There is continued bilateral basilar\n atelectasis, but the lung fields are otherwise clear. Hilar and\n cardiomediastinal contours are normal. Pulmonary vascularity is normal aside\n from some crowding due to lower lung volumes. There is no pneumothorax or\n pleural effusion. A drain is once again noted in the left upper quadrant of\n the abdomen.\n\n IMPRESSION: Marked improvement in lung volume and aeration with continued\n bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2139-05-23 00:00:00.000", "description": "CTA ABD & PELVIS", "row_id": 1241220, "text": " 6:18 AM\n CTA ABD & PELVIS Clip # \n Reason: please assess for source of GI bleed\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman, with new melena, blood from jejunal tube, rapidly dropping\n crit\n REASON FOR THIS EXAMINATION:\n please assess for source of GI bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 31-year-old female with new melena blood from her jejunal tube\n rapidly, drop in hematocrit, ? GI bleed.\n\n COMPARISON: Mesenteric angiogram performed on at 00:09 hours, CTA\n abdomen and pelvis performed at 14:30 hours.\n\n TECHNIQUE: Helical images were acquired of the abdomen and pelvis before and\n after the uneventful administration of 100 cc of Omnipaque intravenously.\n These were reformatted into coronal and sagittal planes. 3D reconstructions\n were reviewed after having them produced on a separate dedicated workstation.\n\n FINDINGS:\n\n LUNG BASES: There is bibasilar atelectasis, with small bilateral pleural\n effusions.\n\n ABDOMEN: An NG tube protrudes just barely into the stomach, the sidehole is\n seen within the distal esophagus. Several central venous catheter tips\n project over the cavoatrial junction. The patient is status post Roux-en-Y.\n The proximal Roux limb is normal in caliber to a point where there is an\n apparent transition following which it becomes progressively more dilated with\n the proximal transition best seen on series 800B, image 24. There are\n markedly dilated loops of jejunum following this leading to a massively\n dilated featureless portion which measures up to 11.8 cm in maximal diameter,\n and contains a catheter. Within this is mottled content, the majority of\n which is in the region of 60 Hounsfield units in density which is nonspecific,\n though is the density of a blood clot. This loop then transitions and\n gradually tapers to a point where there is a more distal transition to normal\n caliber loops, this distal transition point is seen on series 800B, image 29.\n In the decompressed small bowel beyond this massively dilated portion, there\n is moderately high density material throughout a long segment of small bowel\n extending into right colon which measures as high as 197 Hounsfield units. By\n report, and confirmed by review of the medical record, the patient has not had\n any oral contrast recently and thus it is possible that this high density with\n a small bowel represent extravasated intravenous contrast from GI hemorrhage\n despite the fact that none were seen on the patient's recent angiogram. No\n active area of extravasation can be identified on this study.\n\n There is intraperitoneal free air, which is likely postoperative, diffuse\n (Over)\n\n 6:18 AM\n CTA ABD & PELVIS Clip # \n Reason: please assess for source of GI bleed\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n stranding of the intra-abdominal fat, and free fluid within the pelvis along\n the paracolic gutters as well as anterior and lateral to the liver, which is\n intermediate in density. Two surgical drains reside in the left upper\n quadrant, and there is a drain in the anterior abdominal wall.\n\n The liver itself is normal in appearance, the portal veins are patent. The\n gallbladder contains gallstones, and demonstrates wall thickening but is\n nondistended. The pancreas and bilateral adrenals are normal in appearance.\n The kidneys demonstrate uniform contrast enhancement and bilateral contrast\n excretion. The spleen is surgically absent.\n\n CTA demonstrates a normal caliber aorta, as seen on the patient's recent\n angiogram, there is severe narrowing at the celiac axis origin, which may be\n due to vasospasm. A diminutive GDA appears to originate from the common\n hepatic (6A:64). The SMA is widely patent. The is patent, the iliac\n vessels are patent and normal in configuration. There is no significant\n atherosclerotic disease, or occlusion. The IVC is collapsed, and contains an\n infrarenal IVC filter.\n\n PELVIS: There is a fibroid uterus. The rectum contains a rectal tube. The\n colon is fluid filled without wall thickening, and contains more dense\n contents in the cecum and ascending colon as described previously.\n\n There is diffuse body wall edema. Surgical staples are seen anteriorly.\n\n BONES: There is no concerning lytic or blastic osseous lesions. There is\n grade 1 anterolisthesis of L5 on S1, with bilateral spondylolysis, and spina\n bifida occulta of L5.\n\n IMPRESSION:\n\n 1. Massively dilated loop of jejunum, which contains mottled dense contents\n which are not specific for, but are compatible with hemorrhagic material. A\n jejunal tube is present within this loop. The marked dilation is most likely\n due to rapid distension and resultant ileus, however, with both a proximal and\n distal transition point seen, a closed loop obstruction is a possibility if\n for instance the loop was rapidly distended and then volvulized upon itself.\n\n 2. High density material seen within distal ileum and proximal colon in the\n absence of recent or remote positive oral contrast is concerning for\n extravasation of intravenous contrast. No definite site of contrast\n extravasation is identified on this study.\n\n 3. Gallstones, with gallbladder wall thickening likely due to systemic\n illness.\n (Over)\n\n 6:18 AM\n CTA ABD & PELVIS Clip # \n Reason: please assess for source of GI bleed\n Admitting Diagnosis: CHOLYCYSTITIS\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. Fibroid uterus.\n\n 5. Grade 1 anterolisthesis of L5 on S1, with bilateral spondylolysis.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237709, "text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for consolidation, effusion, congestion, col\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multi-system organ failure, respiratory failure with\n high PEEP requirement\n REASON FOR THIS EXAMINATION:\n Please evaluate for consolidation, effusion, congestion, collapse\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 3:22\n\n CLINICAL INDICATION: 31-year-old with multisystem organ failure. Evaluate\n for consolidation, effusion, congestion or collapse.\n\n Comparison is made to the patient's prior study of at 9:48.\n\n Single portable supine chest film at 3:22 is submitted.\n\n IMPRESSION:\n 1. Right internal jugular central line has its tip in the proximal SVC,\n unchanged. Endotracheal tube has its tip 7 cm above the carina. Advancing\n 2-3 cm for better positioning should be considered as previously mentioned on\n . Left internal jugular catheter remains in the brachiocephalic\n vein. Nasogastric tube is seen coursing below the diaphragm with the tip\n projecting over the stomach.\n 2. Heart remains stable in size. There continues to be pneumopericardium.\n Lung volumes are diminished again on the right where there is patchy and hazy\n opacity suggestive of atelectasis and a layering effusion. Pneumonia would be\n less likely. More focal consolidation at the left base is also stable, which\n may reflect partial lower lobe atelectasis in the setting of a layering\n effusion, although pneumonia again cannot be excluded. No overt pulmonary\n edema. No pneumothorax is appreciated, although the sensitivity to detect the\n pneumothorax is diminished on the supine radiograph. Right costophrenic angle\n is not entirely included.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-04-26 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1237829, "text": " 11:24 AM\n PORTABLE ABDOMEN Clip # \n Reason: R/O FOREIGN BODY\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with open abdomen. s/p washout\n REASON FOR THIS EXAMINATION:\n r/o foreing body also include chest to check ET tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 31-year-old woman with open abdomen status post washout.\n Evaluate for foreign body.\n\n FINDINGS: Comparison of a feeding tube is seen with distal tip in site port\n below the gastroesophageal junction within the body and fundus of the stomach.\n Tubular device projecting over the left lower pelvis. This is likely external\n to the patient. No additional radiopaque densities are seen. The bowel gas\n pattern is poorly evaluated due the increased density throughout the abdomen,\n potentially due to ascites. There are bilateral pleural effusions and a left\n retrocardiac opacity.\n\n IMPRESSION:\n\n No definite foreign bodies aside from the nasogastric tube and the tubular\n device projecting over the left pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237791, "text": " 1:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with open abdomen, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 31-year-old woman with open abdomen, intubated.\n\n FINDINGS: Comparison is made to prior study from at 3:22 a.m.\n\n The endotracheal tube, nasogastric tube, central venous catheters are all\n stable in position. There are large bilateral pleural effusions, right side\n worse than left with retrocardiac opacity. Mild pulmonary edema is seen and\n there are no pneumothoraces.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237592, "text": " 9:15 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiorgan system failure with acute desaturation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with multiorgan system failure and acute\n desaturation, evaluate for interval change.\n\n COMPARISONS: Prior radiograph from at approximately 3:00 a.m.\n\n FINDINGS: Compared to the prior radiograph, there is persistence of\n pneumopericardium. The lungs are stable and there has been no interval\n change. There are no new parenchymal infiltrates. Again seen are bilateral\n layering pleural effusions and bibasilar atelectasis. The ET tube is situated\n 8.3 cm from the carina. NG tube is seen coursing below the diaphragm. Other\n monitoring and support devices are stable. There is no pneumothorax.\n\n IMPRESSION:\n 1. Persistent pneumopericardium.\n 2. ET tube 8.2 cm from the carina. Recommend advancing 2-3 cm for better\n positioning.\n\n These findings were discussed with the by Dr. via\n telephone at 11:15 a.m.\n\n" }, { "category": "ECG", "chartdate": "2139-05-05 00:00:00.000", "description": "Report", "row_id": 303679, "text": "Sinus rhythm. Extensive ST-T wave changes are non-specific. Compared to the\nprevious tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2139-05-04 00:00:00.000", "description": "Report", "row_id": 303680, "text": "Sinus tachycardia and change in the atrial morphology as compared with previous\ntracing of . The Q-T interval has normalized. There is diffuse\nST-T wave flattening. No diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237394, "text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f interval progression\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p punctured aorta s/p repair\n REASON FOR THIS EXAMINATION:\n e/f interval progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman status post punctured aorta and repair,\n evaluate for interval progression.\n\n COMPARISONS: Portable AP chest radiograph from .\n\n FINDINGS: Since the most recent prior radiograph, there has been no\n significant change. The ET tube, right IJ central line and feeding tube are\n unchanged in position. Again seen are bilateral layering pleural effusions\n and bilateral bibasilar atelectasis. There are no new parenchymal\n infiltrates. A left-sided dialysis catheter is unchanged in position. There\n is no pneumothorax.\n\n IMPRESSION: No significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237553, "text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess progression of pulmonary disease\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with hypoxia, ARDS\n REASON FOR THIS EXAMINATION:\n assess progression of pulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with hypoxia, ARDS, assess for progression of\n pulmonary disease.\n\n COMPARISONS: Prior radiographs from and .\n\n FINDINGS: ET tube is approximately 8 cm from the carina. There is a right IJ\n central line in the mid SVC left IJ dialysis catheter in appropriate\n positioning. There is an NG tube that courses below the diaphragm. Again\n seen are layering bilateral effusions and bilateral atelectasis. There are no\n definite new parenchymal infiltrates. Since the prior radiograph, there has\n been development of pneumopericardium which can be seen on the left lateral\n heart border. The heart remains mildly enlarged. There is no pneumothorax.\n\n IMPRESSION:\n 1. Development of what appears to be pneumopericardium at the left lateral\n heart border. Recommend repeat radiograph for confirmation.\n 2. No significant change in layering bilateral effusions. No new parenchymal\n infiltrates.\n 3. ET tube 8 cm from the carina. Recommend advancing 2-3 cm.\n\n These findings were reported to , M.D. by Dr. at 10:45\n a.m. As per team caring for the patient, there has been no intervention to\n explain pneumopericardium.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1237127, "text": " 9:47 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: LIJ TLC PLCT\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with sp multiple abd surgerysd\n REASON FOR THIS EXAMINATION:\n LIJ TLC PLCT\n ______________________________________________________________________________\n FINAL REPORT\n 31-year-old woman status post multiple surgeries, now with line placement.\n\n COMPARISON: .\n\n FINDINGS: A right-sided IJ terminates in the high SVC. A left sided CVC is\n not in appropriate position. Lung volumes are low. NG tube tip is in the\n stomach. ET tube is about 6.5 cm from the carina and can be further advanced\n for better seating. The right upper lobe is partially collapsed as well as the\n left lower lobe. The lack of definition in the bronchi suggest difficulty\n clearing secretions leading to this atelectasis.\n\n These findings were discussed with by Dr. at 11:30 a.m. via\n telephone.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237897, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman intubated, high PEEP\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old female, intubated, with high PEEP.\n\n COMPARISON: .\n\n CHEST, AP: Endotracheal tube again terminates 5 cm from the carina. Dobbhoff\n tube terminates in the stomach. There is a left internal jugular catheter in\n midline position, and right internal jugular catheter with tip at the upper\n SVC. There are persistent moderate layering pleural effusions. Lung volumes\n remain low with bibasilar atelectasis, left greater than right. Mild\n interstitial edema and central venous congestion are unchanged. Heart size is\n top normal.\n\n IMPRESSION:\n Continued pulmonary edema and low lung volumes.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-24 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1237636, "text": " 1:38 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: e/f acute cholecystitis\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p aortic injury s/p repair\n REASON FOR THIS EXAMINATION:\n e/f acute cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND DATED \n\n INDICATION: 31-year-old woman status post aortic injury, status post repair,\n ? acute cholecystitis.\n\n COMPARISON: Comparison is made to previous ultrasound dated .\n\n FINDINGS: The liver is diffusely echogenic with focal areas of fat sparing\n adjacent to the gallbladder. No focal liver lesions are identified. No\n intra- or extra-hepatic duct dilation. The common duct measures 3 mm. Normal\n hepatopetal flow within the portal vein.\n\n There are multiple gallstones present within the gallbladder along with a\n sludge/bile level. There is gallbladder wall thickening. The gallbladder wall\n measures 5 mm in diameter. No pericholecystic fluid.\n\n Patient is status post splenectomy. There is a small right pleural effusion.\n The visualized portions of the right kidney are normal in appearance. No\n evidence of right hydronephrosis.\n\n IMPRESSION:\n 1. Small right pleural effusion.\n 2. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease such as cirrhosis or fibrosis cannot be excluded on this study. No\n focal liver lesions identified.\n 3. Cholelithiasis with gallbladder wall thickening without pericholecystic\n fluid. No biliary dilation. Acute cholecystitis cannot be outruled on this\n basis. Clinical correlation is recommended.\n\n Findings were discussed by phone with Dr. at 17:10 on .\n\n" }, { "category": "Radiology", "chartdate": "2139-04-23 00:00:00.000", "description": "RENAL U.S.", "row_id": 1237449, "text": " 10:59 AM\n RENAL U.S. Clip # \n Reason: e/f renal pathology\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p traumatic aortic injury during lap choly, with multiple\n organ failure\n REASON FOR THIS EXAMINATION:\n e/f renal pathology\n ______________________________________________________________________________\n WET READ: 12:04 PM\n No hydronephrosis or other cause of acute renal failure.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with multiorgan failure, status post traumatic\n injury at the aortic bifurcation during laparoscopic cholecystectomy.\n\n COMPARISONS: None.\n\n FINDINGS: The left kidney measures 12.7 cm. The right kidney measures 11.1\n cm. There are no stones, masses, or hydronephrosis in either kidney.\n\n IMPRESSION: No hydronephrosis or other radiographic explanation for acute\n renal injury.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1237310, "text": " 12:03 PM\n PORTABLE ABDOMEN Clip # \n Reason: assess for abomdinal packing left over from OR -- should be\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with Multisystem organ failure\n REASON FOR THIS EXAMINATION:\n assess for abomdinal packing left over from OR -- should be ONE in RUQ only\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multisystem organ failure with abdominal packing left in the OR.\n Packing expected to be located in the right upper quadrant.\n\n COMPARISON: \n\n FINDINGS: Supine abdominal radiograph is technically limited. The right\n upper quadrant is not completely imaged. Multiple lines and drains are seen.\n There is a single curvilinear foreign body overlying the T11 vertebral body\n adjacent to the cardia of the stomach.\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2139-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237831, "text": " 11:40 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check for ET tube placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman s/p abd washout\n REASON FOR THIS EXAMINATION:\n check for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 31-year-old woman status post abdominal washout. Evaluate\n for placement of endotracheal tube.\n\n FINDINGS: There is an endotracheal tube whose distal tip is at the level of\n the clavicles. There are bilateral central venous catheters whose distal tips\n are in the proximal SVC. Feeding tube tip and side port are below the\n gastroesophageal junction. There are again seen large bilateral pleural\n effusions, right greater than left and a left retrocardiac opacity. There is\n also an element of fluid overload, unchanged. There is some fluid in the\n right minor fissure.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1237159, "text": " 11:31 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: T IJ TLC\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with multiple abd surgerys\n REASON FOR THIS EXAMINATION:\n T IJ TLC\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 31-year-old woman with multiple abdominal surgeries and now\n right IJ.\n\n COMPARISON: .\n\n FINDINGS: There has been no relevant change since the prior exam. ET tube\n remains 6.5 cm from the carina and can be further advanced for better seating.\n Left sided CVC is misplaced and not in the superior vena cava. The lack of\n definition in the bronchi suggest difficulty clearing secretions leading to\n collapse of lung segments as described earlier.\n\n These findings were discussed with Dr. at the time of discovery\n which was 11:35 a.m. by Dr. via telephone. The left-sided CVC had\n been removed at that point.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1237258, "text": " 4:37 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess for consolidation, effusion, edema, L IJ HD line posi\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with respiratory failure, intubated, s/p new L IJ HD line\n placement\n REASON FOR THIS EXAMINATION:\n assess for consolidation, effusion, edema, L IJ HD line position.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATIONS: intubated, assess for consolidation, effusion and edema.\n\n TECHNIQUE: Portable supine chest view was read in comparison with prior\n radiographs from to .\n\n FINDINGS:\n\n Endotracheal tube tip is approximately 4.7 cm above the carina. A left\n central line through the internal jugular approach has been replaced with\n dual-lumen catheter with its tip reaching up to the mid SVC/junction of\n brachiocephalic and SVC. Right internal jugular line tip is at upper/mid SVC.\n Orogastric tube courses below the diaphragm and ends into the body of the\n stomach. Over last 24 hours right upper lung opacity reflecting partial\n collapse of upper lobe has progressively worsened between and today\n reflected by gradually increased density and size of the right upper lung\n opacity. Minimal and indistinct left suprahilar opacity could be new\n atelectasis. Lung volumes persistently remain low. Increased retrocardiac\n density reflects left lower lung volume loss, unchanged since yesterday.\n Pleural effusion if any is small bilaterally.\n\n IMPRESSION:\n\n Over last 24 hours, right upper lung opacity due to partial collapse of upper\n lobe has progressed, increased retrocardiac density suggesting left lower lobe\n volume loss is unchanged and small, indistinct left suprahilar opacity which\n is likely atelectasis is new.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1237043, "text": " 3:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p cordis placement\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with Aortic injury\n REASON FOR THIS EXAMINATION:\n s/p cordis placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Aortic injury after Cordis placement.\n\n COMPARISON: No prior studies available for comparison.\n\n The study was obtained with very lordotic projection diminishing assessment of\n position of tubes and lines. At this point, the left internal jugular line,\n the right internal jugular line and the ET tube all appear to be positioned\n too high but repeated radiograph with appropriate projection is required. NG\n tube tip is in the stomach. Right upper lobe opacity is partially seen, might\n reflect atelectasis.\n\n Re-evaluation with radiograph appropriately centered is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-04-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1237044, "text": " 3:58 PM\n PORTABLE ABDOMEN Clip # \n Reason: OGT location\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with Aortic injury\n REASON FOR THIS EXAMINATION:\n OGT location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic injury. Confirmation of OGT position.\n\n COMPARISON: Chest radiograph of .\n\n FINDINGS: Portable AP abdominal radiograph barely images the tip of the OGT,\n which appears to terminate in a subdiaphragmatic position as seen on\n concurrent chest radiograph. Multiple lines and radiopaque densities\n represent surgical intstrumentation.\n\n IMPRESSION: OGT tip is better visualized on concurrent chest radiograph.\n\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2139-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237309, "text": " 12:03 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: intubated, new dilaysis catheter\n Admitting Diagnosis: CHOLYCYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with Multisystem organ failure\n REASON FOR THIS EXAMINATION:\n intubated, new dilaysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n 31-year-old woman with multiorgan system failure. New dialysis catheter.\n\n COMPARISON: .\n\n AP VIEW OF THE CHEST: Previous right upper lobe opacity has substantially\n decreased in size and density consistent with reopening of the airways. Right\n lower lobe opacity remains, combination of atelectasis and effusion. No new\n focal opacities are noted. Right-sided IJ is in unchanged position.\n Endotracheal tube is 6 cm from the carina. Left-sided dialysis catheter\n terminates at the confluence of the subclavian and IJ. Retrocardiac density\n remains. There is no pneumothorax.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2173-10-01 00:00:00.000", "description": "Report", "row_id": 1376669, "text": "Alt in resp:Much better day, less pain med requirements.Able to\nuse voice without difficulty.Using IS independently.Ambulating in\nroom without incident.Foley out at 1030, dtv 1830-.\nTolerating tf at 70cc/hr.No stool yet.Abdomen benign.Lungsounds clear\nable to clear secretions.Incision clean and dry,Jp d/c'd this afternoon.Decadron d/c'd after 3 doses.Aline out.TLC intact, site\nbenign.To continue to stay in icu for airway precautions.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-02 00:00:00.000", "description": "Report", "row_id": 1376670, "text": "Neuro: Pt alert and oriented x3,MAE, follows commands.\n\nCV: heart rate 80's to 90's NSR. SBP 110 to 120's and stable.\n\nResp: 40% OFM cont. O2sats 98 to 100%, lungs with few scattered rhonchi, pt has strong productive cough and is able to clear his own secretions. No resp distress during the night.\n\nGI: Abd soft, +BS, tube feeds cont at goal rate of 7o/hr. via PEG No BM.\n\nGU: Pt voids qs\n\nPLAN; Cont to monitor resp status\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-02 00:00:00.000", "description": "Report", "row_id": 1376671, "text": "Ambulating with nurse x3 this shift gait steady. physical therapy did see and went over some exercises with him, has been on ra all day sats >94% enc to c/db and is q1h and he is doing well with that, pain controlled with oxycodone - main discomfort is neck. tolerating tube feeds.\n\nPlan cont to monitor resp status, cont to increase activity, meds as needed for pain\n" }, { "category": "Nursing/other", "chartdate": "2173-10-03 00:00:00.000", "description": "Report", "row_id": 1376672, "text": "CSRU NURSING NOTE:\n\nNEURO: PT ALERT AND ORIENTED. NO DIFFICULITES WITH SPEECH OR SWALLOW.\n\nCV: PT DENIES CP, PALP, SOB. TELE: SB-NSR. HR 50-80'S. BP STABLE.\n\nRESP: LS CTA, DIMIN AT BASES. STRONG NPC. USING IS WITHOUT ASSIST. REMAINED ON RA THIS SHIFT- MAINTAINING O2 SATS > 95%.\n\nGI: TF CONTINUE AT 70CC/HR. +BS, NO BM THIS SHIFT.\n\nGU: VOIDING VIA URINAL DK YELLOW URINE.\n\nID: CONTINUES ON KEFZOL AND FLAGYL. AFEB.\n\nPAIN: PT OXYCODONE FOR PAIN WITH GOOD EFFECT. REQUIRING LESS PAIN MED THAN PREVIOUS. PT MORE COMFORTABLE.\n\nPLAN: CONTINUE SAME- ? TX TO FLOOR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-03 00:00:00.000", "description": "Report", "row_id": 1376673, "text": "NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nC/V NSR NO ECT B/P STABLE\n\nRESP SATS 97% RA NO RESP DIFFICULTY LUNGS CLEAR NONPRODUCTIVE\n\nGU/GI TOLERATES TF 70CC HOUR ABD SOFT NO STOOL TODAY DARK AMBER URINE VOIDS URINAL REMAINS NPO\n\nACTIVITY OOB WITHOUT ASSIST WELL AMBULATES WITH PT WELL\n\nPLAN CONTINUE TO ENCOURAGE ACTIVITY MONITOR AIRWAY\n" }, { "category": "Nursing/other", "chartdate": "2173-10-04 00:00:00.000", "description": "Report", "row_id": 1376674, "text": "CSRU NURSING NOTE:\n\n\nNO CHANGE. PT STABLE . SLEPT MOST OF THIS SHIFT. REQUIRING LESS PAIN MEDICATION. CONTINUES ON IV ANTIBX AND TF. WELL. VSS. AFEB.\n\nPLAN: TRANSFER TO FLOOR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-04 00:00:00.000", "description": "Report", "row_id": 1376675, "text": "REMAINS STABLE AMBULATING INDEPENDENT IN ROOM AND AROUND FLOOR WITH PT WELL NO SOB SATS 97 RA TF WELL MED PAIN WITH GOOD EFFECT ALERT ORIENTED NO C/O AWAITING AVAILABILITY OF FLOOR BED\n" }, { "category": "Nursing/other", "chartdate": "2173-10-05 00:00:00.000", "description": "Report", "row_id": 1376676, "text": "CSRU Update\nAwake, alert, oriented x 3. Ambulates about room w/o assistance. O2 sat on RA - 97%. CS clr. Reminder sutures intact. Voice much improved. VSS. TF's. No stool. Voiding QS. Percocet elixer for neck and back pain x 3. Slept very well.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-29 00:00:00.000", "description": "Report", "row_id": 1376663, "text": "arrived from 0.r. ~ 1900. tachycardic,diaphoretic & c/o pain. medicated multiple times w fentanyl. usual dose valium resumed via peg. hr down into low 100's & able to sleep in naps after pain controlled. head flexed & \"reminder\" sutures intact. bs clear but decreased bilat. no wheezes,stridor. spo2 maintained > 95% on closed face mask per pt. preference. weak cough,non-productive.tol. racemic epi per dr. well w minimal change in hr. ambu & bronch cart, add'l et tubes at bedside. nesk incision w scant sero-sang dng,steri's intact. lt. neck jp->self suction w minimal sero-sang.venodyne machine presently unavailable from distribution,heparin sq for dvt prophylaxis.huo adequate,minimal volumw to be given. plan maintain airway,control pain,resume tf's in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-30 00:00:00.000", "description": "Report", "row_id": 1376664, "text": "Respiratory care:\nPatient receiving recemic epi Q 4 hours to help maintain airway swelling. No stridor heard this shift. Patient received recemic epi at 9,1,5. HR 100 - 120 tolerating epi. Breathsounds essentially clear. cough getting stronger through out the night. Please see respiratory section of carevue for further data.\nPlan; Monitor respiratory status closely.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-30 00:00:00.000", "description": "Report", "row_id": 1376665, "text": "PT ALERT AND ORIENATATED~WRITTING NOTES AND USING NONVERBAL CUES FOR COMMUNICATION. FENTANYL Q1-2 HOURS THRU NOC~INCREASING DOSING TOWARD AM. SR-ST WITHOUT ECTOPY. BP STABLE. PULSES PALPABLE~EXTREMITIES WARM. VENODYNES ON. HCT STABLE. PT ON 40%OFM WITH STABLE SATS~NASAL TRUMPET IN PLACE~LS DIMINISHED THRU OUT~RACEMIC EPI Q 4 THRU NOC. PT WITH UPPER CONGESTION~WEAK COUGH BUT EFFECTIVELY RAISING SMALL AMTS OF THICK, CLEAR SECRETIONS. NECK INCISION INTACT WITH STERIS/SUTURE INTACT~DSD TO SITE.\n\nPLAN~?INCREASE PAIN MED DOSING, OOB TO CHAIR~CONTINUE TO CLOSELY MONITOR AIRWAY MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-30 00:00:00.000", "description": "Report", "row_id": 1376666, "text": "Initial assessment within normal limits.Pt alert and oriented x3, able\nto verbally and nonverbally to communicate needs.Denies diff resp.\nLungsounds clear with dim bases.To instruct on use of IS.Pt receptive.\nSkin clean and dry.IV site benign as is aline.States having pain in neck and op site, but tolerable at this time with good pain control\nwith percosett.Plan:to keep as comfortable as possible with percs q4hr\nassess need for further pain control as needed.Resp support as needed\nwith pulm toilet, assessment of status, treat as needed.Cont racemic\nepi.Provide supportive and safe enviroment.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-30 00:00:00.000", "description": "Report", "row_id": 1376667, "text": "Oob with assist, for approx 2hr.Tolerated fair.Using IS intermittently\nwith good effect.Able to cough and clear secretions effectively.\nSputum clear.Requiring pain meds q3hr.Incision clean and dry.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-01 00:00:00.000", "description": "Report", "row_id": 1376668, "text": "Neuro: Pt awake, alert and oriented x3\n\nResp: OFM @ 40%, O2 sats 100%, Lungs clear upper lobes with scattered rhonchi lower lobes bilat. He has a strong productive cough,no stridor\nnoted and no difficulty breathing. HOB elevated 45 degrees.\nLasix 10mg given x1 given and Decadron given per order.\n\nCV: Heart Rate 70's NSR.K+ replaced. SBP 100's to 120's.\n\nGI: ABd soft and with +BS. Tube feeding via PEG without difficulty.\nTube feeding increased to 60cc/hr small residuals.\n\nGU: Foley to gravity, clear yellow urine.\n\nPlan: Continue to monitor resp status.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2182-08-09 00:00:00.000", "description": "Report", "row_id": 1340048, "text": "S/P CABG X 4\nO: CARDIAC: A PACED @ 8O WITH AN UNDERLYING RYTHYM OF 50'S, PRESENTLY SR 70'S WITHOUT VEA.PACER A DEMAND @ 60. BOTH A+V WIRES SENSE AND CAPTURE APPROPRIATELY. K 3.7 RECIEVED 40 MEQ KCL WITH REPEAT K 4.5. SBP 90-140'S NTG @ 2 MCQ TO KEEP SBP 120'130'S. DSGS D+I, FEET SLIGHTLY COOL, PALP PP, CT MINIMAL DRAINAGE UNTIL 1700 WITH 110 ML X 1 HOUR, HCT 32.\n RESP: CPAP 5/5 7.32 AND NOT RAISING HEAD THEREFORE TO GIVE PT A LITTLE MORE TIME -PT NOT HAPPY ABOUT THIS. O2 SAT 96%. RR 20-40'S WITH AGITATION. REINFORCED NEED TO REMAIN CLAM AND BREATH. BS DIMINISHED BIBASILAR. NO CHEST TUBE LEAK.\n NEURO: PROPOFOL OFF AND REVERSED MAE AGITATED UPON FIRST AWAKENING THEREFORE PLACED BACK ON 20 MCQ PROPOFOL, PROPOFOL, PT FOLLOWING COMMANDS, MAE. AGITATION WITH ETT. PERL.\n GI: HAS REMAINED NPO, OGT + PLACEMENT, INITIALLY DRAINED OLD BLOODY DRAINAGE. ABD SOFT. ABSENT BOWEL SOUNDS.\n GU: GOOD UO\n ENDO: INSULIN GTT PRESENTLY @ 4 UNITS/HR.\n PAIN: 2 MG MSO4 X 4 WITH GOOD EFFECT.\n ID: TO RECIEVE VANCO\n SOCIAL: WIFE AND FAMILY INTO VISIT AND UPDATED.\nA: AWAITING REMOVAL OF ETT\nP: MONITOR COMFORT, HR AND RYTHYM, SBP- 120'S, CT DRAINAGE, DSGS, PP, RESP STATUS- WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2182-08-09 00:00:00.000", "description": "Report", "row_id": 1340049, "text": "extubated without difficulty, placed on face tent, 70% with 12 l flow, spo2 96%. speaks hoarsely, is alert and oriented, telling bad jokes.\n" }, { "category": "Nursing/other", "chartdate": "2182-08-10 00:00:00.000", "description": "Report", "row_id": 1340050, "text": "ekg nsr, no ectopy. sbp managed with ntg gtt, goal to keep in 120s, currently weaning down slowly. afebrile. adequate uo, now ~40cc/hr. k repleted, glucose rx per protocol. breath sounds clear, decreased at bases. deep breathes well, used spirometer with coaching. nonproductive cough, needs encouragement due to discomfort. maintaining spo2 94-97, currently on 5 l nc. abd soft, hypoactive bowel sounds, no nausea, vomiting. tolerating small amts clear liquids. chest and ct dressings dry. mod drainage from l fem site, ecchymotic area present around site. r leg site dry, ace rewrapped, ditto l leg. feet cool, dp and pt pulses palp bilat. alert and oriented, mae spont and to command. medicated for pain x 3 with mso4 2 mg, x 1 with percocet. wife called x 2 for update, reassurance.\n" }, { "category": "ECG", "chartdate": "2182-08-09 00:00:00.000", "description": "Report", "row_id": 183210, "text": "Sinus bradycardia with demand atrial pacing\nLeft atrial abnormality\nBorderline first degree A-V block\nLeft axis deviation - anterior fascicular block\nPoor R wave progression - cannot rule out anteroseptal infarct\nLateral ST-T changes are nonspecific\nNo previous tracing\n\n" } ]

[ { "category": "ECG", "chartdate": "2117-10-01 00:00:00.000", "description": "Report", "row_id": 150019, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of no\nsignificant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2103-10-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 980899, "text": " 5:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Postop CT - s/p Left temporal lobe resection - please evalua\n Admitting Diagnosis: EPILEPSY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with intractable seizures\n REASON FOR THIS EXAMINATION:\n Postop CT - s/p Left temporal lobe resection - please evaluate for postop\n changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-op CT, status post left temporal lobe resection. Evaluate\n for post-op change.\n\n COMPARISONS: Preoperative CT of .\n\n HEAD CT WITHOUT CONTRAST: The patient is status post left\n frontotemporoparietal craniotomy and left temporal lobe resection. There is\n expected pneumocephalus at the left temporal lobe defect and along the left\n cerebral convexity. There is a small amount of extra-axial high-density\n material consistent with blood along the left frontal lobe. In addition,\n there is a small focus of intraparenchymal hemorrhage with a mild amount of\n surrounding edema in the left frontal lobe (2:13) measuring 11 x 9 mm. There\n is mild right-sided midline shift of approximately 5 mm. There is mild mass\n effect on the left lateral ventricle. Basilar cisterns are intact. The\n visualized paranasal sinuses and mastoid air cells are clear. Expected post-\n surgical changes in the surrounding scalp with small galeal hematoma and air\n along the incision is seen. Skin staples are in place. The previously seen\n electrodes have been removed.\n\n IMPRESSION:\n 1. Status post left temporal lobe resection with expected pneumocephalus and\n small amount of extra-axial blood.\n 2. 11 x 9 mm focus of intraparenchymal hemorrhage in the left frontal lobe,\n surrounded by very mild edema.\n 3. Mild mass effect on the left lateral ventricle and rightward midline shift\n of 5 mm.\n\n The pertinent findings have been discussed with Dr. .\n\n" }, { "category": "Nursing/other", "chartdate": "2103-10-31 00:00:00.000", "description": "Report", "row_id": 1641238, "text": "NURSING NOTE\nPLEASE SEE CARVUE SOR DETAILS\n D: PT EASILY , MORE COOPERATIVE/COMPLIANT W/CARE AT START OF SHIFT, BUT REFUSING CARE, STATING \"I'M NOT DOING THAT\", W/MD'S. ORIENTED X3 W/VERY BRIEF EPISODE OF ACUTE CONFUSION & REPEATING SELF, DR. AWARE. INCONSISTENTLY FOLLOWS CMNDS, DEPENDING ON LEVEL OF IRRITABILITY. C/O HEADACHE & BILAT EYE PAIN. NEW ONSET RIGHT EYE EDEMA>LEFT OVER NOC, DR. AWARE. HR NSR, SBP<140 GOAL PER NEUROSURG. Tm 99.6, PT D/C'D IVF W/CONSTANT TOSSING/TURNING IN BED. LUNGS CLEAR, NARD/SOB. POOR PO INTAKE R/T, \"BECAUSE OF THE HEADACHES/THROBBING\" PER PT. VOIDING IN URINAL AT BEDSIDE.\n\n A: ICE PACKS GIVEN FOR BILAT EYE EDEMA, OXYCODONE GIVEN X1 FOR PAIN. NEURO ASSESSMENTS ATTEMPTED, THOUGH PT NOT ALWAYS COMPLIANT. NEEDS ENC W/PO'S, REFUSING TO ATTEMPT IV RESTART.\n\n R: RIGHT>LEFT EYELID EDEMA, BP STABLE. NEUROS UNCHANGED, NO SEIZURE ACT NOTED. PT , THOUGH MORE IRRITABLE THIS AM.\n\n P: CONT FREQUENT NEURO CHECKS, ENC PO INTAKE, RESTART IF CONT POOR PO'S. PAIN MGMT, ICE PACKS FOR EYE EDEMA. MAINTAIN SBP<140 PER NEUROSURG. TRANSFER WHEN BAD AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2103-10-30 00:00:00.000", "description": "Report", "row_id": 1641236, "text": "condition update\nD: pt alert and angry. follows commands at time and other is noncompliant with neuro exam. at start of shift pt compliant with exam but as the night went on he became more resist to exam. Dr. aware and Dr. aware and in to speak to pt. pt very angry about the plan and q1 hour neuro checks. Rn explained the reason for frequent checks and need to check blood pressure. He allowed bp cuff to be placed back on arm but pt still upset and refusing to cooperate with neuro exam.. Dr. aware of inability to get a good neuro exam. pt denies any pain meds and states \"My head doesn't hurt I am tired. leave me alone\". currently pt moves all extremities and speech is clear. pt refusing to allow rn to check pupil reaction. De. aware.\ncardiac: pt in nsr rate in the 80's. sbp less than 110-130/50's.\nresp: o2 sat is 96-98% on room air.\ngi: pt tolerating clears with meds.\ngu: pt voiding clear yellow urine.\nskin: head dressing is dry with small amt of bloody drainange with no increase in size.\na: continue to attempt neuro exams. reinforce need for current treatment plan with pt and discuss with team in the am. assess for pain and offer pain meds. provide emotional support to pt and family and reassure pt about the need for close monitoring post-op.\nr: neuro is unchanged with current exam. unable to obtain complete neuro exam and neuro team is aware. pt still angry about need to be assess q1.\n" }, { "category": "Nursing/other", "chartdate": "2103-10-30 00:00:00.000", "description": "Report", "row_id": 1641237, "text": "D; S/P TEMPORAL LOBE CRANI FOR UNREMITTING SEIZURE ACTIVITY, PT UNCOOPERATIVE AND AGITATED THIS AM,USING FOUL LANGUAGE WITH STAFF, REFUSING AM LAB DRAWS AND BS CHECK, DIET ADVANCED TO REGULAR BUT PO INTAKE POOR, C/O HEADACHE X2 ALONG WITH INCISIONAL DISCOMFORT, LEFT PUPIL EDEMATOUS AND NOT ABLE TO EXAMINE PUPILLARY RESPONSE PER DISCOMFORT TO PT, TEMP MAX 99.5, A&OX3AND LETHARGIC AT TIMES BUT EASILY AROUSEABLE\n\nA; PT'S FAMILY IN THIS AM,(given update on condition and behavior);MAITENANCE IV IN PLACE DUE TO POOR PO INTAKE, MEDIC X 1 WITH MORPHINE 2 MGM AND ONCE WITH OXYCODONE, ICE PACK SEVERAL X TO LEFT EYELID, PT ENCOURAGE TO KEEP HOB ELEV TO DECREASE EDEMA, NEURO EXAM Q 2 HRS, PT NOT ALWAYS COOPERATIVE THIS AM BUT IMPORVED THIS PM\n\nR PT ATTEMPTING TO EAT SOME SOLID FOOD AT DINNERTIME BUT PO INTAKE STILL POOR, LEFT EYELID REMAINS EDEMATOUS, AND PT NOT ABLE TO OPEN WITHOUT PAIN, SLEEPING IN LONG NAPS AFTER MEDICATION, BUT EASILY AROUSED FOR EXAM, BP STABLE (GOAL IS SYS < 140),\n\nPLAN; ENCOURAGE PO INTAKE AND HEPLOCK IV, SET LIMITS WITH PT REGARDING COOPERATION AND USE OF PROFANITY, FREQUENT NEURO CHECKS, ICEPACKS PRN TO LEFT EYELID, MONITOR TEMP TRANSFER TO TELE 5 WHEN BED AVAILABLE\n" }, { "category": "Nursing/other", "chartdate": "2103-10-29 00:00:00.000", "description": "Report", "row_id": 1641235, "text": "Focus: Status Update\nData:\nPt. arrived in SICU post elective awake left temporal lobectomy with intraop EEG monitoring due to epilepsy. He is awake, alert and oriented x3. Moves all extremities with normal strength. Follows commands. PERL at 3-4mm. He is at times non-compliant, initially refused CT postop, has refused glucose monitoring as well as HOB>30degrees. He appears angry and at times very insulting calling the staff \"retarded\".\n\nLungs clear, sats 100% on RA.\n\nAbd soft, nontender with positive bowel sounds. Will start clears this pm.\n\nVoids clear urine. Maintenance IVF, NS at 100ml/hr.\n\nPlan:\nCT scan, Sitter at bedside if becomes agitated. KVO ivf with good po's.\n" } ]

[ { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1176877, "text": " 5:43 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hypotension, chest pain, s/p line placement\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male with hypertension and chest pain status post line\n placement.\n\n STUDY: Portable supine AP chest radiograph.\n\n COMPARISON: , at 16:56.\n\n FINDINGS: There has been interval placement of a right-sided IJ line with its\n tip in the left brachiocephalic vein. The cardiomediastinal contours appear\n widened, compatible with either lipomatosis versus vigorous fluid\n resuscitation. The lung volumes are low but clear with mild vascular\n congestion noted. There is no large pleural effusion or pneumothorax.\n Prominence of the superior mediastinum was seen to represent mediastinal\n lipomatosis on concurrent CT.\n\n IMPRESSION:\n 1. Interval placement of right IJ line with tip in the left brachiocephalic\n vein; recommend repositioning. These findings were discussed with \n at 21:21 on .\n 2. Vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1176882, "text": " 6:14 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? cause for hypotension. Please perform non-contrast study\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with altered mental status, chest pain, reported weakness.\n Hypotensive in ED.\n REASON FOR THIS EXAMINATION:\n ? cause for hypotension. Please perform non-contrast study - in acute renal\n failure, creatinine 1.7\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: JEKh MON 7:14 PM\n no acute intrathoracic or intraabdominal process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh MON 11:17 PM\n 1. Right central line tip in left brachiocephalic vein - findings were\n discussed with at 21:21 on .\n 2. Right femoral periprosthetic lucency, concerning for loosening or even\n periprosthetic fracture - dedicated radiographs are recommended for better\n assessment.\n 3. Right thyroid nodule - nonemergent ultrasound is recommended if clinically\n warranted.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male with altered mental status, chest pain, and\n weakness.\n\n STUDY: CT of the torso without contrast; coronal and sagittal reformatted\n images were also generated.\n\n COMPARISON: CTA of the chest from .\n\n FINDINGS:\n\n CHEST: The visualized portion of the thyroid demonstrates a hypodense nodule\n in the right lobe, 16 mm in diameter (2;2).\n\n There is no axillary, hilar, or mediastinal lymphadenopathy. The aorta is of\n a normal caliber along its course with mild calcified atherosclerotic disease\n at the aortic arch branch origins. The pulmonary artery is of a normal\n caliber at its trunk. Calcified atherosclerotic disease is also noted in the\n coronary arteries. There is no pericardial or pleural effusion. Mild\n bibasilar atelectasis is seen. There is a small hiatal hernia.\n\n Incidental note is made of the right central line tip coursing into the left\n brachiocephalic vein.\n\n ABDOMEN: Within the limits of a non-contrast study, the liver demonstrates no\n focal abnormality. The gallbladder is distended with a small amount of dense\n material that may represent sludge or small stones; there is no\n pericholecystic stranding or fluid. The spleen is normal in size and\n (Over)\n\n 6:14 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? cause for hypotension. Please perform non-contrast study\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appearance. The pancreas and adrenal glands show no masses.\n\n The kidneys demonstrate no hydronephrosis or perinephric fat stranding. A\n small fat density in the right lower pole is most consistent with an AML.\n\n Calcified atherosclerotic disease is seen in a tortuous splenic artery.\n Calcified atherosclerotic disease is also seen throughout the abdominal aorta\n and into the iliac branches. The small and large intestine show no evidence\n of obstruction. There is no free air or free fluid. There is no\n lymphadenopathy.\n\n PELVIS: Bilateral hip replacements obscure much of the pelvis. The bladder\n and rectum appear grossly unremarkable. The appendix is visualized and is\n normal.\n\n BONES: There are no aggressive-appearing lytic or sclerotic lesions. Again\n bilateral total hip arthroplasties are seen with extensive streak artifact\n limited their status. Lucency is seen about the right femoral component,\n concerning for loosening. Additionally, a lucent line may represent a\n periprosthetic fracture of indeterminate age. Grade 1 spondylolisthesis of L5\n over S1 is noted.\n\n IMPRESSION:\n 1. Right central line tip in left brachiocephalic vein, repositioning\n recommended- findings were discussed with at 21:21 on .\n 2. Right femoral periprosthetic lucency, concerning for loosening or even\n periprosthetic fracture - dedicated radiographs/orthopedic evaluation\n recommended for better assessment.\n 3. Right thyroid nodule - nonemergent ultrasound is recommended for further\n evaluation.\n 4. No CT findings to explain hypotension.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1176883, "text": ", M. EU 6:14 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? cause for hypotension. Please perform non-contrast study\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with altered mental status, chest pain, reported weakness.\n Hypotensive in ED.\n REASON FOR THIS EXAMINATION:\n ? cause for hypotension. Please perform non-contrast study - in acute renal\n failure, creatinine 1.7\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PFI REPORT\n 1. Right central line tip in left brachiocephalic vein - findings were\n discussed with at 21:21 on .\n 2. Right femoral periprosthetic lucency, concerning for loosening or even\n periprosthetic fracture - dedicated radiographs are recommended for better\n assessment.\n 3. Right thyroid nodule - nonemergent ultrasound is recommended if clinically\n warranted.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176868, "text": " 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for e/o CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with resolved weakness L arm few days ago\n REASON FOR THIS EXAMINATION:\n eval for e/o CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JEKh MON 6:54 PM\n no acute intracranial process - MR is more sensitive for acute infarct\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male with left arm weakness from few days ago.\n\n STUDY: CT of the head without contrast; coronal and sagittal reformatted\n images were also generated.\n\n COMPARISON: None.\n\n FINDINGS: There is no intracranial hemorrhage. The -white matter\n differentiation is preserved. There is no edema or mass effect. Ventricles\n and sulci are normal in size and configuration. The paranasal sinuses and\n mastoid air cells are clear.\n\n IMPRESSION: No acute intracranial process; please note MR is more sensitive\n for the detection of acute infarct.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176873, "text": " 4:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with L arm weakness, resolved,\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male with left arm weakness.\n\n STUDY: Portable AP upright chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The cardiomediastinal and hilar contours are unchanged. The lung\n volumes are low but clear. There is no large pleural effusion or\n pneumothorax. Exam is somewhat suboptimal due to patient body habitus.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2198-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176918, "text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for abnormalities\n Admitting Diagnosis: HYPOTENSION;WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hypotension and hematoma, nausea after attempt at LIJ line\n placement.\n REASON FOR THIS EXAMINATION:\n please assess for abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension and hematoma with nausea after attempted IJ placement,\n to assess for pneumothorax.\n\n FINDINGS: In comparison with study of , the IJ line has been removed.\n There is no evidence of pneumothorax.\n\n Increasing prominence of the pulmonary vessels suggests elevated pulmonary\n venous pressure with left basilar atelectatic change.\n\n Of incidental note is an impression on the lower cervical trachea on the\n right, raising the possibility of a thyroid mass.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1176935, "text": " 6:13 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: placement\n Admitting Diagnosis: HYPOTENSION;WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with triple lumen\n REASON FOR THIS EXAMINATION:\n placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Triple-lumen placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a central catheter in the left subclavian region. The tip\n extends to about the junction with the superior vena cava. The prominence of\n interstitial markings is less marked on the current study.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-20 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1177076, "text": " 4:40 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: eval for DVT\n Admitting Diagnosis: HYPOTENSION;WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old male with a history of CAD s/p DES x2 (LCx and mLAD), DM, OSA, CHF\n and HTN who presented to ED after 1 day of fatigue, bilateral leg pain\n and left arm pain. Now with continued borderline hypotension.\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec TUE 5:12 PM\n No evidence of lower extremity deep vein thrombosis in either the left or\n right lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Man with bilateral leg pain, fatigue, and borderline\n hypertension. Please evaluate for DVT bilaterally.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Grayscale and Doppler son of bilateral common femoral,\n superficial femoral and popliteal veins were performed. There is normal\n compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of lower extremity deep vein thrombosis in either the\n left or right lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-03-20 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1177077, "text": ", MED MICU 4:40 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: eval for DVT\n Admitting Diagnosis: HYPOTENSION;WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old male with a history of CAD s/p DES x2 (LCx and mLAD), DM, OSA, CHF\n and HTN who presented to ED after 1 day of fatigue, bilateral leg pain\n and left arm pain. Now with continued borderline hypotension.\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of lower extremity deep vein thrombosis in either the left or\n right lower extremity.\n\n\n" }, { "category": "Echo", "chartdate": "2198-03-20 00:00:00.000", "description": "Report", "row_id": 75802, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Hypertension. Left ventricular function. Valvular heart disease\nHeight: (in) 72\nWeight (lb): 250\nBSA (m2): 2.34 m2\nBP (mm Hg): 97/72\nHR (bpm): 78\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\nLEFT VENTRICLE: Normal LV cavity size.\n\nRIGHT VENTRICLE: Dilated RV cavity.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - body habitus. Suboptimal image quality - patient unable to\ncooperate.\n\nConclusions:\nExremely limited image quality. The left ventricular cavity size is normal or\nsmall; systolic function appears grossly normal. The right ventricular cavity\nappears dilated and hypocontractile.\n\n\n" }, { "category": "ECG", "chartdate": "2198-03-21 00:00:00.000", "description": "Report", "row_id": 194468, "text": "Sinus bradycardia. Diffuse low voltage. Prominent R waves in leads V1-V2 which\nmay represent prior true posterior myocardial infarction. Clinical correlation\nis suggested. Compared to the previous tracing of no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2198-03-20 00:00:00.000", "description": "Report", "row_id": 194469, "text": "Artifact is present. Sinus rhythm. Low voltage in the precordial leads.\nCompared to the previous tracing of precordial lead voltage is less and\nthe rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2198-03-19 00:00:00.000", "description": "Report", "row_id": 194470, "text": "Marked sinus bradycardia. Since the previous tracing the rate is slower.\nPrecordial voltage is more prominent. T wave flattening in lead aVF persists.\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2198-03-19 00:00:00.000", "description": "Report", "row_id": 194471, "text": "Sinus rhythm. Early R wave progression. T wave flattening in lead aVF. Low\nprecordial voltage. Since the previous tracing of precordial voltage is\nless prominent. Otherwise, findings are unchanged from previously noted\nabnormalities.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2122-02-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318603, "text": "Chief Complaint: respiratory failure/copd exac\n I saw and examined the patient, and was physically present with the ICU\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 06:07 PM--acidemic on PS wean\n and rested on ACV\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Heparin Sodium (Prophylaxis) - 06:17 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:12 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 79 (70 - 89) bpm\n BP: 115/60(79) {101/52(67) - 141/89(95)} mmHg\n RR: 15 (10 - 18) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 2,246 mL\n 487 mL\n PO:\n TF:\n 1,463 mL\n 127 mL\n IVF:\n 692 mL\n 180 mL\n Blood products:\n Total out:\n 3,720 mL\n 705 mL\n Urine:\n 3,720 mL\n 705 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,474 mL\n -218 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 678 (678 - 678) mL\n PS : 0 cmH2O\n RR (Set): 14\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 90%\n ABG: 7.38/91/62/49/23\n Ve: 6.9 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : scant, No(t) Wheezes : , Diminished: but improved)\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, Rash: L le cellulitis looks improved/chronic stasis\n changes, easy bruising,\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): intubated, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 12.8 g/dL\n 155 K/uL\n 146 mg/dL\n 0.8 mg/dL\n 49 mEq/L (38-->45)\n 4.6 mEq/L\n 42 mg/dL (36)\n 90 mEq/L\n 143 mEq/L\n 40.1 %\n 6.5 K/uL\n [image002.jpg]\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n WBC\n 7.5\n 6.5\n Hct\n 40.0\n 40.1\n Plt\n 143\n 155\n Cr\n 1.0\n 0.8\n TCO2\n 48\n 48\n 52\n 48\n 47\n 55\n 56\n 53\n Glucose\n 187\n 146\n Other labs: PT / PTT / INR:12.0/35.7/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:9.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: no new cxr\n Microbiology: sputum--oropharengeal flora, other data pending, ngtd\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n - Complete course of levoflox , day \n - PCP with bactrim given chronic steroids\n - Taper 60 prednisone\n - Albuterol mdi's and atrovent Q 6,\n - RSBI < 100 and bronchospasm improved, alert without secreation,\n diruesed well, but still tenuous on 10 oeeo and with worsening\n acidemia/co2 retension yesterday\n - wean to PS, try dropping PEEP--follow agb, severe copd and will\n be tenuous for extubation, and will need to be extubated to noninvasive\n # LE cellulitis--remains af and with nl wbc ct (on chronic now high\n dose steroids) , has improved and may be venous stasis\n f/u blood cxs with ngtd\n d/c vanco -- compelting course of levoflox today\n # diastolic dysfx-diuresed well, now more alkalotic\n Restarted ace-i , hoem lasix and hctz\n # elevated BUN--h/h stable, cr improved, ? steroids, follow\n # Skin lesions-seen by derm, plan for outpt f/u/bx\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-02-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318809, "text": "Chief Complaint: resp failure, copd exac\n I saw and examined the patient, and was physically present with the ICU\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 extubated yesterday, requiring NPPV to maintain ph\n family mtg--code status and goals of care, now dnr, dni, with move\n towards home hospice care\n INVASIVE VENTILATION - STOP 09:59 AM\n NON-INVASIVE VENTILATION - START 12:00 PM\n increased work of breathing, NIPPV initiated.\n NON-INVASIVE VENTILATION - STOP 11:05 PM\n increased work of breathing, NIPPV initiated.\n History obtained from Patient, hosue staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Lorazepam (Ativan) - 10:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.2\nC (97.2\n HR: 114 (82 - 114) bpm\n BP: 103/67(73) {103/65(73) - 123/67(79)} mmHg\n RR: 24 (18 - 24) insp/min\n SpO2: 89%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 270 mL\n 240 mL\n PO:\n 240 mL\n TF:\n 63 mL\n IVF:\n 56 mL\n Blood products:\n Total out:\n 2,050 mL\n 970 mL\n Urine:\n 2,050 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,780 mL\n -730 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 441 (441 - 574) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 89% (40% shovel + 3 L NC) intermittent NPPV)\n ABG: 7.35/91/51/46/19\n Ve: 8.6 L/min\n PaO2 / FiO2: 128\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Diminished: ), tachypneic, acc m use\n Abdominal: Soft, Bowel sounds present, No(t) Distended, No(t) Tender: ,\n Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 13.7 g/dL\n 148 K/uL\n 78 mg/dL\n 0.8 mg/dL\n 46 mEq/L\n 4.5 mEq/L\n 30 mg/dL\n 91 mEq/L\n 139 mEq/L\n 42.3 %\n 7.2 K/uL\n [image002.jpg]\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n 01:10 PM\n 04:57 PM\n 11:35 PM\n 03:27 AM\n WBC\n 6.6\n 7.2\n Hct\n 38.3\n 42.3\n Plt\n 141\n 148\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 57\n 54\n 53\n 51\n 51\n 52\n 52\n Glucose\n 126\n 78\n Other labs: PT / PTT / INR:11.8/27.0/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr--clear zones with some LLL haziness, atelectasis vs small\n effsuion\n Microbiology: no new micro\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic, copd\n flare/bronchitis/pna, s/p course of levoflox\n --extubated yesterday, oxygenation near baseline, but remains tenuous\n and after extensive discussions with pt and family goals of care\n readdressed with change to dnr/dni and transiton to home hospice\n continue to treat anxiety, wob with ativam, morphine, NPPV as he\n tolerates\n - treat anxiety which appears large component and\n bronchospasm--ativan and morphine\n taper prednisone slowly hnow at 80 daily\n nebs\n - Albuterol mdi's and atrovent Q 6\n # diastolic dysfx-diuresed well, now more alkalotic, in part\n contraction from diuresis, le edema much improved\n continue ace-i , home lasix and hctz\n ICU Care\n Nutrition:\n Comments: diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:17 PM\n Comments: d/c a-line\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :home with hospice, arrnagements for NPPV\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2122-02-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318815, "text": "Chief Complaint: resp failure, copd exac\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 69 yo m with severe COPD (chronic prednisone, home O2) with\n chronic hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n 24 Hour Events:\n extubated yesterday\n requiring NPPV to maintain ph\n family mtg\ncode status and goals of care addressed, changed to dnr/\n dni, transition to home hospice care\n INVASIVE VENTILATION - STOP 09:59 AM\n NON-INVASIVE VENTILATION - START 12:00 PM\n increased work of breathing, NIPPV initiated.\n NON-INVASIVE VENTILATION - STOP 11:05 PM\n increased work of breathing, NIPPV initiated.\n History obtained from Patient, hosue staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Lorazepam (Ativan) - 10:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.2\nC (97.2\n HR: 114 (82 - 114) bpm\n BP: 103/67(73) {103/65(73) - 123/67(79)} mmHg\n RR: 24 (18 - 24) insp/min\n SpO2: 89%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 270 mL\n 240 mL\n PO:\n 240 mL\n TF:\n 63 mL\n IVF:\n 56 mL\n Blood products:\n Total out:\n 2,050 mL\n 970 mL\n Urine:\n 2,050 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,780 mL\n -730 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 441 (441 - 574) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 89% (40% shovel + 3 L NC) intermittent NPPV)\n ABG: 7.35/91/51/46/19\n Ve: 8.6 L/min\n PaO2 / FiO2: 128\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Diminished: ), tachypneic, acc m use\n Abdominal: Soft, Bowel sounds present, No(t) Distended, No(t) Tender: ,\n Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 13.7 g/dL\n 148 K/uL\n 78 mg/dL\n 0.8 mg/dL\n 46 mEq/L\n 4.5 mEq/L\n 30 mg/dL\n 91 mEq/L\n 139 mEq/L\n 42.3 %\n 7.2 K/uL\n [image002.jpg]\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n 01:10 PM\n 04:57 PM\n 11:35 PM\n 03:27 AM\n WBC\n 6.6\n 7.2\n Hct\n 38.3\n 42.3\n Plt\n 141\n 148\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 57\n 54\n 53\n 51\n 51\n 52\n 52\n Glucose\n 126\n 78\n Other labs: PT / PTT / INR:11.8/27.0/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr--clear zones with some LLL haziness, atelectasis vs small\n effsuion\n Microbiology: no new micro\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure, extibated yesterday\n Pt has severe end-stage COPD with tenuous resp status at baseline.\n Extensive discussion with pt and family, after extubation, and pt does\n not want repeat intubation, wishes to return home with hospice care.\n Code status changed to DNR DNI.\n He ahs completed course of antibx for ? retrocardiac pna/bronchitis.\n Continue prednisone with slopw taper 9on 30 daily at baseline).\n Continue nebs/mdi\ns. Will eval whether NPPV can be arranged for\n home, as pt reports that he does not have/use biPAP at home and he may\n benefit from comfort and wob standpoint with intermittent use.\n Anxiety remains issue and will continue to treat w/ ativan, morphine.\n Regarding his known diastolic dysfx, he appears well diuresed w/\n improved LE edema, continuing home regimen of ace-I, lasix, and\n thiazide.\n ICU Care\n Nutrition:\n Comments: diabetic diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:17 PM\n Comments: d/c a-line, picc pending plans for d/c\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :discharge planning about home hospice, arrangements for\n NPPV\n Total time spent: 40 minutes\n" }, { "category": "Radiology", "chartdate": "2122-02-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1003169, "text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate ET tube placement and lung fields\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with COPD flair, intubated\n REASON FOR THIS EXAMINATION:\n evaluate ET tube placement and lung fields\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube placement in patient with COPD\n flare.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is approximately 4.5 cm above the carina. The perihilar\n opacity which might represent mild pulmonary edema is again noted. The lung\n bases were not included on the field of view. No apical pneumothorax is\n demonstrated. The right PICC line tip is in mid SVC.\n\n DL\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2122-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002567, "text": " 9:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OGT placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with COPD\n REASON FOR THIS EXAMINATION:\n OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n CLINICAL INDICATION: 69-year-old man with COPD, assess OGT line placement.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n prior examinations dated and . There is slight improved\n aeration of the left base. Left basilar streaky opacities persist, likely\n reflecting underlying atelectasis. No new focal airspace opacities are seen.\n The right hemithorax is clear. There is persistent elevation of the left\n hemidiaphragm. A new feeding catheter has been placed that extends below the\n gastroesophageal junction and terminates within the expected region of the\n gastric fundus.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1002599, "text": " 2:19 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please check picc tip position. #%f, dl,47cm picc for abx's.\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n please check picc tip position. #%f, dl,47cm picc for abx's. please page beeper\n # with wet read asap. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable chest.\n\n CLINICAL INDICATION: A 69-year-old man with respiratory distress, please\n check PICC line position.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n prior examinations, earlier today at 9:53 a.m. There is a right PICC line in\n place that terminates within the expected region of the distal superior vena\n cava. An endotracheal tube noted that terminates approximately 5.5 cm above\n the carina. The left costophrenic angle was not included in its entirety. The\n right hemithorax is grossly clear. There is a persistent left retrocardiac\n opacity likely secondary to underlying atelectasis and a possible small\n effusion, difficult to exclude an associated pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002594, "text": " 1:46 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ET tube repositioning, OG tube placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man intubated, COPD flare\n REASON FOR THIS EXAMINATION:\n ET tube repositioning, OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Assess OG tube placement.\n\n FINDINGS: Two images of the chest were obtained that demonstrate an\n orogastric tube terminating below the gastroesophageal junction with its tip\n in the expected region of the gastric fundus. The lateral aspect of the right\n hemithorax was not included on this image. The endotracheal tube terminates\n 4.4 cm above the carina. There is a persistent left pleural effusion.\n Although the image is underpenetrated, there is a suggestion of a left\n retrocardiac opacity likely secondary to underlying atelectasis and the\n associated effusion. The hila remains prominent concerning for underlying\n pulmonary venous congestion.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002425, "text": " 11:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with acute dyspena\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute dyspnea.\n\n FINDINGS: Single bedside frontal upright chest radiograph is compared to\n . The right costophrenic angle is not imaged. There are\n streaky opacities at both bases that are nonspecific, likely atelectasis. No\n airspace consolidations are definitively seen. The pulmonary vasculature is\n within normal limits.\n\n IMPRESSION: Limited evaluate evaluation, likely demonstrates bibasilar\n atelectasis. A PA and lateral chest radiograph may be helpful for further\n evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-21 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1002478, "text": " 10:54 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: please evaluate for DVT. PLEASE PERFORM IN AFTER 8AM on \n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with L>R lower extremity edema.\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT. PLEASE PERFORM IN AFTER 8AM on \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with left more than right lower extremity edema.\n Evaluate for DVT.\n\n BILATERAL LOWER EXTREMITY VEIN DOPPLER ULTRASOUND: Grayscale and Doppler\n examination of the bilateral common femoral, superficial femoral, and\n popliteal veins was performed. Normal compressibility and augmentation is\n demonstrated, with no evidence of intraluminal clot. Note is made of\n relatively slow flow in the venous system with transmission of the cardiac\n waveforms, which could be indicative of right heart failure. There is marked\n subcutaneous edema along the left calf.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002528, "text": " 10:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate ET tube placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with COPD w/ respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n please evaluate ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: PORTABLE CHEST.\n\n CLINICAL INDICATION: Evaluate endotracheal tube placement in patient with\n COPD and respiratory failure.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated . In the interim, an endotracheal tube\n has been placed that terminates approximately 9 cm above the carina. The\n image is slightly underpenetrated. There is a new left pleural effusion. In\n addition, suggestion of a new left retrocardiac opacity is noted, likely\n secondary to the underlying effusion and atelectasis, difficult to exclude\n pneumonia. The right hemithorax is relatively clear.\n\n IMPRESSION:\n\n 1. Endotracheal tube not in ideal position, consider right repositioning.\n\n 2. New left retrocardiac opacity, likely secondary to a small-to-moderate\n size effusion and atelectasis, difficult to exclude pneumonia.\n\n These findings were discussed with Dr. at 9:44 a.m., .\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002669, "text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate ET tube placement and lung fields\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with COPD intubated\n REASON FOR THIS EXAMINATION:\n evaluate ET tube placement and lung fields\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD with intubation.\n\n FINDINGS: In comparison with the study of , the right PICC line has either\n been removed or pulled back outside of the thorax. Endotracheal and\n nasogastric tubes remain in place. The right hemidiaphragm is not sharply\n seen, consistent with atelectatic changes or effusion at the base. The left\n base opacification persists, consistent with some combination of atelectasis\n and effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-02-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1003382, "text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for infiltrate vs effusion\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with severe COPD s/p extubation on BiPAP\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate vs effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD, status post extubation.\n\n FINDINGS: In comparison with study of , the endotracheal tube has been\n removed. The patient has taken a better inspiration than on the previous\n study. Mild blunting of the costophrenic angles and basilar atelectatic\n change is seen.\n\n" }, { "category": "Radiology", "chartdate": "2122-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1002840, "text": " 6:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate/pulm edema\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with severe COPD, requiring positive pressure ventilation.\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate/pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe COPD, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there is no interval change.\n Again there is evidence of pulmonary vascular congestion that has been\n increasing since the study of . Poor definition of the hemidiaphragms\n could be consistent with some combination of atelectasis, effusion, and even\n pneumonia at the bases. Tubes remain in place.\n\n\n" }, { "category": "ECG", "chartdate": "2122-02-28 00:00:00.000", "description": "Report", "row_id": 219039, "text": "Regular tachycardia. Mechanism is uncertain, may be sinus tachycardia or\npossible atrial flutter with 2:1 response. Right bundle-branch block. Left\nanterior fascicular block. Non-specific ST-T wave changes. Clinical\ncorrelation is suggested. Since previous tracing of there may be no\nsignificant change but unstable baseline on both tracings makes comparison\ndifficult.\n\n" }, { "category": "ECG", "chartdate": "2122-02-20 00:00:00.000", "description": "Report", "row_id": 219266, "text": "The rhythm is probably sinus tachycardia. Right bundle-branch block. Left\nanterior fascicular block. Compared to the previous tracing of \nthere has been a marked increase in rate. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318233, "text": "69yr old man admitted from ED with respiratory distress.\n PMH: COPD, CHF, HTN.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG done in ED on bipap, 7.29/93/121\n Action:\n Changed to NC 4L for CO2 retention. Start methylpred., first dose given\n in ED.\n Response:\n ABG 7.26/100/85\n Plan:\n Placed on bipap, follow ABGs.\n Tachycardia, Other\n Assessment:\n HR 140s\n Action:\n Cont to monitor\n Response:\n No change\n Plan:\n Cont to monitor, possible chest CT ?PE.\n Dyspnea (Shortness of breath)\n Assessment:\n c/o SOB, RR 30s-40s, exp. wheezes.\n Action:\n Nebs, sputum cx, start abx (vanco&levaquin given in ED), ?flu.\n Response:\n RR 30s\n Plan:\n Cont nebs and methylpred.\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318313, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n LS: expiratory wheezes t/o, minimal air movement, anxiety r/t\n ineffective gas exchange. ABG on bipap 7.28/94/88 on %\n breathing 18 w/7-8Lmin\n Action:\n Bipap as tolerated, medicated for dyspnea w/.5mg morphine w/poor\n effect, medicated w/.5mg ativan for anxiety and dyspnea w/excellent\n effect.\n Right radial a-line placed.\n Response:\n Able to tolerate bipap face mask ventilation much better after\n medicated w/morphine and ativan\n Plan:\n Medicate for pain w/morphine, medicate for anxiety w/ativan as orderd.\n Continue bipap as tolerated. Pt now in agreement to be intubated if\n necessary, attempting to stave off intubation.\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318226, "text": "69yr old man admitted from ED with respiratory distress.\n PMH: COPD, CHF, HTN.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG done in ED on bipap, 7.29/93/121/47\n Action:\n Changed to NC 4L for CO2 retention. Start solumedrol, first dose given\n in ED.\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR 140s\n Action:\n Response:\n Plan:\n Dyspnea (Shortness of breath)\n Assessment:\n c/o SOB, RR 30s-40s, exp. wheezes.\n Action:\n Nebs, sputum cx, start abx (vanco&levaquin given in ED), ?flu.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318231, "text": "69yr old man admitted from ED with respiratory distress.\n PMH: COPD, CHF, HTN.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG done in ED on bipap, 7.29/93/121\n Action:\n Changed to NC 4L for CO2 retention. Start solumedrol, first dose given\n in ED.\n Response:\n ABG 7.26/100/85\n Plan:\n Tachycardia, Other\n Assessment:\n HR 140s\n Action:\n Cont to monitor\n Response:\n No change\n Plan:\n Dyspnea (Shortness of breath)\n Assessment:\n c/o SOB, RR 30s-40s, exp. wheezes.\n Action:\n Nebs, sputum cx, start abx (vanco&levaquin given in ED), ?flu.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318232, "text": "69yr old man admitted from ED with respiratory distress.\n PMH: COPD, CHF, HTN.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG done in ED on bipap, 7.29/93/121\n Action:\n Changed to NC 4L for CO2 retention. Start methylpred., first dose given\n in ED.\n Response:\n ABG 7.26/100/85\n Plan:\n Placed on bipap, follow ABGs.\n Tachycardia, Other\n Assessment:\n HR 140s\n Action:\n Cont to monitor\n Response:\n No change\n Plan:\n Dyspnea (Shortness of breath)\n Assessment:\n c/o SOB, RR 30s-40s, exp. wheezes.\n Action:\n Nebs, sputum cx, start abx (vanco&levaquin given in ED), ?flu.\n Response:\n RR 30s\n Plan:\n Cont nebs and methylpred.\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318383, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n HPI: 69 yo with copd , chronic co2 retention, on home o2 and 30\n prednisone daily, diastolic chf, and ? h/o p a-fib (not on coumadin)\n presented 3/1/8 with sob X 2 days with sick contacts at home.\n In ED was tachy and hypoxic (150\ns, RA sats 83) though af and stable\n bp. Treated for copd flare and pna with steroids, nebs, antibx (vanco\n and levo). Covered broadly for concern of cellulitis given LE\n erythema. Initially sats improved with NRB though abg showed\n significant co2 retention, acute on chronic and transitioned to BiPAP.\n MICU course: Non invasive mask ventilated until evening as no\n longer able to tolerate mask ventilation and progressive hypercapnia\n requiring intubation which was complicated by peri intubation\n hypotension rx w/one fluid bolus and change of sedation. Tachycardia to\n 140s resolved spontaneously 3/1/8 morning, has remained SR 80s, no VEA,\n no Afib noted.\n Presently ROS:\n Neuro: sedate on fentanyl 75mcg/hr and versed 2mg/hr, rec\nd 50mcg\n fentanyl bolus x2 for apparent pain as evidenced by grimacing and\n obvious bronchospasm w/good effect, no hypotension noted.\n Afebrile. Pt fully cultured prior to start of vancomycin.\n Resp: remains vented on AC 14 x 550, 40%, transiently increased to 45%\n as O2 sats 88%, just decreased back to 40% and will check ABG this eve.\n Secretions minimal, thick yellow to white. LS: insp upper wheezes,\n deminished bibasilar. Conts on solumedrol for COPD.\n GI: OGT place, initial 100cc mucusy gastric contents removed, placed on\n low intermittant suction and appeared to have occult + gastric\n secretions over 5hours and drained 400cc. Started PPI and PO\n medications restarted, lisinopril restarted today and may restart HCTZ\n this eve or by am. Tube feeds of replete w/fiber started @10cc/hr will\n advance rate q4-6hr as tolerated to goal of 65cc/hr, anticipate\n nutrition consult tomorrow and may need change of tube feeds but did\n want to start some nutrition.\n GU: foley patent, yellow sedimentous urine to start, UA,CS sent and\n now urine cloudy. Noted small amt leakage around foley w/morning bed\n changes, suspect leakage w/coughing, no further leakage noted this\n afternoon after bath.\n CV: normotensive and HR 80s SR, no VEA. Lisinopril restarted, noted\n increase in edema of hands and lower extremities, anticipate restart of\n HCTZ soon.\n Skin: appeared to venous stasis ulcer on right lower calf, unable to\n remove what appeared to be a scab, soaked w/NS dressing and then noted\n lesion left upper thigh which appears very suspicious for neoplasm. ICU\n team in to eval and will consult dermatology. Right lower lesion now\n covered w/NS w->d drsg, Left upper thigh lesion open to air if bleeds\n will need DSD and will probably be biopsied by derm.\n Access: double lumen PICC cath placed today by IV RN @ bedside. Appears\n to be working well, left forearm IV infiltrated and will d/c 2^nd\n peripheral.\n" }, { "category": "Respiratory ", "chartdate": "2122-02-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318236, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous non-invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use; Comments:\n Pt RR 40 prior to NIV. Albuterol/Atrovent neb given. BS decreased with\n exp wheezes throughout. NPC.pAcO2 100. Placed on NIV. Will repeat ABG\n seems to tol well.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Tolerated well\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: Repeat ABG\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318333, "text": "69yo M admitted with SOBx2 days/COPD exacerbation w/ hypercabia.\n PMH: COPD w/ CO2 retention on home O2, HTN, CHF.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG on bipap at 7.25/105/102, pt not tolerating mask w/\n ativan/morphine, no improvement w/ bipap: 7.27/104/86 and 7.26/100/90.\n Action:\n Intubated CMV/40%/550/14/10 and sedated, fent@75 and versed@2\n Response:\n ABG@100 7.35/75/83\n Plan:\n Follow ABGs,\n Hypotension (not Shock)\n Assessment:\n Bp 80s post intubation\n Action:\n Sedation lowered, 500cc NS bolusx1 given\n Response:\n Bp stable 90s\n Plan:\n Cont to monitor bp, bolus as necessary.\n" }, { "category": "Physician ", "chartdate": "2122-02-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318418, "text": "Chief Complaint: hypoxia/respiratory distress\n 24 Hour Events:\n BLOOD CULTURED - At 12:07 PM\n PICC LINE - START 02:17 PM\n URINE CULTURE - At 02:20 PM\n SPUTUM CULTURE - At 02:30 PM\n - 2 large black, cauliflower-like lesions on right calf and left thigh,\n will need derm consult in am\n - started tube feeds but will need nutrition rec's\n - restarted ACEI and HCTZ\n - restarted vanc for RLE cellulitis\n - PICC placed\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 04:15 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, Edema, No(t) Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: No(t) Tachypnea, Wheeze, Intubated\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis, No(t) Diarrhea\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 80 (73 - 96) bpm\n BP: 113/65(80) {95/49(64) - 119/69(85)} mmHg\n RR: 14 (11 - 17) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 993 mL\n 290 mL\n PO:\n TF:\n 115 mL\n 125 mL\n IVF:\n 668 mL\n 105 mL\n Blood products:\n Total out:\n 964 mL\n 215 mL\n Urine:\n 664 mL\n 215 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 29 mL\n 75 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 19 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 93%\n ABG: 7.36/82./74/42/16\n Ve: 6.4 L/min\n PaO2 / FiO2: 148\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t)\n Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n improved, L > R)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, worsened erythema on left > right leg\n Skin: Warm, worsening eryethma, fungating black necrotic mass on right\n ankle\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 12.6 g/dL\n 156 mg/dL\n 0.9 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 94 mEq/L\n 138 mEq/L\n 38.4 %\n 6.5 K/uL\n [image002.jpg]\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n WBC\n 5.6\n 6.5\n Hct\n 39.1\n 38.4\n 38.4\n Plt\n 148\n 146\n Cr\n 0.7\n 0.9\n TropT\n <0.01\n TCO2\n 50\n 47\n 43\n 46\n 47\n 48\n 49\n Glucose\n 153\n 156\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 69 y/o male w/ hx of COPD, dCHF, admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. While b/l LE edemao on exam, no\n evidence on CXR of fluid overlaod, and wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intuvated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator.\n n continue intubation for ventalatory support, will discuss\n extubation today\n n continue solumedro 80mg ivq8, but likely start prednisone\n tomorrow w/ taper\n n frequent albuterol / atrovent nebs\n n continue levaquin for empiric coverage\n n sputum CX showed no organisims, urine legonalla pending\n n DFA negative\n n CE negative x 3\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n n Ischemia: ROMI negative, was started on ASA, now d/c\n n Rhythem: sinus tach, now resolved. Felt was likely to\n hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n n Pump: euvolemic on exam, EF > 55% w/ dCHF.\n ICU Care\n Nutrition:\n Comments: TF, need nutirition recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2122-02-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318403, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\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 Comments: audible wheeze with coughing and activity\n Assessment of breathing comfort: No claim of dyspnea); Comments: pt\n appeared to rest comfortably most of the night.Awake/alert and able to\n communicate.\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated; Comments: still bronchospastic-requiring\n frequent mdi's. Auto peep level much better-currently 0-3.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved; Comments: frequent mdi's\n" }, { "category": "Physician ", "chartdate": "2122-02-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318406, "text": "Chief Complaint: hypoxia/respiratory distress\n 24 Hour Events:\n BLOOD CULTURED - At 12:07 PM\n PICC LINE - START 02:17 PM\n URINE CULTURE - At 02:20 PM\n SPUTUM CULTURE - At 02:30 PM\n - 2 large black, cauliflower-like lesions on right calf and left thigh,\n will need derm consult in am\n - started tube feeds but will need nutrition rec's\n - restarted ACEI and HCTZ\n - restarted vanc for RLE cellulitis\n - PICC placed\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 04:15 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, Edema, No(t) Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: No(t) Tachypnea, Wheeze, Intubated\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis, No(t) Diarrhea\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 80 (73 - 96) bpm\n BP: 113/65(80) {95/49(64) - 119/69(85)} mmHg\n RR: 14 (11 - 17) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 993 mL\n 290 mL\n PO:\n TF:\n 115 mL\n 125 mL\n IVF:\n 668 mL\n 105 mL\n Blood products:\n Total out:\n 964 mL\n 215 mL\n Urine:\n 664 mL\n 215 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 29 mL\n 75 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 19 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 93%\n ABG: 7.36/82./74/42/16\n Ve: 6.4 L/min\n PaO2 / FiO2: 148\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t)\n Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n improved, L > R)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, worsened erythema on left > right leg\n Skin: Warm, worsening eryethma, fungating black necrotic mass on right\n ankle\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 12.6 g/dL\n 156 mg/dL\n 0.9 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 94 mEq/L\n 138 mEq/L\n 38.4 %\n 6.5 K/uL\n [image002.jpg]\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n WBC\n 5.6\n 6.5\n Hct\n 39.1\n 38.4\n 38.4\n Plt\n 148\n 146\n Cr\n 0.7\n 0.9\n TropT\n <0.01\n TCO2\n 50\n 47\n 43\n 46\n 47\n 48\n 49\n Glucose\n 153\n 156\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Comments: TF, need nutirition recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2122-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318409, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Hypoxic with baseline hypercarbia on 40% FI02 at beginning of shift,\n sats down to 88%. u.o. trending down as low as 25cc/hr. borderline low\n bp down to 90s-remains with le edema. Bilat lower ext. remain very\n red/appear to have cellulitis. Outlined in black marker. unable to\n restart HCTZ at this time. u.o. improved without intervention at\n 30+cc/hr. remains comfortable on light sedation fentanyl 75mcg/hr and\n versed 2mg/hr. occasionally requires .5-1mg iv versed bolus for anxiety\n with good effect. Tube feeding replete with fiber increased to\n 50cc/hr (goal is 65cc/hr).\n Action:\n Fi02 increased back to 50% with improved oxygenation, remains with\n baseline hypercarbia. 02 sats improving up to 90-91%. Monitor u.o.\n closely. Continue fentanyl and versed gtts for sedation. Continue iv\n abx (levoflox and vanco).\n Response:\n Stable 02 sats on fi02 50%. Presently maintaining u.o. 30cc/hr.\n comfortable/lightly sedated.\n Plan:\n Continue to monitor 02 sats, wean fi02 back down to 40% when able to.\n Monitor u.o. may need to add HCTZ today if bp improves. Continue iv\n abx.\n" }, { "category": "Physician ", "chartdate": "2122-02-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318489, "text": "Chief Complaint: COPD flare\n 24 Hour Events:\n - per derm consult, unlikely melanoma, will need shave biopsy as outpt\n - continue vanc for RLE cellulitis\n - ABGs closer to baseline on MinVent but serum bicarb rising at 45,\n switched back to A/C to increased PCO2\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 78 (70 - 110) bpm\n BP: 105/56(72) {94/53(68) - 143/81(100)} mmHg\n RR: 15 (10 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 2,558 mL\n 518 mL\n PO:\n TF:\n 1,625 mL\n 387 mL\n IVF:\n 873 mL\n 131 mL\n Blood products:\n Total out:\n 2,562 mL\n 1,645 mL\n Urine:\n 2,562 mL\n 1,645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4 mL\n -1,127 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n SpO2: 91%\n ABG: 7.38/77/64/45/15\n Ve: 5.6 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress, No(t) Diaphoretic\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n slight at bases, but improved, Wheezes : significantly )\n Extremities: Right: 1+, Left: 1+\n Skin: Warm, improved let erythema, not hot to touch, necrotic black\n lesion at left ankle\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Not assessed, Sedated, Tone:\n Normal, responsds to questions, lightly sedated\n Labs / Radiology\n 143 K/uL\n 12.8 g/dL\n 187 mg/dL\n 1.0 mg/dL\n 45 mEq/L\n 4.2 mEq/L\n 36 mg/dL\n 91 mEq/L\n 140 mEq/L\n 40.0 %\n 7.5 K/uL\n [image002.jpg]\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n WBC\n 6.5\n 7.5\n Hct\n 38.4\n 38.4\n 40.0\n Plt\n 146\n 143\n Cr\n 0.9\n 1.0\n TCO2\n 48\n 49\n 48\n 48\n 52\n 48\n 47\n Glucose\n 156\n 187\n Other labs: PT / PTT / INR:12.6/33.5/1.1, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:8.9 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: CXR: FINDINGS: In comparison with the study of , the\n right PICC line has either\n been removed or pulled back outside of the thorax. Endotracheal and\n nasogastric tubes remain in place. The right hemidiaphragm is not\n sharply\n seen, consistent with atelectatic changes or effusion at the base. The\n left\n base opacification persists, consistent with some combination of\n atelectasis\n and effusion.\n Microbiology: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n GRAM STAIN (Final ):\n NO MICROORGANISMS SEEN.\n Blood Culture, Routine (Pending):\n Assessment and Plan\n 69 y/o male w/ hx of COPD, dCHF, admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intubated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator.\n &#; continue intubation for ventalatory support, now\n changed to PS/AC, likely extubation tomorrow/today\n &#; decreased solumedrol to 60mg ivq8, assess\n decreasing to 40mg IVq8/60mg prednisone daily\n &#; frequent albuterol / atrovent nebs, decreased\n frequency q4\n &#; continue levaquin for empiric coverage\n &#; sputum CX showed no organisims, urine legonalla\n negative\n &#; DFA negative\n &#; CE negative x 3\n &#; CXR yesterday showing pleural edema, pt w/ hx of\n dCHF on home lasix not being given. Will diurese w/ goal of 1L.\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n &#; Ischemia: ROMI negative, was started on ASA, now\n d/c\n &#; Rhythem: sinus tach, now resolved. Felt was\n likely to hypoxa,distress from BIPAP, EKG unrevealing, cont\n telemetry\n &#; Pump: now w/ pleural edema on CXR, hx of dCHF,\n will diurese and resume home lasix dose.\n # HTN: hx of HTN. Restarted lisinopril, holding HCTZ given low\n pressures, lasix as tolerated given evidence of CHF.\n #LE edema/erythema: worsening LE erythema, no WBC, no fever.\n Startarted on vanc. Follow up bcx, wound cx, and decrease per\n culture/sensitivities.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:20 AM 60 mL/hour\n Comments: TF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Comments: Check on positinoning of PICC in today's CXR\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Call once once extubated\n" }, { "category": "Nursing", "chartdate": "2122-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318394, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Hypoxic with baseline hypercarbia on 40% FI02 at beginning of shift,\n sats down to 88%. u.o. trending down as low as 25cc/hr. borderline low\n bp down to 90s-remains with le edema. Bilat lower ext. remain very\n red/appear to have cellulitis. Outlined in black marker. unable to\n restart HCTZ at this time. u.o. improved without intervention at\n 30cc/hr. remains comfortable on light sedation fentanyl 75mcg/hr and\n versed 2mg/hr. tf increased to 40cc/hr (goal is 65cc/hr).\n Action:\n Fi02 increased back to 50% with improved oxygenation, remains with\n baseline hypercarbia. 02 sats improving up to 90-91%. Monitor u.o.\n closely. Continue fentanyl and versed gtts for sedation.\n Response:\n Stable 02 sats on fi02 50%. Presently maintaining u.o. 30cc/hr.\n comfortable/lightly sedated.\n Plan:\n Continue to monitor 02 sats, wean fi02 back down to 40% when able to.\n Monitor u.o. may need to add HCTZ today if bp improves.\n" }, { "category": "Respiratory ", "chartdate": "2122-02-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318302, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\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: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern: Nasal flaring, Accessory muscle\n use, Prolonged exhalation, Frequent desaturation episodes, Intercostal\n retractions, Active exhalations\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment: Mask discomfort\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n ABG puncture (0700)\n nasal aspirate (1000)\n Comments: pt had nasal aspirate sent to lab and results negative.\n" }, { "category": "Nursing", "chartdate": "2122-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318547, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and lle\n cellulitis. He required intubation and has remained intubated with\n difficulty weaning vent settings d/t the severity of his COPD.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n RSBI 90 this AM and pt tolerated SBT well\n Pt tolerated PSV 5+5 x2hrs\n ABG on PSV 5+5 indicated hypercarbia and acidemia\n SpO2 87-90\n LS diminished all fields\n Action:\n Pt was returned to higher PSV level of 12+5\n Continue steroid taper\n Response:\n Ongoing assessment\n Plan:\n Repeat RSBI and SBT in AM\n Consider extubation to NIMV if hypercarbic failure persists\n Continue streroid taper\n Dyspnea (Shortness of breath)\n Assessment:\n Intermittently pt subjectively\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318548, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and lle\n cellulitis. He required intubation and has remained intubated with\n difficulty weaning vent settings d/t the severity of his COPD.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n RSBI 90 this AM and pt tolerated SBT well\n Pt tolerated PSV 5+5 x2hrs\n ABG on PSV 5+5 indicated hypercarbia and acidemia\n SpO2 87-90\n LS diminished all fields\n Action:\n Pt was returned to higher PSV level of 12+5\n Continue steroid taper\n Response:\n Ongoing assessment\n Plan:\n Repeat RSBI and SBT in AM\n Consider extubation to NIMV if hypercarbic failure persists\n Continue streroid taper\n Dyspnea (Shortness of breath)\n Assessment:\n Intermittently pt subjectively reports dyspnea\n Dyspnea not associated with activity or changes in ventilatory support\n Action:\n MDIs delivered to pt by RT\n Response:\n Subjective improvement in Dyspnea\n Plan:\n Continue MDIs ATC\n Continue steroid taper\n Consider extubation to NIMV if hypercarbia persists\n" }, { "category": "Physician ", "chartdate": "2122-02-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318554, "text": "Chief Complaint: COPD flare\n 24 Hour Events:\n - per derm consult, unlikely melanoma, will need shave biopsy as outpt\n - continue vanc for RLE cellulitis\n - ABGs closer to baseline on MinVent but serum bicarb rising at 45,\n switched back to A/C to increased PCO2\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Furosemide (Lasix) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 78 (70 - 110) bpm\n BP: 105/56(72) {94/53(68) - 143/81(100)} mmHg\n RR: 15 (10 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 2,558 mL\n 518 mL\n PO:\n TF:\n 1,625 mL\n 387 mL\n IVF:\n 873 mL\n 131 mL\n Blood products:\n Total out:\n 2,562 mL\n 1,645 mL\n Urine:\n 2,562 mL\n 1,645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4 mL\n -1,127 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n SpO2: 91%\n ABG: 7.38/77/64/45/15\n Ve: 5.6 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress, No(t) Diaphoretic\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n slight at bases, but improved, Wheezes : significantly )\n Extremities: Right: 1+, Left: 1+\n Skin: Warm, improved let erythema, not hot to touch, necrotic black\n lesion at left ankle\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Not assessed, Sedated, Tone:\n Normal, responsds to questions, lightly sedated\n Labs / Radiology\n 143 K/uL\n 12.8 g/dL\n 187 mg/dL\n 1.0 mg/dL\n 45 mEq/L\n 4.2 mEq/L\n 36 mg/dL\n 91 mEq/L\n 140 mEq/L\n 40.0 %\n 7.5 K/uL\n [image002.jpg]\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n WBC\n 6.5\n 7.5\n Hct\n 38.4\n 38.4\n 40.0\n Plt\n 146\n 143\n Cr\n 0.9\n 1.0\n TCO2\n 48\n 49\n 48\n 48\n 52\n 48\n 47\n Glucose\n 156\n 187\n Other labs: PT / PTT / INR:12.6/33.5/1.1, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:8.9 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: CXR: FINDINGS: In comparison with the study of , the\n right PICC line has either\n been removed or pulled back outside of the thorax. Endotracheal and\n nasogastric tubes remain in place. The right hemidiaphragm is not\n sharply\n seen, consistent with atelectatic changes or effusion at the base. The\n left\n base opacification persists, consistent with some combination of\n atelectasis\n and effusion.\n Microbiology: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n GRAM STAIN (Final ):\n NO MICROORGANISMS SEEN.\n Blood Culture, Routine (Pending):\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intubated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator.\n -- continue intubation for ventalatory support, now changed\n to PS/AC, likely extubation tomorrow/today\n -- decreased solumedrol to 60mg ivq8, assess decreasing to\n 40mg IVq8/60mg prednisone daily\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- continue levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- CXR yesterday showing pleural edema, pt w/ hx of on\n home lasix not being given. Will diurese w/ goal of 1L.\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. Restarted lisinopril, will restart HCTZ today,\n lasix as tolerated given evidence of CHF on CXR with goal of negative\n .5-1L.\n #LE edema/erythema: LE erythema slightly improved. Cellulitis vs.\n changes from LE edema. Noted that no WBC, no fever. Startarted on\n vanc b/c looked notably angre. Follow up bcx, wound cx. Low suspicisn\n for MRSA cellultiis, feel adequate treatment on levofloxacin.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:20 AM 60 mL/hour\n Comments: TF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Comments: Check on positinoning of PICC in today's CXR\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Call once once extubated\n" }, { "category": "Physician ", "chartdate": "2122-02-21 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 318297, "text": "Chief Complaint: sob, copd exacerbation with acute on chronic\n hypercarbia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 69 yo with copd , chronic co2 retention, on home o2 and 30\n prednisone daily, diastolic chf, and ? h/o p a-fib (not on coumadin)\n presents with sob X 2 days with sick contacts at home.\n In ED was tachy and hypoxic (150\ns, RA sats 83) though af and stable\n bp. Treated for copd flare and pna with steroids, nebs, antibx (vanco\n and levo). Covered broadly for concern of cellulitis given LE\n erythema. Initially sats improved with NRB though abg showed\n significant co2 retention, acute on chronic and transitioned to BiPAP.\n Patient admitted from: ER\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home regimen Medications: per wife, confirmed with pharmacy cvs\n .\n -ipratropium Bromide 0.02 % IH Q6HR\n -albuterol Sulfate 0.083 % IH Q6HR\n -lisinopril 10 mg po qdaily\n -hctz 12.5 mg po qdaily (zestoretic)\n -prednisone 30mg po qdaily\n -bactrim 400-80 mg po qdaily\n -CALCIUM 500+D 500 po qdaily\n -chantix\n lasix (dose per wife, not recorded on pharmacy list)\n coumadin (not taking)\n in house:\n per (reviewed)\n Past medical history:\n Family history:\n Social History:\n copd no pfts available, on 3 L home O2, chronic prednisone 30 qd, no\n prior intubations\n htn\n diastolic CHF (TTE EF>55%, RV free wall HK, mod\n aortic dilation)\n ? h/o afib\n .\n NC\n Drugs: none\n Tobacco:3- 4 PPD X 50 yrs, now < 1 ppd\n Denies etoh/illicts.\n Married. 8 children. Taxi driver.\n Review of systems: negative for F/C/N/V/D, CP, dysuria, constipation.\n +sick contacts, fatigue.\n .\n Flowsheet Data as of 09:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 140 (140 - 145) bpm\n BP: 117/71(80) {112/71(80) - 126/82(92)} mmHg\n RR: 12 (12 - 39) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 104 kg\n Total In:\n 67 mL\n PO:\n TF:\n IVF:\n 67 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 67 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 506 (380 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n SpO2: 91%\n ABG: 7.28/94./131//13\n Ve: 8 L/min\n PaO2 / FiO2: 328\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Distant), (Murmur: No(t)\n Systolic), tachy\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: Wheezes :\n throughout, Diminished: air movement)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: 1+, Left: 1+, Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , erythema pretibial b/l with chronic venous\n changes\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 126\n 0.9\n 16\n 45 (38-40's)\n 97\n 3.5\n 145\n [image002.jpg]\n 03:29 AM\n 05:26 AM\n 08:21 AM\n WBC\n 8.1\n Hct\n 13\n Plt\n 171\n TC02\n 47\n 48\n 46\n Other labs: Lactic Acid:0.7 mmol/L\n Fluid analysis / Other labs: bnp 5000\n ck cardiac enzymes flat trop 0.03\n Imaging: no clear new infiltrate, chronic (stable appearing RLL opactiy\n likely atelectasis), slight L base blunting at cp angle\n ECG: LAD, chronic RBBB, nonspecific st depression, precordials\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare and acute on chronic hypercarbic\n resp failure likely from bronchitisverses pna\n MAIN ISSUES:\n # hypoxemia\n copd exacerbation most likely etiology, with pe (given tachycardia)\n verses chf on ddx\n acute on chronic hypercarbic resp failure\n no new infiltrate on cxr, given significant bronchospasm most\n concerned for copd with bronchitis verses early pna (bacterial verses\n viral) low suspicion for pe, though has b/l le edema. Pt is on high\n dose of chronic steroids so immunosupressed, though on PCP .\n Would have low threshold for obtaining ct if no improvement with\n current treatment\n Sputum cx, blood cx if spikes, r/u influenze and check urine legionella\n continue solumedrol 80 Q 8, Q 2 hr nebs and atrovent Q 6,\n empiric antibx (levo and would d/c vanco) and f/u cxr\n BiPAP and follow abgs, looks comfortable but if worsening acidosis or\n fatigue would move toward intubation\n # diastolic dysfx-does not appear overtly fluid overloaded, BNP\n elevated, has chronic LE edema likely from pulm htn\n Would diurese gently, continue home bp meds\n # tachycardia-lower suspicion of pe given improvement in tachycardia\n with treatment for copd, will check leni\ns for dvt\n # elevated troponin and nonspecific ecg changes--follow enzymes and\n continue asa pending next set\n # LE edema/erythema - pt with similar sx during admission and\n appears chronic\n LENIs.\n follow\n ICU Care\n Nutrition:\n Comments: NPO given tenuous respiratory status\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 02:00 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318375, "text": "Chief Complaint: hypercarbic respiratory failure, copd exacerbation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare and acute on chronic hypercarbic\n resp failure likely from bronchitis verses pna\n 24 Hour Events:\n ULTRASOUND - At 01:48 PM\n ARTERIAL LINE - START 03:00 PM\n Worsening of abg's on bipap and fatigue resulting in semi-elective\n intubation overnight.\n Difficult ventilation with significant bronchospasm, improvement in\n abg w/ aggressive MDI's\n lenis negative\n History obtained from Medical records, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 09:40 PM\n Midazolam (Versed) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 73 (73 - 103) bpm\n BP: 99/65(78) {89/54(0) - 146/90(290)} mmHg\n RR: 14 (12 - 38) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 1,104 mL\n 205 mL\n PO:\n 360 mL\n TF:\n IVF:\n 744 mL\n 205 mL\n Blood products:\n Total out:\n 400 mL\n 290 mL\n Urine:\n 400 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 704 mL\n -85 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 680 (680 - 680) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 18 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 90%\n ABG: 7.37/77./76./38/14\n Ve: 5.8 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Wheezes : decreased, Diminished: ), tight with limited air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, venous stasis ulcer R medial\n calf, purulent smelling (pt refused bandage removal yesterday)\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 12.7 g/dL\n 148 K/uL\n 153 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.5 mEq/L\n 25 mg/dL\n 95 mEq/L\n 138 mEq/L\n 39.1 %\n 5.6 K/uL\n [image002.jpg]\n 05:26 AM\n 08:21 AM\n 03:54 PM\n 08:21 PM\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n WBC\n 5.6\n Hct\n 39.1\n Plt\n 148\n Cr\n 0.7\n TropT\n <0.01\n TCO2\n 48\n 46\n 46\n 48\n 50\n 47\n 43\n 46\n 47\n Glucose\n 153\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Imaging: cxr- clear on right, left retrocardiac opacity likely\n atelectasis and poissibly a tiny effusion, picc ok, et ok\n Microbiology: influenza dfa negative\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare/bronchitis and acute on chronic\n hypercarbic and hypoxic resp failure, intubated overnight\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic\n -progressive fatigue and bronshospasm leading to intubation\n - no new infiltrate on cxr, given significant bronchospasm most\n concerned for copd with bronchitis verses early pna (bacterial verses\n viral) low suspicion for pe (neg lenis, resolution in tachy). Pt is\n on high dose of chronic steroids so immunosupressed, though on PCP\n .\n Sputum cx with ngtd, ruled out for influenze and urine legionella\n pending\n Continue solumedrol 80 Q 8, Q 2 hr albuterol and atrovent Q 6, follow\n abg though ventilation improving and some increased air movement noted\n on exam.\n Would continue antibx with levoflox for 7 day and recheck sputum for ET\n sx, follow LLL on cxr--likely atelectasis\n # LE edema/erythema -now appears more erythematous concerning for\n cellulitis, though af and with nl wbc ct. Also with R venous stasis\n ulcer on calf, swab ulcer and check blood cx given chronic steroids.\n Resume vanco.\n # diastolic dysfx-does not appear overtly fluid overloaded, has chronic\n LE edema and stasis changes,\n restart ace-i and add back hctz later if bp stable\n # tachycardia-now improved, suspect from copd/resp distress with low\n suspicon of PE given exam and nelenis\n ICU Care\n Nutrition:\n Comments: start tf's once placement confirmed\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n Comments: picc consult\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker--will start pre-tf's\n VAP: aspiration and mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2122-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318647, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Remains on vent, CMV settings 40%. Appeared comfortable this shift, no\n increased WOB noted. Remains on 50mcg/hr of fentanyl, and 2mg/hr\n versed. Pt alert, able to mouth words/ write on board/nod head to make\n needs known.\n Action:\n Pt c/o feeling anxious at times, intermittently bolus for comfort. TF\n off at midnight pnding possible extubation in AM. Pt also asking to be\n sxned, sxned infrequently for sm. Amounts of white thick sputum.\n Response:\n No vent changes made over nt, pt remains resting comfortably.\n Plan:\n RSBI/SBT and possible extubation in am.\n" }, { "category": "Respiratory ", "chartdate": "2122-02-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318652, "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: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\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: White / 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: appears comfortable and able to sleep most of the night\n Assessment of breathing comfort: No claim of dyspnea); Comments: no\n episodes of tachypnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: will check rsbi in am and place back on psv. Mdi given\n q3-4.Auto peep level (peep from yesterday)\n Reason for continuing current ventilatory support: will wean to psv in\n am with plan of possible extubation\n .\n .\n" }, { "category": "Physician ", "chartdate": "2122-02-21 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 318267, "text": "Chief Complaint: sob, copd exacerbation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 69 yo with copd 2 L O2, diastolic chf, afib (? on coumadin) presents\n with sob. X 2 days.\n + sick contacts\n AF stable BP 153 HR 83% RA. improved in stas with NRB but still\n tachypneic. started on BiPAP andntransitioned to NC. Pulmonary exam\n frlt c/w COPD falre with ? pna RLL on cxr. Treated with steroids,\n levo/vanco and transferred to MICU for care. R > L edema LE and L\n cellultiis. Unable to lie flat for ctpa\n Patient admitted from: ER\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Past medical history:\n Family history:\n Social History:\n copd 3 L home O2 chronic prednisone 30 qd, no prior intubations\n htn\n diastolic dysfx\n afib ?\n no hx of blood\n Occupation:\n Drugs: none\n Tobacco: 4 PPD X 50 yrs, now 1 ppd\n Alcohol: none\n Other:\n Review of systems:\n Flowsheet Data as of 09:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 140 (140 - 145) bpm\n BP: 117/71(80) {112/71(80) - 126/82(92)} mmHg\n RR: 12 (12 - 39) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 104 kg\n Total In:\n 67 mL\n PO:\n TF:\n IVF:\n 67 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 67 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 506 (380 - 506) mL\n PS : 15 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n SpO2: 91%\n ABG: 7.28/94./131//13\n Ve: 8 L/min\n PaO2 / FiO2: 328\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Distant), (Murmur: No(t)\n Systolic), tachy\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: Wheezes :\n throughout, Diminished: air movement)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: 1+, Left: 1+, Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , erythema pretibial b/l with chronic venous\n changes\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 126\n 0.9\n 16\n 45 (38-40's)\n 97\n 3.5\n 145\n [image002.jpg]\n 03:29 AM\n 05:26 AM\n 08:21 AM\n WBC\n 8.1\n Hct\n 13\n Plt\n 171\n TC02\n 47\n 48\n 46\n Other labs: Lactic Acid:0.7 mmol/L\n Fluid analysis / Other labs: bnp 5000\n ck cardiac enzymes flat trop 0.03\n Imaging: no clear new infilttrate, chronic (stable appearing RLL\n opactiry likely atelctasis)\n ECG: LAD, chronic RBBB, nonspecific st depression, precordials\n Assessment and Plan\n 69 Yo m with severe COPD on chronic pred and home O2 with chronic\n hypercarbia presents with copd flare with hypercrabic respiratroy\n failure, acute on chronic\n # copd exacerbation with acute on chronic hypercarbic resp\n failure--continue solumedrol 80 Q 8, Q 2 hr nebs and atrovent Q 6,\n sputum cx r/o flu, low suspicion of PCP and on bactrim prophy, empiric\n levoquine, f/u cxr,\n # diastolic dysfx-\n tachycardia-lower suspicion of pe given improvement in tachycardia with\n treatment and stable o2 sats\n follow enxymes and continue asa pending next set enzymes\n appears intravascuallrly euvolemic to dry without JVD, chronic LE edema\n ICU Care\n Nutrition:\n Comments: NPO given tenuous respiratory status\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 02:00 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318251, "text": "69yr old man admitted from ED with respiratory distress.\n PMH: COPD, CHF, HTN, Afib\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG done in ED on bipap, 7.29/93/121\n Action:\n Changed to NC 4L for CO2 retention. Start methylpred., first dose given\n in ED.\n Response:\n ABG 7.26/100/85\n Plan:\n Placed on bipap, follow ABGs.\n Tachycardia, Other\n Assessment:\n HR 140s\n Action:\n Cont to monitor\n Response:\n No change\n Plan:\n Cont to monitor, possible chest CT ?PE.\n Dyspnea (Shortness of breath)\n Assessment:\n c/o SOB, RR 30s-40s, exp. wheezes.\n Action:\n Nebs, sputum cx, start abx (vanco&levaquin given in ED), ?flu.\n Response:\n RR 30s\n Plan:\n Cont nebs and methylpred.\n" }, { "category": "Nursing", "chartdate": "2122-02-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318252, "text": "69yr old man admitted from ED with respiratory distress.\n PMH: COPD, CHF, HTN, Afib\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG done in ED on bipap, 7.29/93/121\n Action:\n Changed to NC 4L for CO2 retention. Start methylpred., first dose given\n in ED.\n Response:\n ABG 7.26/100/85\n Plan:\n Placed on bipap, follow ABGs.\n Tachycardia, Other\n Assessment:\n HR 140s\n Action:\n Cont to monitor\n Response:\n No change\n Plan:\n Cont to monitor, possible chest CT ?PE.\n Dyspnea (Shortness of breath)\n Assessment:\n c/o SOB, RR 30s-40s, exp. wheezes.\n Action:\n Nebs, sputum cx, start abx (vanco&levaquin given in ED), ?flu.\n Response:\n RR 30s\n Plan:\n Cont nebs and methylpred.\n" }, { "category": "Respiratory ", "chartdate": "2122-02-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318367, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: P > 30cm/H2O\n Comments:\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\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: Prolonged exhalation\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Possible air trapping, Erratic exhaled Tidal\n Volumes\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP 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 Pt remains intubated requiring bronchodilators Q2-Q4 as needed for\n persistent bronchospasms with sxing and turning. Noticeable decrease in\n peak airway pressures post treatments.\n" }, { "category": "Nutrition", "chartdate": "2122-02-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 318364, "text": "Subjective\n Patient intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 104 kg\n 103.1 kg ( 08:00 AM)\n 34\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 73\n 142\n 81\n Diagnosis: Respiratory Distress\n PMH : COPD, CHF, hypertension, afib\n Food allergies and intolerances: unable to assess\n Pertinent medications: senna, vitamin D, calcium carbonate\n Labs:\n Value\n Date\n Glucose\n 153 mg/dL\n 04:00 AM\n BUN\n 25 mg/dL\n 04:00 AM\n Creatinine\n 0.7 mg/dL\n 04:00 AM\n Sodium\n 138 mEq/L\n 04:00 AM\n Potassium\n 4.5 mEq/L\n 04:00 AM\n Chloride\n 95 mEq/L\n 04:00 AM\n Phosphorus\n 3.4 mg/dL\n 04:00 AM\n Magnesium\n 1.9 mg/dL\n 04:00 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen obese with hypoactive bowel sounds\n Assessment of Nutritional Status\n Adequately nourished\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1620-2400 (BEE x or / 20-30 cal/kg)\n Protein: 97-121 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n 69 year old male presenting with respiratory distress now intubated in\n ICU. Patient with history of COPD. Consult received for tube feeding\n recommendations. Would suggest Nutren Pulmonary at 60ml/hr to provide\n 2160kcal and 98g protein. Will for changes and make adjustment to tube\n feeding PRN.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start Nutren Pulmonary at 20ml/hr, advance by 20ml q6H to goal\n rate of 60ml/hr\n 2. Monitor residuals q4H and hold if >150ml\n 14:17\n" }, { "category": "Physician ", "chartdate": "2122-02-21 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 318243, "text": "Chief Complaint: shortness of breath.\n HPI:\n 69 M h/o COPD, dCHF, on coumadin for h/o afib (per wife, though pt not\n taking it now) presenting for respiratory distress. Per wife, pt with\n 2d increasing SOB, non-productive cough, \"in bed all day\", multiple\n other family members sick with \"flu.\"\n .\n Pt presented to the ED with VS: 97.4 153 134/89 34 83% RA, improved\n to 96% with NRB, though RR 40s, so pt started on CPAP, with sats 93%,\n SBP 130s->94, so put back on 4L, with sats 91%. pulmonary exam sounded\n tight, +wheezing, sinus tach on EKG, CXR showed no CHF, ?PNA in RLL.\n given solumedrol 125, nebs, levo/vanco for broad coverage.\n .\n Pt also with L>R edema, and bilateral LE redness concerning for\n cellulitis, had similar sx , LENIs negative. unable to lie flat\n for CTA.\n .\n ROS negative for F/C/N/V/D, CP, dysuria, constipation. +sick contacts,\n fatigue.\n admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\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 (no available PFTs) - on 2L O2 at home, keeps a nebulizer\n at home and in his taxi\n - HTN\n - dCHF (TTE EF>55%, RV free wall HK, mod aortic dilation)\n - h/o ?afib\n nc\n Occupation:\n Drugs: denies\n Tobacco: 3ppdx50yrs, now <1pd.\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Chest pain, Tachycardia\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Flowsheet Data as of 05:28 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 141 (141 - 145) bpm\n BP: 112/77(84) {112/77(84) - 126/82(92)} mmHg\n RR: 24 (24 - 39) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 104 kg\n Total In:\n 29 mL\n PO:\n TF:\n IVF:\n 29 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 29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 380 (380 - 418) mL\n PS : 12 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n SpO2: 90%\n ABG: 7.26/99./85.//13\n Ve: 6 L/min\n PaO2 / FiO2: 213\n Physical Examination\n General Appearance: Anxious, ill appearing, blue, speaks in word\n sentences\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 2+, Clubbing\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A3/1/ 03:29 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 47\n Other labs: Lactic Acid:1.0 mmol/L\n Assessment and Plan\n 69M h/o COPD, dCHF, admitted with SOB, tachycardia, LE erythema.\n .\n # hypoxia - most likely COPD flare given ABG, though ddx also includes\n PE (tachy, LE edema, ?h/o coumadin use), PNA, CHF/MI. chronically on\n steroids, and on bactrim prophylaxis.\n - restart bipap.\n - continue iv solumedrol 80iv q8, albuterol, atrovent nebs.\n - continue levaquin, would d/c vanco.\n - check sputum cx. consider pcp, cxr not consistent.\n - check DFA to r/o flu.\n - consider heparin gtt empirically for PE if not improving with\n steroids, though feel copd most likely given pulmonary exam.\n - consider CTA in AM if not improving, though currently unable to lie\n flat.\n - check LENIs in AM.\n - cycle CE x 2, once more in AM.\n .\n .\n # cardiac - +SOB, no CP, orthopnea, pnd, has LE edema however. feel MI\n unlikely.\n ## ischemia:\n - start aspirin.\n - cycle CE x 2 to r/o MI with AM labs.\n .\n ## rythym: sinus tachycardia, not clearly MAT, not afib. ddx includes\n hypoxia, dehydration, PE. given pulmonary exam, feel hypoxia most\n likely.\n - continue telemetry.\n - treat underlying hypoxia/copd.\n - if not improving in AM, consider CTA.\n - repeat EKG in AM.\n .\n .\n ## pump: euvolemic/dry on exam. EF >55% 11/07, though some evidence of\n diastolic dysfunction, with elevated BNP which could suggest mild\n volume overload.\n - consider gentle lasix if worsening hypoxia, though feel more likely\n is dry.\n .\n ## htn: h/o HTN, with resultant dCHF.\n - continue home BP meds.\n .\n .\n # LE edema/erythema - pt with similar sx during admission, being\n covered for cellulitis presently with levaquin, received one dose of\n vanco in ED. no recent trauma.\n - LENIs in AM to r/o DVT.\n - consider broadening abx coverage for cellulitis.\n - mark region.\n .\n .\n #FEN\n - regular diet.\n - encourage po hydration, no need for IVF.\n .\n #PPx\n - SubC heparin for DVT prophylaxis\n - bowel regimen\n .\n #CODE: FULL\n .\n #DISPO\n - pending clinical improvement\n .\n #COMM: (wife) cell .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 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": "2122-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318346, "text": "Chief Complaint: hypoxia\n 24 Hour Events:\n -- intial attempts at improving ventilation by increasing BIPAP I/E\n -- patient with worsened ABG w/ PCO2 of 105 and increasing fatigue\n -- patinet underwent elective intubation, intially difficult to\n ventilate to significant obstruction to expiration, continued high\n PCO2, and high auto PEEP, all improved w/ frequent nebs\n -- LENI negative\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 09:40 PM\n Midazolam (Versed) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: NPO\n Respiratory: Wheeze\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.8\nC (96.5\n HR: 77 (74 - 141) bpm\n BP: 102/60(73) {89/54(0) - 146/90(290)} mmHg\n RR: 14 (12 - 38) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 104 kg\n Total In:\n 1,104 mL\n 136 mL\n PO:\n 360 mL\n TF:\n IVF:\n 744 mL\n 136 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 704 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 680 (550 - 680) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 22 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 90%\n ABG: 7.37/77./76./38/14\n Ve: 6.2 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm, erythema w/ venoustasis changes b/l\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 148 K/uL\n 12.7 g/dL\n 153 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.5 mEq/L\n 25 mg/dL\n 95 mEq/L\n 138 mEq/L\n 39.1 %\n 5.6 K/uL\n [image002.jpg]\n 05:26 AM\n 08:21 AM\n 03:54 PM\n 08:21 PM\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n WBC\n 5.6\n Hct\n 39.1\n Plt\n 148\n Cr\n 0.7\n TropT\n <0.01\n TCO2\n 48\n 46\n 46\n 48\n 50\n 47\n 43\n 46\n 47\n Glucose\n 153\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Imaging: LENI: IMPRESSION: No evidence of DVT.\n Microbiology: DIRECT INFLUENZA A ANTIGEN TEST (Final ):\n Negative for Influenza A viral antigen.\n DIRECT INFLUENZA B ANTIGEN TEST (Final ):\n NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.\n Assessment and Plan\n A/P:\n 69M h/o COPD, dCHF, admitted with SOB, tachycardia, LE erythema.\n .\n # hypoxia - most likely COPD flare given ABG, though ddx also includes\n PE (tachy, LE edema, ?h/o coumadin use), PNA, CHF/MI. chronically on\n steroids, and on bactrim prophylaxis.\n - restart bipap.\n - continue iv solumedrol 80iv q8, albuterol, atrovent nebs.\n - continue levaquin, would d/c vanco.\n - check sputum cx. consider pcp, cxr not consistent.\n - check DFA to r/o flu.\n - consider heparin gtt empirically for PE if not improving with\n steroids, though feel copd most likely given pulmonary exam.\n - consider CTA in AM if not improving, though currently unable to lie\n flat.\n - check LENIs in AM.\n - cycle CE x 2, once more in AM.\n .\n .\n # cardiac - +SOB, no CP, orthopnea, pnd, has LE edema however. feel MI\n unlikely.\n ## ischemia:\n - start aspirin.\n - cycle CE x 2 to r/o MI with AM labs.\n .\n ## rythym: sinus tachycardia, not clearly MAT, not afib. ddx includes\n hypoxia, dehydration, PE. given pulmonary exam, feel hypoxia most\n likely.\n - continue telemetry.\n - treat underlying hypoxia/copd.\n - if not improving in AM, consider CTA.\n - repeat EKG in AM.\n .\n .\n ## pump: euvolemic/dry on exam. EF >55% 11/07, though some evidence of\n diastolic dysfunction, with elevated BNP which could suggest mild\n volume overload.\n - consider gentle lasix if worsening hypoxia, though feel more likely\n is dry.\n .\n ## htn: h/o HTN, with resultant dCHF.\n - continue home BP meds.\n .\n .\n # LE edema/erythema - pt with similar sx during admission, being\n covered for cellulitis presently with levaquin, received one dose of\n vanco in ED. no recent trauma.\n - LENIs in AM to r/o DVT.\n - consider broadening abx coverage for cellulitis.\n - mark region.\n .\n .\n #FEN\n - regular diet.\n - encourage po hydration, no need for IVF.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318341, "text": "69yo M admitted with SOBx2 days/COPD exacerbation w/ hypercabia.\n PMH: COPD w/ CO2 retention on home O2, HTN, CHF.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG on bipap at 7.25/105/102, pt not tolerating mask w/\n ativan/morphine, no improvement w/ bipap: 7.27/104/86 and 7.26/100/90.\n Action:\n Intubated CMV/40%/550/14/10 and sedated, fent@75 and versed@2\n Response:\n ABG 7.37/78/76\n Plan:\n Follow ABGs\n Hypotension (not Shock)\n Assessment:\n Bp 80s post intubation\n Action:\n Sedation lowered, 500cc NS bolusx1 given\n Response:\n Bp stable 90s\n Plan:\n Cont to monitor bp, bolus as necessary.\n" }, { "category": "Physician ", "chartdate": "2122-02-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318356, "text": "Chief Complaint: hypercarbic respiratory failure, copd exacerbation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare and acute on chronic hypercarbic\n resp failure likely from bronchitis verses pna\n 24 Hour Events:\n ULTRASOUND - At 01:48 PM\n ARTERIAL LINE - START 03:00 PM\n Worsening of abg's on bipap and fatigue--semi-elective intubation\n overnight.\n Difficult ventilation-- overnight with evidence of bronchospasm,\n improvement in abg with aggressive MDI's\n lenis negative\n History obtained from Medical records, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 09:40 PM\n Midazolam (Versed) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 73 (73 - 103) bpm\n BP: 99/65(78) {89/54(0) - 146/90(290)} mmHg\n RR: 14 (12 - 38) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 1,104 mL\n 205 mL\n PO:\n 360 mL\n TF:\n IVF:\n 744 mL\n 205 mL\n Blood products:\n Total out:\n 400 mL\n 290 mL\n Urine:\n 400 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 704 mL\n -85 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 680 (680 - 680) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 18 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 90%\n ABG: 7.37/77./76./38/14\n Ve: 5.8 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Wheezes : decreased, Diminished: ), tight with limited air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, venous stasis ulcer R medial\n calf, purulent smelling (pt refused bandage removal yesterday)\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 12.7 g/dL\n 148 K/uL\n 153 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.5 mEq/L\n 25 mg/dL\n 95 mEq/L\n 138 mEq/L\n 39.1 %\n 5.6 K/uL\n [image002.jpg]\n 05:26 AM\n 08:21 AM\n 03:54 PM\n 08:21 PM\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n WBC\n 5.6\n Hct\n 39.1\n Plt\n 148\n Cr\n 0.7\n TropT\n <0.01\n TCO2\n 48\n 46\n 46\n 48\n 50\n 47\n 43\n 46\n 47\n Glucose\n 153\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Imaging: cxr-\n Microbiology: influenza dfa negative\n Assessment and Plan\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare and acute on chronic hypercarbic\n and hypoxic resp failure likely from bronchitis verses pna\n now with evidence of venous stasis ulcer and ? cellulitis, intubated\n overnight\n MAIN ISSUES:\n # hypoxemia\n copd exacerbation remains most likely etiology, with pe (given\n tachycardia) verses chf on ddx, though low suspicon--lenis neagtive and\n given significant bronchospasm\n acute on chronic hypercarbic resp failure, with progressive fatigue and\n bronshospam leading to intubation\n no new infiltrate on cxr, given significant bronchospasm most\n concerned for copd with bronchitis verses early pna (bacterial verses\n viral) low suspicion for pe, though has b/l le edema. Pt is on high\n dose of chronic steroids so immunosupressed, though on PCP which\n we are continuing.\n Sputum cx, blood cx if spikes, ruled out for influenze and urine\n legionella pending\n continue solumedrol 80 Q 8, Q 2 hr mdis and atrovent Q 6, follow abg\n though ventialtion making slow imrpovement\n empiric antibx levoflox for 7 day and recheck sputum for ET sx, follow\n LLL on cxr--likely ateelcatsis as clinically without new evidence of\n infection\n # diastolic dysfx-does not appear overtly fluid overloaded, BNP\n elevated, has chronic LE edema likely from pulm htn\n would restart ace-i and sadd back hctz later if bp stable\n # tachycardia-now improved, suspect from copd/resp distress with low\n suspicon of PE given exam and eng lenis\n # elevated troponin and nonspecific ecg changes--follow enzymes and\n continue asa pending next set\n # LE edema/erythema -now appears more erythematous ? positonal though\n cellulitiss concer--af with stable wbc, also with R venous stasis\n ulcer, swab and check blood cx given steroids chronically and may not\n mount fever, resume vanco and follow\n ICU Care\n Nutrition:\n Comments: start tf's once palcement confirmed\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n Comments: picc consult\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker--will start pre-tf's\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-02-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318359, "text": "Chief Complaint: hypoxia\n 24 Hour Events:\n -- intial attempts at improving ventilation by increasing BIPAP I/E\n -- patient with worsened ABG w/ PCO2 of 105 and increasing fatigue\n -- patinet underwent elective intubation, intially difficult to\n ventilate to significant obstruction to expiration, continued high\n PCO2, and high auto PEEP, all improved w/ frequent nebs\n -- LENI negative\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 09:40 PM\n Midazolam (Versed) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: NPO\n Respiratory: Wheeze\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.8\nC (96.5\n HR: 77 (74 - 141) bpm\n BP: 102/60(73) {89/54(0) - 146/90(290)} mmHg\n RR: 14 (12 - 38) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 104 kg\n Total In:\n 1,104 mL\n 136 mL\n PO:\n 360 mL\n TF:\n IVF:\n 744 mL\n 136 mL\n Blood products:\n Total out:\n 400 mL\n 200 mL\n Urine:\n 400 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 704 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 680 (550 - 680) mL\n PS : 15 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 22 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 90%\n ABG: 7.37/77./76./38/14\n Ve: 6.2 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm, erythema w/ venoustasis changes b/l\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 148 K/uL\n 12.7 g/dL\n 153 mg/dL\n 0.7 mg/dL\n 38 mEq/L\n 4.5 mEq/L\n 25 mg/dL\n 95 mEq/L\n 138 mEq/L\n 39.1 %\n 5.6 K/uL\n [image002.jpg]\n 05:26 AM\n 08:21 AM\n 03:54 PM\n 08:21 PM\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n WBC\n 5.6\n Hct\n 39.1\n Plt\n 148\n Cr\n 0.7\n TropT\n <0.01\n TCO2\n 48\n 46\n 46\n 48\n 50\n 47\n 43\n 46\n 47\n Glucose\n 153\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Imaging: LENI: IMPRESSION: No evidence of DVT.\n Microbiology: DIRECT INFLUENZA A ANTIGEN TEST (Final ):\n Negative for Influenza A viral antigen.\n DIRECT INFLUENZA B ANTIGEN TEST (Final ):\n NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.\n Assessment and Plan\n A/P:\n 69M h/o COPD, dCHF, admitted with SOB, tachycardia, LE erythema and\n ulcer who is admitted w/ hypoxia likely COPD flare, Intubated overnight\n .\n # hypoxia - most likely COPD flare. No evidence of fluid overload, and\n chest exam w/ wheezes and poor air movement c/w obstructive etiology.\n Patient shows no signs of fluid overload, a w/ negative LENI, now\n suspicion of PE. Patient was Intubated overnight, and now shows\n improved ABG.\n -- continue intubation for ventilatory support.\n - continue iv solumedrol 80iv q8, and frequent albuterol, atrovent\n nebs.\n - continue levaquin for empiric overage\n - check sputum cx. consider pcp, cxr not consistent. Continue\n ppx w/ bactrim\n - dFA negative for flu\n - LENI negative, now pre-test probability for CTA to evaluate for PE\n - cycle CE x 3\n - f/u urine legonella\n .\n .\n # cardiac - +SOB, no CP, orthopnea, pnd, has LE edema however. feel MI\n unlikely.\n ## ischemia:\n - patient was started on ASA on admission, but w/ ROMI negative, now\n d\n .\n ## rythym: sinus tachycardia, now resolved. Was likely to\n hypoxia, distress from BIPAP, EKG unrevealing.\n - continue telemetry. .\n .\n ## pump: euvolemic/dry on exam. EF >55% 11/07, though some evidence of\n diastolic dysfunction, with elevated BNP which could suggest mild\n volume overload.\n - patient dropped his BP w/ intubation, improved w/ IVF\n .\n ## htn: h/o HTN, with resultant dCHF.\n - holding BP meds as BP currently okay and recent hypotension w/\n intubation\n .\n .\n # LE edema/erythema - pt with similar sx during admission, being\n covered for cellulitis presently with levaquin, received one dose of\n vanco in ED.\n -- worsened erythema on left leg today and removal of foot bandage\n reveals purulent ulcer. Patient w/o fever/WBC, but will get swab and\n treat w/ vanc empirically. If progresses, would add flagyl for\n anerobic coverage\n .\n #FEN\n - NPO, NG placed now, start tube feeds.\n ICU Care\n Nutrition:\n Comments: NPO, starting TF\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2122-02-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318335, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time); Comments: required intubation due to\n worsening hypercapnea\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\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 Comments: initially very difficult to ventilate with inc flow demand\n and autopeep\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: much more comfortable with inc sedation\n Non-invasive ventilation assessment: failed non invasive-kept removing\n mask or falling asleep with apnea periods\n .\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH; Comments: baseline co2 retainer\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n .\n Bedside Procedures: intubated for worsening hypercarbia\n Alb/atro mdi given with good response.\n Autopeep initially 16\ncurrently \n .\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318337, "text": "69yo M admitted with SOBx2 days/COPD exacerbation w/ hypercabia.\n PMH: COPD w/ CO2 retention on home O2, HTN, CHF.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG on bipap at 7.25/105/102, pt not tolerating mask w/\n ativan/morphine, no improvement w/ bipap: 7.27/104/86 and 7.26/100/90.\n Action:\n Intubated CMV/40%/550/14/10 and sedated, fent@75 and versed@2\n Response:\n ABG7.35/75/83, 7.37/76/79\n Plan:\n Follow ABGs,\n Hypotension (not Shock)\n Assessment:\n Bp 80s post intubation\n Action:\n Sedation lowered, 500cc NS bolusx1 given\n Response:\n Bp stable 90s\n Plan:\n Cont to monitor bp, bolus as necessary.\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318330, "text": "69yo M admitted with SOB.\n PMH: COPD, HTN, CHF.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318331, "text": "69yo M admitted with SOBx2 days/COPD exacerbation w/ hypercabia.\n PMH: COPD w/ CO2 retention on home O2, HTN, CHF.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG on bipap at 7.25/105/102, pt not tolerating mask w/\n ativan/morphine, no improvement w/ bipap: 7.27/104/86 and 7.26/100/90.\n Action:\n Intubated CMV/40%/550/14/10 and sedated, fent@75 and versed@2\n Response:\n ABG@100 7.35/75/83\n Plan:\n Follow ABGs,\n" }, { "category": "Nursing", "chartdate": "2122-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318332, "text": "69yo M admitted with SOBx2 days/COPD exacerbation w/ hypercabia.\n PMH: COPD w/ CO2 retention on home O2, HTN, CHF.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n ABG on bipap at 7.25/105/102, pt not tolerating mask w/\n ativan/morphine, no improvement w/ bipap: 7.27/104/86 and 7.26/100/90.\n Action:\n Intubated CMV/40%/550/14/10 and sedated, fent@75 and versed@2\n Response:\n ABG@100 7.35/75/83\n Plan:\n Follow ABGs,\n" }, { "category": "Nursing", "chartdate": "2122-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318664, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Remains on vent, CMV settings 40%. Appeared comfortable this shift, no\n increased WOB noted. Remains on 50mcg/hr of fentanyl, and 2mg/hr\n versed. Pt alert, able to mouth words/ write on board/nod head to make\n needs known.\n Action:\n Pt c/o feeling anxious at times, intermittently bolus for comfort. TF\n off at midnight pnding possible extubation in AM. Pt also asking to be\n sxned, sxned infrequently for sm. Amounts of white thick sputum.\n Response:\n No vent changes made over nt, pt remains resting comfortably.\n Plan:\n RSBI/SBT and possible extubation in am.\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318795, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and lle\n cellulitis. He required intubation and had difficulty weaning d/t\n the severity of his COPD. He was extubated successfully on to\n mask ventilation and has been maintained on nasal cannula and cool mist\n with intermittent mask ventilation.\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318797, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and lle\n cellulitis. He required intubation and had difficulty weaning d/t\n the severity of his COPD. He was extubated successfully on to\n mask ventilation and has been maintained on nasal cannula and cool mist\n with intermittent mask ventilation. Pt has expressed that he would not\n want to be intubated again and wants to go home. Pt\ns is now DNR/DNI\n and a hospice referral has been made.\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Case Management ", "chartdate": "2122-02-27 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 318798, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: \n Hospital days authorized to:\n Current Discharge Plan: Home with services\n Home w/ Hospice\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n 1) Hospice Care Inc.\n Narrative / Plan (Patient):\n I recieved a telephone call from the nurse caring for Mr. last\n evening () that he wishes to go home with hospice. I met with Mr.\n today and he wishes to go home w/ hospice. I attempted to\n contact his wife but there was no answer at home. I was informed\n she is aware of the plan and is in agreement. I placed the referral to\n Hospice Care telephone fax , the agency will\n meet Mr. at 12noon today.\n" }, { "category": "Nutrition", "chartdate": "2122-02-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 318789, "text": "Subjective\n Patient now extubated, wanting to leave AMA.\n Objective\n Pertinent medications: Vitamin D, calcium carbonate, prednisone taper\n Labs:\n Value\n Date\n Glucose\n 78 mg/dL\n 03:27 AM\n Glucose Finger Stick\n 83\n 12:00 AM\n BUN\n 30 mg/dL\n 03:27 AM\n Creatinine\n 0.8 mg/dL\n 03:27 AM\n Sodium\n 139 mEq/L\n 03:27 AM\n Potassium\n 4.5 mEq/L\n 03:27 AM\n Chloride\n 91 mEq/L\n 03:27 AM\n CO2 (Calc) arterial\n 52 mEq/L\n 11:35 PM\n Calcium non-ionized\n 9.2 mg/dL\n 03:27 AM\n Phosphorus\n 3.8 mg/dL\n 03:27 AM\n Magnesium\n 2.2 mg/dL\n 03:27 AM\n Current diet order / nutrition support: Regular diet\n GI: Abdomen soft/distended with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 69 year old male presenting with respiratory distress, intubated.\n Patient extubated yesterday and now on NIV. Patient\ns tube feedings\n held yesterday and diet advanced to regular diet today. Noted plans for\n possible d/c to hospice.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with regular diet, encourage PO intake PRN\n 2. If PO intake is low, consider adding nutritional supplements\n with meals\n 3. Will follow for plan of care\n 09:12\n" }, { "category": "Respiratory ", "chartdate": "2122-02-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318762, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: NIV prn\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Insp Wheeze\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: Supra-sternal retractions,\n Accessory muscle use, Prolonged exhalation, Frequent desaturation\n episodes, Tachypneic (RR> 35 b/min), Active exhalations, High flow\n demand\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Tolerated well, Mask discomfort;\n Comments: Wore NIV mot of early shift, wanted it off second half of\n shift\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Patient to be sent home with hospice\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318776, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt intermittently experiencing tachypnea, anxiety\n Action:\n Morphine sulfate IV 1mg x3\n Response:\n Moderate to good improvement in respiratory rate and comfort\n Plan:\n Morphine IV prn\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318777, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt intermittently experiencing tachypnea, anxiety\n Action:\n Morphine sulfate IV 1mg x3\n Response:\n Moderate to good improvement in respiratory rate and comfort\n Plan:\n Morphine IV prn\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt initially comfortable on NIV with sats 89-92%. Began to sat>95%\n Action:\n Changed to NC 3L with intermittent use of cool neb face tent at 40-70%\n . Ativan .5mg IV x2 prn agitation\n Response:\n Labile saturations. Pt expressing desire to leave hospital setting as\n soon as possible,\n \n , I just want to get out of here\n Plan:\n Continue to monitor RR and sats, ativan/morphine prn. Case management\n to work on dispo with hospice today\n" }, { "category": "Physician ", "chartdate": "2122-02-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318779, "text": "Chief Complaint: COPD flare\n 24 Hour Events:\n extubated & ABGs showed worsening acidosis, placed on BiPAP & ABGs\n improved\n -pt wanting to leave AMA, very anxious on biPAP, inc'd ativan/moprhine\n -discussion with family& pt- made DNR/DNI, plan to go home with hospice\n in am\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 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: 36.5\nC (97.7\n HR: 90 (81 - 107) bpm\n BP: 143/97(113) {109/62(76) - 162/115(131)} mmHg\n RR: 20 (14 - 22) insp/min\n SpO2: 86%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 270 mL\n PO:\n TF:\n 63 mL\n IVF:\n 56 mL\n Blood products:\n Total out:\n 2,050 mL\n 790 mL\n Urine:\n 2,050 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,780 mL\n -790 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 441 (417 - 574) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 86%\n ABG: 7.35/91/51/46/19\n Ve: 8.6 L/min\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious,\n Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Shovel Mask\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: Trace\n Skin: Warm, Pinked face. improved LLE erythema\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): PPt, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 148 K/uL\n 13.7 g/dL\n 78 mg/dL\n 0.8 mg/dL\n 46 mEq/L\n 4.5 mEq/L\n 30 mg/dL\n 91 mEq/L\n 139 mEq/L\n 42.3 %\n 7.2 K/uL\n [image002.jpg]\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n 01:10 PM\n 04:57 PM\n 11:35 PM\n 03:27 AM\n WBC\n 6.6\n 7.2\n Hct\n 38.3\n 42.3\n Plt\n 141\n 148\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 57\n 54\n 53\n 51\n 51\n 52\n 52\n Glucose\n 126\n 78\n Other labs: PT / PTT / INR:11.8/27.0/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR:\n The ET tube tip is approximately 4.5 cm above the carina. The\n perihilar\n opacity which might represent mild pulmonary edema is again noted. The\n lung\n bases were not included on the field of view. No apical pneumothorax\n is\n demonstrated. The right PICC line tip is in mid SVC.\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intubated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator. Patient\n was extubated yesterday, ABG w/ acidemia, started on CPAP. Patient\n hyperventilating w/ anxiety.\n -- started on 80mg PO predniosone, still wheezy on exam,\n will likely maintain at current dose, and taper when possible\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- s/p levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- some component of w/ fluid overoloand on CE and LE\n edema during hospitalization. Has been diureeded w/ significant\n improvoemnton exam. Will try to run even and maintain on home lasix\n dose.\n #Anxiety: Patient notably anxious, w/ htn, tachycarida,\n hyperventilation. Somewhat improved on anxietylitics.\n - continue ativan/morphine\n -patinent does not want to be re-intubated, and after family meeting,\n patinet now DNR/DNI w/ planned d/c to hospice\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. continue home lisinopril/HCTZ, BP Well controlled\n #LE edema/erythema: LE erythema slightly improved. Cellulitis vs.\n changes from LE edema. Noted that no WBC, no fever. Startarted on\n vanc b/c looked notably angre. Follow up bcx, wound cx. Low suspicisn\n for MRSA cellultiis, feel adequate treatment on levofloxacin.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Comments: Regular Diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:Home w/ Hospice today\n" }, { "category": "Physician ", "chartdate": "2122-02-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318871, "text": "Chief Complaint: COPD flare\n 24 Hour Events:\n extubated & ABGs showed worsening acidosis, placed on BiPAP & ABGs\n improved\n -pt wanting to leave AMA, very anxious on biPAP, inc'd ativan/moprhine\n -discussion with family& pt- made DNR/DNI, plan to go home with hospice\n in am\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:02 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: 36.5\nC (97.7\n HR: 90 (81 - 107) bpm\n BP: 143/97(113) {109/62(76) - 162/115(131)} mmHg\n RR: 20 (14 - 22) insp/min\n SpO2: 86%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 270 mL\n PO:\n TF:\n 63 mL\n IVF:\n 56 mL\n Blood products:\n Total out:\n 2,050 mL\n 790 mL\n Urine:\n 2,050 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,780 mL\n -790 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 441 (417 - 574) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 13 cmH2O\n SpO2: 86%\n ABG: 7.35/91/51/46/19\n Ve: 8.6 L/min\n PaO2 / FiO2: 128\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious,\n Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Shovel Mask\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: Trace\n Skin: Warm, Pinked face. improved LLE erythema\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): PPt, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 148 K/uL\n 13.7 g/dL\n 78 mg/dL\n 0.8 mg/dL\n 46 mEq/L\n 4.5 mEq/L\n 30 mg/dL\n 91 mEq/L\n 139 mEq/L\n 42.3 %\n 7.2 K/uL\n [image002.jpg]\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n 01:10 PM\n 04:57 PM\n 11:35 PM\n 03:27 AM\n WBC\n 6.6\n 7.2\n Hct\n 38.3\n 42.3\n Plt\n 141\n 148\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 57\n 54\n 53\n 51\n 51\n 52\n 52\n Glucose\n 126\n 78\n Other labs: PT / PTT / INR:11.8/27.0/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR:\n The ET tube tip is approximately 4.5 cm above the carina. The\n perihilar\n opacity which might represent mild pulmonary edema is again noted. The\n lung\n bases were not included on the field of view. No apical pneumothorax\n is\n demonstrated. The right PICC line tip is in mid SVC.\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intubated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator. Patient\n was extubated yesterday, ABG w/ acidemia, started on CPAP. Patient\n hyperventilating w/ anxiety.\n -- started on 80mg PO predniosone, still wheezy on exam,\n will likely maintain at current dose, and taper slowly\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- s/p levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- some component of w/ fluid overoloand on CE and LE\n edema during hospitalization. Has been diureeded w/ significant\n improvoemnton exam. Will try to run even and maintain on home lasix\n dose.\n #Anxiety: Patient notably anxious, w/ htn, tachycarida,\n hyperventilation. Somewhat improved on anxietylitics.\n - continue ativan/morphine\n -patinent does not want to be re-intubated, and after family meeting,\n patinet now DNR/DNI w/ planned d/c to hospice\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. continue home lisinopril/HCTZ, BP Well controlled\n #LE edema/erythema: LE erythema slightly improved. Cellulitis vs.\n changes from LE edema. Noted that no WBC, no fever. Startarted on\n vanc b/c looked notably angre. Follow up bcx, wound cx. Low suspicisn\n for MRSA cellultiis, feel adequate treatment on levofloxacin.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Comments: Regular Diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM, will d/c today\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition:Home w/ Hospice today\n" }, { "category": "Physician ", "chartdate": "2122-02-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318694, "text": "Chief Complaint: resp failure, copd exac\n I saw and examined the patient, and was physically present with the ICU\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 PS 5/5 this am and extubated pre-rounds\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 87 (68 - 91) bpm\n BP: 162/88(114) {90/51(66) - 162/122(187)} mmHg\n RR: 21 (12 - 22) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 771 mL\n 240 mL\n PO:\n TF:\n 340 mL\n 63 mL\n IVF:\n 251 mL\n 56 mL\n Blood products:\n Total out:\n 1,985 mL\n 935 mL\n Urine:\n 1,985 mL\n 935 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n -695 mL\n Respiratory support\n Ventilator mode: CPAP/PPS\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 417 (155 - 782) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 35 cmH2O\n Plateau: 19 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 88%\n ABG: 7.32/95./56/48/17\n Ve: 6.8 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Anxious, acc m\n use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Crackles : decreased basilar, No(t) Wheezes : ), distant\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+, edema decreased\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, No(t) Sedated,\n Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 141 K/uL\n 126 mg/dL\n 0.8 mg/dL\n 48 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 93 mEq/L\n 142 mEq/L\n 38.3 %\n 6.6 K/uL\n [image002.jpg]\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n WBC\n 6.5\n 6.6\n Hct\n 40.1\n 38.3\n Plt\n 155\n 141\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 56\n 53\n 55\n 57\n 54\n 53\n 51\n Glucose\n 146\n 126\n Other labs: PT / PTT / INR:12.1/29.6/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n --extubated on rounds and oxygentaion near baseline, sounds slightly\n wheezy and very anxious\n try bridge with NPPV though low threshold for reintubate, treat\n anxiety which appears large component and bronchospasm--ativan and\n morphine\n and nebs, follow abg's\n - s/p levoflox X 7 days d/c'd yesterday\n - continue PCP / bactrim given chronic steroids\n - Taper prednisone -->80 Q D today and reassess daily\n - Albuterol mdi's and atrovent Q 6\n # LE cellulitis--remains af and with nl wbc ct (on chronic now high\n dose steroids) , iimproved and may be venous stasis\n f/u blood cxs with ngtd\n off vanco and s/p course of levo\n # diastolic dysfx-diuresed well, now more alkalotic, in part\n contraction from diuresis, le edema much improved\n continue ace-i , home lasix and hctz\n # elevated BUN--h/h stable, cr improved, ? steroids, follow, down\n slightly form\n # Skin lesions-seen by derm, plan for outpt f/u/bx\n # abd distention--benign exam, bowel reg\n ICU Care\n Nutrition:\n Comments: NPO given distress\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2122-02-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318706, "text": "Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Comments: pt extubated this shift, after approx 2 hrs\n WOB increased so pt was started on NIPPV.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Scant\n Comments:\n Ventilation Assessment\n Non-invasive ventilation assessment: Tolerated well; Comments: Pt feels\n that breathing is much easier w/ mask on.\n Plan\n Next 24-48 hours: continue NIPPV and HHN.\n" }, { "category": "Physician ", "chartdate": "2122-02-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318707, "text": "Chief Complaint: COPD Flare\n 24 Hour Events:\n - tolerate PS trial, likely extubate in am\n - rapid steroid taper - 60mg today, less tomorrow\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: Tube feeds\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: Foley\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: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 84 (68 - 89) bpm\n BP: 101/70(82) {90/51(66) - 162/122(187)} mmHg\n RR: 20 (12 - 20) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 771 mL\n 108 mL\n PO:\n TF:\n 340 mL\n 63 mL\n IVF:\n 251 mL\n 45 mL\n Blood products:\n Total out:\n 1,985 mL\n 500 mL\n Urine:\n 1,985 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n -392 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 155 (155 - 782) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 32 cmH2O\n Plateau: 19 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 89%\n ABG: 7.38/91./71/48/23\n Ve: 7 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diminsished at hilum)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: 1+, significantly improved\n Skin: Warm, improved LLE erythema, not hot to touch\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 141 K/uL\n 12.6 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 48 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 93 mEq/L\n 142 mEq/L\n 38.3 %\n 6.6 K/uL\n [image002.jpg]\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n 03:41 PM\n 05:25 PM\n 02:56 AM\n WBC\n 7.5\n 6.5\n 6.6\n Hct\n 40.0\n 40.1\n 38.3\n Plt\n 143\n 155\n 141\n Cr\n 1.0\n 0.8\n 0.8\n TCO2\n 48\n 47\n 55\n 56\n 53\n 55\n 57\n Glucose\n 187\n 146\n 126\n Other labs: PT / PTT / INR:12.1/29.6/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Fluid analysis / Other labs: ABG on PS: pH 7.40 / pCO2 86 / pO2 64 /\n HCO3 55\n ABG at 5pm at TV 460 5:25p\n pH 7.38/ pCO2 92/ pO2 71/ HCO3\n Assessment and Plan\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Likely to infectious etiology, DFA negative,\n sputum Cx negative, urine legonella negative, s/p levo rx. Patient was\n intubated due to increasing hypercapnea and increased work of\n breathing. Improved ABG on ventilator.\n -- continue intubation for ventalatory support, now changed\n to PS/AC, likely extubation today\n -- started on 80mg PO prednisone, likely taper to 60mg\n tomorrow\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- s/p levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- some component of w/ fluid overload on CE and LE\n edema during hospitalization, has been diuressed, w/ significant\n improvement on clinical exam. Will try to run -0.5 to even\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. Has been well controlled on lisinopril / HCTZ,\n lasix as tolerated given evidence of CHF on CXR with goal of negative\n .5-even.\n #LE edema/erythema: LE erythema improved. Cellulitis vs. changes from\n LE edema. Noted that no WBC, no fever. Startarted on vanc b/c looked\n notably angry. Follow up bcx, wound cx. Low suspicisn for MRSA\n cellultiis, feel adequate treatment on levofloxacin, s/p treatment.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Comments: TF, once extubated, regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2122-02-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318708, "text": "Chief Complaint: COPD Flare\n 24 Hour Events:\n - tolerate PS trial, likely extubate in am\n - rapid steroid taper - 60mg today, less tomorrow\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: Tube feeds\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: Foley\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: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 84 (68 - 89) bpm\n BP: 101/70(82) {90/51(66) - 162/122(187)} mmHg\n RR: 20 (12 - 20) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 771 mL\n 108 mL\n PO:\n TF:\n 340 mL\n 63 mL\n IVF:\n 251 mL\n 45 mL\n Blood products:\n Total out:\n 1,985 mL\n 500 mL\n Urine:\n 1,985 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n -392 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 155 (155 - 782) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 32 cmH2O\n Plateau: 19 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 89%\n ABG: 7.38/91./71/48/23\n Ve: 7 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diminsished at hilum)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: 1+, significantly improved\n Skin: Warm, improved LLE erythema, not hot to touch\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 141 K/uL\n 12.6 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 48 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 93 mEq/L\n 142 mEq/L\n 38.3 %\n 6.6 K/uL\n [image002.jpg]\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n 03:41 PM\n 05:25 PM\n 02:56 AM\n WBC\n 7.5\n 6.5\n 6.6\n Hct\n 40.0\n 40.1\n 38.3\n Plt\n 143\n 155\n 141\n Cr\n 1.0\n 0.8\n 0.8\n TCO2\n 48\n 47\n 55\n 56\n 53\n 55\n 57\n Glucose\n 187\n 146\n 126\n Other labs: PT / PTT / INR:12.1/29.6/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Fluid analysis / Other labs: ABG on PS: pH 7.40 / pCO2 86 / pO2 64 /\n HCO3 55\n ABG at 5pm at TV 460 5:25p\n pH 7.38/ pCO2 92/ pO2 71/ HCO3\n Assessment and Plan\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Likely to infectious etiology, DFA negative,\n sputum Cx negative, urine legonella negative, s/p levo rx. Patient was\n intubated due to increasing hypercapnea and increased work of\n breathing. Improved ABG on ventilator.\n -- continue intubation for ventalatory support, now changed\n to PS/AC, likely extubation today\n -- started on 80mg PO prednisone, likely taper to 60mg\n tomorrow\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- s/p levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- some component of w/ fluid overload on CE and LE\n edema during hospitalization, has been diuressed, w/ significant\n improvement on clinical exam. Will try to run -0.5 to even\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. Has been well controlled on lisinopril / HCTZ,\n lasix as tolerated given evidence of CHF on CXR with goal of negative\n .5-even.\n #LE edema/erythema: LE erythema improved. Cellulitis vs. changes from\n LE edema. Noted that no WBC, no fever. Startarted on vanc b/c looked\n notably angry. Follow up bcx, wound cx. Low suspicisn for MRSA\n cellultiis, feel adequate treatment on levofloxacin, s/p treatment.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Comments: TF, once extubated, regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Patient extubated during rounds. Initial ABG w/ more pronounced\n acidosis, wheezes on exam, tachycardic and hyptertensive. Patient\n admitts to feel significant anxiety. Patient started on Bipap,\n started on ativan 1-2mg q4h and morphine 0.5-1mg q4h to treat anxiety.\n ABG improved. Will continue to assess throughout today, and need for\n reintubation.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:37 ------\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318855, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and LLE\n cellulitis. He required intubation and had difficulty weaning d/t\n the severity of his COPD. He was extubated successfully on to\n mask ventilation and has been maintained on nasal cannula and cool mist\n with intermittent mask ventilation. Pt has expressed that he would not\n want to be intubated again and wants to go home. Pt\ns is now DNR/DNI\n and a hospice referral has been made.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt is tachypneic, LS have diffuse I/E wheezes, pt is anxious\n Action:\n Pt OOB to chair in tripod position\n Medicated with MSO4 and lorazepam for anxiety/dyspnea\n Continue NP and cool neb as neeed\n Continue albuterol PRN\n Response:\n Pt continues to have periods of dyspnea/SOB\n Plan:\n Continue supportive measures\n Continue to medicate for anxiety/dyspnea\n Problem\n Discharge Planning/Hospice referral\n Assessment:\n Pt referred to Hospice Care services today\n Hospice liason will be here in AM to make arrangements for hospital\n bed, commode, and meds\n Action:\n Hospice referral and intake completed\n Meeting with pt, pt\ns wife and son and plan for d/c home tommorow\n Response:\n Ongoing\n Plan:\n Plan for d/c home tomorrow with hospice\n" }, { "category": "Physician ", "chartdate": "2122-02-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318698, "text": "Chief Complaint: resp failure, copd exac\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 69 yo m with severe COPD (chronic prednisone, home O2) with\n chronic hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n 24 Hour Events:\n Weaning yesterday\n PS 5/5 this am with stable abg\n extubated pre-rounds\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 87 (68 - 91) bpm\n BP: 162/88(114) {90/51(66) - 162/122(187)} mmHg\n RR: 21 (12 - 22) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 771 mL\n 240 mL\n PO:\n TF:\n 340 mL\n 63 mL\n IVF:\n 251 mL\n 56 mL\n Blood products:\n Total out:\n 1,985 mL\n 935 mL\n Urine:\n 1,985 mL\n 935 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n -695 mL\n Respiratory support\n Ventilator mode: CPAP/PPS\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 417 (155 - 782) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 35 cmH2O\n Plateau: 19 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 88%\n ABG: 7.32/95./56/48/17\n Ve: 6.8 L/min\n PaO2 / FiO2: 140\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Anxious, acc m\n use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:\n Crackles : decreased basilar, No(t) Wheezes : ), distant\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+, edema decreased\n Skin: decreased erythema at LLE, chronic stasis changes\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: all 4 ext\n No(t) Sedated\n Labs / Radiology\n 12.6 g/dL\n 141 K/uL\n 126 mg/dL\n 0.8 mg/dL\n 48 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 93 mEq/L\n 142 mEq/L\n 38.3 %\n 6.6 K/uL\n [image002.jpg]\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n WBC\n 6.5\n 6.6\n Hct\n 40.1\n 38.3\n Plt\n 155\n 141\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 56\n 53\n 55\n 57\n 54\n 53\n 51\n Glucose\n 146\n 126\n Other labs: PT / PTT / INR:12.1/29.6/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic, copd\n flare/bronchitis/pna\n --extubated on rounds, oxygenation near baseline, now sounds wheezy\n and very anxious\n - bridge with NPPV though low threshold for reintubation,\n - treat anxiety which appears large component and\n bronchospasm--ativan and morphine\n and nebs\n - follow abg's\n - s/p levoflox X 7 days, d/c'd yesterday\n - continue PCP / bactrim given chronic steroids\n - prednisone --> 80 Q D today and reassess daily\n - Albuterol mdi's and atrovent Q 6\n # LE cellulitis--remains af and with nl wbc ct (on chronic now high\n dose steroids) , iimproved and likely venous stasis\n f/u blood cxs ngtd\n off vanco and s/p course of levo\n # diastolic dysfx-diuresed well, now more alkalotic, in part\n contraction from diuresis, le edema much improved\n continue ace-i , home lasix and hctz\n # Skin lesions-seen by derm, plan for outpt f/u/bx\n # abd distention--benign exam, start bowel reg\n ICU Care\n Nutrition:\n Comments: NPO given tenuos status\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2122-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318739, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Weaned to PSV 5/5, extubated and requiring non invasive face mask\n ventlilation.\n Action:\n Extubated to 40% face shovel, i/e wheezing t/o, rx w/albuterol neb, c/o\n anxiety, med w/.5mg po ativan x 2 w/little effect, restarted NIFMV.\n Response:\n Pt threatening to leave AMA, wants to go home and acknowledges if he\n leaves he may be going home to die. Family at bedside when team in to\n discuss pt\ns wishes. Called back into room after family discussion and\n pt stated he wanted to leave tonight and knew he may die. Pt then\n agreed that if he had antianxiety medication that he would agree to\n stay tonight and wear the mask.\n Plan:\n Pt now DNR/DNI, phone message left for nurse case manager to begin\n plans for home hospice. Ativan dosing now more liberal, responed well\n to 1mg IV and face mask ventilation appears to be tolerated.\n" }, { "category": "Nursing", "chartdate": "2122-02-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318884, "text": "Tachycardia, Other\n Assessment:\n Acute onset SVT to 140\ns. asymptomatic\n Action:\n EKG, 6mg adenosine IVP x1 during continuous EGK monitoring with Drs\n and present. 500cc NS IVF x1\n Response:\n NSR in 80\ns with frequent PAC\n Plan:\n Continue to monitor\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt lethargic. LS diminished t/o, sats 89-92 on 4L NC and face tent at\n 40%.\n Action:\n Monitored t/o shift. Pt requested morphine po 10mg x1 for perceived\n resp discomfort, ativan 1.5mg IV for anxiety\n Response:\n Pt resting comfortably\n Plan:\n Home with hospice today.\n" }, { "category": "Physician ", "chartdate": "2122-02-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318539, "text": "Chief Complaint: respiratory failure,copd exac/bronchitis, cellulitis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 69 yo m with severe COPD (chronic prednisone, home O2) with\n chronic hypercarbia, diastolic heart failure presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n 24 Hour Events:\n ps during day then fatigued, rested on ACV overnight\n derm c/s w/ plan for outpt shve bx of leg lesion\n diuresed 1 L neg\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:15 AM\n Heparin Sodium (Prophylaxis) - 08:12 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 75 (74 - 110) bpm\n BP: 126/68(85) {94/54(69) - 143/81(100)} mmHg\n RR: 11 (11 - 26) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 2,558 mL\n 1,253 mL\n PO:\n TF:\n 1,625 mL\n 725 mL\n IVF:\n 873 mL\n 439 mL\n Blood products:\n Total out:\n 2,562 mL\n 1,895 mL\n Urine:\n 2,562 mL\n 1,895 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4 mL\n -642 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 90\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n SpO2: 87%\n ABG: 7.38/77/64/45/15\n Ve: 7.6 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases, Wheezes : less, Diminished: bases), improved air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing,\n chronic changes, of venous stasis\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, L cellulitis less inflamed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Normal\n Labs / Radiology\n 12.8 g/dL\n 143 K/uL\n 187 mg/dL\n 1.0 mg/dL\n 45 mEq/L\n 4.2 mEq/L\n 36 mg/dL\n 91 mEq/L\n 140 mEq/L\n 40.0 %\n 7.5 K/uL\n [image002.jpg]\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n WBC\n 6.5\n 7.5\n Hct\n 38.4\n 38.4\n 40.0\n Plt\n 146\n 143\n Cr\n 0.9\n 1.0\n TCO2\n 48\n 49\n 48\n 48\n 52\n 48\n 47\n Glucose\n 156\n 187\n Other labs: PT / PTT / INR:12.6/33.5/1.1, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:8.9 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: underpenetrated, vascular congestion, increased haziness at\n LUL though no clear collapse\n Microbiology: urine leg neg\n blood neg\n sputum ngtd\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n - Complete course of levoflox , day \n - PCP with bactrim given chronic steroids\n - Sputum cx with ngtd, ruled out for influenza and rsv, urine\n legionella pending\n - Continue solumedrol\ndecrease to 60 , change to prednisone in\n am,\n - Albuterol mdi's and atrovent Q 6,\n - RSBI < 100 and bronchospasm improved, alert without secreation,\n diruesed well\n - Check abg on PS and consider extubation\n # LE cellulitis--remains af and with nl wbc ct (on chronic now high\n dose steroids) , has improved and may be venous stasis\n f/u blood cxs with ngtd\n d/c vanco -- changing to PO meds for cellulitis after completes\n course levo (keflex)\n # Skin lesions-seen by derm, plan for outpt f/u/bx\n # diastolic dysfx-cxr looks wet with limited film,\n Restarted ace-i , diruese with lasix then resume home regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:20 AM 60 mL/hour\n Comments: hold TF's for extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2122-02-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318626, "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: 24 cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt place on CPAP 10/5 and is tolerating well.\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Currently weaning Pt on CPAP 10/5\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 Pt remains intubated. Current vent settings CPAP 10/5. Pt is tolerating\n well. MDI\ns given. No other changes noted.\n" }, { "category": "Physician ", "chartdate": "2122-02-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318627, "text": "Chief Complaint: COPD Exacerbation\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:07 PM\n -- patient w/ worsened acidosis on PS w/ pCO2 of 105, patient put back\n on AC w/ improvement to 84\n -- continued steroid taper\n -- continued diuresis\n -- restarted HCTZ\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Heparin Sodium (Prophylaxis) - 06:17 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 06:56 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 (97.8\n HR: 82 (70 - 89) bpm\n BP: 112/62(78) {102/52(67) - 146/74(97)} mmHg\n RR: 14 (10 - 18) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 2,246 mL\n 263 mL\n PO:\n TF:\n 1,463 mL\n 127 mL\n IVF:\n 692 mL\n 135 mL\n Blood products:\n Total out:\n 3,720 mL\n 410 mL\n Urine:\n 3,720 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,474 mL\n -147 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): 678 (500 - 678) mL\n PS : 0 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 90\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SpO2: 87%\n ABG: 7.38/91/62/49/23\n Ve: 6.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, sclera injected\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: Absent, Left: Absent, erythema RLE stable: erythema\n around PICC RUE\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, Rash: erythema LLE stable\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 155 K/uL\n 12.8 g/dL\n 146 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 4.6 mEq/L\n 42 mg/dL\n 90 mEq/L\n 143 mEq/L\n 40.1 %\n 6.5 K/uL\n [image002.jpg]\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n WBC\n 7.5\n 6.5\n Hct\n 40.0\n 40.1\n Plt\n 143\n 155\n Cr\n 1.0\n 0.8\n TCO2\n 48\n 48\n 52\n 48\n 47\n 55\n 56\n 53\n Glucose\n 187\n 146\n Other labs: PT / PTT / INR:12.0/35.7/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:9.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 69 y/o male w/ hx of COPD, dCHF, admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Presented with wheezes on chest\n exam w/ poor pair movement c/w obstructive etiology. Patient w/\n negative LENI, low suspicison of PE. Patient was intubated due to\n increasing hypercapnea and increased work of breathing. Improved ABG\n on ventilator.\n -- pCO2 to 105 on PS, switched to AC overnight, will try PS\n again today with hope of extubation\n -- cont prednisone taper and bactrim proph\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- completed levaquin for empiric coverage\n \n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n .\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxia,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of dCHF, restarted\n home HCTZ, negative 1.5 L for day, can give lasix prn\n # HTN: hx of HTN. Restarted lisinopril, restarted HCTZ , lasix as\n tolerated given evidence of CHF on CXR with goal of negative .5-1L.\n #LE edema/erythema: LE erythema slightly improved. Cellulitis vs.\n changes from LE edema. Noted that no WBC, no fever. Startarted on\n vanc b/c looked notably angry. Follow up bcx, wound cx. Low\n suspicision for MRSA cellultiis, feel adequate treatment on\n levofloxacin.\n -- outpatient shave bx of ankle mass\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2122-02-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318427, "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 BLOOD CULTURED - At 12:07 PM\n PICC LINE - START 02:17 PM\n URINE CULTURE - At 02:20 PM\n SPUTUM CULTURE - At 02:30 PM\n vanco added for cellulitis\n new black lesions seen on L thigh and R calf cocnerning for malignancy\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:00 AM\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:06 PM\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: 35.6\nC (96\n HR: 78 (70 - 96) bpm\n BP: 115/57(74) {95/49(64) - 122/66(84)} mmHg\n RR: 13 (10 - 15) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 993 mL\n 873 mL\n PO:\n TF:\n 115 mL\n 365 mL\n IVF:\n 668 mL\n 448 mL\n Blood products:\n Total out:\n 964 mL\n 465 mL\n Urine:\n 664 mL\n 465 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 29 mL\n 408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 18 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 90%\n ABG: 7.36/81./72/42/16\n Ve: 6.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases, Wheezes : , Diminished: ), some improved air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+, errythemia on L calf\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, Rash: erythema at L calf, pretibial, lesions black thigh L\n and r calf\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 12.6 g/dL\n 146 K/uL\n 156 mg/dL\n 0.9 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 94 mEq/L\n 138 mEq/L\n 38.4 %\n 6.5 K/uL\n [image002.jpg]\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n 10:45 AM\n WBC\n 5.6\n 6.5\n Hct\n 39.1\n 38.4\n 38.4\n Plt\n 148\n 146\n Cr\n 0.7\n 0.9\n TropT\n <0.01\n TCO2\n 47\n 43\n 46\n 47\n 48\n 49\n 48\n Glucose\n 153\n 156\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Fluid analysis / Other labs: u/a + rbc and wbc, bacteria\n Imaging: cxr--new blunting r cp angle, probable effusion, atelectasis,\n full vessels, loss more wet\n Microbiology: urine and blood ngtd, urine legionella pending, sputum\n neg\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare/bronchitis and acute on chronic\n hypercarbic and hypoxic resp failure and cellulitis\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n -progressive fatigue and bronshospasm leading to intubation\n Would continue antibx with levoflox for 7 day\n follow LLL on cxr--likely atelectasis\n Pt is on high dose of chronic steroids so immunosupressed, though\n on PCP with bactrim\n continue levoflox\n Sputum cx with ngtd, ruled out for influenze and urine legionella\n pending\n Continue solumedrol at decreased dose of 60 Q 8, likely chnage to\n prednisone in am, frequent albuterol mdi's and atrovent Q 6,\n Follow abg though ventilation improving and some increased air\n movement noted on exam.\n ON PS and improving but not yet ready for extubation\n # LE cellulitis--now appears more erythematous concerning for\n cellulitis, though af and with nl wbc ct.\n Check blood cx given chronic steroids.\n Resume vanco and changing to PO med for cellulitis\n # skin lesions-consult derm for input\n # diastolic dysfx-cxr looks wet, and with slightly icnreased le edema\n restart ace-i , diruese with lasix athen resume home regimen\n # tachycardia-now resolved , suspect from copd/resp distress with low\n suspicon of PE given exam and neg lenis\n ICU Care\n Nutrition:\n Comments: tfs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-02-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318432, "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: 69 yo m with severe COPD (chronic prednisone, home O2) with\n chronic hypercarbia presents with copd flare/bronchitis, acute on\n chronic hypercarbic and hypoxic resp failure, and cellulitis\n 24 Hour Events:\n BLOOD CULTURED - At 12:07 PM\n PICC LINE - START 02:17 PM\n URINE CULTURE - At 02:20 PM\n SPUTUM CULTURE - At 02:30 PM\n vanco added for cellulitis LLE\n new black lesions seen on L thigh and R calf concerning for ? skin\n malignancy\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:00 AM\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:06 PM\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: 35.6\nC (96\n HR: 78 (70 - 96) bpm\n BP: 115/57(74) {95/49(64) - 122/66(84)} mmHg\n RR: 13 (10 - 15) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 993 mL\n 873 mL\n PO:\n TF:\n 115 mL\n 365 mL\n IVF:\n 668 mL\n 448 mL\n Blood products:\n Total out:\n 964 mL\n 465 mL\n Urine:\n 664 mL\n 465 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 29 mL\n 408 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 18 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 90%\n ABG: 7.36/81./72/42/16\n Ve: 6.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases, Wheezes : , Diminished: ), some improved air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 1+, errythemia on L calf\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, Rash: erythema at L calf, pretibial, lesions black thigh L\n and r calf\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 12.6 g/dL\n 146 K/uL\n 156 mg/dL\n 0.9 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 94 mEq/L\n 138 mEq/L\n 38.4 %\n 6.5 K/uL\n [image002.jpg]\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n 10:45 AM\n WBC\n 5.6\n 6.5\n Hct\n 39.1\n 38.4\n 38.4\n Plt\n 148\n 146\n Cr\n 0.7\n 0.9\n TropT\n <0.01\n TCO2\n 47\n 43\n 46\n 47\n 48\n 49\n 48\n Glucose\n 153\n 156\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Fluid analysis / Other labs: u/a + rbc and wbc, bacteria\n Imaging: cxr--new blunting r cp angle, probable effusion, L basilar\n atelectasis, pulm vascular congestion/edema\n Microbiology: urine and blood ngtd, urine legionella pending, sputum\n neg\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia presents with copd flare/bronchitis, intubated for acute\n on chronic hypercarbic and hypoxic resp failure, and cellulitis\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n Continue antibx with levoflox for 7 day\n Follow LLL on cxr--likely atelectasis\n Pt is on high dose of chronic steroids at home so\n immunosuppressed, on PCP with bactrim\n Sputum cx with ngtd, ruled out for influenza and rsv, urine\n legionella pending\n Continue solumedrol\ndecrease to 60 Q 8, likely change to prednisone\n in am,\n frequent albuterol mdi's and atrovent Q 6,\n Follow abg though ventilation improving and some increased air\n movement noted on exam.\n Stable now on PS, not yet ready for extubation, diurese today\n # LE cellulitis--now appears more erythematous c/t admit, though af and\n with nl wbc ct (on chronic now high dose steroids)\n f/u blood cxs\n Resume vanco-- changing to PO med for cellulitis\n # Skin lesions-consult derm for input\n # diastolic dysfx-cxr looks wet today\n restart ace-i , diruese with lasix then resume home regimen\n # tachycardia-now resolved , suspect from copd/resp distress with low\n suspicion of PE given exam and neg lenis\n ICU Care\n Nutrition:\n Comments: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-02-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318436, "text": "Chief Complaint: hypoxia/respiratory distress\n 24 Hour Events:\n BLOOD CULTURED - At 12:07 PM\n PICC LINE - START 02:17 PM\n URINE CULTURE - At 02:20 PM\n SPUTUM CULTURE - At 02:30 PM\n - 2 large black, cauliflower-like lesions on right calf and left thigh,\n will need derm consult in am\n - started tube feeds but will need nutrition rec's\n - restarted ACEI and HCTZ\n - restarted vanc for RLE cellulitis\n - PICC placed\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 04:15 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, Edema, No(t) Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: No(t) Tachypnea, Wheeze, Intubated\n Gastrointestinal: No(t) Abdominal pain, No(t) Emesis, No(t) Diarrhea\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 80 (73 - 96) bpm\n BP: 113/65(80) {95/49(64) - 119/69(85)} mmHg\n RR: 14 (11 - 17) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 993 mL\n 290 mL\n PO:\n TF:\n 115 mL\n 125 mL\n IVF:\n 668 mL\n 105 mL\n Blood products:\n Total out:\n 964 mL\n 215 mL\n Urine:\n 664 mL\n 215 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 29 mL\n 75 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 19 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 93%\n ABG: 7.36/82./74/42/16\n Ve: 6.4 L/min\n PaO2 / FiO2: 148\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t)\n Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n improved, L > R)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 1+, Left: 1+, worsened erythema on left > right leg\n Skin: Warm, worsening eryethma, fungating black necrotic mass on right\n ankle\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 12.6 g/dL\n 156 mg/dL\n 0.9 mg/dL\n 42 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 94 mEq/L\n 138 mEq/L\n 38.4 %\n 6.5 K/uL\n [image002.jpg]\n 09:05 PM\n 10:27 PM\n 01:11 AM\n 04:00 AM\n 04:21 AM\n 06:04 AM\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n WBC\n 5.6\n 6.5\n Hct\n 39.1\n 38.4\n 38.4\n Plt\n 148\n 146\n Cr\n 0.7\n 0.9\n TropT\n <0.01\n TCO2\n 50\n 47\n 43\n 46\n 47\n 48\n 49\n Glucose\n 153\n 156\n Other labs: CK / CKMB / Troponin-T:41/4/<0.01, Differential-Neuts:90.2\n %, Band:0.0 %, Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7\n mmol/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intubated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator.\n n continue intubation for ventalatory support, now changed to\n PS, likely extubation tomorrow\n n decrease solumedrol to 60mg ivq8, but likely start prednisone\n tomorrow w/ taper\n n frequent albuterol / atrovent nebs\n n continue levaquin for empiric coverage\n n sputum CX showed no organisims, urine legonalla pending\n n DFA negative\n n CE negative x 3\n n CXR today showing pleural edema, pt w/ hx of on home\n lasix not being given. Will diurese w/ goal of 1L.\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n n Ischemia: ROMI negative, was started on ASA, now d/c\n n Rhythem: sinus tach, now resolved. Felt was likely to\n hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n n Pump: now w/ pleural edema on CXR, hx of , diurese\n and resume home lasix dose.\n # HTN: hx of HTN. Restarted lisinopril, holding HCTZ given low\n pressures, lasix as tolerated given evidence of CHF.\n #LE edema/erythema: worsening LE erythema, no WBC, no fever.\n Startarted on vanc. Follow up bcx, wound cx, and decrease per\n culture/sensitivities.\n -fungating necrotic mass on left ankle, derm c/s requested\n ICU Care\n Nutrition:\n Comments: TF, need nutirition recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n 20 Gauge - 10:45 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2122-02-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318438, "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: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Tubular\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: 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: Triggering synchronously\n Dysynchrony assessment: Possible air trapping\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 Pt on the vent tol well changes made see medivision for more\n information.\n" }, { "category": "Nursing", "chartdate": "2122-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318528, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and lle\n cellulitis. He required intubation and has remained intubated with\n difficulty weaning vent settings d/t the severity of his COPD.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Case Management ", "chartdate": "2122-02-27 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 318823, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: Mass Health\n Hospital days authorized to:\n Current Discharge Plan: Skilled nursing facility\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n 1) Health Care\n 2) Health Care, Nursing and Rehab\n 3) Health Care\n Narrative / Plan (Multidisciplinary team):\n After a lengthy discussion w/ the hospice representive, primary nurse\n and the patient's oldest daughter it was decided home was not the best\n plan because 24 hour help is not in place. I spoke w/ Mrs. via\n telephone and she is inagreement w/ placement and hospice. The\n referrals have been called in.\n" }, { "category": "Physician ", "chartdate": "2122-02-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318512, "text": "Chief Complaint: respiratory failure,copd exac/bronchitis, cellulitis\n I saw and examined the patient, and was physically present with the ICU\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 ps during day then fatigued, rested on ACV overnight\n derm c/s w/ plan for outpt shve bx of leg lesion\n diuresed 1 L neg\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 12:15 AM\n Heparin Sodium (Prophylaxis) - 08:12 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 75 (74 - 110) bpm\n BP: 126/68(85) {94/54(69) - 143/81(100)} mmHg\n RR: 11 (11 - 26) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 2,558 mL\n 1,253 mL\n PO:\n TF:\n 1,625 mL\n 725 mL\n IVF:\n 873 mL\n 439 mL\n Blood products:\n Total out:\n 2,562 mL\n 1,895 mL\n Urine:\n 2,562 mL\n 1,895 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4 mL\n -642 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 90\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n SpO2: 87%\n ABG: 7.38/77/64/45/15\n Ve: 7.6 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases, Wheezes : less, Diminished: bases), improved air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing,\n chronic changes, of venous stasis\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, L cellulitis less inflamed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Normal\n Labs / Radiology\n 12.8 g/dL\n 143 K/uL\n 187 mg/dL\n 1.0 mg/dL\n 45 mEq/L\n 4.2 mEq/L\n 36 mg/dL\n 91 mEq/L\n 140 mEq/L\n 40.0 %\n 7.5 K/uL\n [image002.jpg]\n 07:00 PM\n 07:05 PM\n 09:00 PM\n 04:15 AM\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n WBC\n 6.5\n 7.5\n Hct\n 38.4\n 38.4\n 40.0\n Plt\n 146\n 143\n Cr\n 0.9\n 1.0\n TCO2\n 48\n 49\n 48\n 48\n 52\n 48\n 47\n Glucose\n 156\n 187\n Other labs: PT / PTT / INR:12.6/33.5/1.1, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:8.9 mg/dL,\n Mg++:2.1 mg/dL, PO4:4.3 mg/dL\n Imaging: underpenetrated, vascular congestion, increased haziness at\n LUL though no clear collapse\n Microbiology: urine leg neg\n blood neg\n sputum ngtd\n Assessment and Plan\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure, and cellulitis\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n Continue antibx with levoflox for day\n Pt is on high dose of chronic steroids at home so\n immunosuppressed, on PCP with bactrim\n Sputum cx with ngtd, ruled out for influenza and rsv, urine\n legionella pending\n Continue solumedrol\ndecrease to 60 , likely change to prednisone\n in am,\n Frequent albuterol mdi's and atrovent Q 6,\n RSBI < 100 and bronchospasm imrpoved, alert without secreation,\n diiruesed well\n Will extubate today and use NPPV\n # LE cellulitis--remains af and with nl wbc ct (on chronic now high\n dose steroids) , has improved and may be venous stasis\n f/u blood cxs\n Improving, no blood cx growth, d/c vanco vanco-- changing to PO med\n for cellulitis after completes course levo (keflex)\n # Skin lesions-seen by derm, plan for outpt f/u/bx\n # diastolic dysfx-cxr looks wet wityh limtieed film\n Restarted ace-i , diruese with lasix then resume home regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:20 AM 60 mL/hour\n Comments: hold TF's for extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-02-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318604, "text": "Chief Complaint: respiratory failure/copd exac\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 69 yo m with severe COPD (chronic prednisone, home O2) with\n chronic hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:07 PM\nbecame\n acidemic/increased CO2 on PS wean and rested on ACV overnight\n History obtained from Patient, house staff\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Heparin Sodium (Prophylaxis) - 06:17 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:12 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 79 (70 - 89) bpm\n BP: 115/60(79) {101/52(67) - 141/89(95)} mmHg\n RR: 15 (10 - 18) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 2,246 mL\n 487 mL\n PO:\n TF:\n 1,463 mL\n 127 mL\n IVF:\n 692 mL\n 180 mL\n Blood products:\n Total out:\n 3,720 mL\n 705 mL\n Urine:\n 3,720 mL\n 705 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,474 mL\n -218 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 678 (678 - 678) mL\n PS : 0 cmH2O\n RR (Set): 14\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 90%\n ABG: 7.38/91/62/49/23\n Ve: 6.9 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : scant, No(t) Wheezes : , Diminished: but improved) without\n wheeze\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, Rash: L le cellulitis looks improved/chronic stasis\n changes, easy bruising,\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): intubated, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 12.8 g/dL\n 155 K/uL\n 146 mg/dL\n 0.8 mg/dL\n 49 mEq/L (38-->45)\n 4.6 mEq/L\n 42 mg/dL (36)\n 90 mEq/L\n 143 mEq/L\n 40.1 %\n 6.5 K/uL\n [image002.jpg]\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n WBC\n 7.5\n 6.5\n Hct\n 40.0\n 40.1\n Plt\n 143\n 155\n Cr\n 1.0\n 0.8\n TCO2\n 48\n 48\n 52\n 48\n 47\n 55\n 56\n 53\n Glucose\n 187\n 146\n Other labs: PT / PTT / INR:12.0/35.7/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:9.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: no new cxr\n Microbiology: sputum--oropharengeal flora, other data pending, ngtd\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure\n MAIN ISSUES INCLUDE:\n # Respiratory failure, acute on chronic hypercarbic and hypoxemic from\n copd flare/bronchitis/pna\n - Completing course of levoflox , day \n - continue PCP / bactrim given chronic steroids\n - Taper prednisone\n 60 Q D\n - Albuterol mdi's and atrovent Q 6,\n - RSBI < 100 and bronchospasm improved, alert without secreation,\n diuresed well, still on 10 peep and with worsening acidemia/co2\n retention yesterday during PS trial\n - wean to PS, try dropping PEEP--follow agb,\n Has severe copd\npending PS abg, will consider extubation to\n noninvasive\n # LE cellulitis--remains af and with nl wbc ct (on chronic now high\n dose steroids) , has improved and may be venous stasis\n f/u blood cxs with ngtd\n off vanco and completing course of levoflox today\n # diastolic dysfx-diuresed well, now more alkalotic, part contraction\n from diuresis\n Restarted ace-i , home lasix and hctz\n # elevated BUN--h/h stable, cr improved, ? steroids, follow\n # Skin lesions-seen by derm, plan for outpt f/u/bx\n ICU Care\n Nutrition:\n Holding tf pending reassessment for extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2122-02-24 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 318503, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: Vitamin D, Calcium Carbonate, lasix\n Labs:\n Value\n Date\n Glucose\n 187 mg/dL\n 02:51 AM\n BUN\n 36 mg/dL\n 02:51 AM\n Creatinine\n 1.0 mg/dL\n 02:51 AM\n Sodium\n 140 mEq/L\n 02:51 AM\n Potassium\n 4.2 mEq/L\n 02:51 AM\n Chloride\n 91 mEq/L\n 02:51 AM\n Calcium non-ionized\n 8.9 mg/dL\n 02:51 AM\n Phosphorus\n 4.3 mg/dL\n 02:51 AM\n Magnesium\n 2.1 mg/dL\n 02:51 AM\n Current diet order / nutrition support: Replete with Fiber at 60ml/hr -\n provides 1440kcal and 89g protein\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Estimated Nutritional Needs\n Calories: 1620-2400 (BEE x or / 20-30 cal/kg)\n Protein: 97-121 (1.2-1.5 g/kg)\n Specifics:\n 69 year old male presenting with respiratory distress, still intubated.\n Patient started on tube feedings of Replete with Fiber at 60ml/hr.\n Patient tolerating well, but current tube feeding not meeting calorie\n or protein needs. Suggest goal TF of Nutren Pulmonary at 60ml/hr to\n provide 2160kcal and 98g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Please consider changing tube feeding to Nutren Pulmonary at\n 60ml/hr\n 2. Monitor tolerance, hold if residuals >150ml\n 09:47\n" }, { "category": "Nursing", "chartdate": "2122-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318568, "text": "Cellulitis\n Assessment:\n Action:\n Response:\n Plan:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2122-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318569, "text": "Cellulitis\n Assessment:\n Action:\n Response:\n Plan:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt remains intubated, LS diminished t/o\n Action:\n ABG 7.35/98/63/22/56 on CPAP , Vent settings changed to AC\n Response:\n Resulting ABG 7.39/84/68/20/53, sats 88-90%, sat goal > 88%\n Plan:\n Plan to repeat RSBI/SBT, with possible extubation, consider extubation\n to NIMV if hypercarbic failure persists, cont. steroid taper\n" }, { "category": "Nursing", "chartdate": "2122-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318571, "text": "Cellulitis\n Assessment:\n Pt with generalized edema, skin with purple-ish skin tone, RtLE with\n vascular wound. Skin around Aline appearing mosit/, MD aware.\n Cont. to monitor.\n Action:\n DSD intact\n Response:\n DSD remains intact\n Plan:\n Cont. to assess/Change dressing. Cont. providing wound care.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt remains intubated, LS diminished t/o\n Action:\n ABG 7.35/98/63/22/56 on CPAP , Vent settings changed to AC,\n requiring only minimal sxning, with sm. Amounts of white thick\n sercretions returned.\n Response:\n Resulting ABG 7.39/84/68/20/53, sats 88-90%, sat goal > 88%\n Plan:\n Plan to repeat RSBI/SBT, with possible extubation, consider extubation\n to NIMV if hypercarbic failure persists, cont. steroid taper\n Neuro: Pt adequately sedated on 75 mcg/hr fentanyl, and 3 mg/hr\n versed. Pt opens eyes to voice, follow commands. Nods/ mouths words,\n able to make needs known. MAE, cooperative with care. PERRLA 3mm/bsk\n bilaterally.\n Cont. providing supportive care.\n" }, { "category": "Respiratory ", "chartdate": "2122-02-25 00:00:00.000", "description": "Generic Note", "row_id": 318574, "text": "TITLE:\n RESPIRATORY CARE:\n Pt remains intubated, vent supported overnight. Remains on AC mode w/\n 10peep, minimal spontaneous effort. BS\ns coarse w/ exp wheezes\n throughout(prolonged exp phase). Administering Albuterol and Atrovent\n MDI\ns as ordered. See flowsheet for further pt data. Will follow.\n 05:34\n" }, { "category": "Physician ", "chartdate": "2122-02-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318583, "text": "Chief Complaint: COPD Exacerbation\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:07 PM\n -- patient w/ worsened acidosis on PS w/ pCO2 of 105, patient put back\n on AC w/ improvement to 84\n -- continued steroid taper\n -- continued diuresis\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:30 PM\n Heparin Sodium (Prophylaxis) - 06:17 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 06:56 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 (97.8\n HR: 82 (70 - 89) bpm\n BP: 112/62(78) {102/52(67) - 146/74(97)} mmHg\n RR: 14 (10 - 18) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 104 kg\n Total In:\n 2,246 mL\n 263 mL\n PO:\n TF:\n 1,463 mL\n 127 mL\n IVF:\n 692 mL\n 135 mL\n Blood products:\n Total out:\n 3,720 mL\n 410 mL\n Urine:\n 3,720 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,474 mL\n -147 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): 678 (500 - 678) mL\n PS : 0 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 90\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n SpO2: 87%\n ABG: 7.38/91/62/49/23\n Ve: 6.1 L/min\n PaO2 / FiO2: 155\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, sclera injected\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: Absent, Left: Absent, erythema RLE stable: erythema\n around PICC RUE\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, Rash: erythema LLE stable\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 155 K/uL\n 12.8 g/dL\n 146 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 4.6 mEq/L\n 42 mg/dL\n 90 mEq/L\n 143 mEq/L\n 40.1 %\n 6.5 K/uL\n [image002.jpg]\n 10:45 AM\n 01:21 PM\n 05:14 PM\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n WBC\n 7.5\n 6.5\n Hct\n 40.0\n 40.1\n Plt\n 143\n 155\n Cr\n 1.0\n 0.8\n TCO2\n 48\n 48\n 52\n 48\n 47\n 55\n 56\n 53\n Glucose\n 187\n 146\n Other labs: PT / PTT / INR:12.0/35.7/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, Differential-Neuts:90.2 %, Band:0.0 %, Lymph:4.8\n %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, Ca++:9.0 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Patient was intubated due to increasing hypercapnea\n and increased work of breathing. Improved ABG on ventilator.\n -- continue intubation for ventalatory support, now changed\n to PS/AC, likely extubation tomorrow/today\n -- decreased solumedrol to 60mg ivq8, assess decreasing to\n 40mg IVq8/60mg prednisone daily\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- continue levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- CXR yesterday showing pleural edema, pt w/ hx of on\n home lasix not being given. Will diurese w/ goal of 1L.\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. Restarted lisinopril, will restart HCTZ today,\n lasix as tolerated given evidence of CHF on CXR with goal of negative\n .5-1L.\n #LE edema/erythema: LE erythema slightly improved. Cellulitis vs.\n changes from LE edema. Noted that no WBC, no fever. Startarted on\n vanc b/c looked notably angre. Follow up bcx, wound cx. Low suspicisn\n for MRSA cellultiis, feel adequate treatment on levofloxacin.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2122-02-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318920, "text": "NPN/Discharge Note:\n Mr. and his wife met with the ICU team and the palliative care\n service to discuss options for discharge from the hospital last\n evening. Mr again expressed the strong desire to go home,\n rather than to a with hospice services. This AM Hospice Care\n saw the pt and arranged for a hopsital bed and services at home. Mr\n was in agreement with this plan.\n Prescritions and referrals were faxed to Hospice Care and an\n ambulance was scheduled to transport Mr home.\n" }, { "category": "Nursing", "chartdate": "2122-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318480, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and lle\n cellulitis. He required intubation and has remained intubated with\n difficulty weaning vent settings d/t the severity of his COPD.\n Hypotension (not Shock)\n Assessment:\n Pt with initial hypotension with sbp to 80s s/p intubation .\n hypotension tx\nd with fluid boluses and has remained stable in the\n 90s-100s.\n Action:\n Llisinopril and hctz being held for sbp in the 90s. bp up to 100s this\n shift- able to tolerate diuresis of lasix 40mg iv for fluid overload.\n Response:\n Bp remains stable in 90s-100s.\n Plan:\n Monitor bp and hold antihypertensives per parameters.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Remains Intubated with insp/exp wheezes in r upper airways. Diminished\n in l upper airways and at bases. Strong cough/turns very red when\n coughs/bronchospastic but resolves quickly and with mdis. remains\n lightly sedated with mild anxiety. Maintaining adequate 02 sats of\n 88-90% on ac: .4x550x14+10. abg: 7.38/77/64. improved hypercarbia with\n slightly worse hypoxia.\n Action:\n No vent changes made as pt becomes more hypercarbic when fio2 is\n increased d/t his severe copd. Remains on fentanyl/versed for sedation\n with fentanyl and versed drips. Versed drip was increased for anxiety\n with good effect. Remains on iv vanco, levoflox, mdis, solumedrol.\n Response:\n Maintaining adequate sats on present vent settings. Appears comfortable\n on fentanyl and versed drips. Remains afebrile.\n Plan:\n Attempt to wean vent settlings in am. Decrease sedation as vent\n settings weaned. Continue mdis, iv abx, monitor temp. abgs.\n Lle cellulitis\n Assessment: remains erythematous , warm to touch. Afebrile. Denies\n discomfort. Skin lesions on l thigh and r calf concerning for ? skin\n malignancy.\n Action: iv vanco, lower ext. elevated. Awaiting derm consult.\n Response: cellulitis unchanged from . afebrile.\n Plan: iv abx, elevate lower extremities, follow up with derm consult.\n Monitor temp.\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318836, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and LLE\n cellulitis. He required intubation and had difficulty weaning d/t\n the severity of his COPD. He was extubated successfully on to\n mask ventilation and has been maintained on nasal cannula and cool mist\n with intermittent mask ventilation. Pt has expressed that he would not\n want to be intubated again and wants to go home. Pt\ns is now DNR/DNI\n and a hospice referral has been made.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt is tachypneic, LS have diffuse I/E wheezes, pt is anxious\n Action:\n Pt OOB to chair in tripod position\n Medicated with MSO4 and lorazepam for anxiety/dyspnea\n Continue NP and cool neb as neeed\n Continue albuterol PRN\n Response:\n Pt continues to have periods of dyspnea/SOB\n Plan:\n Continue supportive measures\n Continue to medicate for anxiety/dyspnea\n" }, { "category": "Nursing", "chartdate": "2122-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318471, "text": "Hypotension (not Shock)\n Assessment:\n Pt with initial hypotension with sbp to 80s s/p intubation .\n hypotension tx\nd with fluid boluses and has remained stable in the\n 90s-100s.\n Action:\n Llisinopril and hctz being held for sbp in the 90s. bp up to 100s this\n shift- able to tolerate diuresis of lasix 40mg iv for fluid overload.\n Response:\n Bp remains stable in 90s-100s.\n Plan:\n Monitor bp and hold antihypertensives per parameters.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Remains Intubated with insp/exp wheezes in r upper airways. Diminished\n in l upper airways and at bases. Strong cough/turns very red when\n coughs/bronchospastic but resolves quickly and with mdis. remains\n lightly sedated with mild anxiety. Maintaining adequate 02 sats of\n 88-90% on ac: .4x550x14+10. abg: 7.38/77/64. improved hypercarbia with\n slightly worse hypoxia.\n Action:\n No vent changes made as pt becomes more hypercarbic when fio2 is\n increased d/t his severe copd. Remains on fentanyl/versed for sedation\n with fentanyl and versed drips. Versed drip was increased for anxiety\n with good effect. Remains on iv vanco, levoflox, mdis, solumedrol.\n Response:\n Maintaining adequate sats on present vent settings. Appears comfortable\n on fentanyl and versed drips. Remains afebrile.\n Plan:\n Attempt to wean vent settlings in am. Decrease sedation as vent\n settings weaned. Continue mdis, iv abx, monitor temp. abgs.\n" }, { "category": "Nursing", "chartdate": "2122-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318632, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Not yet ready for extubation.\n Action:\n Off sedation x 1 hour per wake up protocol and restarted at lower\n rates. Had c/o feeling hot and little anxious off both fent and versed.\n A/C mode of ventilation changed to PSV 12/10 40%, appeared to be\n breathing comfortably, ABG w/ph 7.40PCO2 80s, PSV then decreased to 10\n and PEEP 5 w/ph 7.3 and PCO2 R 90s, pt becoming anxious wanting ETT\n out. Explained plan of care to rest over night on AC and increase\n sedation to have restful night. Tube feeds off by 4am in hopes of\n extubation.\n Response:\n Resp acidosis w/decrease in vent support.\n Plan:\n Rest overnight on AC mode of ventilation. Versed gtt for anxiety, was\n on 3mg versed/hr overnight (now on 2mg/hr\n" }, { "category": "Nursing", "chartdate": "2122-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318837, "text": "69 y.o. man adm with severe COPD (on chronic prednisone, home\n 02) and chronic hypercarbia. He presents with COPD flare/bronchitis,\n acute on chronic hypercarbic and hypoxic resp failure and LLE\n cellulitis. He required intubation and had difficulty weaning d/t\n the severity of his COPD. He was extubated successfully on to\n mask ventilation and has been maintained on nasal cannula and cool mist\n with intermittent mask ventilation. Pt has expressed that he would not\n want to be intubated again and wants to go home. Pt\ns is now DNR/DNI\n and a hospice referral has been made.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt is tachypneic, LS have diffuse I/E wheezes, pt is anxious\n Action:\n Pt OOB to chair in tripod position\n Medicated with MSO4 and lorazepam for anxiety/dyspnea\n Continue NP and cool neb as neeed\n Continue albuterol PRN\n Response:\n Pt continues to have periods of dyspnea/SOB\n Plan:\n Continue supportive measures\n Continue to medicate for anxiety/dyspnea\n Problem\n Discharge Planning/Hospice referral\n Assessment:\n Pt referred to Hospice Care services today\n Pt will need additional services in place prior to discharge home\n Action:\n Hospice referral and intake completed\n Pt referred to \ns for inpatient hospice\n Response:\n Ongoing\n Plan:\n Pt will remain in hospital until accepted at for inpatient hospice\n or family has a plan to provide 24h care at home\n" }, { "category": "Physician ", "chartdate": "2122-02-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 318904, "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 Severe COPD, extubated, persistent resp distress. Set up for home\n hospice and awaiting discharge.\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:16 AM\n EKG - At 06:17 AM\n Episode of SVT resolved with Adenosine 6mg. Asymptomatic but observed\n to have minor shaking with tachycardia.\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:49 AM\n Lorazepam (Ativan) - 05:26 AM\n Adenosine - 06:35 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 Constitutional: Complains of wanting to go home\n Respiratory: Dyspnea\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 82 (80 - 143) bpm\n BP: 99/57(68) {98/57(68) - 138/73(85)} mmHg\n RR: 22 (17 - 30) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 240 mL\n 560 mL\n PO:\n 240 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 2,085 mL\n 540 mL\n Urine:\n 2,085 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,845 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 89%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) Anxious, Mild respiratory\n distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 13.7 g/dL\n 148 K/uL\n 78 mg/dL\n 0.8 mg/dL\n 46 mEq/L\n 4.5 mEq/L\n 30 mg/dL\n 91 mEq/L\n 139 mEq/L\n 42.3 %\n 7.2 K/uL\n [image002.jpg]\n 03:41 PM\n 05:25 PM\n 02:56 AM\n 06:57 AM\n 09:04 AM\n 11:28 AM\n 01:10 PM\n 04:57 PM\n 11:35 PM\n 03:27 AM\n WBC\n 6.6\n 7.2\n Hct\n 38.3\n 42.3\n Plt\n 141\n 148\n Cr\n 0.8\n 0.8\n TCO2\n 55\n 57\n 54\n 53\n 51\n 51\n 52\n 52\n Glucose\n 126\n 78\n Other labs: PT / PTT / INR:11.8/27.0/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 69 yo m with severe COPD (chronic prednisone, home O2) with chronic\n hypercarbia, diastolic heart failure, presents with copd\n flare/bronchitis, intubated for acute on chronic hypercarbic and\n hypoxic resp failure, extibated yesterday\n Pt has severe end-stage COPD with tenuous resp status at baseline.\n Extensive discussion with pt and family, after extubation, and pt does\n not want repeat intubation, wishes to return home with hospice care.\n Code status changed to DNR/DNI. Plan clarified last night with family\n with goal of discharge to home hospice. Awaiting for hospital bed to be\n delivered to home.\n He has completed course of antibx for ? retrocardiac pna/bronchitis.\n Continue prednisone. Continue nebs/mdi\ns. BiPAP ordered and will be\n delivered.\n Anxiety remains issue and will continue to treat w/ ativan mostly.\n Morphine ordered.\n Regarding his known diastolic dysfx, he appears well diuresed w/\n improved LE edema, continuing home regimen of ace-I, lasix, and\n thiazide.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :D/C Home\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2122-02-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318474, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 02\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: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2122-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318633, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Not yet ready for extubation.\n Action:\n Off sedation x 1 hour per wake up protocol and restarted at lower\n rates. Had c/o feeling hot and little anxious off both fent and versed.\n A/C mode of ventilation changed to PSV 12/10 40%, appeared to be\n breathing comfortably, ABG w/ph 7.40PCO2 80s, PSV then decreased to 10\n and PEEP 5 w/ph 7.38 and PCO2 R 92s, pt becoming anxious wanting ETT\n out. Explained plan of care to rest over night on AC and increase\n sedation to have restful night. Tube feeds off by 4am in hopes of\n extubation.\n Response:\n Resp acidosis w/decrease in vent support.\n Plan:\n Rest overnight on AC mode of ventilation. Versed gtt for anxiety, was\n on 3mg versed/hr overnight (now on 2mg/hr\n" }, { "category": "Nursing", "chartdate": "2122-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 318454, "text": "This is a 69 yr male w/ hx COPD, CHF who presented to EW w/ respiratory\n distress requiring intubation. Pt has ruled out for flu.\n Hypotension (not Shock)\n Assessment:\n Pt w initial hypotension s/ SBP to 80\ns s/p intubation yesterday per\n notes. Hypotension was initially tx w/ fluid boluses. BP has remained\n stable.\n Action:\n Monitoring BP continuously via A-line. HCTZ continues to be held.\n Lisinopril was re-ordered, but was held this am for SBP 90\ns. Dr. \n notified and orders given to continue to hold lisinopril this shift.\n Response:\n SBP has remained 95 to 1teens.\n Plan:\n Continue to follow BP continuously. Collaborate w/ team regarding\n antihypotensives in am.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt remains intubated w/ diminished BS and occasional wheezes noted.\n Action:\n Pt tolerated CPAP/PS FiO2 40-50% for several hours today. Repeat\n ABG this evening 7.29/103/89 s/p increasing FiO2 to 50% - settings\n returned to AC 550/10 FiO2 40% to rest patient overnoc. Continues on\n fentanyl/versed sedation. Monitoring SpO2 continuously. Monitoring\n respiratory status closely. Pt continues on vancyomycin, levofloxacin,\n nebs and solumedrol as ordered. Snx q4hr for scant to small amounts\n thin clear/white secretions.\n Response:\n Pt remains lightly sedated. Opening eyes spontaneously at times,\n otherwise easily arousable to soft voice. Pt following commands and\n mouthing words. Wrist restraints D/C\nd. BBS remain diminished t/o w/\n occasional expiratory wheezes noted. ABG on CPAP/PS 101 FiO2 40%\n 7.35/84/63 w/ most recent ABG as above. Pt reports comfortable t/o\n shift. Denies pain or shortness of breath t/o shift, and remains free\n of diaphoresis or distress. Remains afebrile.\n Plan:\n Continue to titrate vent settings\n plan to rest on AC overnoc and\n return to CPAP/PS in am. Pt will likely need increased sedation to\n facilitate rest tonight. Continue nebs, abx and steroids as ordered.\n Continue support for pt and family.\n" }, { "category": "Respiratory ", "chartdate": "2122-02-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 318540, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved; Comments: high pc02\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Rsbi was 90. tolerated but pc02 105. increased back to .\n Continue to try and wean each morning.\n" }, { "category": "Physician ", "chartdate": "2122-02-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 318670, "text": "Chief Complaint: COPD Flare\n 24 Hour Events:\n - tolerate PS trial, likely extubate in am\n - rapid steroid taper - 60mg today, less tomorrow\n Allergies:\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: Tube feeds\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: Foley\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: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 84 (68 - 89) bpm\n BP: 101/70(82) {90/51(66) - 162/122(187)} mmHg\n RR: 20 (12 - 20) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 101 kg (admission): 104 kg\n Total In:\n 771 mL\n 108 mL\n PO:\n TF:\n 340 mL\n 63 mL\n IVF:\n 251 mL\n 45 mL\n Blood products:\n Total out:\n 1,985 mL\n 500 mL\n Urine:\n 1,985 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,214 mL\n -392 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 155 (155 - 782) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 32 cmH2O\n Plateau: 19 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 89%\n ABG: 7.38/91./71/48/23\n Ve: 7 L/min\n PaO2 / FiO2: 178\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diminsished at hilum)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: 1+, significantly improved\n Skin: Warm, improved LLE erythema, not hot to touch\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 141 K/uL\n 12.6 g/dL\n 126 mg/dL\n 0.8 mg/dL\n 48 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 93 mEq/L\n 142 mEq/L\n 38.3 %\n 6.6 K/uL\n [image002.jpg]\n 07:05 PM\n 09:36 PM\n 02:51 AM\n 12:14 PM\n 07:45 PM\n 09:30 PM\n 03:37 AM\n 03:41 PM\n 05:25 PM\n 02:56 AM\n WBC\n 7.5\n 6.5\n 6.6\n Hct\n 40.0\n 40.1\n 38.3\n Plt\n 143\n 155\n 141\n Cr\n 1.0\n 0.8\n 0.8\n TCO2\n 48\n 47\n 55\n 56\n 53\n 55\n 57\n Glucose\n 187\n 146\n 126\n Other labs: PT / PTT / INR:12.1/29.6/1.0, CK / CKMB /\n Troponin-T:41/4/<0.01, ALT / AST:19/17, Alk Phos / T Bili:36/0.3,\n Amylase / Lipase:29/19, Differential-Neuts:90.2 %, Band:0.0 %,\n Lymph:4.8 %, Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.7 mmol/L, LDH:161\n IU/L, Ca++:9.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Fluid analysis / Other labs: ABG on PS: pH 7.40 / pCO2 86 / pO2 64 /\n HCO3 55\n ABG at 5pm at TV 460 5:25p\n pH 7.38/ pCO2 92/ pO2 71/ HCO3\n Assessment and Plan\n Assessment and Plan\n 69 y/o male w/ hx of COPD, , admitted w/ dyspnea, likely worsening\n hypoxia in setting of COPD flaire, now intubated.\n # hypoxia: most likely COPD flare. Wheezes on chest exam w/ poor\n pair movement c/w obstructive etiology. Patient w/ negative LENI, low\n suspicison of PE. Likely to infectious etiology, DFA negative,\n sputum Cx negative, urine legonella negative, s/p levo rx. Patient was\n intubated due to increasing hypercapnea and increased work of\n breathing. Improved ABG on ventilator.\n -- continue intubation for ventalatory support, now changed\n to PS/AC, likely extubation tomorrow/today\n -- started on 80mg PO prednisone, will decrease to 60mg\n today and continue rapid taper\n -- frequent albuterol / atrovent nebs, decreased frequency\n q4\n -- s/p levaquin for empiric coverage\n -- sputum CX showed no organisims, urine legonalla negative\n -- DFA negative\n -- CE negative x 3\n -- some component of w/ fluid overload on CE and LE\n edema during hospitalization, has been diuressed, w/ significant\n improvement on clinical exam. Will try to run -0.5 to even\n #cardiac: + SOB, no CP, orthopnea, PND, has LE edema however. Low\n suspision for MI\n -- Ischemia: ROMI negative, was started on ASA, now d/c\n -- Rhythem: sinus tach, now resolved. Felt was likely \n to hypoxa,distress from BIPAP, EKG unrevealing, cont telemetry\n -- Pump: now w/ pleural edema on CXR, hx of , \n diurese and resume home lasix dose.\n # HTN: hx of HTN. Has been well controlled on lisinopril / HCTZ,\n lasix as tolerated given evidence of CHF on CXR with goal of negative\n .5-even.\n #LE edema/erythema: LE erythema improved. Cellulitis vs. changes from\n LE edema. Noted that no WBC, no fever. Startarted on vanc b/c looked\n notably angry. Follow up bcx, wound cx. Low suspicisn for MRSA\n cellultiis, feel adequate treatment on levofloxacin, s/p treatment.\n -- outpatieted shave bx of ankle mass\n ICU Care\n Nutrition:\n Comments: TF, once extubated, regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:00 PM\n PICC Line - 02:17 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" } ]

[ { "category": "Radiology", "chartdate": "2175-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950222, "text": " 5:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: R basilic 54cm DL PICC up IJ, repositioned; please determine\n Admitting Diagnosis: FEVER-NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with AML getting HIDAC chemotherapy, spiking temps\n\n REASON FOR THIS EXAMINATION:\n R basilic 54cm DL PICC up IJ, repositioned; please determine tip location.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 64-year-old male with AML getting HiDAC chemotherapy,\n spiking temperatures. Please evaluate PIC line location.\n\n COMPARISON: .\n\n PORTABLE AP CHEST RADIOGRAPH: Compared to the prior film taken one hour\n prior, there has been interval repositioning of the right PIC line, which the\n tip now overlies the expected region of the mid SVC. No pneumothorax is\n identified. The heart size is normal. The mediastinal and hilar contours are\n normal. The lungs are clear. No pleural effusion is identified.\n\n IMPRESSION: Repositioning of the right PIC line as above. Otherwise no change.\n\n" }, { "category": "Radiology", "chartdate": "2175-03-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 950219, "text": " 3:36 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p 54cm DL right basilic PICC placement, please determine t\n Admitting Diagnosis: FEVER-NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with AML getting HIDAC chemotherapy, spiking temps\n\n REASON FOR THIS EXAMINATION:\n s/p 54cm DL right basilic PICC placement, please determine tip location\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AML. PICC line placement.\n\n Single portable radiograph of the chest demonstrates a right-sided PICC line.\n The tip of the PICC line is within the right internal jugular vein.\n Cardiomediastinal contours are unchanged when compared to . No\n effusion. No consolidation. Trachea is midline.\n\n IMPRESSION:\n\n Right-sided PICC line with its tip in the right internal jugular vein.\n Subsequent chest radiograph demonstrates repositioning of the PICC line.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-03-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 950122, "text": " 12:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: FEVER, ABD PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with high fevers, ?free air in the abdomen\n REASON FOR THIS EXAMINATION:\n -gastrograffin -assess for free air, perforation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SAT 2:25 AM\n Small amounts of free intraperitoneal air present. Mesenteric stranding in the\n right mid abdomen, indicating an acute inflammatory process. No bowel wall\n thickening. Small bowel loops in the area are mildly dilated, though there is\n no obstruction as oral contrast passes through the colon to the rectum. No\n discrete abscess seen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: High fever and free air in the abdomen on plain radiographs.\n History of leukemia and Crohn's disease.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained following the administration of oral Gastrografin and 130 cc of IV\n Optiray contrast. Coronal and sagittal reformatted images were generated.\n\n CT OF THE ABDOMEN WITH CONTRAST: There are mild dependent changes in the lung\n bases. The liver, spleen, pancreas, and adrenal glands are normal. The\n patient is post cholecystectomy. The kidneys enhance symmetrically and\n excrete normally. There are a few small rounded sub 5 mm hypodensities of the\n kidneys, which are too small to characterize.\n\n Free air is seen anterior to the left lobe of the liver and anterior to the\n transverse colon and a rounded focus of extraluminal air is seen within the\n right mid abdomen (series 2, image 37). Stranding is seen within the\n mesenteric fat of the right mid abdomen, just medial to the small bowel-colic\n anastomosis. (This is best appreciated on series 2, image 50). Small bowel\n loops are mildly distended in this area, measuring up to 3.2 cm in diameter.\n No areas of bowel wall thickening are appreciated. The stomach and proximal\n small bowel are unremarkable. There is no evidence of obstruction on this\n scan, as oral contrast passes from the small bowel into the large bowel, and\n some contrast is seen at the rectum. There are no fluid collections within\n the abdomen. No pathologically enlarged mesenteric or retroperitoneal lymph\n nodes. The abdominal aorta is of normal caliber, and the proximal celiac,\n SMA, and are patent.\n\n CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid, seminal vesicles,\n prostate, and bladder are normal. No free pelvic fluid, and no pathologically\n enlarged pelvic or inguinal lymph nodes.\n\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.\n (Over)\n\n 12:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: FEVER, ABD PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Multiplanar reformatted images were essential in delineating the anatomy and\n pathology in this case.\n\n IMPRESSION:\n 1. Small amounts of free air are seen within the abdomen. There is\n mesenteric stranding within the right mid abdomen, just superior to the\n neoterminal ileum, indicating acute inflammation. There is no thickening of\n the bowel wall, however. There are mildly dilated loops of small bowel in the\n right lower quadrant, though there is no obstruction as oral contrast passes\n through to the rectum. The findings are consistent with neoterminal ileitis\n related to Crohn's flare, with perforation. No abscesses are seen at this\n time.\n 2. Small rounded hypodensities of each kidney, which are too small to\n characterize.\n\n Findings were discussed with Dr. in the emergency department at the\n time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2175-03-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 950116, "text": " 10:01 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with leukemia, now with fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with leukemia and fever. Evaluate for infiltrate.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The heart size is normal. Mediastinal and hilar\n contours are normal. The lungs are clear. No pleural effusion or\n pneumothorax. There is a linear lucency of the upper abdomen seen anteriorly\n in the lateral view which may represent free air. Surgical clips are seen\n within the right upper quadrant.\n\n IMPRESSION: Probable free air beneath the hemidiaphragms.\n\n The findings were discussed with Dr. , and a CT will be obtained.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-03-18 00:00:00.000", "description": "Report", "row_id": 1332458, "text": "64 yo with h/o AML presented to ED yesterday he had shoveled snow for about 1/2 hr and went into the house and then started feeling chills temp 101 slight headache, wife called oncologist who told him to come into ED. He denied abd pain, sob, vomiting or sore throat. He has crohns so has 6 loose stools qd no increase noted. He was recently admitted for HIDAC therapy which he tolerated well. In ED he had temp 102.3 on CT there was concern for pneumoperitoneum his abd CT showed some free air and dilated loops of small bowel. Was seen by surgery who suggested that he stay npo and start antibiotic. He was transferred to 4 for close monitor after dropping his bp 80/ he was put on dopamine 4mcg/kg/min, his HR remained nsr rate 70, no sob.\nPMH diagnosed with AML M6a erythroeukemia he was tx with 7+3 but he did not achieve complete ablation and on day 24 given high dose ARA-C. His induction was c/b crohn's exacerbation requiring icu. He is 2months s/p ileal resection for his crohn's. He is s/p 4 cycles of HIDAC consolidation. Herpes zoster on acyclovir has pain over left eye chronically take elavil qhs, MVP, h/o appendectomy, h/o cholecystectomy, hemochromatosis. Allergies dolasetron, percocet, solumedrol. Social lives with wife has three children one son living at home, he works in home inspection quit smoking no etoh when he did drink it was 1-2 beers at night.\nO. Pt arrived to ICU appearing well able to climb into the bed himself, he was on 4mcg/kg/min dopamine bp 110/70. No oxygen\nNeuro a/o x3 mae fc pupils equal and reactive\ncvs HR 70's nsr had episodes of increased ectopy Mag 1.6 tx 3gm mag sulfate and K+ 3.2 tx 60 meq kcl po given repeat lytes pnding ectopy continues but infrequent. bp 134/80-84/ dopamine shut off pt given 1300cc NS IVF, hct 17 tx with 2 uprbc hct also pnding, given bag platlets for ct of 11 repeat plt was 47, skin w+d pp+\nresp room air o2 sats 99% lungs cta\ngi abd snt bs+ having flatus no stool\ngu voiding well\nid afebrile flagyl cefipime, vanco given neutrapenic, bld cx gram stains neg rods both bottles cefapime d/c started on ceftazidime\naccess picc line placed in rt antecub confirmed by xray\na. + bld cx gm neg rods neutrapenic s/p HIDAC therapy, anemia, hypotension, hypomag, hypokalemia\nP. monitor temp, maintain neutra penic precautions, monitor bp check Hct give bld products as needed, antibx as needed, replete labs aggressively, needs cortisol stem test tonight\n" }, { "category": "Nursing/other", "chartdate": "2175-03-19 00:00:00.000", "description": "Report", "row_id": 1332459, "text": "NPN 1900-0700\n\nNEURO: AXOX3, C/O ONE EPISODE OF NAUSEA EARLY IN SHIFT. ADMINISTERED ANZEMET W/ GOOD RESULTS. PT CONTINUED TO HAVE A LOW GRADE TEMP OF 99 OVER NOC.AMBIEN 5 MG FOR INSOMNIA( PT USES THIS AT HOME)\n\nRESP: LCTA, RR UNLABORED.\n\nC/V: SR RARE PVC'S , BP 90'S-120'S, RECIEVED 1 UNIT PRBC FOR HCT OF 21. PREMEDICATED W/ ( BENDARYL FOUND TO BE \"TOO SEDATING\" AS PER HO)\n\nF/E/N: REPLETED K+ OF 3.5 W/ 40 KCL IV , REPLETED CA++ AS WELL.CONT TO BE NPO SIPS W/ MEDS.VOIDS IN URINAL, 2 LOOSE STOOLS IN COMMODE PT STATES HE HAS CHRONIC LOOSE STOOLS CHROHNS DISEASE.\n\nPLAN: CONT AB TX, MONITOR LYTES, HCT , HEMODYNAMICS, EMOTIONAL SUPPORT FOR FAMILY\n" } ]

[ { "category": "Radiology", "chartdate": "2185-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1204904, "text": " 3:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pt hypoxic\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n pt hypoxic\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, assess for acute process.\n\n TECHNIQUE: Supine portable radiograph of the chest.\n\n COMPARISONS: Chest radiograph from earlier the same date.\n\n FINDINGS: Endotracheal tube terminates 5.4 cm above the carina. Lung volumes\n are low without focal opacity, pleural effusion or pneumothorax. The heart is\n normal in size. Normal cardiomediastinal silhouette. NG tube courses into\n the stomach.\n\n IMPRESSION: No acute intrathoracic process with appropriate position of\n endotracheal tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-08-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1204970, "text": " 2:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assessment of pulmonary process.\n Admitting Diagnosis: ETOH INTOXICATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with alcohol intoxication s/p intubation\n REASON FOR THIS EXAMINATION:\n Assessment of pulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with alcohol intoxication and recent intubation.\n Followup examination.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Radiographs dated , and .\n\n FINDINGS: Mild haziness of the vasculature is suggestive of congestion. No\n new focal parenchymal opacity to suggest pneumonia is seen. No pleural\n effusion or pneumothorax is present. The heart size is normal. Endotracheal\n tube is in satisfactory position. An esophageal catheter is in place with tip\n within the stomach and side port at the level of the gastroesophageal junction\n and would need to be advanced by 5 cm to ensure most proximal side port is\n within stomach.\n\n IMPRESSION: Interval development of mild pulmonary vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2185-08-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1205227, "text": " 8:37 PM\n CHEST (PA & LAT) Clip # \n Reason: effusion? PNA?\n Admitting Diagnosis: ETOH INTOXICATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with EtOH withdrawl extubated after being in the MICU\n for airway protection\n REASON FOR THIS EXAMINATION:\n effusion? PNA?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Withdrawal, extubation, questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. There is no evidence of\n complications, notably no pneumothorax. No pleural effusion, normal size of\n the cardiac silhouette. No evidence of pneumonia. No pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-08-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1204915, "text": " 4:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? acute ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with acute AMS\n REASON FOR THIS EXAMINATION:\n ? acute ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHSf MON 5:21 PM\n No acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status. Assess for acute intracranial hemorrhage.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISONS: Head CT, most recently .\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarction. Extensive periventricular and\n subcortical white matter hypodensities likely reflect chronic small vessel\n ischemic disease. Ventricles and sulci are prominent, compatible with\n age-related involutional changes. There is no shift of normally midline\n structures. There is no acute fracture with old nasal bone fractures. Imaged\n paranasal sinuses and mastoid air cells demonstrate ethmoid and maxillary\n bilateral mucosal thickening. Secretions in the nasopharynx are likely from\n endotracheal intubation.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "ECG", "chartdate": "2185-08-24 00:00:00.000", "description": "Report", "row_id": 307528, "text": "Sinus rhythm. Possible left atrial abnormality. Compared to the previous\ntracing of the ventricular rate has increased.\n\n" }, { "category": "ECG", "chartdate": "2185-08-22 00:00:00.000", "description": "Report", "row_id": 307529, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrate is slower.\n\n" } ]

[ { "category": "Echo", "chartdate": "2137-02-07 00:00:00.000", "description": "Report", "row_id": 87133, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Hypertension. Pulmonary embolus.\nHeight: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 136/75\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 10:48\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with >55% decrease during respiration (estimated RA pressure\n(0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral\nvalve supporting structures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). Right ventricular chamber size and\nfree wall motion are normal. The ascending aorta is mildly dilated. The aortic\narch is mildly dilated. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\n\n\n" }, { "category": "Physician ", "chartdate": "2137-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 561564, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n headache\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n Current medications:\n NS at 70 ml/hr, Metoclopramide 10 mg IV Q6H:PRN, Ondansetron 4 mg IV\n Q6H, Acetaminophen-Caff-Butalbital 2 TAB PO Q4H:PRN, Pantoprazole 40 mg\n IV QD, Bisacodyl 10 mg PO/PR DAILY:PRN, Phenytoin 100 mg IV Q8H,\n Fentanyl Citrate 25-100 mcg IV Q4H, Insulin SC\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 PM\n FEVER - 101.2\nF - 08:00 PM\n : nausea - improved w zofran and reglan, episode of SVT w\n bradycardia following, dilantin rebolused for subtheraputic level\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Fentanyl - 04:45 PM\n Dilantin - 11:00 PM\n Flowsheet Data as of 04:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.3\nC (99.2\n HR: 54 (49 - 150) bpm\n BP: 97/39(55) {72/23(41) - 136/82(88)} mmHg\n RR: 21 (14 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 3,253 mL\n 151 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,747 mL\n 151 mL\n Blood products:\n 506 mL\n Total out:\n 1,449 mL\n 100 mL\n Urine:\n 1,199 mL\n 100 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,804 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), bradycardia\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 130 K/uL\n 10.8 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 140 mEq/L\n 30.2 %\n 7.8 K/uL\n [image002.jpg]\n 02:00 AM\n 10:26 PM\n WBC\n 7.8\n Hct\n 30.8\n 30.2\n Plt\n 130\n Creatinine\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:17.0/25.6/1.5, Ca:8.7 mg/dL, Mg:2.2 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin\n Neurologic: AOx3. Neurologically intact. Q2h neuro checks, dilantin Q8h\n (level low yesterday - rebolused, f/u AM level), rpt CT stable\n Cardiovascular: SBP < 140, currently well controlled, episode of\n transient SVT overnight followed by bradycardia - resolving\n Pulmonary: stable.\n Gastrointestinal / Abdomen: clear liquids. Nausea/emesis - improved w\n zofran and reglan\n Nutrition: clear liquids\n Renal: f/u UOP, creat stable\n Hematology: stable Hct, plts, coags\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV\n Wounds: none\n Imaging: none\n Fluids: NS 70ml/h, KVO when tolerating POs\n Consults: Nsurg\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n" }, { "category": "Nursing", "chartdate": "2137-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561329, "text": ".H/O subdural hemorrhage (SDH)\n Assessment:\n Pt\nsleepy\n but easy to awake. Alert and oriented x3, moving all\n extremities on bed w/ normal strength. Pupils equal and reactive. C/o\n headache upon arrival and throughout shift\n rates pain at 5. Pt also\n c/o nausea, vomited x2.\n Action:\n Frequent neuro checks md\ns orders, Tylenol x1 for c/o heacahce.\n Zofran for nausea. 2 additional units of FFP given for iINR of 1.6.\n Response:\n Neuro checks wnl, pt admits to mild improvement in headache post\n Tylenol, pt admits to relief post zofran. INR 1.5 this am.\n Plan:\n Cont to monitor for s/s of worsening bleed,pain management, pt teaching\n and support.\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units FFP in\n ICU. Neurologically intact. Denies chest pain, palpitation, SOB.\n" }, { "category": "Nursing", "chartdate": "2137-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561331, "text": ".H/O subdural hemorrhage (SDH)/SAH\n Assessment:\n Pt\nsleepy\n but easy to awake. Alert and oriented x3, moving all\n extremities on bed w/ normal strength. Pupils equal and reactive. C/o\n headache upon arrival and throughout shift\n rates pain at 5. Pt also\n c/o nausea, vomited x2.\n Action:\n Frequent neuro checks md\ns orders, Tylenol x1 for c/o heacahce.\n Zofran for nausea. 2 additional units of FFP given for iINR of 1.6.\n Response:\n Neuro checks wnl, pt admits to mild improvement in headache post\n Tylenol, pt admits to relief post zofran. INR 1.5 this am.\n Plan:\n Cont to monitor for s/s of worsening bleed,pain management, pt teaching\n and support.\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units FFP in\n ICU. Neurologically intact. Denies chest pain, palpitation, SOB.\n" }, { "category": "Nursing", "chartdate": "2137-02-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 561664, "text": "Pt is a 77 y/o female with a hx of PE's, hyperlipidemia, CAD, afib\n and arthritis. She was in a normal state of health until when\n she developed a severe headache that initially improved with Tylenol.\n On the morning of , the patient was shopping and had sudden\n dizziness and collapsed to the floor. She was brought to an outside\n hospital found to both SAH and SDH. Airlifted to and admitted to\n ICU care. ICU course uneventful.\n Allergies: Sulfa, Codeine (nausea), PCN\n Neuro: Sleepy, but easily arousable. Oriented x3. MAE appropriately.\n PERRL. c/o h/a\n fioricet given with + effect. No seizure activity -\n receiving dilantin tid as ordered.\n CV: SB/SR with occasional PACs\n HR 40\ns-60\ns. X1 episode on pm of\n nonsustained SVT with concurrent hypotension with SBP to 70\n team\n aware, lytes wnl, no further occurrence. +pp/csm. Wearing THTs and PBs\n PE hx.\n Resp: LS with wheezes\n albuterol neb with some effect. O2 sats >95% on\n 3L face mask (pt mouth breather). Denies difficulty breathing. Using IS\n with good effect.\n GI: Tolerating small amounts house diet. Denies n/v. BS covered per\n RISS.\n GU: Foley d/c\nd at 1600\n DTV. Prior to d/c Foley draining adequate\n amounts cyu.\n Skin: WDI. Multiple ecchymotic areas.\n Social: Supportive husband and son.\n" }, { "category": "Physician ", "chartdate": "2137-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 561722, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n R frontal SDH/SAH\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n Current medications:\n albuterol, Acetaminophen-Caff-Butalbital, Acetaminophen, bisacodyl,\n Fentanyl Citrate, HYDROmorphone (Dilaudid), Insulin, Influenza Virus\n Vaccine, Labetalol, Magnesium Sulfate, Metoclopramide, Ondansetron,\n Pantoprazole, Phenytoin, Phenytoin, Pneumococcal Vac Polyvalent\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Diltiazem - 15 mg/hour\n Other ICU medications:\n Dilantin - 02:00 PM\n Diltiazem - 11:40 PM\n Metoprolol - 02:50 AM\n Haloperidol (Haldol) - 03:15 AM\n Furosemide (Lasix) - 03:20 AM\n Other medications:\n Flowsheet Data as of 04:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.7\nC (99.8\n HR: 94 (43 - 129) bpm\n BP: 113/45(62) {98/36(54) - 134/90(115)} mmHg\n RR: 29 (11 - 37) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,576 mL\n 161 mL\n PO:\n 750 mL\n Tube feeding:\n IV Fluid:\n 1,727 mL\n 161 mL\n Blood products:\n 1,099 mL\n Total out:\n 2,110 mL\n 1,810 mL\n Urine:\n 2,110 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,466 mL\n -1,649 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 96%\n ABG: 7.51/39/111/29/7\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Diminished: ),\n (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, confused at times, but oriented to person,\n place, and date\n Labs / Radiology\n 103 K/uL\n 10.3 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 99 mEq/L\n 137 mEq/L\n 29.1 %\n 9.0 K/uL\n [image002.jpg]\n 02:00 AM\n 10:26 PM\n 04:19 AM\n 10:46 PM\n 02:28 AM\n WBC\n 7.8\n 8.5\n 9.0\n Hct\n 30.8\n 30.2\n 30.5\n 29.1\n Plt\n 130\n 103\n 103\n Creatinine\n 0.8\n 0.9\n 0.8\n Troponin T\n 0.01\n TCO2\n 32\n Glucose\n 181\n 130\n 143\n Other labs: PT / PTT / INR:18.1/26.1/1.7, CK / CK-MB / Troponin\n T:286/5/0.01, Ca:9.1 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Imaging: CTA head: There has been progression of intracranial\n hemorrhage since prior study of 4 hours earlier: new foci of\n parenchymal hemorrhage in the right frontal cortex inferiorly could be\n due to contusion. Increase in subarachnoid hemorrhage overlying the\n right anterior convexity now including the right temporal lobe. Acute\n blood again seen layering in the sphenoid air cells, slightly\n increased. Scalp hematoma at the posterior vertex, contrecoup to the\n site of bleeding in the right frontal lobe. No fractures. Axial CTA\n images show no vascular anomalies. Final report pending reformats.\n .\n CT Cspine (OSH):No fracture. C3 on C4 anterolisthesis resulting in\n mild central canal narrowing. Mild cervical spondylosis with mild\n spinal stenosis and multilevel neural foraminal narrowing. MRI is a\n more sensitive modality for evaluation of spinal cord and ligamentous\n injury.\n CT head: no change\n CT head: little interval change in right frontal hemorrhagic\n contusion with surrounding edema, subarachnoid blood also appears\n unchanged\n CT angio chest: Multifocal PE with filling defects in segmental and\n subsegmental branches; Mod-large bilateral pleural effusions with\n associated atelectasis.\n Microbiology: MRSA screen:\n UCx: pending\n BCx: pending\n Assessment and Plan\n .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: AOx3. Neurologically intact. Q2h neuro checks, dilantin Q8h\n (extra dilantin dose for level 8.9); receiving\n Acetaminophen-Caff-Butalbital for headache with good effect\n Cardiovascular: SBP < 140, currently well controlled\n Pulmonary: some wheezing, albuterol given, multiple bilateral pulmonary\n emboli, may start ASA in AM but probably unable to get full\n anticoagulation for some time due to recent head bleed, patient may\n need placement of IVC filter\n Gastrointestinal / Abdomen: Nausea/emesis better s/p zofran and reglan\n and d/c morphine\n Nutrition: regular diet\n Renal: Cr stable, diuresing nicely\n Hematology: stable Hct, plts, coags; goal INR < 1.4; given 2u FFP for\n INR 1.8 -> INR subsequently 1.7 for which she received 2u additional\n FFP; vitamin K 10mg po given at request of neurosurgery, may need to be\n re-ordered for additional days although this may not be done in light\n of newly diagnosed PEs\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural), Other:\n pulmonary embolism\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2137-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561541, "text": ".H/O subdural hemorrhage (SDH)\n Assessment:\n Pt arousable to voice\n Oriented x3\n MAE\n Follows all commands\n Pupils equal and reactive\n C/O severe HA (baseline since arrival to SICU)\n Nausea has subsided\n No seizures noted\n Dilantin level 2.2\n Brady to 40\ns throughout shift (MD English notified, neuro \n notified)\n Action:\n added to pain med regimen\n Neuro checks Q2hrs\n Dilantin bolus of 1000mg IV given\n Dilantin given as ordered\n Turn and reposition Q2hrs\n Response:\n Pt verbalized good pain relief from HA with \n Pt remains neurologically intact and unchanged from previous neuro\n exams\n Plan:\n CT scan in AM\n Medicate for HA PRN\n Continue with Dilantin as ordered\n Neuro checks Q2hrs\n Check Dilantin level\n" }, { "category": "Nursing", "chartdate": "2137-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561655, "text": ".H/O subdural hemorrhage (SDH) and .H/O subarachnoid hemorrhage (SAH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2137-02-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 561829, "text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 3\n days. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Comments:\n Ht: 70\n Wt: 85.3kg\n 77 y.o. F adm s/p fall from standing with Right side frontal SDH/SAH.\n Pt developed multiple PE\ns o/n, so plan is to go to OR today for IVC\n filter placement. Pt is currently NPO, however RN, pt is taking\n meds with H20 without difficulty. Will follow plan/progress. If\n mental status worsens, pt may need temporary nutrition support.\n Please page with ?\ns #\n" }, { "category": "Nursing", "chartdate": "2137-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561892, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Pt noted to have acute pulmonary embolism on chest CT angio overnight.\n Currently on 100% cool neb. Face mask. LS clear and diminished in the\n bases with occasional wheezes. RR high 20\n Action:\n Bilateral lower extremity non-invasives done.. Pt sent to OR for IVC\n filter placement. Compression boots applied.\n Response:\n LENI\ns indicated no dvt\ns present. Pt tolerated IVC filter placement\n well, right groin site intact, peripheral pulses palpable.\n Plan:\n Continue to monitor groin site and peripheral pulses. Monitor resp.\n status and wean 02 as tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n A-fib with hr in 90\ns to 100\ns on 15mg/hr diltiazem.\n Action:\n Dilt. stopped. Bolused with 150mg iv amiodarone and gtt initiated.\n EKG obtained, enzymes cycled.\n Response:\n Cardiac enzymes flat, Pt currently in sinus, hr 60\ns-70\ns with\n occasional pac\n Plan:\n Continue amio gtt until tomorrow, then? change to po, monitor hr.\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Pt was noted to be more confused and restless than prior days. Pt\n often attempting to climb out of bed or pull of oxygen mask. Head CT\n was obtained overnight for this reason.\n Action:\n Haldol given x\ns 1:1 supervision, bed alarm on, bed low and locked. Q1\n hour neuro checks done.\n Response:\n Pt remains confused and restless.\n Plan:\n Continue q 1 hour neuro checks, maintain safety.\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561954, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Patient with PE with CTA yesterday, was on 100% NRBR at 1900. No c/o\n of chest pain or discomfort.\n Action:\n NRBR mask changed to cool neb with 70% Fio2 & weaned down to 50% ,\n with O2 sat of 94-98% pt desats to 84-90 when mask off, nebs per order\n given.CXR done this morning.\n Response:\n O 2sat down to 90% when pt went in to rapid A fib, so switched back to\n NRBR with 100%, ABG sent alkalotic SICU MD aware, O2 sat to 96-97% with\n NRBR\n Plan:\n Cont monitoring, wean o2 as tolerates\n Atrial fibrillation (Afib)\n Assessment:\n Patient with h/o A fib, was in NSR at 1900 on amio gtt at 0.5mg/min\n for 18 hrs, Turned in to rapid A fib at 0100 with rate of 130-140.\n Action:\n Lopressor 5mg given & informed Dr. , repeated lopressor 5mg x3\n again with no effect,\n Response:\n Still in A fib rate not controlled. SBP stable.\n Plan:\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Patient is confused , aware of self & the year & month, confused with\n place, following commands, moving all extremities, PERL, not c/o any\n head ache.\n Action:\n Neuro checks qih, reoriented back to place PRN.agitated and did not\n sleep most of the night, haldol 1mg x1.\n Response:\n Still confused, pt slept around 4am, no neuro changes during the\n shift.\n Plan:\n Cont monitoring, neuro checks q1hr, reorient as needed, support to pt &\n family.\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561944, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O subarachnoid hemorrhage (SAH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561950, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Patient with PE with CTA yesterday, was on 100% NRBR at 1900. No c/o\n of chest pain or discomfort.\n Action:\n NRBR mask changed to cool neb with 70% Fio2 & weaned down to 50% ,\n with O2 sat of 94-98% pt desats to 84-90 when mask off, nebs per order\n given.CXR done this morning.\n Response:\n O 2sat down to 90% when pt went in to rapid A fib, so switched back to\n NRBR with 100%, ABG sent alkalotic SICU MD aware, O2 sat to 96-97% with\n NRBR\n Plan:\n Cont monitoring, wean o2 as tolerates\n Atrial fibrillation (Afib)\n Assessment:\n Patient with h/o A fib, was in NSR at 1900 on amio gtt at 0.5mg/min\n for 18 hrs, Turned in to rapid A fib at 0100 with rate of 130-140.\n Action:\n Lopressor 5mg given & informed Dr. , repeated lopressor 5mg x3\n again with no effect,\n Response:\n Still in A fib rate not controlled. SBP stable.\n Plan:\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O subarachnoid hemorrhage (SAH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 562062, "text": " Problem - Description In Comments\n Assessment:\n LLE 20g IV site with redness/firmness.\n Action:\n Marked with skin marker. IV Amio rotated to 20g in RUE.\n Response:\n Plan:\n Cont to monitor.\n Atrial fibrillation (Afib)\n Assessment:\n NSR 50-70s.\n Action:\n Amio gtt changed to 0.5mg/min from 1.0mg/min @ 1520.\n Response:\n Pt able to stay in a NSR without episodes of RAF/AF this shift\n (11a-7p).\n Plan:\n Cont to monitor hemodynamics. Cont amio gtt at 0.5mg/hr until 0920 AM\n when pt should be switched to PO Amio.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n RR slightly tachypneac around 20s. LS clear, diminished bases. Dry, non\n productive strong cough. O2 sat on 100% Fi02 95-100%.\n Action:\n Pt weaned from NRB\naerosol mask\n face tent.\n Response:\n Tolerating face tent.\n Plan:\n Cont to wean O2 as tolerated.\n" }, { "category": "Radiology", "chartdate": "2137-02-07 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1067495, "text": " 2:53 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with no access requiring heparin drip\n REASON FOR THIS EXAMINATION:\n please place\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 77-year-old requiring heparin drip. Please place PICC line.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. performed the procedure and Dr. supervised.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left cephalic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guide wire, and a double lumen PICC line measuring 48 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guide wire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double lumen PICC line placement via the left cephalic venous approach. Final\n internal length is 48 cm, with the tip positioned in SVC. The line is ready\n to use.\n\n" }, { "category": "Physician ", "chartdate": "2137-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 562209, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB. Course c/b\n recurrent pulmonary emboli.\n Chief complaint:\n PMHx:\n PMH: PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Current medications:\n gtt: amiodarone\n standing: protonix, dulcolax\n PRN: atrovent nebs, reglan, acetaminophen-caff-butalbital, lopressor,\n albuterol nebs, fentanyl, dilaudid, haldol\n sliding scale: magnesium, k-phosphate, RISS\n 24 Hour Events:\n EKG - At 08:45 AM\n ULTRASOUND - At 09:07 AM\n Post operative day:\n POD#2 - ivc filter placement\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.1\nC (98.8\n HR: 69 (59 - 128) bpm\n BP: 113/58(80) {101/45(58) - 149/106(110)} mmHg\n RR: 19 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,978 mL\n 547 mL\n PO:\n 560 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,418 mL\n 187 mL\n Blood products:\n Total out:\n 3,990 mL\n 1,400 mL\n Urine:\n 3,990 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,012 mL\n -853 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: intermittenly agitated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3, x 2), AAO2-3\n Labs / Radiology\n 163 K/uL\n 12.2 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 35.7 %\n 8.0 K/uL\n [image002.jpg]\n 04:19 AM\n 10:46 PM\n 02:28 AM\n 04:26 AM\n 07:15 AM\n 03:53 PM\n 02:28 AM\n 03:38 AM\n 06:55 PM\n 02:29 AM\n WBC\n 8.5\n 9.0\n 9.4\n 8.3\n 8.0\n Hct\n 30.5\n 29.1\n 29.0\n 29.6\n 35.7\n Plt\n 103\n 103\n 117\n 125\n 163\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n 0.7\n 0.6\n Troponin T\n 0.01\n 0.01\n <0.01\n TCO2\n 32\n 30\n Glucose\n 130\n 143\n 113\n 104\n 118\n 129\n Other labs: PT / PTT / INR:15.8/26.1/1.4, CK / CK-MB / Troponin\n T:292/4/<0.01, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Imaging: UENIS: right superficial thrombus\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), ATRIAL FIBRILLATION (AFIB), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, - seizure\n prophylaxis: dilantin Q8h\n - receiving Acetaminophen-Caff-Butalbital for headache with good effect\n - SBP goal <160\n Cardiovascular:\n - afib - back on amiodarone + metoprolol for AFib + RVR, good control\n overnight in sinus rhythm although did require amiodarone boluses x 2.\n Will try to convert to PO regimen today.\n Pulmonary:\n - IS, - pulm emboli - IVC filter given, no anticoag until 7 days after\n SDH per neurosurgery.\n - nebs prn\n - continue to attempt to decrease O2 requirement\n Gastrointestinal / Abdomen: - tolerating soft diet\n Nutrition: - soft diet\n Renal: Foley, - maintain net balance. Question of polyuria due to\n central DI\n compensating with polydipsia, UOP has decreased, to\n continue monitoring.\n Hematology: - stable Hct, plts, coags; goal INR < 2.0\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley\n Wounds: multiple thrombophlebitis sites\n Imaging: UENIs\n right superficial thrombus\n Fluids: KVO\n Consults: Neuro surgery, Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress), Other: pulmonary\n embolism\n ICU Care\n Nutrition: soft diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:00 PM\n 22 Gauge - 09:21 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2137-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 562232, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB. Course c/b\n recurrent pulmonary emboli.\n PMHx:\n PMH: PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Current medications:\n gtt: amiodarone\n standing: protonix, dulcolax\n PRN: atrovent nebs, reglan, acetaminophen-caff-butalbital, lopressor,\n albuterol nebs, fentanyl, dilaudid, haldol\n sliding scale: magnesium, k-phosphate, RISS\n 24 Hour Events:\n EKG - At 08:45 AM\n ULTRASOUND - At 09:07 AM\n Post operative day:\n POD#2 - ivc filter placement\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Infusions:\n Amiodarone - 0.5 mg/min\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.1\nC (98.8\n HR: 69 (59 - 128) bpm\n BP: 113/58(80) {101/45(58) - 149/106(110)} mmHg\n RR: 19 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,978 mL\n 547 mL\n PO:\n 560 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,418 mL\n 187 mL\n Blood products:\n Total out:\n 3,990 mL\n 1,400 mL\n Urine:\n 3,990 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,012 mL\n -853 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: intermittenly agitated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3, x 2), AAO2-3\n Labs / Radiology\n 163 K/uL\n 12.2 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 35.7 %\n 8.0 K/uL\n [image002.jpg]\n 04:19 AM\n 10:46 PM\n 02:28 AM\n 04:26 AM\n 07:15 AM\n 03:53 PM\n 02:28 AM\n 03:38 AM\n 06:55 PM\n 02:29 AM\n WBC\n 8.5\n 9.0\n 9.4\n 8.3\n 8.0\n Hct\n 30.5\n 29.1\n 29.0\n 29.6\n 35.7\n Plt\n 103\n 103\n 117\n 125\n 163\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n 0.7\n 0.6\n Troponin T\n 0.01\n 0.01\n <0.01\n TCO2\n 32\n 30\n Glucose\n 130\n 143\n 113\n 104\n 118\n 129\n Other labs: PT / PTT / INR:15.8/26.1/1.4, CK / CK-MB / Troponin\n T:292/4/<0.01, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Imaging: UENIS: right superficial thrombus\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), ATRIAL FIBRILLATION (AFIB), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, - seizure\n prophylaxis: dilantin Q8h\n - receiving Acetaminophen-Caff-Butalbital for headache with good effect\n - SBP goal <160\n Cardiovascular:\n - afib - back on amiodarone + metoprolol for AFib + RVR, good control\n overnight in sinus rhythm although did require amiodarone boluses x 2.\n Will try to convert to PO regimen today.\n Pulmonary:\n - IS, - pulm emboli - IVC filter given, no anticoag until 7 days after\n SDH per neurosurgery.\n - nebs prn\n - continue to attempt to decrease O2 requirement\n Gastrointestinal / Abdomen: - tolerating soft diet\n Nutrition: - soft diet\n Renal: Foley, - maintain net balance. Question of polyuria due to\n central DI\n compensating with polydipsia, UOP has decreased, to\n continue monitoring.\n Hematology: - stable Hct, plts, coags; goal INR < 2.0\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley\n Wounds: multiple thrombophlebitis sites\n Imaging: UENIs\n right superficial thrombus\n Fluids: KVO\n Consults: Neuro surgery, Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress), Other: pulmonary\n embolism\n ICU Care\n Nutrition: soft diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:00 PM\n 22 Gauge - 09:21 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Radiology", "chartdate": "2137-02-01 00:00:00.000", "description": "OUTSIDE FILMS READ ONLY", "row_id": 1066470, "text": " 5:00 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please second eval by rads\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with SDH and SAH on osh films - CT c-spine with degenerative\n changes\n REASON FOR THIS EXAMINATION:\n please second eval by rads\n ______________________________________________________________________________\n WET READ: GWp FRI 5:28 PM\n changes C-spine predisposes to SC trauma\n\n in appropriate clinical context consider MR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman with subdural hematoma and subarachnoid\n hemorrhage on outside films, CT C-spine by report demonstrated degenerative\n changes. Four second evaluation by radiologists.\n\n OUTSIDE FILMS FROM CARITAS , .\n\n TECHNIQUE: Caritas study with axial images obtained from\n the skull base through T3 without intravenous contrast. Sagittal and coronal\n reformations are supplied from the outside facility.\n\n CT OF THE CERVICAL SPINE WITHOUT IV CONTRAST: There is no fracture or\n dislocation. Prevertebral tissues are normal. The craniocervical junction is\n normal. There is mild straightening of normal cervical lordosis. There are\n multilevel degenerative changes with grade 1 anterolisthesis of C3 on C4\n resulting in mild narrowing of the central canal. Multilevel\n degenerative changes with anterior and posterior osteophytosis at numerous\n levels, most pronounced at C4- C5, C5- C6, and C6-C7 are present. Facet joints\n and lateral bodies are well aligned. At C4-C5, spondylytic ridge causes mild\n effacement of the thecal sac. At C5-6 a spondylytic ridge causes mild thecal\n sac effacement. There is multilevel neural foraminal narrowing, most severe at\n C4 on the right.\n\n Secretions are noted within the trachea.\n\n IMPRESSION: No fracture. C3 on C4 anterolisthesis resulting in mild central\n canal narrowing. Mild cervical spondylosis with mild spinal stenosis and\n multilevel neural foraminal narrowing. MRI is a more sensitive modality for\n evaluation of spinal cord and ligamentous injury.\n DFDdp\n\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 562032, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt in a-fib, rate of 100\ns-120\ns while on dilt. Gtt\n Action:\n Sicu team notified. Dilt. gtt stopped, amiodarone 150mg iv bolus given\n and gtt initiated at 1mg/min. EKG done.\n Response:\n Pt converted to sinus 55\ns-60\ns at approx 11am with rare pac\n Plan:\n Continue amio gtt, change to 0.5mg/min after 6 hours.\n Problem\n phlebitis/thrombosis\n Assessment:\n Right a.c. (old peripheral iv site) noted to be red and firm. Upper\n extremity u/s indicated clot in superficial cephalic vein.\n Action:\n Sicu team notified and at bedside to evaluate. Warm pack applied, arm\n elevated.\n Response:\n Site remains firm and erythematous.\n Plan:\n Continue heat and elevation, continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2137-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 562126, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt flipped into rapid Afib. Rate 130\ns at 0300. BP maintained at\n 130\ns-140\ns/80\n Action:\n Rebolused with Amio 150 mg. continues on Amio gtt 0.5. Given 5 mg IVP\n Lopressor x2.\n Response:\n HR 100-117. Team aware.\n Plan:\n Continue amio gtt, ?start po dose, ?Dilt, continue IVP Lopressor prn if\n pressure can tolerate, follow labs.\n .H/O subdural hemorrhage (SDH)\n Assessment:\n AOx2-3. Restless at times. PERRL. Able to lift and hold all extremities\n to command. Denies HA.\n Action:\n Neuro checks q 2.\n Response:\n Neuro status stable.\n Plan:\n Continue frequent neuro checks, provide support, maintain safety.\n Problem\n IV access\n Assessment:\n Pt with multiple phlebitic areas on both arms r/t Amio gtt.\n Action:\n SICU team aware-PICC line ordered. Warm packs applied and areas of\n phlebitis marked.\n Response:\n Plan:\n PICC line placement, continue monitor phlebitis.\n" }, { "category": "Physician ", "chartdate": "2137-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 562013, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n SDH/SAH, PE, Afib\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n Current medications:\n ankle surgery in \n 24 Hour Events:\n ULTRASOUND - At 09:12 AM\n LENI's\n EKG - At 11:00 AM\n OR SENT - At 01:23 PM\n OR RECEIVED - At 03:30 PM\n ivc filter placement\n - She was on Afib back to sinus rythm, now on afib d/c amiodarone\n started, diltiazem drip after a bolus of Diltiazem. episode of\n desaturation to mid 80's most likely due to PE. neg DVT Lower ext\n Post operative day:\n POD#1 - ivc filter placement\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Haloperidol (Haldol) - 02:00 AM\n Metoprolol - 04:20 AM\n Other medications:\n Flowsheet Data as of 05:52 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: 37.4\nC (99.4\n HR: 94 (65 - 132) bpm\n BP: 135/67(83) {98/50(68) - 143/82(106)} mmHg\n RR: 28 (11 - 34) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Total In:\n 1,251 mL\n 404 mL\n PO:\n 80 mL\n 50 mL\n Tube feeding:\n IV Fluid:\n 1,171 mL\n 354 mL\n Blood products:\n Total out:\n 4,180 mL\n 665 mL\n Urine:\n 4,180 mL\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,929 mL\n -261 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 98%\n ABG: 7.50/37/123/26/5\n PaO2 / FiO2: 246\n Physical Examination\n General Appearance: No(t) No acute distress, Well nourished\n HEENT: PERRL, EOMI, confused\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilateral, Diminished: at the base bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 125 K/uL\n 10.1 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 101 mEq/L\n 137 mEq/L\n 29.6 %\n 8.3 K/uL\n [image002.jpg]\n 02:00 AM\n 10:26 PM\n 04:19 AM\n 10:46 PM\n 02:28 AM\n 04:26 AM\n 07:15 AM\n 03:53 PM\n 02:28 AM\n 03:38 AM\n WBC\n 7.8\n 8.5\n 9.0\n 9.4\n 8.3\n Hct\n 30.8\n 30.2\n 30.5\n 29.1\n 29.0\n 29.6\n Plt\n 130\n 103\n 103\n 117\n 125\n Creatinine\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n Troponin T\n 0.01\n 0.01\n <0.01\n TCO2\n 32\n 30\n Glucose\n 181\n 130\n 143\n 113\n 104\n Other labs: PT / PTT / INR:16.5/26.6/1.5, CK / CK-MB / Troponin\n T:292/4/<0.01, Ca:8.9 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), ATRIAL FIBRILLATION (AFIB), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: Neuro checks Q: 1 hr, Pain controlled, dilantin Q8h\n receiving Acetaminophen-Caff-Butalbital for headache with good effect,\n check albumin and phenytoin level. avoid narcotics and ativan, give\n Haldol PRN\n Cardiovascular: Beta-blocker, HD stable, on Afib, monitor Heart rate,\n continue Hydralazine PRN for high BP Restart amio\n Pulmonary: Episode of desaturation overnight, s/placement of IVC\n filter, some wheezing, albuterol given, multiple bilateral pulmonary\n emboli, may start ASA in AM but probably unable to get full\n anticoagulation for some time due to recent head bleed. follow upper\n ext US to rule out DVT\n Gastrointestinal / Abdomen: No issue\n Nutrition: NPO, consider placing Dobhoff to start TF\n Renal: Foley, Adequate UO, Creatinine stable\n Hematology: Serial Hct, Anemia Hct 29.6 we will monitor, Unble to\n anticougulate to treat PE due to her recent head bleed\n Endocrine: RISS, Goal BS<150, Continue RISS\n Infectious Disease: No issue--> Afebrile and nl WBC\n Lines / Tubes / Drains: Foley, PIV\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural), Other: Afib, PE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561986, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Patient with PE with CTA yesterday, was on 100% NRBR at 1900. Not c/o\n of chest pain or discomfort.\n Action:\n NRBR mask changed to cool neb with 70% Fio2 & weaned down to 50% ,\n with O2 sat of 94-98% pt desats to 84-90 when mask off, nebs per order\n given.CXR done this morning.\n Response:\n O 2sat down to 90% when pt went in to rapid A fib, so switched back to\n NRBR with 100%, ABG sent alkalotic SICU MD aware, O2 sat to 96-97% with\n NRBR\n Plan:\n Cont monitoring, wean o2 as tolerates\n Atrial fibrillation (Afib)\n Assessment:\n Patient with h/o A fib, was in NSR at 1900 on amio gtt at 0.5mg/min\n for 18 hrs, Turned in to rapid A fib at 0100 with rate of 130-140.\n Action:\n Lopressor 5mg given & informed Dr. , repeated lopressor 5mg x3\n again with no effect, 15 mmol Sodium phos replaced with am lab\n Response:\n Still in A fib rate not controlled. SBP stable. So started with\n DItiazem 7mg bolus and 5mg /hr drip, HR down to 110\ns -120. still A\n fib.\n Plan:\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Patient is confused , aware of self & the year & month, confused with\n place, following commands, moving all extremities, PERL, not c/o any\n head ache.\n Action:\n Neuro checks qih, reoriented back to place PRN.agitated and did not\n sleep most of the night, haldol 1mg x1.\n Response:\n Still confused, pt slept around 4am, no neuro changes during the\n shift.\n Plan:\n Cont monitoring, neuro checks q1hr, reorient as needed, support to pt &\n family.\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561987, "text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Patient with PE with CTA yesterday, was on 100% NRBR at 1900. Not c/o\n of chest pain or discomfort.\n Action:\n NRBR mask changed to cool neb with 70% Fio2 & weaned down to 50% ,\n with O2 sat of 94-98% pt desats to 84-90 when mask off, nebs per order\n given.CXR done this morning.\n Response:\n O 2sat down to 93% when pt went in to rapid A fib, so switched back to\n NRBR with 100%, ABG sent alkalotic SICU MD aware, O2 sat to 96-97% with\n NRBR\n Plan:\n Cont monitoring, wean o2 as tolerates\n Atrial fibrillation (Afib)\n Assessment:\n Patient with h/o A fib, was in NSR at 1900 on amio gtt at 0.5mg/min\n for 18 hrs, Turned in to rapid A fib at 0100 with rate of 130-140.\n Action:\n Lopressor 5mg given & informed Dr. , repeated lopressor 5mg x3\n again with no effect, 15 mmol Sodium phos replaced with am lab\n Response:\n Still in A fib rate not controlled. SBP stable. So started with\n DItiazem 7mg bolus and 5mg /hr drip, HR down to 110\ns -120. still A\n fib.\n Plan:\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Patient is confused , aware of self & the year & month, confused with\n place, following commands, moving all extremities, PERL, not c/o any\n head ache.\n Action:\n Neuro checks q1h, reoriented back to place PRN. Agitated and did not\n sleep most of the night, haldol 1mg x1.\n Response:\n Still confused, pt slept around 4am, no neuro changes during the\n shift.\n Plan:\n Cont monitoring, neuro checks q1hr, reorient as needed, support to pt &\n family.\n" }, { "category": "Physician ", "chartdate": "2137-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 561970, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n SDH/SAH, PE, Afib\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n Current medications:\n ankle surgery in \n 24 Hour Events:\n ULTRASOUND - At 09:12 AM\n LENI's\n EKG - At 11:00 AM\n OR SENT - At 01:23 PM\n OR RECEIVED - At 03:30 PM\n ivc filter placement\n - She was on Afib back to sinus rythm, now on afib d/c amiodarone\n started, diltiazem drip after a bolus of Diltiazem. episode of\n desaturation to mid 80's most likely due to PE. neg DVT Lower ext\n Post operative day:\n POD#1 - ivc filter placement\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Haloperidol (Haldol) - 02:00 AM\n Metoprolol - 04:20 AM\n Other medications:\n Flowsheet Data as of 05:52 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: 37.4\nC (99.4\n HR: 94 (65 - 132) bpm\n BP: 135/67(83) {98/50(68) - 143/82(106)} mmHg\n RR: 28 (11 - 34) insp/min\n SPO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Total In:\n 1,251 mL\n 404 mL\n PO:\n 80 mL\n 50 mL\n Tube feeding:\n IV Fluid:\n 1,171 mL\n 354 mL\n Blood products:\n Total out:\n 4,180 mL\n 665 mL\n Urine:\n 4,180 mL\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,929 mL\n -261 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 98%\n ABG: 7.50/37/123/26/5\n PaO2 / FiO2: 246\n Physical Examination\n General Appearance: No(t) No acute distress, Well nourished\n HEENT: PERRL, EOMI, confused\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilateral, Diminished: at the base bilateral)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 125 K/uL\n 10.1 g/dL\n 104 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 101 mEq/L\n 137 mEq/L\n 29.6 %\n 8.3 K/uL\n [image002.jpg]\n 02:00 AM\n 10:26 PM\n 04:19 AM\n 10:46 PM\n 02:28 AM\n 04:26 AM\n 07:15 AM\n 03:53 PM\n 02:28 AM\n 03:38 AM\n WBC\n 7.8\n 8.5\n 9.0\n 9.4\n 8.3\n Hct\n 30.8\n 30.2\n 30.5\n 29.1\n 29.0\n 29.6\n Plt\n 130\n 103\n 103\n 117\n 125\n Creatinine\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n Troponin T\n 0.01\n 0.01\n <0.01\n TCO2\n 32\n 30\n Glucose\n 181\n 130\n 143\n 113\n 104\n Other labs: PT / PTT / INR:16.5/26.6/1.5, CK / CK-MB / Troponin\n T:292/4/<0.01, Ca:8.9 mg/dL, Mg:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), ATRIAL FIBRILLATION (AFIB), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: Neuro checks Q: 1 hr, Pain controlled, dilantin Q8h\n receiving Acetaminophen-Caff-Butalbital for headache with good effect,\n check albumin and phynetoin level. avoid narcotics and ativan, give\n Haldol PRN\n Cardiovascular: Beta-blocker, HD stable, on Afib started on Diltiazem\n drip, monitor Heart rate, continue Hydralazine PRN for high BP\n Pulmonary: Episode of desaturation overnight, s/pplacement of IVC\n filter, some wheezing, albuterol given, multiple bilateral pulmonary\n emboli, may start ASA in AM but probably unable to get full\n anticoagulation for some time due to recent head bleed. follow upper\n ext US to rule out DVT\n Gastrointestinal / Abdomen: No issue\n Nutrition: NPO, conseder placing Debhoff to start TF\n Renal: Foley, Adequate UO, Creatinine stable\n Hematology: Serial Hct, Anemia Hct 29.6 we will monitor, Unble to\n anticougulate to treat PE due to her recent head bleed\n Endocrine: RISS, Goal BS<150, Continue RISS\n Infectious Disease: No issue--> Afibrile and nl WBC\n Lines / Tubes / Drains: Foley, PIV\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural), Other: Afib, PE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 562072, "text": " Problem - Description In Comments\n Assessment:\n LLE 20g IV site with redness/firmness.\n Action:\n Marked with skin marker. IV Amio rotated to 20g in RUE.\n Response:\n Plan:\n Cont to monitor.\n Atrial fibrillation (Afib)\n Assessment:\n Through out most of shift, NSR 50-70s. SBP 100-140s. SBP goal per NSURG\n <160. @ 1750, pt back into RAF to 130s. SBP at time 140s.\n Action:\n Amio gtt changed to 0.5mg/min from 1.0mg/min @ 1520. When pt back in\n RAF, SICU Resident Dr. made aware and pt rebolused with 150mg\n amiodarone.\n Response:\n Plan:\n Cont to monitor hemodynamics. Cont amio gtt at 0.5mg/hr until 0920 AM\n when ?pt should be switched to PO Amio.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n RR slightly tachypneac around 20s. LS clear, diminished bases. Dry, non\n productive strong cough. O2 sat on 100% Fi02 95-100%.\n Action:\n Pt weaned from NRB\naerosol mask\n face tent.\n Response:\n Tolerating face tent.\n Plan:\n Cont to wean O2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2137-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 562161, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB. Course c/b\n recurrent pulmonary emboli.\n Chief complaint:\n PMHx:\n PMH: PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Current medications:\n gtt: amiodarone\n standing: protonix, dulcolax\n PRN: atrovent nebs, reglan, acetaminophen-caff-butalbital, lopressor,\n albuterol nebs, fentanyl, dilaudid, haldol\n sliding scale: magnesium, k-phosphate, RISS\n 24 Hour Events:\n EKG - At 08:45 AM\n ULTRASOUND - At 09:07 AM\n Post operative day:\n POD#2 - ivc filter placement\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.1\nC (98.8\n HR: 69 (59 - 128) bpm\n BP: 113/58(80) {101/45(58) - 149/106(110)} mmHg\n RR: 19 (16 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,978 mL\n 547 mL\n PO:\n 560 mL\n 360 mL\n Tube feeding:\n IV Fluid:\n 1,418 mL\n 187 mL\n Blood products:\n Total out:\n 3,990 mL\n 1,400 mL\n Urine:\n 3,990 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,012 mL\n -853 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: intermittenly agitated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3, x 2), AAO2-3\n Labs / Radiology\n 163 K/uL\n 12.2 g/dL\n 129 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 35.7 %\n 8.0 K/uL\n [image002.jpg]\n 04:19 AM\n 10:46 PM\n 02:28 AM\n 04:26 AM\n 07:15 AM\n 03:53 PM\n 02:28 AM\n 03:38 AM\n 06:55 PM\n 02:29 AM\n WBC\n 8.5\n 9.0\n 9.4\n 8.3\n 8.0\n Hct\n 30.5\n 29.1\n 29.0\n 29.6\n 35.7\n Plt\n 103\n 103\n 117\n 125\n 163\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n 0.7\n 0.6\n Troponin T\n 0.01\n 0.01\n <0.01\n TCO2\n 32\n 30\n Glucose\n 130\n 143\n 113\n 104\n 118\n 129\n Other labs: PT / PTT / INR:15.8/26.1/1.4, CK / CK-MB / Troponin\n T:292/4/<0.01, Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Imaging: UENIS: right superficial thrombus\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), ATRIAL FIBRILLATION (AFIB), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, .H/O SUBDURAL HEMORRHAGE (SDH), .H/O\n SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, - seizure\n prophylaxis: dilantin Q8h\n - receiving Acetaminophen-Caff-Butalbital for headache with good effect\n - SBP goal <160\n Cardiovascular: - afib - back on amiodarone + metoprolol for AFib +\n RVR, good control overnight in sinus rhythm although did require\n amiodarone boluses x 2\n Pulmonary: IS, - pulm emboli - IVC filter given, no anticoag given\n recent SDH.\n - nebs prn\n - continue to attempt to decrease O2 requirement\n Gastrointestinal / Abdomen: - tolerating soft diet\n Nutrition: - soft diet\n Renal: Foley, - maintain net balance\n Hematology: - stable Hct, plts, coags; goal INR < 2.0\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley\n Wounds: multiple thrombophlebitis sites\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress), Other: pulmonary\n embolism\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:00 PM\n 22 Gauge - 09:21 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2137-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 561309, "text": "TITLE: SICU ADMISSION / PROGRESS NOTE\n SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units FFP in\n ICU. Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n headache\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Current medications:\n 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Influenza Virus Vaccine 6.\n Labetalol 7. Morphine Sulfate\n 8. Pantoprazole 9. Phenytoin 10. Pneumococcal Vac Polyvalent 11. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n FFP x 2 overnight, neuro intact\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.9\nC (98.5\n HR: 70 (67 - 75) bpm\n BP: 119/48(64) {119/47(64) - 149/62(81)} mmHg\n RR: 14 (12 - 16) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 182 mL\n 773 mL\n PO:\n Tube feeding:\n IV Fluid:\n 161 mL\n 267 mL\n Blood products:\n 21 mL\n 506 mL\n Total out:\n 1,230 mL\n 360 mL\n Urine:\n 300 mL\n 360 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,048 mL\n 413 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\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, No(t) Sedated\n Labs / Radiology\n 130 K/uL\n 10.8 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 101 mEq/L\n 137 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 02:00 AM\n WBC\n 7.8\n Hct\n 30.8\n Plt\n 130\n Creatinine\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:17.0/25.6/1.5, Ca:9.1 mg/dL, Mg:1.7 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CTA head: There has been progression of intracranial\n hemorrhage since prior study of 4 hours earlier: new foci of\n parenchymal hemorrhage in the right frontal cortex inferiorly could be\n due to contusion. Increase in subarachnoid hemorrhage overlying the\n right anterior convexity now including the right temporal lobe. Acute\n blood again seen layering in the sphenoid air cells, slightly\n increased. Scalp hematoma at the posterior vertex, contrecoup to the\n site of bleeding in the right frontal lobe. No fractures. Axial CTA\n images show no vascular anomalies. Final report pending reformats.\n .\n CT Cspine (OSH):No fracture. C3 on C4 anterolisthesis resulting in\n mild central canal narrowing. Mild cervical spondylosis with mild\n spinal stenosis and multilevel neural foraminal narrowing. MRI is a\n more sensitive modality for evaluation of spinal cord and ligamentous\n injury.\n Assessment and Plan\n 77F with R intraparenchymal hemorrhage, SAH, SDH on Coumadin\n Assessment and Plan:\n Neurologic: AOx3. Neurologically intact. Q1h neuro checks, dilantin\n Q8h, rpt CT in AM\n Cardiovascular: SBP < 140, labetalol gtt if needed\n Pulmonary: stable\n Gastrointestinal / Abdomen: NPO pending CT scan. Nausea/emesis\n resolved.\n Nutrition: cnt NS 70ml/h. f/u lytes. restart diet if CT scan OK\n Renal: f/u UO; Cr baseline.\n Hematology: INR 1.8 on arrival, 1.6 after 2FFP, transfused 2 more o/n\n to 1.5. Target 1.3-1.4\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV x2\n Wounds: none\n Imaging: f/u CT head\n Fluids: NS 70ml/h\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2137-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 561786, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n R frontal SDH/SAH\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n Current medications:\n albuterol, Acetaminophen-Caff-Butalbital, Acetaminophen, bisacodyl,\n Fentanyl Citrate, HYDROmorphone (Dilaudid), Insulin, Influenza Virus\n Vaccine, Labetalol, Magnesium Sulfate, Metoclopramide, Ondansetron,\n Pantoprazole, Phenytoin, Phenytoin, Pneumococcal Vac Polyvalent\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Infusions:\n Diltiazem - 15 mg/hour\n Other ICU medications:\n Dilantin - 02:00 PM\n Diltiazem - 11:40 PM\n Metoprolol - 02:50 AM\n Haloperidol (Haldol) - 03:15 AM\n Furosemide (Lasix) - 03:20 AM\n Flowsheet Data as of 04:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.7\nC (99.8\n HR: 94 (43 - 129) bpm\n BP: 113/45(62) {98/36(54) - 134/90(115)} mmHg\n RR: 29 (11 - 37) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,576 mL\n 161 mL\n PO:\n 750 mL\n Tube feeding:\n IV Fluid:\n 1,727 mL\n 161 mL\n Blood products:\n 1,099 mL\n Total out:\n 2,110 mL\n 1,810 mL\n Urine:\n 2,110 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,466 mL\n -1,649 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 96%\n ABG: 7.51/39/111/29/7\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Diminished: ),\n (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, confused at times, but oriented to person,\n place, and date\n Labs / Radiology\n 103 K/uL\n 10.3 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.1 mEq/L\n 13 mg/dL\n 99 mEq/L\n 137 mEq/L\n 29.1 %\n 9.0 K/uL\n [image002.jpg]\n 02:00 AM\n 10:26 PM\n 04:19 AM\n 10:46 PM\n 02:28 AM\n WBC\n 7.8\n 8.5\n 9.0\n Hct\n 30.8\n 30.2\n 30.5\n 29.1\n Plt\n 130\n 103\n 103\n Creatinine\n 0.8\n 0.9\n 0.8\n Troponin T\n 0.01\n TCO2\n 32\n Glucose\n 181\n 130\n 143\n Other labs: PT / PTT / INR:18.1/26.1/1.7, CK / CK-MB / Troponin\n T:286/5/0.01, Ca:9.1 mg/dL, Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Imaging: CTA head: There has been progression of intracranial\n hemorrhage since prior study of 4 hours earlier: new foci of\n parenchymal hemorrhage in the right frontal cortex inferiorly could be\n due to contusion. Increase in subarachnoid hemorrhage overlying the\n right anterior convexity now including the right temporal lobe. Acute\n blood again seen layering in the sphenoid air cells, slightly\n increased. Scalp hematoma at the posterior vertex, contrecoup to the\n site of bleeding in the right frontal lobe. No fractures. Axial CTA\n images show no vascular anomalies. Final report pending reformats.\n .\n CT Cspine (OSH):No fracture. C3 on C4 anterolisthesis resulting in\n mild central canal narrowing. Mild cervical spondylosis with mild\n spinal stenosis and multilevel neural foraminal narrowing. MRI is a\n more sensitive modality for evaluation of spinal cord and ligamentous\n injury.\n CT head: no change\n CT head: little interval change in right frontal hemorrhagic\n contusion with surrounding edema, subarachnoid blood also appears\n unchanged\n CT angio chest: Multifocal PE with filling defects in segmental and\n subsegmental branches; Mod-large bilateral pleural effusions with\n associated atelectasis.\n Microbiology: MRSA screen:\n UCx: pending\n BCx: pending\n Assessment and Plan\n .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin now with bilateral PEs\n Neurologic: AOx3. Neurologically intact. Q2h neuro checks, dilantin Q8h\n (extra dilantin dose for level 8.9); receiving\n Acetaminophen-Caff-Butalbital for headache with good effect\n Cardiovascular: SBP < 140, currently well controlled\n Pulmonary: some wheezing, albuterol given, multiple bilateral pulmonary\n emboli, may start ASA in AM but probably unable to get full\n anticoagulation for some time due to recent head bleed, patient may\n need placement of IVC filter\n Gastrointestinal / Abdomen: Nausea/emesis better s/p zofran and reglan\n and d/c morphine\n Nutrition: regular diet\n Renal: Cr stable, diuresing nicely Cont lasix.\n Hematology: stable Hct, plts, coags; goal INR < 1.4; given 2u FFP for\n INR 1.8 -> INR subsequently 1.7 for which she received 2u additional\n FFP; vitamin K 10mg po given at request of neurosurgery, may need to be\n re-ordered for additional days although this may not be done in light\n of newly diagnosed PEs\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV\n Wounds: none\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural), Other:\n pulmonary embolism\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots. Consider IVC filter\n Stress ulcer: PPI\n VAP bundle:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2137-02-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 562254, "text": "77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units FFP in\n ICU. Neurologically intact. Denies chest pain, palpitation, SOB. Per\n pt\ns husband, pt c/o headache 2 days prior to event.\n Chief complaint:\n headache\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Atrial fibrillation (Afib)\n Assessment:\n Remains in NSR throughout the day as of this time. IV amiodarone at .5\n mg/hr turned off at 1400,4 hrs after receiving 400 mg of PO amiodarone.\n No VEA observed. BP 120\ns-130\ns/70\ns. HR 60-70\n Action:\n PO amiodarone given (1^st dose) at 1400\n Response:\n No signs of a-fib.\n Plan:\n Pt will receive 400 mg po amio until she has received between \n gms then dose will be decreased to 200 mg qd.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Attempted to wean O2 to off but SaO2 decreased into the high 80\n Weaned down to 4l NC with SaO2 >95%. Lungs clear and diminished in\n bases. Becomes SOB with activity especially eating/drinking.\n Action:\n Weaning O2 to maintain sats >95%.\n Response:\n Tolerating NC @4L\n Plan:\n Con\nt to monitor. Assess for s/s of increasing SOB and DOE. Assess for\n any changes in sputum color\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Pt remains alert and oriented x2. She is lethargic but able to have a\n simple conversation. She is aware of person and place. She is somewhat\n off on time. Hand grasps bilaterally are equal strength, leg pushes are\n equal in strength. Smile is symmetrical. C/O H/A and backache several\n times today. Per husband, pt has chronic back pain and cannot sit or\n lie down for extended periods of time. She takes Tylenol at home.\n Medicated with fiouricet 2 tabs and .125 mg iv Dilaudid with good\n relief of headache. The Dilaudid helped with back pain as pt fell\n asleep and stated that medication helped with back pain.\n Action:\n Fiouricet and Dilaudid given po and IV respectively.\n Response:\n Good relief of back and head pain with above meds.\n Plan:\n Con\nt to monitor for pain, medicate and assess relief. Offer support to\n pt. Cold cloths, reposition frequently.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n SUBARACHNOID HEMORRHAGE\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 85.3 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CAD\n Additional history: hyperlipidemia, afib, PE's, arthritis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:32\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 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 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,627 mL\n 24h total out:\n 2,465 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:29 AM\n Potassium:\n 3.6 mEq/L\n 02:29 AM\n Chloride:\n 103 mEq/L\n 02:29 AM\n CO2:\n 22 mEq/L\n 02:29 AM\n BUN:\n 8 mg/dL\n 02:29 AM\n Creatinine:\n 0.6 mg/dL\n 02:29 AM\n Glucose:\n 129 mg/dL\n 02:29 AM\n Hematocrit:\n 35.7 %\n 02:29 AM\n Finger Stick Glucose:\n 132\n 04:00 PM\n Valuables / Signature\n Patient valuables: Sent home with husband\n valuables: all pt\ns belongings will be sent with patient.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 11\n Date & time of Transfer: 1730\n" }, { "category": "Physician ", "chartdate": "2137-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 561353, "text": "TITLE: SICU ADMISSION / PROGRESS NOTE\n SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units FFP in\n ICU. Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n headache\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Current medications:\n 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Influenza Virus Vaccine 6.\n Labetalol 7. Morphine Sulfate\n 8. Pantoprazole 9. Phenytoin 10. Pneumococcal Vac Polyvalent 11. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n FFP x 2 overnight, neuro intact\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.9\nC (98.5\n HR: 70 (67 - 75) bpm\n BP: 119/48(64) {119/47(64) - 149/62(81)} mmHg\n RR: 14 (12 - 16) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 182 mL\n 773 mL\n PO:\n Tube feeding:\n IV Fluid:\n 161 mL\n 267 mL\n Blood products:\n 21 mL\n 506 mL\n Total out:\n 1,230 mL\n 360 mL\n Urine:\n 300 mL\n 360 mL\n NG:\n 30 mL\n Stool:\n Drains:\n Balance:\n -1,048 mL\n 413 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\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, No(t) Sedated\n Labs / Radiology\n 130 K/uL\n 10.8 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 101 mEq/L\n 137 mEq/L\n 30.8 %\n 7.8 K/uL\n [image002.jpg]\n 02:00 AM\n WBC\n 7.8\n Hct\n 30.8\n Plt\n 130\n Creatinine\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:17.0/25.6/1.5, Ca:9.1 mg/dL, Mg:1.7 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CTA head: There has been progression of intracranial\n hemorrhage since prior study of 4 hours earlier: new foci of\n parenchymal hemorrhage in the right frontal cortex inferiorly could be\n due to contusion. Increase in subarachnoid hemorrhage overlying the\n right anterior convexity now including the right temporal lobe. Acute\n blood again seen layering in the sphenoid air cells, slightly\n increased. Scalp hematoma at the posterior vertex, contrecoup to the\n site of bleeding in the right frontal lobe. No fractures. Axial CTA\n images show no vascular anomalies. Final report pending reformats.\n .\n CT Cspine (OSH):No fracture. C3 on C4 anterolisthesis resulting in\n mild central canal narrowing. Mild cervical spondylosis with mild\n spinal stenosis and multilevel neural foraminal narrowing. MRI is a\n more sensitive modality for evaluation of spinal cord and ligamentous\n injury.\n Assessment and Plan\n 77F with R intraparenchymal hemorrhage, SAH, SDH on Coumadin\n Assessment and Plan:\n Neurologic: AOx3. Neurologically intact. Q1h neuro checks, dilantin\n Q8h, rpt CT in AM\n Cardiovascular: SBP < 140, labetalol gtt if needed\n Pulmonary: stable\n Gastrointestinal / Abdomen: NPO pending CT scan. Nausea/emesis\n resolved.\n Nutrition: cnt NS 70ml/h. f/u lytes. restart diet if CT scan OK\n Renal: f/u UO; Cr baseline.\n Hematology: INR 1.8 on arrival, 1.6 after 2FFP, transfused 2 more o/n\n to 1.5. Target 1.3-1.4\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV x2\n Wounds: none\n Imaging: f/u CT head\n Fluids: NS 70ml/h\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2137-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561462, "text": ".H/O subdural hemorrhage (SDH)\n Assessment:\n Pt sleepy, but easily arousable. Oriented x3. MAE appropriately. PERRL.\n c/o headache. Nausea subsided over course of day. Low grade temps.\n Action:\n Neuro checks q2 hours. Repositioning prn, ice to head, and iv fentanyl\n x1.\n Response:\n Pt observed sleeping after pain interventions. Neurologically stable.\n Plan:\n Continue to monitor neuro status q2 hours. Monitor pain level and\n medicate prn.\n" }, { "category": "Nursing", "chartdate": "2137-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 561781, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Insp/exp wheezes on intial assessment unresolved with alb/atrovent nebs\n Increasing oxygen demands overnight\n 2.5 liters positive\n Inaccurate i/o d/t no foley in place\n CXR indicates fluid overload\n Action:\n Given 20 mg Lasix x 2\n ABG drawn\n CTA chest\n Foley placed\n Response:\n Good diuresis after Lasix doses\n ABG showed adequate oxygenation on nrb\n CTA shows bilateral pleural effusions and bilateral pulmonary embolisms\n Plan:\n No heparin d/t head bleed per Dr . Awaiting rounds for plan.\n Atrial fibrillation (Afib)\n Assessment:\n AT 2200 converted from SB to rapid Afib with rate up to 170\n BP stable\n Action:\n Multiple doses of lopressor and Ivp dilt\n Dilt gtt initiated\n Po betablock started\n Response:\n Better rate control\n BP stable\n 7 second pause noted on telemetry. Dr aware.\n Plan:\n F/u with team this am re: medication regimn.\n Change in mental status\n Assessment:\n Alert and oriented this evening\n Becoming more restless overnight\n Becoming confused overnight\n Action:\n NSURG notified and head ct done to r/o rebleed\n Response:\n CT unchaged\n Plan:\n Continue to monitorl\n" }, { "category": "Physician ", "chartdate": "2137-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 561520, "text": "SICU\n HPI:\n 77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units in ICU.\n Neurologically intact. Denies chest pain, palpitation, SOB.\n Chief complaint:\n headache\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n Current medications:\n NS at 70 ml/hr, Metoclopramide 10 mg IV Q6H:PRN, Ondansetron 4 mg IV\n Q6H, Acetaminophen-Caff-Butalbital 2 TAB PO Q4H:PRN, Pantoprazole 40 mg\n IV QD, Bisacodyl 10 mg PO/PR DAILY:PRN, Phenytoin 100 mg IV Q8H,\n Fentanyl Citrate 25-100 mcg IV Q4H, Insulin SC\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 PM\n FEVER - 101.2\nF - 08:00 PM\n : nausea - improved w zofran and reglan, episode of SVT w\n bradycardia following, dilantin rebolused for subtheraputic level\n Allergies:\n Penicillins\n Unknown;\n Sulfa (Sulfonamide Antibiotics)\n Unknown;\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Fentanyl - 04:45 PM\n Dilantin - 11:00 PM\n Other medications:\n Flowsheet Data as of 04:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.2\n T current: 37.3\nC (99.2\n HR: 54 (49 - 150) bpm\n BP: 97/39(55) {72/23(41) - 136/82(88)} mmHg\n RR: 21 (14 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 3,253 mL\n 151 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,747 mL\n 151 mL\n Blood products:\n 506 mL\n Total out:\n 1,449 mL\n 100 mL\n Urine:\n 1,199 mL\n 100 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,804 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), bradycardia\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 130 K/uL\n 10.8 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 106 mEq/L\n 140 mEq/L\n 30.2 %\n 7.8 K/uL\n [image002.jpg]\n 02:00 AM\n 10:26 PM\n WBC\n 7.8\n Hct\n 30.8\n 30.2\n Plt\n 130\n Creatinine\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:17.0/25.6/1.5, Ca:8.7 mg/dL, Mg:2.2 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n .H/O SUBDURAL HEMORRHAGE (SDH), .H/O SUBARACHNOID HEMORRHAGE (SAH)\n Assessment and Plan: 77F with R intraparenchymal hemorrhage, SAH, SDH\n on Coumadin\n Neurologic: AOx3. Neurologically intact. Q2h neuro checks, dilantin Q8h\n (level low yesterday - rebolused, f/u AM level), rpt CT stable\n Cardiovascular: SBP < 140, currently well controlled, episode of\n transient SVT overnight followed by bradycardia - resolving\n Pulmonary: stable.\n Gastrointestinal / Abdomen: clear liquids. Nausea/emesis - improved w\n zofran and reglan\n Nutrition: clear liquids\n Renal: f/u UOP, creat stable\n Hematology: stable Hct, plts, coags\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV\n Wounds: none\n Imaging: none\n Fluids: NS 70ml/h, KVO when tolerating POs\n Consults: Nsurg\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2137-02-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 562244, "text": "77F on Coumadin for AFib and hx PE, had HA yesterday morning, responded\n to tylenol, worse today. Dizzy this morning, loss consciousness and\n fell from standing while shopping. OSH CT revealed R frontal SDH/SAH;\n received FFP and Profilnine in ED for INR 1.8, 2 more units FFP in\n ICU. Neurologically intact. Denies chest pain, palpitation, SOB. Per\n pt\ns husband, pt c/o headache 2 days prior to event.\n Chief complaint:\n headache\n PMHx:\n PE's, B/L LE DVTs, hyperlipidemia, afib and arthritis\n .\n PSH:\n ankle surgery in \n Atrial fibrillation (Afib)\n Assessment:\n Remains in NSR throughout the day as of this time. IV amiodarone at .5\n mg/hr turned off at 1400,4 hrs after receiving 400 mg of PO amiodarone.\n No VEA observed. BP 120\ns-130\ns/70\ns. HR 60-70\n Action:\n PO amiodarone given (1^st dose) at 1400\n Response:\n No signs of a-fib.\n Plan:\n Pt will receive 400 mg po amio until she has received between \n gms then dose will be decreased to 200 mg qd.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Attempted to wean O2 to off but SaO2 decreased into the high 80\n Weaned down to 4l NC with SaO2 >95%. Lungs clear and diminished in\n bases. Becomes SOB with activity especially eating/drinking.\n Action:\n Weaning O2 to maintain sats >95%.\n Response:\n Tolerating NC @4L\n Plan:\n Con\nt to monitor. Assess for s/s of increasing SOB and DOE. Assess for\n any changes in sputum color\n .H/O subdural hemorrhage (SDH)\n Assessment:\n Pt remains alert and oriented x2. She is lethargic but able to have a\n simple conversation. She is aware of person and place. She is somewhat\n off on time. Hand grasps bilaterally are equal strength, leg pushes are\n equal in strength. Smile is symmetrical. C/O H/A and backache several\n times today. Per husband, pt has chronic back pain and cannot sit or\n lie down for extended periods of time. She takes Tylenol at home.\n Medicated with fiouricet 2 tabs and .125 mg iv Dilaudid with good\n relief of headache. The Dilaudid helped with back pain as pt fell\n asleep and stated that medication helped with back pain.\n Action:\n Fiouricet and Dilaudid given po and IV respectively.\n Response:\n Good relief of back and head pain with above meds.\n Plan:\n Con\nt to monitor for pain, medicate and assess relief. Offer support to\n pt. Cold cloths, reposition frequently.\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 562098, "text": "Atrial fibrillation (Afib)\n Assessment:\n pt in afib lytes repleted\n Action:\n K=3.1 kcl 60 meq po given, k phos 2.2 neutrophos 2 packets po, mag=1.9\n tx with 2 grams mag sulfate\n Response:\n pt converted ot nsr rate 75-80 nsr occasional pvc\n Plan:\n check lytes in am.\n .H/O subdural hemorrhage (SDH)\n Assessment:\n alert and oriented,perrl,mae to command equal strength all extremites.\n Restless, calling out\n Action:\n haldol 1 mg iv\n Response:\n pt resting at present\n Plan:\n q 2 hour neuro checks\n" }, { "category": "Nursing", "chartdate": "2137-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 562099, "text": "Atrial fibrillation (Afib)\n Assessment:\n pt in afib lytes repleted\n Action:\n K=3.1 kcl 60 meq po given, k phos 2.2 neutrophos 2 packets po, mag=1.9\n tx with 2 grams mag sulfate\n Response:\n pt converted ot nsr rate 75-80 nsr occasional pvc\n Plan:\n check lytes in am.\n .H/O subdural hemorrhage (SDH)\n Assessment:\n alert and oriented,perrl,mae to command equal strength all extremites.\n Restless, calling out\n Action:\n haldol 1 mg iv\n Response:\n pt resting at present\n Plan:\n q 2 hour neuro checks\n" }, { "category": "ECG", "chartdate": "2137-02-08 00:00:00.000", "description": "Report", "row_id": 241461, "text": "Atrial fibrillation with rapid ventricular rate. There is right and left arm\nlead reversal. Diffuse non-specific ST segment abnormalities. Compared to the\nprevious tracing of the rhythm is more clearly atrial fibrillation.\nThe other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2137-02-05 00:00:00.000", "description": "Report", "row_id": 241462, "text": "Reversed left-right arm leads\nRegular narrow complex tachycardia of uncertain mechanism but may be atrial\nflutter\nLow limb lead QRS voltages\nDiffuse ST-T wave abnormalities are nonspecific but cannot exclude in part\nischemia\nClinical correlation is suggested\nSince previous tracing of the same date, ventricular response now regular and\nfaster, reversed left-right arm leads present, and further ST-T wave changes\nseen\n\n" }, { "category": "ECG", "chartdate": "2137-02-05 00:00:00.000", "description": "Report", "row_id": 241463, "text": "Atrial fibrillation with rapid ventricular response. Since the previous\ntracing the rate has increased. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2137-02-04 00:00:00.000", "description": "Report", "row_id": 241464, "text": "Atrial fibrillation. Borderline low limb lead voltage. ST-T wave\nabnormalities. Since the previous tracing of atrial fibrillation is\nnew. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2137-02-01 00:00:00.000", "description": "Report", "row_id": 241465, "text": "Sinus rhythm. Left atrial abnormality. Possible left ventricular hypertrophy.\nNon-specific ST-T wave changes. Mild QTc interval prolongation. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2181-02-15 00:00:00.000", "description": "Report", "row_id": 79127, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 194\nBSA (m2): 2.06 m2\nBP (mm Hg): 140/66\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 16:06\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV 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 motion.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta. Focal calcifications in ascending aorta. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular thicknesses are\nnormal. The left ventricular cavity size is normal. Left ventricular systolic\nfunction is hyperdynamic (EF 70-80%). No masses or thrombi are seen in the\nleft ventricle. There is no ventricular septal defect. Right ventricular\nchamber size and free motion are normal. The aortic root is mildly\ndilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-14 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 858477, "text": " 6:35 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Eval for hematoma\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL\n\n REASON FOR THIS EXAMINATION:\n Eval for hematoma\n CONTRAINDICATIONS for IV CONTRAST:\n loss of L kidney\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left renal hematoma, status post fall.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the\n pubic symphysis were obtained without IV or oral contrast.\n\n CT OF ABDOMEN WITHOUT IV CONTRAST:\n\n Bibasilar opacities are present with air bronchograms, increased since the\n prior exam, which may represent atelectasis or developing pneumonia. There\n has been interval increase in size of small bilateral pleural effusions.\n Coronary artery calcifications are again noted.\n\n Again demonstrated is a large left renal subcapsular and perinephric hematoma,\n with extension of the hematoma into the retroperitoneum bilaterally. The\n extent of hematoma within the left subcapsular and perinephric space, as well\n as within the retroperitoneum is not significantly changed since the prior\n examination. Again noted is displacement of the left kidney medially as a\n result of the mass effect from the subcapsular hematoma. Residual contrast is\n demonstrated within both kidneys, as well as within the proximal ureters.\n There is no evidence of contrast extravasation.\n\n There has been slight interval increase in the amount of free fluid within the\n abdomen, particularly within the perihepatic and bilateral paracolic gutters.\n The fluid is hyperdense and is consistent with blood. No focal fluid\n collections are demonstrated, and no new areas of hemorrhage are seen.\n\n A nasogastric tube is demonstrated within the stomach. The stomach and loops\n of large and small bowel otherwise appear unremarkable. There has been\n interval placement of an intfrarenal inferior vena cava filter. The abdominal\n aorta is calcified. There is no evidence of bowel obstruction. No\n pathologically enlarged retroperitoneal or mesenteric lymph nodes are noted.\n The pancreas, spleen, adrenal glands, and liver are stable in appearance. The\n gallbladder is unremarkable. There is no free air.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST:\n\n Contrast is identified within the bladder. Additionally, there is a small\n (Over)\n\n 6:35 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Eval for hematoma\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n amount of air with a Foley catheter noted in the bladder. There is no\n evidence of contrast extravasation. The rectum and pelvic loops of bowel\n appear unremarkable. Again noted is a mild amount of hyperdense fluid within\n the pelvis, which is increased in amount since the prior exam. No pelvic or\n inguinal lymphadenopathy is demonstrated.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are present.\n\n IMPRESSION:\n\n 1) Stable appearance of large left perinephric and subcapsular hematoma\n extending to the retroperitoneum bilaterally. No new areas of hemorrhage\n identified.\n\n 2) Slight interval increase in small amount of hyperdense fluid within the\n peritoneum and pelvis, consistent with hemoperitoneum.\n\n 3) Interval worsening of bibasilar opacities with air bronchograms, suggestive\n of worsening collapse or development of pneumonia. Interval increase in size\n of small bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-14 00:00:00.000", "description": "INTERUP IVC", "row_id": 858450, "text": " 2:49 PM\n IVC GRAM/FILTER Clip # \n Reason: Please place IVC filter.\n Admitting Diagnosis: LEFT RENAL FRACTURE\n Contrast: VISAPAQUE Amt: 40CC\n ********************************* CPT Codes ********************************\n * INTERUP IVC -51 MULTI-PROCEDURE SAME DAY *\n * 1SR ORDER BRANCH VENOUS SYSTEM -51 MULTI-PROCEDURE SAME DAY *\n * 1SR ORDER BRANCH VENOUS SYSTEM -59 DISTINCT PROCEDURAL SERVICE *\n * -52 REDUCED SERVICES PERC PLCMT IVC FILTER *\n * SEL RENAL BILAT VENOGRAPHY -59 DISTINCT PROCEDURAL SERVICE *\n * C1880 VENA CAVA FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with fall, hx. of DVT\n REASON FOR THIS EXAMINATION:\n Please place IVC filter.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male with history of deep vein thrombosis (DVT) and\n contraindication to anticoagulation. Please place retrievable filter in the\n inferior vena cava (IVC).\n\n PHYSICIANS: The procedure was performed by Dr. and Dr. \n . Dr. , the staff radiologist, was present and\n supervising throughout.\n\n PROCEDURE/FINDINGS: After the risks and benefits of the procedure were\n discussed with the patient's daughter and written informed consent was\n obtained, the patient was placed supine on the angiography table. His right\n groin, including the indwelling 9-French sheath, was prepped and draped in the\n standard sterile fashion. Under direct fluoroscopic guidance, a 5-French C-II\n Cobra glide catheter was advanced over a 0.035 wire and through the 9-\n French sheath, into the inferior vena cava. After the wire was\n removed, the 5-French C2 Cobra Glidecatheter was advanced over an 0.035\n Glidewire into the left renal vein at the level of the mid-L1 vertebral body.\n With the catheter tip positioned in the left renal hilum, selective renal\n venography was performed. This revealed a narrow lumen of the left renal vein\n at the hilum, with free and rapid passage of contrast into its central portion\n and the IVC without evidence of leak. This is consistent with the prior CT\n scan from . The Glidecath was then withdrawn from the left renal\n vein and, again under fluoroscopic guidance, advanced over the 0.035 Glidewire\n into the right renal vein. A fluoroscopic image was stored and showed that the\n ostium of the right renal vein was at the mid-portion of the L1 vertebral\n body.\n\n The 9-French sheath was then removed over an 0.035 wire and replaced\n with the 9-French Bard Recovery delivery sheath with inner dilator. The\n delivery sheath was advanced into the inferior vena cava until the marker tip\n was positioned at the middle of the L1 vertebral body. At this time, the inner\n dilator was removed and the Recovery sheath was successfully deployed under\n direct fluoroscopic visualization. A fluoroscopic spot film was obtained,\n (Over)\n\n 2:49 PM\n IVC GRAM/FILTER Clip # \n Reason: Please place IVC filter.\n Admitting Diagnosis: LEFT RENAL FRACTURE\n Contrast: VISAPAQUE Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n revealing the presence of the filter apex at the mid-L1 vertebral body.\n Following deployment, the delivery sheath was removed from the right common\n femoral vein. Manual pressure was held until hemostasis was achieved. A dry\n sterile dressing was applied. Following the procedure, the patient was\n returned to the surgical intensive care unit in stable condition.\n\n COMPLICATIONS: None.\n\n CONTRAST: 30 cc of Visipaque 320 full strength.\n\n IMPRESSION:\n\n 1. Patent left renal vein, narrow in its hilar portion, without evidence of\n extravasation.\n\n 2. Successful placement of a retrievable Bard Recovery IVC filter (nitinol)\n in an infrarenal position. This filter may remain in place permanently or may\n be removed at any time.\n\n" }, { "category": "Radiology", "chartdate": "2181-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858361, "text": " 7:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: post-intubation\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation\n\n REASON FOR THIS EXAMINATION:\n post-intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall and DTs. Now post-intubation.\n\n COMPARISON: at 09:44.\n\n SUPINE AP CHEST AT 19:15: There has been interval placement of an\n endotracheal tube with the tip approximately 1.9 cm from the carina. There\n are very low lung volumes on the current exam. The cardiac and mediastinal\n contours are stable. There is persistent atelectasis at the right base. Left\n basilar atelectasis has worsened in the interim. No definite consolidations\n or congestive failure. No pneumothorax detected on this supine radiograph.\n\n IMPRESSION: Satisfactorily positioned ETT. Interval worsening of left\n basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858848, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new PNA\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation, pulm consolidation\n\n REASON FOR THIS EXAMINATION:\n ? new PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, question new infiltrates.\n\n FINDINGS: There is dense opacification obscuring both hemidiaphragms with\n either collapse or consolidation of the right middle lobe. The ET tube is 2\n cm above the carina. There is a right subclavian line with tip in superior\n vena cava. There is an NG tube with tip in the stomach. Compared to the film\n from 3 days ago, the right-sided infiltrate is markedly worse.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858401, "text": " 8:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ngt placement and source of fever\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation\n\n REASON FOR THIS EXAMINATION:\n ngt placement and source of fever\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n CLINICAL INDICATION: Nasogastric tube placement. Fever.\n\n An endotracheal tube is about 1.5 cm above the carina. A nasogastric tube has\n been placed and terminates in the gastroduodenal junction area. Cardiac and\n mediastinal contours are stable. There is vascular engorgement, bilateral\n perihilar haziness, and more confluent opacities at the bases, unchanged, as\n well as bilateral pleural effusions.\n\n IMPRESSION:\n\n 1). Low position of endotracheal tube.\n\n 2) Nasogastric tube terminates in gastroduodenal junction area. Otherwise,\n no significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-12 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 858201, "text": " 5:12 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: FELL R/O ABD INJURY\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL\n REASON FOR THIS EXAMINATION:\n R/O INTRAABDOMINAL INJURY\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp MON 5:40 PM\n large left subcapsular renal hematoma and perinephric hematoma with active\n extravasation, and extension of blood into retroperitoneum. small amount of\n high density fluid in perihepatic space, likely hemoperitoneum.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Status post fall, on anticoagulation.\n\n COMPARISON: Outside hospital study from .\n\n TECHNIQUE: MDCT-acquired contiguous axial images from the lung bases to the\n pubic symphysis were obtained before and after 150 cc of IV Optiray. Nonionic\n contrast was administered secondary to the rapid bolus requirement needed per\n protocol. Coronal and sagittal reconstructions were performed.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Bibasilar atelectatic changes\n are noted at the lung bases. Additionally, there is a small left pleural\n effusion.\n\n There is a large left renal hematoma noted which is predominantly subcapsular\n in nature, although perinephric blood is also demonstrated. Additionally,\n multiple foci of active contrast extravasation are noted within the left\n anterior, lateral, and posterior perirenal space. The blood within the left\n perinephric space extends into the retroperitoneum and across the midline into\n the right perinephric space. The left subcapsular hematoma compresses and\n displaces the left kidney medially. Both kidneys enhance symmetrically. The\n left renal vein at the left renal hilum is not well visualized, and may be\n suggestive of a possible thrombus within this portion of the renal vein, or\n poor opacification of the renal vein secondary to compression by the hematoma.\n Right renal artery is intact. Additionally, identified within both kidneys are\n multiple renal cysts. Several small bilateral renal calculi are also\n demonstrated on the non- contrast-enhanced CT scan, but there is no evidence\n of hydronephrosis. The ureters are not opacified.\n\n Small amount of high-density fluid is seen within the perihepatic space,\n consistent with hemoperitoneum. The liver appears unremarkable without\n evidence of laceration. The gallbladder, pancreas, spleen, adrenal glands,\n stomach and loops of large and small bowel are all within normal limits. The\n abdominal aorta is intact throughout without evidence of intramural hematoma\n or aneurysmal dilatation. There is no free air.\n\n (Over)\n\n 5:12 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: FELL R/O ABD INJURY\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: Foley catheter is noted within\n the bladder which otherwise appears unremarkable. The rectum, sigmoid colon,\n prostate, and seminal vesicles are normal. No free fluid is demonstrated\n within the pelvis. Stranding and hematoma is still seen within the left\n retroperitoneal space extending from the left perinephric hematoma. No pelvic\n or inguinal lymphadenopathy is demonstrated.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are present.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n delineating the left subcapsular and perinephric hematoma and extention of the\n hemorrhage into the retroperitoneum. These reconstructions are of a grade IV.\n\n IMPRESSION:\n 1. Large left perinephric and subcapsular hematoma which displaces and\n compresses the left kidney medially. Multiple foci of active extravasation are\n demonstrated within the left perinephric space. The hematoma extends to the\n retroperitoneum bilaterally.\n 2. The left renal vein at the left hilum is not well visualized, and this may\n be due to compression of the vein by the left perinephric hematoma or\n formation of thrombus within this region.\n 3. Both kidneys enhance symmetrically. Bilateral renal cysts and renal calculi\n are demonstrated without evidence of hydronephrosis.\n 4. Small amount of hemoperitoneum noted within the perihepatic space likely\n related to the large retroperitonal hematoma.\n 5. Bibasilar atelectasis with small left pleural effusion.\n\n These findings were discussed immediately with Dr. at the time of\n interpretation on .\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-14 00:00:00.000", "description": "INITAL 3RD ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 858451, "text": " 2:51 PM\n RENAL ANGIO Clip # \n Reason: Reeval L. kidney for bleeding\n Admitting Diagnosis: LEFT RENAL FRACTURE\n Contrast: VISAPAQUE Amt: 70CC\n ********************************* CPT Codes ********************************\n * INITAL 3RD ORDER ABD/PEL/LOWER -51 MULTI-PROCEDURE SAME DAY *\n * ADD'L 2ND/3RD ORDER ABD/PEL/LO ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * ADD'L 2ND/3RD ORDER ABD/PEL/LO ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * ADD'L 2ND/3RD ORDER ABD/PEL/LO RENAL UNILAT SEL INCL'ING FLUS *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 100 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx of fall on left flank now with left flank hematoma and\n active extravasation of contrast on CT from around kidney\n REASON FOR THIS EXAMINATION:\n Reeval L. kidney for bleeding\n ______________________________________________________________________________\n FINAL REPORT\n\n\n HISTORY: 63-year-old male status post fall with recent embolization of\n multiple bleeding left renal artery branches. Patient is now hypotensive with\n a drop in hematocrit. Please reevaluate left kidney for bleeding.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the staff radiologist, was present and supervising\n throughout. After the risks and benefits of the procedure were discussed with\n the patient's daughter and written informed consent was obtained, the patient\n was placed supine on the angiography table. His right groin, including the\n indwelling 5 French arterial sheath, was prepped and draped in the standard\n sterile fashion. Through the 5 French angiographic sheath, a 5 French C2\n Cobra glide catheter was advanced over a .035 Glidewire and access into the\n left renal artery was obtained. A selective left renal arteriogram was\n performed revealing a briskly filling nephrogram with patchy filling defects\n present in the middle to lower third of the left kidney consistent with recent\n Gelfoam embolization. No evidence of extravasation or vascular abnormality\n was identified.\n\n A 3 French Tracker microcatheter was then advanced through the 5 French C2\n Cobra glidecath and, using a .016 Glidewire and the fluoroscopic road map\n feature for guidance, access into multiple segmental and interlobar branches\n of the left renal artery was obtained. With the catheter tip positioned\n within each of six segmental branches, superselective arteriography was\n performed. No evidence of extravasation or vascular abnormality was\n (Over)\n\n 2:51 PM\n RENAL ANGIO Clip # \n Reason: Reeval L. kidney for bleeding\n Admitting Diagnosis: LEFT RENAL FRACTURE\n Contrast: VISAPAQUE Amt: 70CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n identified within each of the superselective branches. After the Tracker\n microcatheter was removed, a follow-up selective left renal arteriogram was\n performed via injection through the 5 French C2 Cobra glide cath. No source\n of bleeding was identified. There is a small capsular branch extending into\n the inferior pole of the kidney. A repeat arteriogram was performed focusing\n on this capsular branch, which did not identify a source of extravasation from\n this vessel.\n\n Following the procedure, the 5 French C2 Cobra glide cath was removed,\n followed by the 5 French bright-tipped angiographic sheath. Manual pressure\n was held on the right common femoral artery until hemostasis was achieved. A\n dry sterile dressing was applied. The patient returned to the Surgical ICU\n following the procedure in stable condition.\n\n COMPLICATIONS: None.\n\n CONTRAST: 70 cc of 60% Visipaque 320.\n\n IMPRESSION: Selective left renal arteriography with superselective injection\n in each of six interlobar arteries was performed without evidence of\n extravasation or vascular abnormality.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-12 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 858200, "text": " 4:57 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: R/O PTX, FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL\n REASON FOR THIS EXAMINATION:\n R/O PTX, FX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall.\n\n SUPINE AP VIEW OF THE CHEST: The cardiac and mediastinal contours are normal.\n The pulmonary vascularity is normal. There is patchy opacity present at the\n left lung base, likely representing atelectasis. No effusions or pneumothorax\n is demonstrated. The osseous and soft tissue structures are unremarkable.\n\n AP SUPINE VIEW OF THE PELVIS: No fracture or dislocation is identified. The\n sacral struts are intact. The hips and sacroiliac joints bilaterally are\n preserved.\n\n IMPRESSION: 1. Left lower lobe atelectasis.\n\n 2. No fracture or dislocation identified within the pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2181-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858448, "text": " 2:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: line repositioning. Rt subclavian line.\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation\n\n REASON FOR THIS EXAMINATION:\n line repositioning. Rt subclavian line.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP SUPINE CHEST AT 2:00 P.M. ON .\n\n INDICATION: Multiple medical problems as above. Status post line\n repositioning.\n\n FINDINGS: Compared with a film earlier in the day at 1:10 P.M., the right\n subclavian central venous line has been withdrawn and its tip now projects at\n the level of the mid-SVC.\n\n No other obvious changes.\n\n" }, { "category": "Radiology", "chartdate": "2181-02-13 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 858258, "text": " 9:32 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: dvt\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with h/o dvt\n REASON FOR THIS EXAMINATION:\n dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of DVT, please assess bilateral lower extremities.\n\n BILATERAL LOWER EXTREMITY VEINS ULTRASOUND: scale and color Doppler\n images of both common femoral, superficial femoral and popliteal veins were\n obtained. Normal waveforms, compressibility, and augmentation were\n demonstrated. No intraluminal thrombus was identified.\n\n IMPRESSION: No evidence of lower extremity DVT.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858259, "text": " 9:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL\n\n REASON FOR THIS EXAMINATION:\n ?pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n AP SUPINE PORTABLE CHEST RADIOGRAPH: The heart size is normal. There is an\n opacity at the left base and new opacity at the right lung base, likely\n representing worsening atelectasis. There is left effusion. The vasculature\n is normal. There is no pneumothorax. No rib fractures are seen.\n\n IMPRESSION: Worsening basilar atelectasis, without definite evidence of\n pneumonia. No evidence of CHF. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2181-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858427, "text": " 12:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: new right CVL\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation\n\n REASON FOR THIS EXAMINATION:\n new right CVL\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Trauma and intubation.\n\n Endotracheal tube is 2 cm above the carina. Right subclavian CV line is in\n distal SVC. Tip of NG tube is in region of distal antrum and pyloroduodenal\n junction. No pneumothorax. Allowing for low lung volumes heart size is\n borderline. There is opacity at the left base obscuring the medial portion of\n the left hemidiaphragm consistent with atelectasis/consolidation in the left\n lower lobe, unchanged since the prior film of the same date. In addition\n there is atelectasis at the right lung base.\n\n IMPRESSION: No pneumothorax. Atelectasis/consolidation left lower lobe.\n Atelectasis right lung base.\n\n" }, { "category": "Radiology", "chartdate": "2181-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859078, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: B consolidation, progressive eval of pulmonary status\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation, pulm ,consolidation\n\n REASON FOR THIS EXAMINATION:\n B consolidation, progressive eval of pulmonary status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall with renal laceration and delirium tremens. Post\n intubation. Bilateral consolidation.\n\n COMPARISON: .\n\n AP SUPINE PORTABLE CHEST: The right subclavian line in good position.\n Endotracheal tube tip projects 2.6 cm above the carina. The endotracheal tube\n cuff is distending the tracheal lumen somewhat. There is a nasogastric tube,\n which courses through the left upper quadrant and its tip is present in the\n right upper quadrant, perhaps in the duodenal bulb. This is unchanged in\n position. Additionally, there appears to be an IVC filter.\n\n There is dense bibasilar opacity with accompanying effusions, which may\n represent atelectasis versus aspiration. The appearance is unchanged since\n the prior study.\n\n IMPRESSION: 1) Stable appearance of bibasilar consolidative change which may\n represent aspiration or atelectasis. Accompanying effusions.\n 2) Endotracheal tube cuff appears to be distending the tracheal lumen, and\n therefore is overinflated.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-12 00:00:00.000", "description": "EMBO NON NEURO", "row_id": 858213, "text": " 6:42 PM\n RENAL ANGIO Clip # \n Reason: Embolize L. kidney/?lumnbars\n Contrast: VISAPAQUE Amt: 150\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 EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * TRANCATHETER EMBOLIZATION F/U STATUS INFUSION/EMBO *\n * F/U STATUS INFUSION/EMBO F/U STATUS INFUSION/EMBO *\n * RENAL UNILAT SEL INCL'ING FLUS -59 DISTINCT PROCEDURAL SERVICE *\n * PELVIS SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL ANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL ANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SPINAL SEL ANGIOGRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EA ADD'L VESSEL AFTER BASIC A- -59 DISTINCT PROCEDURAL SERVICE *\n * C1769 GUID WIRES INCL INF C1887 CATHETER GUIDING INF/PERF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx of fall on left flank now with left flank hematoma and\n active extravasation of contrast on CT from around kidney\n REASON FOR THIS EXAMINATION:\n Embolize L. kidney/?lumnbars\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63 year-old man on Coumadin with history of fall and several (5)\n areas of active perinephric extravasation on CT. Please perform selective\n renal and lumbar arteriography with possible embolization of bleeding vessels.\n\n PHYSICIANS: The procedure was performed by Dr. and Dr. \n . Dr. , the staff radiologist, was present and\n supervising throughout.\n\n PROCEDURE/FINDINGS: After the risks and benefits of the procedure, including\n loss of kidney function, were discussed at length with the patient and written\n informed consent was obtained, the patient was placed supine on the\n angiography table. His right groin, including the right common femoral vein\n central line, was prepped and draped in the standard sterile fashion. Through\n an anesthetized skin approach and with the assistance of fluoroscopy, the\n right common femoral artery was accessed in the retrograde fashion using a 19-\n gauge single- puncture needle. A 0.035 wire was advanced through\n the access needle into the abdominal aorta under fluoroscopic visualization.\n The access needle was exchanged for a 5-French angiographic sheath. After the\n inner dilator was removed, the sheath was assembled to a continuous saline\n flush. A 5-French C2 Cobra Glidecatheter was then advanced over the \n wire, through the angiographic sheath, into the abdominal aorta. Using the C2\n Cobra Glidecatheter in combination with an 0.035 Glidewire, access into the\n left renal artery was obtained.\n (Over)\n\n 6:42 PM\n RENAL ANGIO Clip # \n Reason: Embolize L. kidney/?lumnbars\n Contrast: VISAPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Selective left renal arteriography demonstrated a briskly filling nephrogram\n with evidence of extrinsic cortical compression at the mid-pole from overlying\n hematoma. Two focal areas of active extravasation were identified arising from\n the lower half of the cortical surface of the kidney. Delayed imaging did not\n demonstrate distinct opacification of the renal vein. This is a non-specific\n finding and may represent extrinsic compression of the renal vein from\n hematoma or thrombosis of the renal vein. Based on these angiographic findings\n and after a discussed with the referring urologic surgeon (Dr. ), we\n planned to superselectively embolize the bleeding vessels. However, before\n this was performed, we investigated the lumbar branches to rule out additional\n sources of active bleeding (as was suggested by the recent CT scan).\n\n After the 5-French C2 Cobra glidecath was removed, a 5-French tapered HS1\n spinal catheter was advanced through the angiographic sheath into the\n abdominal aorta. Using the 5-French HS1 catheter, selective arteriograms were\n performed of the left L1, L2, and L3 lumbar arteries. No evidence of\n extravasation was identified from these vessels. There was opacification of\n the L4 artery from the L3 injection where some contrast refluxed back into the\n aorta and from there into the L4 artery. After the 5- French HS1 catheter was\n exchanged over the wire for the 5- French C2 Cobra Glidecatheter, our\n attention was turned to embolization of the bleeding renal artery vessels.\n\n With the 5-French C2 Cobra Glidecatheter positioned within the lumen of the\n left renal artery, a 3-French Tracker microcatheter was advanced over an 0.014\n glidewire into a superselective branch perfusing the lower pole of the left\n kidney. After the guidewire was removed, a repeat arteriogram identified the\n site of extravasation. Superselective embolization was then performed using\n gelfoam slurry until stagnant flow was achieved and no further extravasation\n was identified. After the Tracker microcatheter was removed, a repeat\n selective left renal arteriogram was performed, demonstrating continued\n extravasation from a second bleeding vessel arising from the most inferior\n branch of the left renal artery. After this vessel was engaged using the\n combination of the 3-French microcatheter with the 0.014 Glidewire,\n superselective embolization was performed using gelfoam slurry until stagnant\n flow was achieved and no further extravasation was identified.\n\n After the Tracker microcatheter was removed, a repeat selective left renal\n arteriogram was performed, identifying an additional active site of bleeding\n arising from a more superior middle pole branch of the left renal artery. The\n bleeding vessel was superselectively accessed using the 3-French Tracker\n microcatheter with the 0.014 Glidewire. Superselective gelfoam embolization\n was then performed until stagnant flow was achieved and no further\n extravasation was identified. At this time, the Tracker microcatheter was\n removed and a follow-up selective left renal arteriogram was performed. This\n revealed successful embolization of the areas of extravasation with no further\n (Over)\n\n 6:42 PM\n RENAL ANGIO Clip # \n Reason: Embolize L. kidney/?lumnbars\n Contrast: VISAPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bleeding identified. There is good perfusion of the upper half of the kidney,\n along with a branch supplying the most inferior portion of the kidney. Despite\n delayed imaging, we were unable to visualize the left renal vein.\n\n At this time, the Glidecatheter was replaced with a 4-French Omniflush\n catheter and, using the 0.035 Glidewire, the catheter tip was advanced into\n the contralateral left common iliac artery. After the Glidewire was removed,\n an arteriogram was performed identifying the left deep circumflex iliac,\n inferior epigastric, and common femoral arteries. No evidence of vascular\n malformation or abnormality was identified. In addition, branches of the left\n hypogastric artery were identified, again without evidence of extravasation,\n vascular malformation, or abnormality. At the completion of the procedure, the\n 4-French Omniflush catheter was removed. The 5-French angiographic sheath was\n secured to the skin using a 2-0 silk suture. A dry sterile dressing was\n applied. Following the procedure, the patient was transferred to the surgical\n intensive care unit in stable condition.\n\n COMPLICATIONS: There were no immediate postprocedural complications.\n\n MEDICATIONS: 1% Lidocaine SQ. A total of 200 micrograms of Fentanyl was\n administered in intermittent doses with continuous monitoring of vital signs\n by the nursing staff during the entire procedure.\n\n CONTRAST: 150 cc of Visipaque 320 full strength.\n\n IMPRESSION:\n\n 1. Selective left renal arteriography revealed active contrast extravasation\n from two areas arising from the cortical surface of the lower half of the left\n kidney.\n\n 2. Successful superselective gelfoam embolization of three left renal artery\n branches where the extravasation was identified, with good immediate\n angiographic results.\n\n 3. Selective left L1, L2, and L3 lumbar arteriography without evidence of\n extravasation or vascular abnormality.\n\n 4. Left iliac arteriography was performed and showed no evidence of\n extravasation or vascular abnormality from the branches of the hypogastric,\n external iliac, or common femoral arteries.\n\n These findings were discussed with the surgical ICU team and the consulting\n urologist, Dr. , at the time of the procedure.\n (Over)\n\n 6:42 PM\n RENAL ANGIO Clip # \n Reason: Embolize L. kidney/?lumnbars\n Contrast: VISAPAQUE Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2181-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858554, "text": " 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval of pulm consolidation\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation, pulm consolidation\n\n REASON FOR THIS EXAMINATION:\n interval eval of pulm consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with status post fall, intubation.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with a prior chest radiograph dated .\n\n FINDINGS: The endotracheal tube, right subclavian venous line, and\n nasogastric tube are unchanged. The mediastinal and cardiac contours are\n within normal limits. Again, note is made of bilateral pleural effusion with\n atelectasis, decreased compared to the prior study. Again, note is made of\n left lower lobe opacity, probably representing atelectasis.\n\n IMPRESSION: Decreased bilateral pleural effusion with atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859365, "text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval evalution of RML consolidation\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M S/P FALL, renal lac,DTs, now post-intubation, pulm ,consolidation\n\n REASON FOR THIS EXAMINATION:\n interval evalution of RML consolidation\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 63-year-old man, status post fall, with delirium tremens, post-\n\n intubation, please evaluate right middle lobe consolidation.\n\n Portable AP view of the chest dated is compared with the same\n examination from . The right subclavian line terminates in the\n superior vena cava. The endotracheal tube terminates 3 cm above the carina.\n Again noted is tracheal lumen distention from the endotracheal tube. The\n nasogastric tube courses and terminates below the diaphragm. There is a small\n degree of improvement in the bilateral pleural effusions and bibasilar\n opacities. Otherwise, there has been no change.\n\n" }, { "category": "Radiology", "chartdate": "2181-02-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 860130, "text": " 8:49 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o consolidation\n Admitting Diagnosis: LEFT RENAL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M s/p L kidney fracture, now with fever\n REASON FOR THIS EXAMINATION:\n r/o consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with left kidney fracture, fever.\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n The comparison is made with the prior chest radiograph dated .\n\n FINDINGS: The patient is extubated. Nasogastric tube, central venous line\n are removed. Cardiac and mediastinal contours are within normal limits. Note\n is made of bilateral pleural effusion associated with atelectasis, slightly\n decreased compared to the prior study. Note is made of patchy opacity in the\n left lower lobe, which probably represent atelectasis, however, pneumonia\n cannot be totally excluded.\n\n IMPRESSION: Decrease of bilateral pleural effusion with bibasilar\n atelectasis. Left lower lobe opacity, probably representing atelectasis,\n however, pneumonia cannot be totally excluded.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-13 00:00:00.000", "description": "Report", "row_id": 1395093, "text": "t-sicu nsg note:\npt is a 63yo man who on fell getting out of his car and hit door, he was hospitalized at osh w/ fractured l kidney dx on ct. developed inc flank pain and distended abd w/ hypotension and tx to for furthur w/u and rx. Arrived in t-sicu @00 from angio s/p embolization of renal artery, pt w/ #16 angios in antecubs, r femoral art line and trauma line, foley to gravity and 2lnp, sm left forehead lac sutured.\n\nneuro- a+ox3, mae's, fc, c/o back pain.\n\nresp- ft on at 50% fio2, rr 18-20, bs cta, strong nonproductive cough. abg w/ pco2-33, pao2-89\n\ncvs-tm 100po, sbp 120's-150, hr 120's-130's nst no ectopy, lytes repleted. 2l rl, 1uprbc given over night.\n\ngi- abd very distended and tender to touch, no bs, no flatus,\n\ngu- foley patent for ~40-70cc/hr of cyu. cr 1.6.\n\nskin- forehead lac sutured w/ old dry bld, csm wnl, r angio site w/ a-line intact.\n\nendo- bs 189 rx w/ ss reg insulin.\n\nsocial- pt has very supportive family, daughter, son, ex-wife, girlfriend and step-daughter.\n\na: stable night, c/o back pain responded to 0.5mg dilaudid\n\np: monitor cvs per routine, enc c+db, follow serial hcts, HIT, no heparin pnd results, maintain logroll precautions, needs tls films.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-13 00:00:00.000", "description": "Report", "row_id": 1395094, "text": "Social Work\nSW consulted to see pt re: substance abuse issues. Pt is a 63y/o male admitted last night to the T-SICU s/p fall while intoxicated. SW spoke with pt to obtain psychosocial information. Pt lying in bed, somewhat tremulous, although denying withdrawal sx. Pt reports drinking \"7 highballs\" at the VFW before taking a cab home. Pt slipped on the ice while paying the cab driver, landing on his left side and hitting his head. He went to Hosp first, then was later transferred to after is was discovered that pt has a kidney lac.\nPt states that he has been drinking etoh daily x 40 years, since entering the armed services, and has had no periods of sobriety in that time. Pt states he's \"never had a reason\" to be sober. Pt denies any past physical or legal probs from his chronic drinking, but does acknowledge that his marriage to his ex-wife may have suffered from it. Pt lives with his son, , who is 35y/o and has MD. Pt's ex-wife, , and his daughter, , both live in . They are both due to visit pt this evening. Pt worked for the Fire Dept x 35 years, before retiring 5 years ago. Pt denies any past substance abuse tx or withdrawal, but does state that he's diagnosed himself as an alcoholic.\nPt appeared somewhat motivated to abstain from etoh use once he is d/c, stating, \"I was able to quit smoking, I can do this\". However, he later stated he might just cut down his drinking in lieu of possible withdrawal sx. SW encouraged pt to abstain fully from etoh use given past hx and likelihood that he is alcohol dependent. SW stated that he would likely be in the hospital for some time and would have his withdrawal treated while he's here. SW encouraged pt to consider his options and that SW would be checking in from time to time to talk with pt further about his etoh use. SW will also attempt to speak with pt's family later this evening or tomorrow. Page SW if needed.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-21 00:00:00.000", "description": "Report", "row_id": 1395128, "text": "Nsg progress Note 10A-1500\n\nThis is a 63 year old male who presented to OSH on after falling into car door. +ETOH and + head lac. Head CT neg. Pt C/O left lower flank pain-abd CT demonstrated kidney fx and hematoma. Initial INR 6.3(on coumadin for DVT's). Reversed with FFP/vitamin K. Pt underwent angio. Found source of bleed and embolized. On pt was intubated for management of ? ETOH withdrawal.\n\nRemains intubated. Attempted to wean this AM and pt became tachypneic with tachycardia and increase BP. Resedated on proprofol with improved ABG and RR. Current settings CPAP 8PS/5Peep and 40% FIO2. See carevue flowsheet for ABG's. ? RML pneumonia on CXR.\nNSR to ST with no ectopy. BP improved after proprofol re-initiated.\nAdequate urine output. TF re-started at 65cc's an hour via NGT.\nTolerating well.\nSSRI per SS.\nReceiving clinda as ordered. Temp max 100.6 po.\nMouth ulcers remain. Acyclovir ointment as ordered.\nWife called and updated on POC.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-21 00:00:00.000", "description": "Report", "row_id": 1395129, "text": "SICU NPN\nROS:\nNeuro: Pt remains sedated on propofol with ativan Q4hrs and PRN; attempts made to wean propofol, however when light pt becomes tachypnic, tachycardic, hypertensive and drops his sats. PRN ativan given in addition to ATC dosing in attmepts to minimize propofol requirements. Pt able to MAE, follows commands, nodding head yes and no.\n\nResp: Pt remains intubated and ventilated. When lightened from sedation, pt becomes tachypnic and drops O2 sats. Pt also dropped Sats to 90% when turned onto R side. SICU HO notified, pt placed on back and suctioned in attempts to bring sats back up. Unable to maintain sats >91%, so PEEP, PS and FIO2 increased to maximize pt comfort and oxygenation. Currently pt is on 10PEEP/10PS and 50% FIO2. Will attempt to wean back to 5PEEP/8PS overnight if pt tolerates. Lungs very coarse, scattered wheezes at times, suctioned for thick, lt yellow sputum.\n\nCV: HR 90-100's, briefly down to 80's when resting. Pt tachycardic and hypertensive when awake. Pt continues on PO/NG lopressor with good effect. CVP 7-10 this PM. L rad A-line site sl pink, dressing changed this PM. RSC TLC site intact. Extremities warm, easily palpable DP/PTs. Pt shakes head no to any chest pain/discomfort.\n\nGI: Abd softly distended, hypoactive BS throughout. Pt continues on TF via NGT, position checked and tube retaped this PM. No BM this shift.\n\nGU/renal: Good u/o via foley catheter. Lytes stable.\n\nEndo: , pt required 3 U reg insulin coverage for 1800 FS.\n\nID: Low grade temps, max 100.9; plan to culture pt if he spikes overnight. ABX changed to oxacillin and clinda.\n\nSkin: Head lac healing, no drainage noted. R groin stick from angio with bandaid on, old drg on dressing, small ammt ecchymosis also present. Pt's lips with terrible scabbing/ulcerations. Cream applied as ordered. ETT Not rotated this shift due to large scabbed area in L corner of mouth. Back, buttocks intact.\n\nSocial: Pt's dtr phoned for update this PM, aware of increased vent support overnight, will phone in AM for update as well.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-22 00:00:00.000", "description": "Report", "row_id": 1395130, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support and required an increase to 50% FIO2, 10 cm PEEP and 10 cm PSV to accomodate a decreased SPO2. PSV was later able to be dropped back to 8 cm PSV. Awaiting abg results to make further changes.\n\nNo RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-22 00:00:00.000", "description": "Report", "row_id": 1395131, "text": "TSICU NPN 11p-7a\nS/O\n\n pt sedated on propofol 30mcgs/ w/ ativan 2mg q 4hrs. Pt opening eyes spontaneously, MAE's and nodding head appropriately to questions. Pt nodded yes when asked if he was having pain so medicated w/ 2mg morphine sulfate times one w/ good results. Not requiring any extra doses of PRN ativan this shift, does get tachypnic and increasingly tachycardic and HTN when light yet settling on own before additional ativan required.\n\nCV- hemodynamically stable over night , HR 70-80's when resting 80-100's when light, SBP around 120-140, Hct down slightly at 27.0 from 28.5. Extremities warm and dry w/ palpable pulses. Lytes wnl's.\n\n pt maintaining adequates sats overnight from 94-100%, tolerating activity well. Con't on 10 of PEEP, PSV decreased to 8 from 10 w/ TV's from 375-330's, and 50% fio2. Pt breath sounds clear to coarse in upper lobes, diminished at bases bilaterally, slightly bronchial at right base. Suctioned for thick white secretions. ABG pnd.\n\n pt on promote w/ fiber at 65cc's hr, abd soft slightly distended, bowel sounds present. No BM this shift.\n\n pt w/ 65-85cc prer hour u/o.\n\nID- t max 100.3 on clinda and oxacillin.WBC 7.4 this AM.\n\nSkin- intact except oral herpatic lesions and right groin ecchymosis w/ small skin tear at right groin.\n\nA/P- stable over night, no desaturation w/ increased PEEP and PS. MS improving slightly w/ gradually less sedation required. Con't vigirous pulm toilet as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-22 00:00:00.000", "description": "Report", "row_id": 1395132, "text": "Respiratory Care\nPt weaned on CPAP/PSV, ventlating well. Set for possible extubation tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-25 00:00:00.000", "description": "Report", "row_id": 1395140, "text": "TSICU Nursing Progress Note\nEvents - Pt called out to floor. Transfer orders written. Transfer note done.\n\nNeuro - Pt x3 today, conversing appropriately most of shift. Moves all extremities well, frustrated with weakness. Walked to chair with 2 assist.\n\nCV - SR to ST without ectopy. Trace edema. Strong peripheral pulses. BP well controlled with metoprolol. LMWH and pneumoboots for DVT prophylaxis.\n\nResp - Weaned to 4L NC. O2 sat >97%. Strong cough. Using IS independently pulling 1250 cc. Lungs diminished in bases.\n\nGI - NGT removed this AM. Patient taking regular diet. Soft brown stools x2 today.\n\nGU - Clear yellow urine in adequate amounts via foley.\n\n - Pt requiring minimal regular insulin per sliding scale.\n\nID - T Max 100.4. No cultures ordered.\n\nA - Improving mental status. Improving resp status. Febrile.\n\nP - Continue to monitor temp. Monitor resp status and encourage IS use. Ready for transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-24 00:00:00.000", "description": "Report", "row_id": 1395137, "text": "9pm-7am NPN\n pt alert confused to place and date at times. MAE. PERL. cont on CIWA. minimal score. Ativan given ATC 1.5mg iv. no tremors noted. c/o back pain pt repositioned through out night. pt weak and stiff. activity encouraged. attempted to get pt oob into chair. pt unable to sit on edge of bed.\n\nCV.- SR-ST. no ectopy. cvp 7-14. b/p elevated lopressor given. no PRN Hydralizine needed.\n\nResp.- extubated yesterday. lung sounds coarse and diminished. ABG this am 7.49/37/51 o2 increased to 4l nc and 35% face tent. pt restless in bed. o2 found off at times through out night. sat mid 90's. IS used, coughing and deep breathing. productive cough. lg amt thick tan sputum. ABG re-drawn 7.49/33/68. lasix 20mg ordered and given\n\nRenal- u/o good clear yellow/amber. lytes wnl. no repalcment needed this am. lasix given as stated. bun27/creat .9\n\nGI- abd lg firm. + frequent, incontinent BM. rectal bag in place. +bs. TF cont 65cc/hr. via NG.\n\nEndo- ins gtt 2cc/hr. BS wnl\n\nID- cont on oxicillin and clind WBC 9.1\n\nplan- cont to monitor hemodynamics. encourge cough and deep breathing monitor abg\n" }, { "category": "Nursing/other", "chartdate": "2181-02-24 00:00:00.000", "description": "Report", "row_id": 1395138, "text": "TSICU Nursing Progress Note\nNeuro - Pt alert, confused at times. Occ making appropriate conversation, makes innappropriate comments at others. Able to make needs known.\n\nCV - SR to ST without ectopy. Peripheral pulses palp. Pneumoboots for DVT prophylaxis.\n\nResp - continues with 4 l NC and 35% face tent with O2 sat > 95%. Using IS throughout day with volumes >1000cc. Expectorating moderate amounts thick tan secretions. Strong cough. Lungs CTA, diminished at bases.\n\nGI - Tolerating TF at 75 cc/hour. Taking clear liquids well. Medium soft brown stools x2. C-diff sent.\n\nGU - Adequate clear yellow urine via foley.\n\nEndo - Changed from insulin gtt to sliding scale.\n\nA - Resp status improving. Somewhat clearing sensorium.\n\nP - Continue IS, coughing. continue to reorient as needed. Continue to wean Ativan.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-25 00:00:00.000", "description": "Report", "row_id": 1395139, "text": "NPN 1900-0700\nNEURO: Pt A+Ox with brief periods of lucidity and ability to answer all orientation questions appropriately. Pt often restless and caught attempting to pull lines. CIWA <10 all noc. Ativan PO ATC resumes. Roxicet prn back/flank pain with effect.\n\nRESP: LS coarse and diminished at bases. NC weaned off and pt remains on 35% face tent. Sats 96-100% with tent, quickly decreases to 80s when O2 is pulled away from face. ABG with paO2 in 70s. Strong non productive cough.\n\nCV: HR 80s-100s SR/ST no ectopy noted. BP 120s/50s; SBP as high as 170s when agitated.\n\nHEME: Hct in 30s. Fondaparinux and pboots for DVT prophylaxis.\n\nGI: Abd semi firm and slightly distended. +Bowel sounds. TF cont at goal. Pt ordered for clear liquid diet; sips of water given and tolerated without difficulty. NGT remains for TF at this time. No stool this shift.\n\nGU: Adequate u/o via foley. Lytes WNL.\n\nID: Tmax 99.2, no abx at this time.\n\nENDO: FS covered per .\n\nSKIN: Back/buttocks grossly intact. Blisters to mouth cont.\n\nSOCIAL: No contacts from family this shift.\n\nASMT: Pt s/p blunt injury/ left renal fx complicated by alteration in oxygenation. Alteration in mental status.\n\nPLAN: Cont to monitor vs, neuro checks, CIWA scale and appropriate sedation as tolerated, pain mgmt, aggressive pulmonary hygiene, encourage mobility, ?start PO's today, ready for transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-22 00:00:00.000", "description": "Report", "row_id": 1395133, "text": "T/SICU RN Progress Note\nNeuro: Propofol off at 0830, tolerated it well. Remains on ativan 2mg ATC for ETOH withdrawal. Calm and appropriate, following commands.\n\nCV: HR 100's SR when resting. With activity and visitors HR 110-118. ABP systolic 140-160. CVP 6-10.\n\nResp: Remains intubated, multiple vent changes throughout day, see CareVue. Lungs coarse decreased suctioned for only scant amounts of thick white secretions. Sats 94-98%.\n\nGU/GI: Foley with clear yellow urine. Abd softly distended, given ducolax PR and magnesium citrate 3 solid BM over the afternoon. TF at goal promote with fiber at 65cc/hr.\n\nSkin/Mobility: Skin grossly intact, lips with black lesions, some bleeding from lesions. Scrotum still with edema.\n\nEndo: Started on insulin gtt at 2units/hr. Blood Glucose remains 80-120.\n\nID: Tmax 100.0 on oxacillin and clinda.\n\nSocial: Family in appropritate with questions/concerns. Updated on care.\n\nPlan: Cont to monitor, wean vent as tolerated, cont to montior and support.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-23 00:00:00.000", "description": "Report", "row_id": 1395134, "text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time, RSBI 68.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-23 00:00:00.000", "description": "Report", "row_id": 1395135, "text": "t-sicu nsg note:\nneuro-alert, fc, calm, one episode of agitation d/t back pain relieved w/ mso4 2mg iv. mae's.\n\nresp- very congested cough productive for thin white secretions, resolved following dose of iv lasix. remains on cpap ventillation w/ fio2 50% 5peep and 8ps. sao2 93-98%. rr20's-30's.coarse bs and diminished bibasilar.\n\ncvs- tm 100.8po, hr 80's sleeping, 104-115 awake w/ activity. sbp 114-160's depending on degree of resting state. k+ repleted.\n\ngi- tol tf/promote w/ fiber @ goal rate of 65cc/hr, very large soft brown stool.\n\ngu- gd diuresis following lasix ivp. cyu via foley\n\nskin- intact except for lip blisters. scrotal and perirectal edema.\n\nendo- bs maintained under 121 on insulin gtt 2u/hr.\n\na: stable noc, improved resp state following lasix ivp.\n\np: monitor cvs/nvs, monitor fluid and electrolyte levels closely, pulm hygiene, wean vent as tol. support pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-23 00:00:00.000", "description": "Report", "row_id": 1395136, "text": "T/SICU RN Progress Note\nEvents of day, extubated over a Cooks Catheter without incidence, placed on 70% face tent and 4lnc, Cooks catheter removed 2hrs later and FiO2 titrated down.\n\nNeuro: Alert and oriented pleasant. Remains on ativan ATC dose lowered from 2mg to 1.5mg No signs of ETOH withdrawal, pain. Sleeping on/off.\n\nCV: HR 80-90's SR with activity increased to 100's. No ectopy noted. ABP systolic 130-150.\n\nResp: Remains extubated on 35% Face Tent and 2ln/c. Lungs coarse able to expectorate thick secretions without difficulty.\n\nGU/GI: Foley with clear yellow urine. NPO, TF at goal 65cc/hr Promote with fiber. Large BM X2 rectal bag placed.\n\nSkin/Mobility: OOB to chair this am prior to extubation, tolerated well. Skin grossly intact, libs with black lesions.\n\nEndo: On Insulin gtt remains at 2u/hr\n\nSocial: Family in to visit updated and support given.\n\nPlan: Pulmonary hygeine, monitor for s/s ETOH withdrawal, increase mobilty.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-14 00:00:00.000", "description": "Report", "row_id": 1395098, "text": "t-sicu nsg note:\nneuro- sedated on propofol gtt, opens eyes to stimuli, tremors, attempts to pull ett, not fc. strong cough,perrla 3mm.\n\nresp- vented on ac 50% 600x13 5peep, sao2-94-97%, pao2 62, bs coarse in rul, diminished bibasilar.\n\ncvs- sbp 95-130, hr 90-110 sr, tm 99.9po, d5 1/2ns infusing via r fem trauma line @ 75cc/hr. strong pedal pulses, lytes repleted, cont to require prbc for slow falling hct.\n\ngi- soft distended abd, no flatus, hypoactive bs\n\ngu- 30-40cc cyu via foley,\n\nskin- lac above l eye sutured, bacitracin applied,\n\nendo- be elevated and rx w/ ss insulin\n\nA: worsening pulm\n\np: monitor cvs/nvs per routine, cont to sedate, maintain pulm hygiene, serial hcts as ordered, support family\n" }, { "category": "Nursing/other", "chartdate": "2181-02-14 00:00:00.000", "description": "Report", "row_id": 1395099, "text": "Respiratory Therapy\nPt remains orally intubated on full mechanical support. Attempted PSV wean this morning, but pt became very agitated/tachypneic requiring high levels of sedation, so was switched back to CMV where pt currently remains. PIP/Pplat = 25/20. BLBS slightly coarse, suctioned for small amounts of thick blood tinged/brown sputum. SpO2 remained 90s. Traveled to angio w/out incident. ABG WNL. See resp flowsheet for specific vent data/changes.\n\nPlan: maintain support, attempt PSV as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2181-02-14 00:00:00.000", "description": "Report", "row_id": 1395100, "text": "npn 0700-1900\nevent:transfered to angio for re-eval of renal artery and ivc filter placement at 1500.\n\nneuro:arouses to voice,follows commands,maes.perrl,opens eyes spont. denies pain but very agitated,attempting to sit up and reaching for ett.given 2mg ativan ivp q1-2hr w/ some effect.propofol titrated for sedation from 20-60mcg/kg/min w/ moderate effect but does not tolerate well hemodynamically.\n\ncv:labile bp,esp w/ sedation.sbp noted in 70s w/ sedation but otherwise 90-120s.given fb x 4,total of 2L.hr low 100s up to 130s w/ agitation.R sc cvl and L radial a-line placed.p iv d/c'd.R fem trauma line and R fem sheath intact.ivf restarted at 100ml/hr.metoprolol held for low bp.1 of 2 units prbc infusing prior to angio.neosynephrine gtt also started prior to angio r/t increased sedation.\n\nresp:ls coarse.changed vent settings from cmv to cpap.after change, became extremely agitated,hr 130s,rr 30-40s.sedated and returned to cmv w/ good results.improved oxygenation per abg at 1400.suctioned for thick yellow,blood-tinged sputum.copious amts of foul-smelling blood-tinged oral secretions.sao2 96-100% at all times(both vent settings).\n\ngi:firm distended abd.firmer on L side.hypo bs.ngt placed this am.large amt bilious drng.tf ordered but held for angio.\n\ngu:u/o low,2030ml/hr.decreased to <10ml/hr w/ hypotension.urine amber,clear.\n\nskin:head lac intact w/ sutures.applied erythromycin to L eye as ordered.\n\nendo:no coverage required per ss.\n\nid:tmax 101.7 orally.pan cx'd and given tylenol w/ effect.\n\nheme:hct 27->24 in 4hrs.receiving prbc as ordered.\n\nsocial:dtr and her mother visited this am and pm. stated will stay in hosp all day.waiting in angio waiting area. sw to contact.\n\nplan:currently awaiting completion of angiography and ivc filter placement.continue to monitor hemodynamics and maintain map>60(clarify w/ team).provide adequate sedation as tolerated and withdrawal prophylaxis.monitor hct q4hr.monitor u/o.support pt and family.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-15 00:00:00.000", "description": "Report", "row_id": 1395101, "text": "Resp care Note, Pt remains on current vent settings. Unable to tol RSBI this AM due to agitation.Temp 100.7. Suctioned for mod thick tan secretions.X-Ray shows lrg pleural effusions and consolidations. Gm pos cocci in bld.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-17 00:00:00.000", "description": "Report", "row_id": 1395111, "text": "RESP CARE: Pt remains intubated on vent per carevue. No changes this shift. Lungs coarse bilat/ little sputum with sxing. RSBI<100.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-17 00:00:00.000", "description": "Report", "row_id": 1395112, "text": "Patient remains on mechanical ventilation with good ABG. suctioned for minimal amount of secretion.ETOH withdral,responds to stimulation will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-17 00:00:00.000", "description": "Report", "row_id": 1395113, "text": "nursing prog. note\nneuro: pt remains sedated, lightened for neuro assessment. following commands, moving x4. nods and shakes head to ques. note tremors improved w/ sedation off, ativan dosing continues q2h. pt c/o abd pain when lightened, given mso4 prn with good effect.\n\nresp: cpap+ps mode continued, weaned peep 5, ps 10 this am, note pao2 81 after change. o2 sats stable, rr teens to 20s. this aft, pt appeared less sedated, rr rising to 30s without stim., repeat abg with pao2 70. peep increased to 10 d/t rising o2 demand, ps remains 10, fio2 40%. follow up abg this eve improved. sx for thick yellow secretions often, sm amts. ls clear to upper fields, dimin to bases bilat. cough and gag improved.\n\ncv: pt hypertensive with sedation off, lopressor changed to po this am, tol well for few hours, this aft/eve becoming increasingly hypertensive. hr nsr, no ectope, rate 80s-90s. cvp's . ppp bilat, feet warm. lopressor dosing increased. will monitor. edema improved with diuresis. lytes stable, repleted prn.\n\ngi: belly distended, slightly firm. bs present. tol tf at goal rate, residuals minimal. no flatus, no bm thus far.\n\ngu: foley patent sedimented amber/yellow urine. diuresed w/ lasix dosing today, fair effect noted. slowly moving toward goal -1L. bun/cre stable.\n\nendo: bg's stable, no coverage per riss.\n\nid: temp spike this afternoon, 102.3, pan cx obtained per orders. tylenol for comfort. wbc stable. vanco and levaquin dosing continue.\n\nskin: upper and lower lips with red blisters, initially with scant yellow exudate to areas. cleansed w/ saline, vaseline applied after ett rotated and retaped. lac sutured to left eyebrow, no new drainage. ecchymosis/edema to scrotal area remains, edema improved.\n\nsocial: daughter in to visit today, very supportive. updates provided, all ques answered.\n\na/p: 63 yo s/p fall, sustained stable renal lac, developing +etoh withdrawl, found to have bilat pleural effusions, atelectasis. remains intubated, sedated, recently w/ increasing o2 demand. continue aggressive pulm toilet, chest pt, pain management, manage dtz sx w/ ativan, propofol. follow abg's, hct, pending cx.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-18 00:00:00.000", "description": "Report", "row_id": 1395114, "text": "nsg note:\n neuro: pt sedated on propofol. given ativan and ms q2hrs. when lightened from propofol, pt oens eyes, looks at speaker and nods head yes and no. but not moving extremities in short time pt left off sedation. pt gets tachypenic off prop but not tremulous.\n\ncv stable, but blood pressure dropped to 90's sys with 37.5 of lopressor am dose was dropped to 25mgs. hr 70's to low 100's sinus no ectopy. cvp 11 to 18.\n\nurine output good given 20 mgs lasix at 1am when urine out put slowed. from earlier diuresis, pt neg 700+ ccs for last 24 hrs.\n\ntemp max 101.2 this am 100.3. remains on levoflox and vancomycin.\n\ntol tube feeds at goal no stools abd softly distended active bowel sounds. given reg insulin per sliding scale.\n\nrt groin angio site clean and dry pulses present in foot, but rt foot cool from ankle down. lt foot warm. with good pulses.\n\nlips swollen with blister or vesicle formation with yellow exudate. kept moist with vasoline. lt eye brow lac cleaned with ns and bacitracin applied. appears healed with black crusty scar.\n\non vent pressure support mode resp rate teens. adequate abg. sats > 96% on 40% fio2. suctioned for sm amts very thick yellow sputum.\n\na stable night\n\np evaluate lips on am sicu rounds ? herpes. continue to support on vent monitor vs and iand o's\n" }, { "category": "Nursing/other", "chartdate": "2181-02-13 00:00:00.000", "description": "Report", "row_id": 1395095, "text": "nursing progress note\nneuro: pt alert, oriented x3, moving x4, although unable to move right leg d/t sheath and trauma catheter in place. pt becoming increasingly agitated, pulling at o2, attempting to move right leg, tremors worsening as day progressed. (pt w/ 40 yr hx etoh abuse). per ciwa scale, pt receiving ativan prn hourly later in afternoon. pain effectively tx w/ prn dilaudid.\n\nresp: o2 sats stable with face tent o2 intact, sats drop with nc o2. ls clear bilat, diminished to right side. cxr obtained this am. encouraging IS usage, pt needs prompting to remember. rr stable.\n\ncv: remains tachycardic, lopressor dose increased with some short acting effect. mivf infusing 125cc/h, no edema. bp stable when comfortable, hypertensive with agitation/pain. ppp bilat, right groin angio site benign, sheath remains intact, transduced. trauma catheter remains intact as well to right groin, patent. transfused 1u prbc this am, repeat hct 29, stable. given 1L LR bolus this pm for persistent tachycardia, will monitor.\n\ngi: belly firm distended, bs hypoactive x4. denies n/v. no flatus. remains npo. pain to left flank/radiating to lower back persists, relieved w/ dilaudid.\n\ngu: foley patent for clear yellow urine, 30-50cc/h on average.\n\nendo: bg's stable, covered per riss as needed.\n\nskin: sutured lac to left eyebrow w/ dried blood, bacitracin applied.\n\nsocial: daughter and ex wife in to visit this am, per family pt has hx 40+ years of daily etoh intake. family concerned, supportive. all updates provided.\n\na/p: pt s/p fall, left kidney fx w/ retroperitoneal bleeding. hct stable at this time, pt remains npo, worsening etoh withdrawl sx as day progressed, managed w/ ativan dosing prn. plan to continue serial hcts, monitor abd. exam, monitor as per ciwa scale, medicate as required.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-13 00:00:00.000", "description": "Report", "row_id": 1395096, "text": "nursing progress note addendum\npt with worsening sx of etoh withdrawl, becoming increasingly agitated, diaphoretic, thrashing in bed, attempting to get oob. pt became confused, slurring of speech, etc. Dr. aware, in to see pt, ativan dosing increased to manage agitation. tremors worsening, little effect noted from ativan, additional doses ordered, see . pt remained very tachycardic to 160s, bp as high as 200 systolic during dtz. additional LR bolus given to tx tachycardia with no response, some effect noted from standing dose of lopressor, lasting only few minutes. finger pleth unreliable d/t severe tremors, o2 sats not properly, abg sent with pao2 result of 45. decision made to intubate patient by Dr. , anesthesia, respiratory personnel paged. pt intubated after several unsuccessful attempts, adequately ventilated in between attempts. at present ac mode vent, 100%, 700x14, peep 5. currently sedated, calm w/ propofol infusion, pt vss, see flowsheet for specifics. pt's daughter and pt's ex wife in to visit pt during dtz episode as well as after intubation. all updates provided, support offered to family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-16 00:00:00.000", "description": "Report", "row_id": 1395109, "text": "nursing prog note\nneuro: pt remains lightly sedated, lightened for neuro assessment. follows commands, opens eyes spont, moving x 4. note tremors to hands evident when sedation off, ativan dosing increased d/t continued etoh withdrawl sx. localizes pain to abdomen, prn mso4 effective.\n\nresp: cpap+ps cont, 40%, peep weaned to 8, abg's stable. ps remains 15. ls clear to upper right lobe only, dimin to all other fields. chest PT performed with turning/reposit. o2 sats stable. rr 8-20, regular. sx often for thick yellow secretions, little effect noted from chest PT.\n\ncv: bps stable today, hypotensive at times with meds, cvp 10-14. edema to extrem. evident, lasix dosing this pm. ivf kvo'd. ppp bilat. lytes stable. lopressor held x2 today d/t hypotension.\n\ngi: belly distended although firmness improved. bs hypoactive. tf tol well at goal rate. no bm, no flatus.\n\ngu: foley patent for sedimented yellow urine, qs. note lasix dosing this evening for negative fluid goal.\n\nid: tmax 100.9, tylenol given for comfort. continues w/ vanco, levaquin dosing. vanco trough sent this pm.\n\nendo: bg's stable, no coverage needed per riss.\n\nskin: no new issues. abrasion to left eyebrow healing.\n\nsocial: daughter and ex wife in to visit, very supportive, updates provided, all ques. answered.\n\na/p: pt s/p fall, sustaining renal fx with retroperitoneal hematoma. hct stable, pt developing etoh withdrawl 48h post admission. intubated d/t resp distress after being medicated for dtz. subsequently found to have bilat pleural effusions w/ atelectasis. currently sedated, tol psv well, ativan dosing atc for dtz sx. plan for continued peep weaning, aggressive pulm toilet, chest PT. follow cx, hct. full icu monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-20 00:00:00.000", "description": "Report", "row_id": 1395123, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg result were consistent with a combined alkalemia with good oxygenation on the current settings.\n\nRSBI = 214.9 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-17 00:00:00.000", "description": "Report", "row_id": 1395110, "text": "TSICU NPN 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Remains sedated on Propofol @ 30mcg/kg/, opens eyes to voice, following commands, MAE, nodding head to communicate. Tremors noted when sedation turned off. Ativan 3mg Q2/hr continues for ETOH withdrawl. Pt localizes to abd when asked if pain present, PRN morphine given.\n\nCV: SR 70-80's with rare ectopy. SBP 90-140's. Lopressor Q4/hr -held X 1 for SBP in 90's. LE edema present, yet improving. Scrotum remains very edematous and ecchymotic.\n\nRESP: Intubated on CPAP+PS PEEP 8, PS 15, 40% FIO2. SATS 96-100%, LS: clear, diminished at bases. Suctioned for scant amts of thick yellow sputum. CPT continued.\n\nHEME: HCT stable at 28. Pneumoboots intact.\n\nID: TMAX 100.9, Tylenol given. Vanco and Levaquin for abx coverage.\n\nENDO: BS covered per RISS.\n\nGI: ABD firm, distended. TF at goal of 65cc/hr (Promote with fiber). Minimal residuals. Hypoactive BS. Protonix for GI propholaxis.\n\nGU: Foley draining clear yellow urine. Recieved 20mg lasix at beginning of shift with good effect. Lytes WNL.\n\nSKIN: Head lac above left eye OTA, intact. Right angio site with small amt of ecchymosis. Backside intact.\n\nSOCIAL: No contact from family overnoc.\n\nPLAN: Continue with pulm toliet, wean PEEP, monitor DT's.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-16 00:00:00.000", "description": "Report", "row_id": 1395106, "text": "TSICU NPN 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Sedated on Propofol @ 30mcg/kg/. Awakes to voice, opening eyes and following commands. Moves all four extremities. Ativan Q 2hr continues for ETOH withdrawl. PRN morphine given for pain.\n\nCV: SR 70-80's with no ectopy noted. SBP 90-120's. Lopressor 5mg Q4/hr -- held X 1 overnoc for SBP in 90's. CVP 15-20. Right subclavian TLC. Left radial arterial line. Positive pedal pulses.\n\nRESP: Intubated on CAP+PS 10 PEEP, 15 PS, 40% FIO2. No respiratory distress noted, SATS 97-100%, ABG's stable. Suctioned for small amts of thick tan sputum. CPT continues. LS: clear, diminished at bases.\n\nHEME: HCT stable at 28. Pneumoboots intact. IVC filter placed .\n\nID: TMAX 100.6. Sputum cx sent-- pending. IV vanco and levaquin for abx coverage.\n\nENDO: BS covered per RISS -- no coverage needed this shift.\n\nGI: Abd firm, distended. Positive BS. TF (promote with fiber) at goal of 65cc/hr. Residuals minimal. Protonix for GI propholaxis.\n\nGU: Foley draining clear yellow urine. Recieved lasix 20mg X 2, with good effect. Magnesium repleted.\n\nSKIN: Head lac with sutures intact, OTA. Erythromycin to left eye as ordered. Scrotum very edematous and ecchymotic -- MD aware. Right femoral angio site with small amt of ecchymotic area - DSD intact, no drainage. Backside intact.\n\nPLAN: Continue to wean from vent as tolerated, pulm toliet, monitor DT's, continue with family support.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-16 00:00:00.000", "description": "Report", "row_id": 1395107, "text": "RESP CARE: pt remains intubated/on vent per carevue. PEEP decreased to 10 at 0530. Pts lungs coarse bilat. Sxd small amt green plugs. Heated circuit placed on vent to facilitate secretion mobilization. Will cont. to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-16 00:00:00.000", "description": "Report", "row_id": 1395108, "text": "\nPT MAINTAINED ON PSV VENTILATION AT 40%. VITALS STABLE WITH GOOD SATS. SX FOR MOD AMTS. LAST ABG SHOWED NORMAL GAS EXCHANGE WITH ACCEPTABLE OXYGENATION WITH THE REDUCTION IN PEEP. PT WAS ALLOWED TO WAKE UP A BIT TODAY BUT RESUMED WITH THE TOTAL BODY TREMORS. SX FOR SM AMTS. FAMILY VISITING FROM . PLAN IS TO CONT ON PSV VENTILATION WITH PEEP REDUCTIONS AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-19 00:00:00.000", "description": "Report", "row_id": 1395121, "text": "TSICU NPN\nO:\nNEURO: PT AWAKE AND RESTLESS, MAE AND FOLLOWING COMMANDS. DENIES PAIN BUT NODDING YES TO ANXIETY. INCREASINGLY AGITATED, SWEATING, TACHY, HTN AND TACHYPNEIC DESPITE INCREASED ATIVAN. RESTARTED PROPOFOL GTT AND FREQUENCY OF ATIVAN INCREASED W/ GD EFFECT. PT STILL , AND INCONSISTENTLY FOLLOWS COMMANDS.\n\nCV: HTN AND TACHY AS ABOVE W/ INCREASED AGITATION. IMPROVED W/ ATIVAN. HR 90'S NSR AND BP 130'S-140'S/60. CVP 6-12.\n\nRESP: TACHYPNEIC W/ AGITATION. RR 28-32 W/ STV 500'S ON PSV 10 AND 8PEEP. STABLE ABGS ON PRESENT SETTINGS. SXNED FOR SCANT AMT THICK WHITE SECRETIONS. MOD AMT ORAL SECRETIONS.\n\nRENAL: ADEQUATE U/O, AMBER COLORED URINE. 20 LASIX IVP AND GOAL OF 1 LITER NEGATIVE ACHIEVED. K REPLETED. LYTES WNL.\n\nGI: CONT ON PROMOTE W/ FIBER AT GOAL OF 65CC/HR. ABD DISTENDED W/ HYPOACTIVE BS. NO STOOL.\n\nENDO: BS PERSISTENTLY ELEVATED. INSULIN GTT STARTED AND NOW AT 6U/HR W/ BS 112.\n\nHEME: STABLE\n\nID: ABX NOW ARE CLINDA AND LEVOFLOX. VANCO D/CED. REMAINS FEBRILE AT 100.9.\n\nSKIN: LIPS W/ BLACK SCABBED WOUND MAINLY ON R SIDE OF MOUTH. SM AMT BLEEDING, PAINFUL TO THE TOUCH. ACYCLOVAIR APPLIED. BACKSIDE INTACT.\nR GROIN ECHYMOSIS UNCHANGED. SM FLUID FILLED BLISTER NOTED IN R GROIN AREA.\n\nA: AGITATION, ?ETOH WITHDRAWAL, IMPROVED W/ ATIVAN.\n\nP: CONT TO MONITOR NVS AND HEMODYNAMICS. ATIVAN ATC AND PRN. LOW DOSE PROPOFOL OVERNOC AND WEAN ONCE ADEQUATELY CONTROLLED ON ATIVAN. CONT PULM TOILET. REASSESS ABILITY TO WEAN PSV IN AM. DIURESE AS TOLERATED AND REPLETE LYTES. SKIN CARE. FAMILY AND PT SUPPORT. WILL BE IN TOMORROW.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-20 00:00:00.000", "description": "Report", "row_id": 1395122, "text": "ROS:\n\nNeuro: On propofol at 30 mcg/kg/. Arouses slightly and attempts to open eyes. Did not lighten for neuro assement this 8 hr shift. PEARRLA.\n\nCV: RSR w/o ectopy. VSS. Peripheral pulses palpable w/ease. Has left radial abp line. Has right subclavian MML w/prox port transduced for cvp = 7->11. Generalized edema. Right groin echhymotic and soft, puncture site clean dry and intact. Fondaparinux Na and P boots on for DVT prophylaxis. On metoprolol .\n\nResp: Remains orally intubated and on vent, CPAP + PS , 40%. Resp rate 20's. When turned onto right side becomes tachypnec and over a period of ~45 desated to 90% then rapidly desated to 74%. Turned to back sats immediately return to baseline and resp rate slows to baseline as well. Right lung sounds bronchovesicular like. RSBI completed this AM by RT, immediately becomes tachypenic w/rate in 50's.\n\nGI: Abd distended, round, soft w/hypoactive bowelsounds. sump via left nare w/impact w/fiber infusing at goal (65cc/hr) w/minimal residuals. Goal of 75cc/hr when of propofol. No stools or flatus noted this shift. On protonix prophylacticly.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nID: Tmax 101.0 po. On clindamycin and levofloxacin\n\nEndo: FSG covered w/Regular insulin gtt.\n\nLabs: Stable. No lyte repletion necessary this AM.\n\nSoc: No contact w/family this shift.\n\nPlan: Wean propofol this AM to off if managed by ativan. Pulmonary toileting. Monitor for CXR results this AM.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-15 00:00:00.000", "description": "Report", "row_id": 1395103, "text": "NPN 0700-1900\nNEURO: Pt sedated on propofol. When lightened, follows commands and MAE. Nods yes to pain; mso4 ordered prn. ?Effect, as pt nods yes to pain each time he is awakened. Ativan 2mg q2hrs cont for ETOH withdrawal.\n\nRESP: Changed to CPAP+PS 12PEEP 10PS, 60%FiO2. this AM. Pt tolerating well. Initial ABG with marginal oxygenation. PM PaO2 improved; 132. Plan is to decrease FiO2 as tolerated. LS coarse. Per TSICU team CXR today is slightly improved from previous. Pt still has lower lobe consolidations and bilat pleural effusions. CPT done throughout shift; lungs more clear after CPT. Suctioned for thick yellow secretions.\n\nCV: HR 80s-90s NSR with rare PVC's. BP 120s-130s/70s. Lopressor decreased to 5mg IV q4hrs. Surface ECHO done today, results pending.\n\nHEME: AM Hct 29, PM Hct pending. No blood products received today. Pboots for DVT prophylaxis.\n\nGI: Abd semi firm and distended. Colace started today. TF advanced throughout shift and tolerated well with minimal residuals. Bowel sounds hypo. No BM this shift.\n\nGU: U/O amber with sediment. Adequate amt. IVF dc'd. 20mg lasix given in PM. Lytes repleted.\n\nID: Tmax 102.1. Peripheral blood cx's drawn x2 (to r/o line contamination from previous blood cx's). Urine cx sent. Awaiting adequate amt of sputum for sputum cx. 650mg tylenol given and ice packs applied. Pt started on levaquin today. Vanco cont.\n\nENDO: FS WNL, no coverage needed per RISS.\n\nSKIN: Back/buttocks grossly intact; no breakdown noted.\n\nSOCIAL: Family at bedside today. Spoke with Dr. and SW. Updated on pt's condition and prognosis.\n\nASMT: Pt s/p blunt trauma resulting in left kidney fracture. Complicated by alteration in respiratory status. Alteration in body temperature.\n\nPLAN: Cont to monitor VS, monitor respiratory status and wean from vent as tolerated, CPT and aggressive pulmonary hygiene, monitor fever curve, f/u with culture results, CIWA scale, sedation, pain mgmt.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-15 00:00:00.000", "description": "Report", "row_id": 1395104, "text": "Respiratory Therapy\nPt remains orally intubated on PSV. See resp flowsheet for specific vent data/changes. BLBS coarse, suctioned for small amounts of thick light yellow sputum. SpO2 remained 90s. Vt ~500, RR ~20.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2181-02-15 00:00:00.000", "description": "Report", "row_id": 1395105, "text": "Social Work\nSW met with pt's family, sister , brother , and his ex-wife in the family waiting room. Discussed pt's condition as well as his etoh abuse issues. Family are unanimous that pt is in need of etoh tx once he's better, but are understandably cautious about how motivated he'll be to get sober. SW assured them that we would continue to follow-up with pt around this issue. SW provided them with SW's contact info and encouraged them to call with any concerns. SW is availabe for page if needed.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-15 00:00:00.000", "description": "Report", "row_id": 1395102, "text": "TSICU NPN 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: Propofol @30-40mcg/kg/min to maintain adequate sedation. Pt arousable to voice, following commands, opening eyes, moving all four extremities. Pupils 3mm, reactive to light. Agitation continues when sedation lightened. Minimal tremors noted at times. Ativan 2mg Q 2hr continues with moderate effect.\n\nCV: HR NSR 80's with no ectopy noted. SBP 110-140's. Lopressor held throughout shift. CVP 14-21. Right subclavian TLC. Left arterial line. Right groin angio site with DSD - sm amt of old bloody drainage, no hematoma. Positive pedal pulses.\n\nRESP: Remains intubated on CMV 600X12, 8 PEEP, 60% FIO2. SATS 99-100%. LS: course, diminished at bases. ABG's stable. Suctioned for thick tan sputum.\n\nHEME: Serial HCT's continue - stable overnight ranging 30.6--> 29.7. (after completion of 2 units PRBC's from previous shift). IVC filter placed yesterday.\n\nID: TMAX 100.7. WBC 7.6. IV vanco started for gram positive cocci in blood from .\n\nENDO: BS covered per RISS.\n\nGI: Abd firm, distended. Hypoactive BS. TF started (Promote with fiber) with goal of 60cc/hr. Protonix for GI propholaxis.\n\nGU: Foley draining clear yellow urine. UO ranging 15-70cc/hr. Potassium repleted.\n\nSKIN: Head lac with sutures intact, OTA. Erythromycin to left eye as ordered.\n\nSOCIAL: Daughter into visit last evening, update given. requesting to speak with physican - Dr. informed and spoke with daughter over phone.\n\nPLAN: Continue with serial HCT's\n Monitor withdrawl, respiratory status\n Continue with family support\n" }, { "category": "Nursing/other", "chartdate": "2181-02-18 00:00:00.000", "description": "Report", "row_id": 1395115, "text": "nursing prog note\nneuro: pt remains sedated, lightened for exams. moving x4, follows commands. nods and shakes head to ques. pain to abd relieved w/ prn mso4. q2h dosing ativan continues. with sedation off, pt with no evident tremors. clonidine patch started today in attempt to wean ativan. no further s/s etoh withdrawl other than hyperdynamics w/ sedation off.\n\nresp: cpap+ps mode, 40%, 10peep, 10ps. abgs good, rr teens to 20s at rest. becomes tachypneic w/ stimulation, when lightened. sx for scant thick white secretions. o2 sats stable. ls clear, dimin to bases bilat.\n\ncv: hypotensive w/ lopressor dosing, hypertensive w/ stimulation. hr nsr, no ectope, rate 80s. initially right foot cool to touch, after repositioning, foot warm, ppp strong bilat. groin angio site w/ bruising, no hematoma, dsd intact. hct stable, lytes repleted prn.\n\ngi: belly firm, distended, improved from prev. days. bs present, tol tf well at goal. residuals minimal. no bm, no flatus.\n\ngu: diuresed w/ lasix dosing, clear yellow to amber urine draining. bun/cre stable. moving toward goal -1L for day.\n\nid: tmax 101.3, improving w/ no intervention. vanco, levaquin dosing continue. recent vanco trough therapeutic.\n\nendo: bg's slightly elevated, sliding scale increased for coverage.\n\nskin: ulcers to lips tx w/ acyclovir ointment q4h, areas red, oozing scant bloody to yellow exudate. cx obtained to vesicle to right cheek.\n\nsocial: many family in to visit, all very supportive, updates provided as needed.\n\na/p: s/p fall, sustaining renal lac, +etoh withdrawl sx. remains sedated, ativan for dtz, o2 requirements remain an issue. plan for continued aggressive pulm toilet, empiric abx coverage for +blood cx, sputum cx. wean psv as tol, wean ativan, propofol as clonidine becomes effective.\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-18 00:00:00.000", "description": "Report", "row_id": 1395116, "text": "Patient remains on mechanical ventilation,more responsive to commands.Suctioned for minimal amount of secretion. Has herpes @ lips,ETOH withdrawl weaning on PSV will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-19 00:00:00.000", "description": "Report", "row_id": 1395117, "text": "RESP CARe: Pt remains intubated/on vent per carevue. ABGs consistent with comp. met. alkalosis. Lungs coarse bilat. Sxd mod amts frothy white, thick tan sputum.Pt tachypneic on PS-10 Vts 300s. Awaiting plan from team re weaning\n" }, { "category": "Nursing/other", "chartdate": "2181-02-19 00:00:00.000", "description": "Report", "row_id": 1395118, "text": "nsg note:\nneuro: on prop gtt and ativan q 2 hrs. pt not tremoring when lightened. becomes alert, obeys commands.\ncv stable\ntemp max 101.7 pan cultured\nuo brisk lasix given at 2am k and mag repleted\ntol tube feeds dulc supp given at 8pm with no responce pt has not stooled. abd softly distended.\nlips very edematous with crusts forming over vesicles acyclovaire applied.\nstable on vent sats >96 on 40% fio2. sctioned for scant slightly tan sputum/\na styable\np start to wean ativan today.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-19 00:00:00.000", "description": "Report", "row_id": 1395119, "text": "days\nn: pt weaned off of propofol and ativan doses changed to q6 instead of q2. Witihin an hour of weaning, pt became more active in bed, left strengths >right. mae slightly, pt in to see pt. pt had intermittent agitation, but easily reorients and calms. no c/o pain. tmax 100.6, no tylenol given as to not mask infection affect on temp? pt more awake in afternoon and turned q-12 with cpt with 2 assist.\n\ncv: pt nsr with st and htn noted with turns, care. systolic bp 190s and hr 120s max. lopressor given as ordered. pt resolves with time and rest. + edema in all four extremities. pt warm and febrile, no sweating noted. +pp. pneumo boots on and sq anticoagulant given, not heparin due to thrombocytopenia after heparin dosing in the past.\n\nr: pt tachypnic with movement, wakefulness, difficult to wean. abg wnl, requiring much more suctioning while awake- q30 mins large amt thick tan secretions. pt covered with abx for pneumonia,cxr shows new changes in right lower lobe, pan cultured today.sats 94-96% generally with scattered rhonchi and very dim sounds in bases, right worse than left. cpt done frequently and vigorously as pt tolerates. rn ambued pt intermittently with no obvious obstruction to airway clearance.\n\ngi/gu: pt tolerating tube feeds at goal. irss to be changed today with pt recieveing insulin q6. lfts to be followed for alcoholism, no dt's noted today. k repleted as ordered. large soft clear, gelatinous stool guiac neg today. rectal and nasal swab sent for mrsa. abx to be changed today to best cover possbile and known infections. foley with clear amber ruine, amts adequate on lasix. abdomen soft and disteded with hypoactive bs.\n\ns: lips pruple and black scarring noted, treated with acyclovir ointment prn, eye gtts given as ordered and mouth care done q30mis. scattered areas of eccymosis noted on trunk and back, multiple blisters noted with some open and yellow exudate noted. bacitracin to forehead , site of old laceration which is healing.\n\nlines intact, rn to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-19 00:00:00.000", "description": "Report", "row_id": 1395120, "text": "Resp care\nPt remains on vent and stable. Pt was removed from sedation and planned to wean; weaned down on peep based ob blood gases. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-20 00:00:00.000", "description": "Report", "row_id": 1395124, "text": "TISU NPN 0700-1900\nREVIEW OF SYSTEMS:\n\nNEURO: Attempted to wean Propofol off this am, pt became tachypenic and gaging on ET tube. Propofol restarted at decreased rate of 20mcg/kg/ to maintain light sedation and comfort. Pupils 3mm, reactive to light.Follows commonds - wiggles toes, lightly squeezes hand. Extremities remain weak. Ativan 2mg Q4/hr. Pt shakes head no when asked if pain present. PRN morphine for pain if needed.\n\nCV: SR 90's with no ectopy noted. SBP 120-130's. CVP 10-15. Lopressor . Left arterial radial line. Right subclavian TLC. Generalized edema. Right groin site CDI with ecchymotic area.\n\nRESP: Remains intubated on CPAP+PS 8 PEEP, 15 PS, 40% FIO2. Pt tachypenic in the 40's at start of shift, PS was increased to 15. Rate then decreased and maintained at 12-17. SATS 96-100%, ABG's stable. RR 12-17 LS: clear, diminished at bases.\n\nID: TMAX 101.6, tylenol given. Clindamycin and levaquin for abx coverage.\n\nENDO: Insulin gtt discontinued. BS covered per RISS.\n\nGI: Abd soft, slightly distended. Hypoactive BS. TF @ goal of 65cc/hr (promote with fiber). Residuals minimal. No stool. Protonix for GI prophylaxis.\n\nGU: Foley drianing clear yellow urine. Lasix 20mg X 1 given with good effect. Goal= negative 1 liter for today.\n\nSKIN: Head lac OTA, healing well. Lips with cold sores - acyclovair applied. Backside intact.\n\nSOCIAL: Daughter and son into visit - update given.\n\nPLAN: Wean propofol when tolerated, Pulm toliet, ? trach in future\n\n" }, { "category": "Nursing/other", "chartdate": "2181-02-20 00:00:00.000", "description": "Report", "row_id": 1395125, "text": "Pt remains on current vent settings, see carevue for details. No vent changes made this shift.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-21 00:00:00.000", "description": "Report", "row_id": 1395126, "text": "Respiratory Care:\nPatient remains on ventilatory support (CPAP/PSV) with no parameter changes throughout the night. Morning abg results are consistent with a partially compensated metabolic alkalemia with good oxygenation on the current settings.\n\nRSBI = 117 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2181-02-21 00:00:00.000", "description": "Report", "row_id": 1395127, "text": "assessment as noted\n\nres: remains on cpap 5 x 15, in metabolic alkalosis, po2 and so2 dips when aggitated. thick yelow secretions in ett, +cough, ls cear\n\ncv:stable no ectopy. r groin angio site intact with small echymosis\n\nneuro: alert when off sedation, mae, +follows\n\ngi: tolerates t.feeding well @65/h, no residuals, abd soft, tender a bit\n\n\ngu: got 20 lasix last night with good diuresis(see care vue), brisk u/o\n\nskin: both lips are with sores(acyclovir oint. applied) and bleeding time to time(especially when orallly suctioned)\n\nplan: try to wean off vent\n let md know to call family after am rounds(h/o aware)\n" }, { "category": "Nursing/other", "chartdate": "2181-02-14 00:00:00.000", "description": "Report", "row_id": 1395097, "text": "Resp Care Note, Pt weaned down FIO2 and VT . ABG'S show resp alkalosis. Suctioned sml amts thick bld tinged secretions.Sedated with propofol no spont resp @ this time.Will cont to monitor resp status.\n" } ]

[ { "category": "Echo", "chartdate": "2205-10-14 00:00:00.000", "description": "Report", "row_id": 78157, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease. Hypotension.\nHeight: (in) 61\nWeight (lb): 110\nBSA (m2): 1.47 m2\nBP (mm Hg): 110/65\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 12:46\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: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<=2.1cm) with >50%\ndecrease with sniff (estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural\neffusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The estimated\nright atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is an anterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function. Mild mitral regurgitation.\nPulmonary artery hypertension.\nCompared with the prior study (images reviewed) of , aortic\nregurgitation is not seen on the current study (may be due to technical\nissues) and PA systolic hypertension is now identified. The remaining findings\nare similar.\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": "2205-10-13 00:00:00.000", "description": "Report", "row_id": 192756, "text": "Sinus tachycardia, rate 111. Tendency toward low voltage in the limb leads.\nOtherwise, within normal limits. Compared to the previous tracing of \nno diagnostic interval change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2147-04-13 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 822175, "text": " 1:12 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 37 weeks, respiratory distress, on NC\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant born at 37 weeks with respiratory distress on nasal canula.\n\n CHEST: A single frontal radiograph demonstrates very fine diffuse ground-\n glass opacities bilaterally. Lung volumes are normal. Findings likely\n represent mild retained fluid.\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-18 00:00:00.000", "description": "Report", "row_id": 2036794, "text": "Neonatology Attending\nDOL 6 / CGA 37-5/7\n\n has remained in room air for 46 hours. No distress and no cardiorespiratory events.\n\nNo murmur. BP 84/59 (47). Well-perfused.\n\nBilirubin 10.8/0.2 ( from 13.0 the day prior).\n\nWt 2735 (-55) on ad lib demand BM20, with intake 92 cc/kg/day in addition to breastfeeds. Voiding and stooling.\n\nTemperature stable in open crib. Car seat test passed. Hepatitis B immunization given. Hearing screen passed.\n\nA&P\n36-6/7 week GA infant with resolved retained fetal lung fluid\n-For discharge home today with PMD follow-up this week (Dr. \n-Weight loss is acceptable given good breastfeeding and absence of jaundice\n-Discharge planning completed as above\n\nDischarge time > 30 minutes\n" }, { "category": "Nursing/other", "chartdate": "2147-04-18 00:00:00.000", "description": "Report", "row_id": 2036795, "text": "Discharge note\n\n1 Term Respiratory Distress\n2 FEN\n3 G/D\n4 PARENTS\n\n1. 36 week infant admitted to NICU with diagnosis of\nTTN. Infant has been in RA for over 48 hours, no spells, no\ndesats. LSC and equal, no retractions. RR 40-60's.\n\n2. Discharge weight- 2735gms. Infant\nbreastfeeding/bottling ad lib, approx every 3-4 hours. Mom\nsaw lactation consultant while in house, has phone number to\nfollow up if needed. Infant with strong, eager suck reflex,\ngood latch. Belly soft, +BS, no loops. Infant voiding and\nstooling.\n\n3. Temp stable, swaddled in crib. Infant alert and awake.\nPassed hearing screen, passed car seat test. Mom aware she\nneeds to call to reschedule MD appointment for this week-\n(currently has appointment for Tuesday).\n\n4. Discharge teaching reinforced (see D/C instruction\nsheet). Questions/concerns addressed. Parents loving and\nattentive. Infant discharged to home in infant car seat\nwith mom and dad at 11:30AM, bracelets checked.\n\nREVISIONS TO PATHWAY:\n\n 1 Term Respiratory Distress; resolved\n 2 FEN; resolved\n 3 G/D; resolved\n 4 PARENTS; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-17 00:00:00.000", "description": "Report", "row_id": 2036792, "text": "NPN 7a-7p\n\n\n#1: remains in RA, breathing comfortably with no\nretractions. Sats >/=96%. No drifts or desats noted. No\napnea/brady spells noted. RR stable. BBS cl/=. A: stable\nfor over 24hrs in RA P:Cont to monitor and provide support\nas needed.\n\n#2: conts on her ad lib demand feeding schedule,\nwaking ~q3-5hrs for feeds. Breastfed very well today,\n~15-20mins of eager strong feeding. Consistent latch and\neager suck. Also bottles well- good coordination. Taking\n60cc BM20/E20. No spits noted. Abd soft, +, no loops.\nVoiding qs. Stooled x2. A: tol'ing feeds, no desats with\nfeeds P:Cont to follow wt and exam. Monitor tol to feeds.\n\n#3: Temps stable while swaddled in an open crib. Infant is\nwaking on own for feeds. Alert/active with cares. MAE. Fonts\nsoft/flat. Brings hands to face. Mild bruising noted over\nforehead. A: AGA P:Cont to support dev needs. Repeat\ncarseat test overnight.\n\n#4: Parents in for visit, update given. Mom in throughout\nthe day to breastfeed infant. Will be staying at hotel\nagain tonight. Mom very with care and feeding. Did\nspeak with at bedside and agreeable to plan for\ntenative d/c home tomorrow. Teary this am, but understands\nrationale. Aware that bili level will be checked in am and\ncarseat test will be repeated. A: Involved family P:Cont\nto support and educate. Prepare for d/c.\n\n#5: Temps stable. Infant with appropriate behaviors. Not\non antbx. Blood work stable. A: stable. P:Cont to monitor\nfor s&s of infection.\n\nInfant slightly jaundice. Bili stable thus far, but plan to\ncheck level in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-18 00:00:00.000", "description": "Report", "row_id": 2036793, "text": "NPN\n\n\n#1 Infant remains in RA breathing comfortably. RR 40-60's.\n BS clear and equal. No desats or bradys.\n\n#2 Mom attempted to BF at 9pm but infant too sleepy.\nInfant woke up at 10:30pm and bottled 75cc BM20 and then\nslept until 4am and took 90cc BM20. Abd benign. Med spit\nx1. Infant took in 92cc/k/d +BF x24hrs. Voiding and\nstooling. Wt 2735(-55gms).\n\n#3 Infant waking on own for feeds. Temp stable in open\ncrib, swaddled. Infant active and alert with cares. Sucks\non pacifier. Bili this am 10.8/.2/10.6.\n\n#4 Mom in at beginning of the shift. Independent with\ncares. Anxious to take infant home. passed her\ncarseat test tonight. Mom called this am and aware that\ninfant is scheduled to go home today. has done\ndischarge exam. Mom needs to make pedi appt for this week.\nDoesn't want VNA services at home.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-14 00:00:00.000", "description": "Report", "row_id": 2036775, "text": "NPN\n\n\nNPN#1 O= remains in NCO2 200cc started the shift in 80%FIO2\nand has weaned to 60% O2 maintaining sats 93-96%, RR remains\ncomforatably tachypnic RR high 60's to 80's ( occ 90's)LS\nclear & equal bilat with good aeration, mild SCR,no grunting\nnoted A= clinical picture c/w TTN P= cont to monitor resp\nstatus closely, wean O2 as tol\n\nNPN#2 O= WT down 80gms to 2945 ( BW= 3025), remains NPO with\nTF at 60cc/kg/d of D10w with lytes infusing well via PIV,\nDS= 64, abd exam soft & flat + active BS/ no loops, no\nstool, voiding well..see flow sheet, A= adequate hydration/\nstable DS P= cont plan of care..,consider allowing mom to BF\nonce RR comes down & WOB stable\n\nNPN#3 O= remains swaddled on off warmer with stable temp, AF\nsoft & flat, active & alert with cares..easily settles with\npacifer/ containment, good , , swaddled with\nboundaries, bruising of ext especially right forearm & head\nevident A= behaviors appropriate for GA P= cont to assess &\nsupport dev needs\n\nNPN#4 O=mom called x2 for updates..feeling somewhat\nbetter...anxious to BF when resp status\nstabilizes...Dad in to visit..asking appropriate\nquestions..updated at bedside A= involved/ appropriately\nconcerned parents P= cont to keep updated & supported\n\nNPN#5 O= remains on IV Abx ampi & gent as ordered for 48hr\nrule out..good / stable temp/ active & alert with cares,\nblood cx remains - to date A=r/o sepsis P=cont per plan/\nmonitor for S & S of sepsis....hope to d/c Abx after 48hrs\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-14 00:00:00.000", "description": "Report", "row_id": 2036776, "text": "Neonatology Attending\nDOL 2\n\nRemains on NC 200 cc/min of 60-80% FIO2 with mild tachypnea.\n\nNo murmur. BP mean 42.\n\nOn ampicillin and gentamicin with negative culture so far (WBC 22 83 neut 3 bands).\n\nWt 2945 (-80) on TFI 60 cc/kg/day D10W. NPO for respiratory symptoms, although did breast feed once today. D-stick 64. Abd soft. Urine output 1.3 cc/kg/hr, stooling normally.\n\nTemperature stable in open crib.\n\nA&P\n37 week GA infant with retained fetal lung fluid, slowly improving\n-Continue to wean supplemental oxygen as tolerated\n-Discontinue antibiotics at 48 hours\n-Advance TFI to 80 cc/kg/day today. Will continue with breastfeeds and wean supplemental IV as indicated\n-Bilirubin in 24 hours\n-Parents updated at bedside\n" }, { "category": "Nursing/other", "chartdate": "2147-04-14 00:00:00.000", "description": "Report", "row_id": 2036777, "text": "SOCIAL WORK\nMet with both parents briefly following family meeting today. They seemed pleased with daughter's progress however continue to be concerned. They have 2 small children at home and father is a sr resident in anesthesia here. He will be on vacation for next 10 days so they will be able to visit often. Will provide info on reduced parking tickets and continue to be available as needed.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-14 00:00:00.000", "description": "Report", "row_id": 2036778, "text": "Neonatology Attending - Family Meeting\nFamily meeting held to discuss current status, diagnostic considerations and our management plan.\n\nMeeting 45 minutes\n" }, { "category": "Nursing/other", "chartdate": "2147-04-13 00:00:00.000", "description": "Report", "row_id": 2036770, "text": "Neonatology Attending\n\nPreterm infant with respiratory distress admitted for NICU management.\n\nInfant, now 7 hours old, born at 36 6/7 weeks to 36 yo G5P2 A+, Ab-, GBS-, HBsAg-, RPR-NR woman. Past medical history of chronic hypertension. Antepartum remarkable for hypertension. Admitted for induction. AROM three hours PTD. No maternal fever. Second stage of 18 minutes. NSVD with Apgars 8, 8.\n\nMild GFR noted in nursery. With persistence, transferred to NICU. 44 40-62.\n\nFather is senior anesthesia resident.\n\nExam remarkable for pink infant in cannula oxygen with vital signs as noted, pink color, soft AF, nl facies, intact palate, mild grunting retractions, fair-good air entry, no murmur, present femoral pulses, flat soft n-t abdomen without hsm, nl external genitalia, patent anus, stable hips, ecchymosis dorsal aspect of right forearm, nl perfusion, nl tone/activity.\n\nSaO2 98% on nasal cannula at 125 cc/min flow\nBlood glucose 79\n\nTerm newborn with respiratory symptoms. Possible diagnoses include retained fetal lung fluid, mild surfactant deficiency. Will check CXR to rule out other potential etiologies including pneumothorax. Short second stage makes delayed transition feasible. Will monitor cardio-respiratory status closely.\n\nNo known sepsis risk. Nevertheless, given oxygen requirement will check cbc, blood culture and treat with ampicillin and gentamicin pending cultures.\n\nWill make NPO during transition and administer IV dextrose. Following blood glucose.\n\nSpoke with father at bedside. He is aware of current condition and immediate plan of care.\n\nPrimary pediatrician is Pediatrics.\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-13 00:00:00.000", "description": "Report", "row_id": 2036771, "text": "NPN 7pm-7am\n37 week girl, born to 36y.o. G5 P3. Induced for hypertension. SVD with nuchal cord, apgars . Please see MD note for further details. Received infant from NBN at 0030 for grunting x 6hrs. Tags checked with NBN nurse. Placed on warmer and monitors placed. Resp: Infant has sat of 30% with possible problems with probe. Infant was fast and had facial bruising, lips looked pink. BBO2 was placed near infant and sats increased to 98% and color changed from dusky to pink. LS clear and equal with grunting and SC rets. NC placed at 100% 200cc's. Occ desats noted with crying self resolved with no increase in O2. CXR was done and looked like retained lung fluid. CV: No murmur noted, HR and BP stable. Pulse good with brisk cap refill. ID: CBC and Bld cx sent. Started on amp/gent. Fen: IV took multiple attempt to start. Dr. started IV in right foot. TF started at 60cc/kg/day of D10W. Infant made NPO, Mom plans to BF. Voided and no stool at this time. Abd soft, girth stable, +bs. Dev: Infant on warmer, temp stable. Alert and active with cares. Family: Dad came up with infant and spoke with and Dr. . He is aware of infants need for O2 and Abx started. Will cont to monitor and keep parents informed.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-16 00:00:00.000", "description": "Report", "row_id": 2036788, "text": "NPN 0700-\n\n\n1. Recieved infant in NC O2, 13cc 100% FiO2. NC O2 dc'd at\n9am, infant currently in RA with O2 sats 94-99%. RR\n30-60's, yet tachypneic to 70's at times. LSC and equal,\nmild subcostal retractions. No spells, no desats. Continue\nto monitor resp status.\n\n2. Infant po ad lib, breastfeeding or bottlefeeding.\nBottled 35cc BM this AM, and breastfeeding this afternoon\nwith mom. Belly soft, +BS, no loops. Small spit this am.\nVoiding, stooling. D stick 63 this am. Continue to monitor\ntolerance to feeds, po ad lib.\n\n3. Temp stable in open crib. Alert and active with cares,\nresting well between cares. Infant passed hearing screen.\nContinue to promote growth and development.\n\n4. Mom here throughout the day, updated on progress and\nplan of care. Mom pleased with infant's progress and\npotential d/c tomorrow. Discharge teaching initiated.\nCOntinue to update, educate and support parents.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-17 00:00:00.000", "description": "Report", "row_id": 2036789, "text": "NPN 1900-0730\n\n\n1. RECEIVED INFANT IN RA. SAO2 93- 100%. LS CLEAR /=. CONT\nWITH OCCASSIONAL TRANSEINT TACHYPNEA. NO SPELLS NOTED THIS\nSHIFT. PASSING CAR SEAT TEST. PLAN; CONT. TO MONITOR RESP\nSTATUS ON RA.\n\n2, WT THIS SHIFT 2.790GMS. DOWN 60GMS FROM YESTERDAY. CONT\nON AD LIB DEMAND SCHEDULE. TOTAL INTAKE FOR 24HRS. 58CC/K/D.\nABD SOFT, NO LOOPS,+BS. NO STOOL SO FAR THIS SHIFT. D/S 69.\nNO SPITS NOTED. VOIDING WELL. NO STOOL THIS SHIFT, PLAN;\nCONT. TO MONITOR TOTAL FLUIDS ON AD LIB SCHEDULE.\n\n3. REMAINS IN OAC. TEMPS STABLE. MOVING ALL EXTREMETIES\nWELL. WAKING FOR CARES. BOTTLING ALL FEEDINGS. PLAN; CONT.\nTO SUPPORT G/D.\n\n4. MOM IN AT . INFANT WITH NO INTEREST WITH BF, SOME D.C\nPLANNING WITH MOM. MON CALM AND WITH GOOD\nUNDERSTANDING OF TEACHING. . PLAN; CONT. TO SUPPPORT AND\nEDUCATE PARENTS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-17 00:00:00.000", "description": "Report", "row_id": 2036790, "text": "Neonatology Attending\nDOL 5 / CGA 37-4/7 weeks\n\nIn room air with occasional mild tachypnea and no cardiorespiratory events. Car seat test unsuccessful with SaO2 borderline at 89%.\n\nNo murmur. BP 77/39 (52).\n\nBilirubin 13/0.3 this morning (unchanged from 13 yesterday)\n\nWt 2790 (-60) on ad lib demand feeds with intake 58 cc/kg/day in addition to breastfeeding well for approx 20 minutes. Abd benign. D-stick 69. Voiding normally, no stools overnight.\n\nTemperature stable in open crib.\n\nA&P\n37 week GA infant with stable hyperbilirubinemia, resolving retained fetal lung fluid\n-Repeat bilirubin in 24 hours\n-Home tomorrow\n-Repeat car seat test prior to discharge, with plan for car bed if positive\n-Hearing screen passed; HB immunization given yesterday\n-Pediatrician \n" }, { "category": "Nursing/other", "chartdate": "2147-04-17 00:00:00.000", "description": "Report", "row_id": 2036791, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nface and trunk jaundice\nactive with symmetric and reflexes\n\nUpdated Mom at bedside\n" }, { "category": "Nursing/other", "chartdate": "2147-04-15 00:00:00.000", "description": "Report", "row_id": 2036784, "text": "nursing note\n\n\n1)resp: babe remains with nasal cannula 200cc flow,\ndecreased to 40%fio2. moderate supraclavicular retractions\nnoted. breath sounds clear and equal. respiratory rate 40\n-80's. no increased work of breathing noted. plan to\ncontinue to monitor respiratory status closely and wean as\ntolerated.\n2)fen: babe continues on d10 with electrolytes, total\nfluids of 80cc/kg/day. plan to encourage breast\nfeeding/bottle feeding of tolerated. will monitor tolerance\nto feeds closely.\n3)g/d: babe remains swaddled in open crib. maintaining\ntemperature. sucks on pacifier when stimulated. babe\nquiet, irritable when stimulated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-15 00:00:00.000", "description": "Report", "row_id": 2036785, "text": "Neonatology- Progress Note\n\nPE; in her open crib, in nasal cannual O2, bbs cl=, rrr s1s2no murmur, abd soft, nontender, V&S, afso, slightly jaundiced, afso, active with care, peripheral iv in place\n\nSee attending note for plan\n\nUpdated Dad at bedside\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-16 00:00:00.000", "description": "Report", "row_id": 2036786, "text": "NPN 1900-0700\n\n5 INFECTION\n\n1. Resp: Received infant in NC O2 100-200 cc flow requiring\n40 % FiO2 to maintain her O2 sats greater than 94%. Infant\nwas switched to a low-flow meter and currently is in 25 cc\nflow, 100% FiO2. Lung sounds clear/=. RR 40-70's. No A's\nor B's noted. P: Cont. to monitor resp. status and wean\nflow as tolerated.\n\n2. FEN: Weight is 2850 gms up 35 gms. Infant is adlib\nbreastfeeding/bottling E20/BM20. Infant has bottled between\n30-45 q 2-3 hours with good coordination. IVF have been\nweaned throughout night. IVF was heplocked at 0500. D/S\n73/69. Tolerating feedings well; abd exam benign, no spits.\n Voiding qs and no stool noted thus far. P: Cont. to\nsupport nutritional needs.\n\n3. G/D: Temps stable swaddled in open crib. Alert and\nactive with cares. Settles well in between cares. Wakes\nfor feedings q 2 - 3 hours for feedings. AFSF. AGA. P:\nCont. to support developmental needs.\n\n4. Parents: Mom in to breastfeed last evening. Independent\nwith cares and handling infant. Updated on infant's\ncondition and plan of care by this RN. Asking appropriate\nquestions. Loving, involved parents. Mom will be in at 06\nthis am. P: Cont. to support and update parents.\n\nREVISIONS TO PATHWAY:\n\n 5 INFECTION; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-16 00:00:00.000", "description": "Report", "row_id": 2036787, "text": "Newborn Med Attending\n\nDOL#4. Cont in low flow O2 per NC. AF flat, clear BS, no murmur, abd soft, MAE. Bili=13. WT=2850 down 35, BM ad lib.\nA/P: Infant with resolving resp distress. Wean O2 as tolerated. Cont PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-14 00:00:00.000", "description": "Report", "row_id": 2036779, "text": "NPN DAYS\n\n\nTerm Respiratory Distress: Baby remains on NC 200cc flow,\n50-80% FiO2. LS clear and equal. Mild SC retractions noted.\nMild nasal flaring noted at times. No grunting. No spells.\nDoes desat to the 80's after crying. Will follow closely.\n\nFEN: TF increased to 80cc/kg/day D10 with Nacl and KCl via\nPIV in right foot. Baby Attempted BF x2 with little success.\nHolding on bottling until respiratory rate comes down WNL.\nTachypneic 60's-90. Belly benign. No spits. Voiding and\nstooling. Continue with current plan of care.\n\nG/D: Temp stable in open crib while swaddled. Awake and\nalert with cares. Good suck on pacifier but does not appear\nto be very hungry. Bruising continues to be present to\nextremities and head. Continue to support developmental\nneeds.\n\nParents: Mom and dad up to visit. Family meeting with Dr.\n and myself. Parents updated on course.\nWill continue to update and provide support. Mom dc'd today\nbut staying in parent room tonight.\n\nInfection: Blood cx negative to date. Have order to d/c\nantibiotics if cx remains negative after 48 hours.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-14 00:00:00.000", "description": "Report", "row_id": 2036780, "text": "Neonatology Np Exam Note\nPlease refer to Dr note for details of evaluation and plan.\n\nPE: term infant swaddled in open crib. Facial bruising, caput over occiput. AFOF, sutures approximated. MMMP\nChest: clear, comfortably tachypneac\nCV: RRR, no murmur, pulses +2=\nAbd: soft, active BS.\nExt: MAE, WWP\nNeuro: active symmetric and reflexes\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-15 00:00:00.000", "description": "Report", "row_id": 2036781, "text": "1900-0700 NPN\n\n\n#1RDS\nO:REMAINS IN NC 200CC 50-60%. ABLE TO WEAN TO 45% FOR SHORT\nTIME AND REQUIRES INCREASED FIO2 DURING BF ATTEMPTS/CRYING\nFOR DRIFTS. BS CLEAR. RESP RATE 60-80 WITH MILD SC\nRETRACTIONS.\nA:NC TO KEEP SATS >94% PER ORDER\nP:CONTINUE 02, MONITOR RESP RATE\n\n#2F/E/N\nO:TF AT 80CC/KG D10 W/LYTES VIA PIV IN RIGHT FOOT. BF AD\nLIB. BF WELL X1; NOT INTERESTED SECOND TIME. PIV INFUSING\nWIHTOUT S/S OF INFILTRATE. ABDOMEN SOFT, FULL WITH GOOD BS.\nNO SPITS. VOIDING WELL; SMALL STOOL X1. WT DOWN 60GM.\nA:BF AD LIB WITH IVF UNTIL RESP STATUS MORE STABLE\nP:CONTINUE TO ALLOW AD LIB BF, BEGIN BOTTLES AND WEAN IVF AS\nRESP STATUS IMPROVES\n\n#3G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH.\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#4PARENTING\nO:PARENTS IN Q4HR OVERNIGHT. MOM DID WELL X1.\nPARENTS SPOKE TO RE:TRANSFER TO IF STAY\nIS PROLONGED\nA:INVOLVED, INVESTED PARENTS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-15 00:00:00.000", "description": "Report", "row_id": 2036782, "text": "1900-0700 NPN ADDENDUM\n\n\n#5SEPSIS\nO:BLOOD CULTURE NEGATIVE AT 48HR. ANTIBIOTICS DISCONTINUED\n MD ORDER\nA:SEPSIS RULED OUT\nP:D/C PROBLEM\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-15 00:00:00.000", "description": "Report", "row_id": 2036783, "text": "NICU Attending Note\n\nDOL # 3 for this term infant with resolving TTN.\n\nPlease see full Zacagnini\n\nCVR/RESP: RRR without murmur, skin pink and well perfused, mild supraclavicular retractions, BS clear/=, weaned to NCO2 200 cc/min flow, FiO2 40%. Will continue to wean NCO2 as tolerated.\n\nFEN: Abd benign, weight today 2885 gm (down 60 gm), on TF of 80 cc/kg/d, ad lib breast feeding and remainder D1W with lytes. D stick 88, good u/o. Will continue to encourage breast feeding, wean IVF accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-13 00:00:00.000", "description": "Report", "row_id": 2036772, "text": "1 Term Respiratory Distress\n2 FEN\n3 G/D\n4 PARENTS\n5 INFECTION\n\nREVISIONS TO PATHWAY:\n\n 1 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 2 FEN; added\n Start date: \n 3 G/D; added\n Start date: \n 4 PARENTS; added\n Start date: \n 5 INFECTION; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2147-04-13 00:00:00.000", "description": "Report", "row_id": 2036773, "text": "Neonatology Attending\nDOL 1\n\nRemains in NC 200 cc/min of 100% FIO2 with mild tachypnea and retractions. CXR consistent withe retained fetal lung fluid.\n\nNo murmur. BP 64/34 (49).\n\nOn ampicillin and gentamicin. WBC 22 (81 poly 3 bands) Hct 41.2 Plt 271.\n\nWt 3025 (BW). Remains NPO on TFI 60 cc/kg/day PIV. D-stick 79. Voiding, no stools yet.\n\nA&P\n37 week GA infant with mild respiratory compromise clinically and radiographically consistent with retained fetal lung fluid after precipitous delivery.\n-Continue to monitor cardiorespiratory status on NC\n-Consider feeds once respiratory symptoms have stabilized.\n-Plan to continue antibiotics to 48-hour course\n-Parents updated by Dr. . Continue to provide support.\n" }, { "category": "Nursing/other", "chartdate": "2147-04-13 00:00:00.000", "description": "Report", "row_id": 2036774, "text": "NPN DAYS\n\n\nTerm Respiratory Distress: Remains in NC 200cc flow, 70-100%\nFiO2. LS clear and equal. Mild to moderate SC retractions.\nTachypneic at rest but appears comfortable. Desats to the\n80's with crying. Pink and well perfused. Will continue to\nmonitor closely.\n\nFEN: TF 60cc/kg/day IV D10 via PIV right foot. D/S 70. Baby\nhas not eaten yet r/t respiratory symptoms but may try to\nbreast feed when mom visits. Voiding and stooling. Will\nallow baby to feed if resp status remains stable.\n\nG/D: Temp stable on warmer. Awake and alert with cares and\nsleeping well between cares. Good suck on pacifier. Bruising\nremains to right side of head and her right arm. Will\nswaddled her and monitor her temp.\n\nParents: Mom and dad up to visit. Asking appropriate\nquestions. Both are very concerned about their baby. \nset up family meeting and continue to provide teaching and\nsupport.\n\nInfection: Remains on Ampicillin and Gentamicin. Blood cx\nnegative to date.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2155-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356753, "text": "Pt is an 86 year old woman admitted after developing weakness for past\n few day and dark tarry stools. Hct 29.9 in ew, and INR ~7. Pt recently\n restarted on coumadin for afib. Please see FHPA for pmed hx.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Elevated INR in setting of coumadin and tarry stools, weakness\n Action:\n FFP 2u given (1 administered in EW and 1 after arrival to MICU)\n Pt presently denies, pain, dizziness, or weakness, c/o thirst and\n hunger\n GI consulted, awaiting recs\n Bp elevated to 190\ns, team aware and are following, hr stable 60-70\n SR.\n Response:\n VSS with no episodes of melena or stooling since admission.\n Plan:\n Will recheck labs to eval INR and HCt\n T&C for 3u PC\ns ordered, clot already avail in BB.\n F/U GI team recs\n" }, { "category": "Nursing", "chartdate": "2155-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356832, "text": "Pt is an 86 year old woman admitted after developing weakness for past\n few day and dark tarry stools. Hct 29.9 in ew, and INR ~7. Pt recently\n restarted on coumadin for afib. Please see FHPA for pmed hx. Pt\n received Vit K and 2 FFP in EW, transferred ro MICU. Serial Hcts\n 22->23. transfused 2 UPRBC.\n Hypertension, benign\n Assessment:\n NBP 187/72 last night. NSR 60s.\n Action:\n Hydralazine 10 PO x 1\n Response:\n BP decreased to 140-170/50s.\n Plan:\n restart BP meds today if looks stable from GIB standpoint.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n A&O x 3, no c/o abd pain or cramping .No N/V. No stools. Pt refused EDG\n and NGT after discussion with GI \n Action:\n Transfused 2 UPRBC. Hct drawn between 1^st and 2^nd unit blood and 3\n hrs after 2^nd UPRBC finished.\n Response:\n Serial Hcts 29->>31.\n Plan:\n No further S/S GIB. Hct bumped appropriately to blood transfusion. EGD\n if pt rebleeds.\n" }, { "category": "Nursing", "chartdate": "2155-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356752, "text": "Pt is an 86 yo woman admitted after developing wekness for past few day\n and dark tarry stool. Hct 29.9 in ew, and INR ~7. Pt recently restarted\n on coumadin for afib.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2155-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356824, "text": "Pt is an 86 year old woman admitted after developing weakness for past\n few day and dark tarry stools. Hct 29.9 in ew, and INR ~7. Pt recently\n restarted on coumadin for afib. Please see FHPA for pmed hx. Pt\n received Vit K and 2 FFP in EW, transferred ro MICU. Serial Hcts\n 22->23. transfused 2 UPRBC.\n Hypertension, benign\n Assessment:\n NBP 187/72 last night. NSR 60s.\n Action:\n Hydralazine 10 PO x 1\n Response:\n BP decreased to 140-170/50s.\n Plan:\n restart BP meds today if looks stable from GIB standpoint.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n A&O x 3, no c/o abd pain or cramping .No N/V. No stools. Pt refused EDG\n and NGT after discussion with GI \n Action:\n Transfused 2 UPRBC. Hct drawn between 1^st and 2^nd unit blood and 3\n hrs after 2^nd UPRBC finished.\n Response:\n Serial Hcts 29->>31.\n Plan:\n No further S/S GIB. Hct bumped appropriately to blood transfusion. EGD\n if pt rebleeds.\n" }, { "category": "Nursing", "chartdate": "2155-11-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356928, "text": "Pt is an 86 year old woman admitted after developing weakness x a few\n days and dark tarry stools. PMH sig for: CAD, HTN, AAA, AFib (on\n Coumadin). Hct 29.9 in ew, and INR ~7. Of note, pt was recently\n restarted on Coumadin for her AFib. Pt received Vit K and 2units FFP in\n transferred to MICU 6 for further management. -- Serial Hcts\n ~ 22-23 >> Pt received 2units PRBC on the eve of . HCT this am\n (post blood tx) = 32.1, followed by 34.1, at 09:00 this am. Pt had an\n ABD CT on to r/o RP bleed\n prelim negative. Pt is now stable for\n transfer to medical floor.\n Hypertension, benign\n Assessment:\n NIBP ranging 140\ns-190\ns / 40\ns-70\ns. HR 60\ns-70\ns, NSR. Pt w/o\n complaints.\n Action:\n Pt started on HCTZ (25 mg PO Daily), BP monitored closely.\n Response:\n BP now ranging 140\ns-150\ns / 50\ns-70\n Plan:\n Continue BP meds; ? need for further agents.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt w/o N/V/D, abd exam benign. No bm today. HCT this am = 32.1, post\n blood-tx last eve.\n Action:\n Repeat HCT sent later this am (approx 6 hrs after last HCT of 32.1).\n Pt started on clear liquid diet.\n Response:\n Repeat HCT = 34.1; no bm thus far; pt continues to deny n/v/abd pain;\n pt tolerated clear liquids well.\n Plan:\n Follow HCTs and coags; transfuse prn for HCT < 27; hold ASA and\n Coumadin; f/u GI recs.\n" }, { "category": "Nursing", "chartdate": "2155-11-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356922, "text": "Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2155-11-08 00:00:00.000", "description": "Resident / Attending Admission Note", "row_id": 356790, "text": "Chief Complaint: Dark stool\n PCP: , , Gerontology\n HPI:\n 86 y/o lady with CAD s/p CABG, HTN, Afib on coumadin has experienced\n generlaized weakness. Patient experienced dark stool yesterday for the\n first time. No stools since then. Did not notice any other bleeding\n including hematuria. She denies any fever, chills, cough, cold, chest\n pain, abdominal pain, shortness of breath, orhtopnea, PND, lower\n extremity swelling, nausea, vomitting, dizzenss, numbness, tingling,\n dizziness, change in vision, change in hearing, headache,\n neckstiffness, and or backpain. No focal weakness but has generalized\n weakness. She was restarted on coumadin on admission and also\n restarted on amiodarone given the presentation with aftrial\n fibrillation with rapid ventricular response.\n In ED her vitals were 97.1 62 192/75 16 95% RA. She received\n NS 1 L, Vitamin 10 units IV, and FFP 2 units once. She was transfered\n to the MICU for possible scope.\n On arrival to MICU her vitals were T 98.1 HR 70 BP 197/55 RR 27\n 2LNC 100% oxygen saturation. Her blood pressure improved to 154/66.\n Otherwise she is asymptomatic. She currently refused upper endoscopy\n or colonscopy. She is able to walk 1.5 blocks five times a week\n without any limiting symtpoms.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 AM\n Other medications:\n Aspirin 81 mg daily\n Toprol XL 100 mg daily\n Hydrochlorothiazide 12.5 mg daily\n Amiodarone 200 mg for one month (written on )\n Cyanocobalamin 500 mcg daily\n Simvastatin 10 mg daily\n Coumadin 3 mg daily\n Past medical history:\n Family history:\n Social History:\n - CAD s/p 3V CABG LIMA->LAD, reversed SVG to Marginal and PDA.\n - H/o Afib priorly treated with coumadin and amiodarone. Stopped\n in and had been in sinus (in theory) since then.\n - AAA 4.5 x 4.7 cm\n - Spinal infarct 7 yrs ago. Patient now has partial numbness in\n right leg, vagina and perineum.\n - Appy, pancreatitis.\n - Hyperlipidemia -\n - Depression - no meds\n - B12 deficiency - on replacement; pt does not know what the\n diagnosis was.\n - Status post gallstone pancreatitis\n Her father died at 77 from bleeding pud, and her mother, who had\n a history of HTN, died in her early 90's from old age. She had a\n sister who died at 59 of colon cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is widowed and lives alone, indepedent in her ADLs. She has\n an involved daughter who lives in and a son in .\n She's smoked 2-3packs per week for 30-40 yrs, quit 15 to 18 yrs ago.\n She drinks wine but never heavily, just with meals.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, melena, maroon stools\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 05:05 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 72 (65 - 78) bpm\n BP: 174/48(81) {154/48(81) - 197/74(123)} mmHg\n RR: 24 (17 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 554 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 412 mL\n Total out:\n 0 mL\n 275 mL\n Urine:\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 279 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Thin, elderly\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, JVP low sitting upright\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 Crackles : fine, bibasilar)\n Abdominal: Soft, Non-tender, Bowel sounds present, midabdominal bruit\n heard. Aorta not enlarged by palpation\n Extremities: Right: Absent, Left: Absent\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 239 K/uL\n 8.0 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 39 mg/dL\n 28 mEq/L\n 105 mEq/L\n 3.2 mEq/L\n 141 mEq/L\n 23.6 %\n 5.6 K/uL\n [image002.jpg]\n \n 2:33 A12/20/ 11:51 AM\n \n 10:20 P12/20/ 01:13 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 5.6\n Hct\n 22.7\n 23.6\n Plt\n 239\n Cr\n 1.0\n Glucose\n 92\n Other labs: PT / PTT / INR:17.4/31.1/1.6, Ca++:8.1 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n Imaging: P-MIBI : No anginal type symptoms or ischemic EKG\n changes. Nuclear report is sent separately.\n 1. Reversible, medium sized, moderate severity perfusion defect\n involving the LAD territory.\n 2. Normal left ventricular cavity size and systolic function.\n .\n Abdomen US :\n 1. Small gallbladder stone, without evidence of acute cholecystitis.\n 2. Limited study with only a small portion of pancreas visible which\n grossly\n appears unremarkable.\n 3. Unchanged appearance abdominal aortic aneurysm measuring\n approximately 4.5\n x 4.7 cm.\n ECG: NSR, rate 70s, qwaves in III and aVF, TW flattening V3-5. LVH\n with R wave in aVL greater than 11 mm. Compared to , patient\n is currently in sinus rhythm without any significant ST-T changes.\n Assessment and Plan\n 62 y/o lady with CAD, HTN, and atrial fibrillation presents with\n gastrointestinal bleed.\n .\n # anemia: Likely lower GIB given guaic positive dark maroon stool in\n rectal volt in ED although reported melena at home. Hemodynamically\n stable currently. Refusing scope at this time.\n - GI notified. Appreciate input\n - Transfuse 2 units PRBCs given Hct drop to 22\n - PIV x 2\n - already 2 units of FFP in ED to reverse INR of 7.4\n - Vit K to reverse INR, already received 10 mg IV in ED\n - trend Hct and coags\n - send for CT noncontrast to eval for spontaneous RP hematoma given sig\n Hct drop without persistent GIB\n - send hemolysis labs\n - if Hct continues to drop and above evaluation negative, must consider\n possibility of herald bleed from aortoenteric fistula\n .\n # Hypertension: Hypertensive in ED. No signs or symptoms of infection\n or ischemia.\n - hold off on beta blockade for now\n - continue HCTZ\n - needs better control of BP given AAA, could consider starting\n amlodipine. Will monitor for now\n .\n # Atrial fibrillation: Currently in sinus.\n - will switch to short acting metoprolol when restarting\n - continue amiodarone for now. Needs 200 mg x 1 month\n - hold coumadin in acute GI bleed. not be good candidate in future\n .\n # : Her BUN is elevated to 40 with Cr relatively elevated to 1.1.\n Her BUN is most likely due to GIB. However she may have some prerenal\n insufficiency.\n - already received 1L NS\n - monitor I&O\n - consider renal lytes if her function worsens\n - IVF and PRBCs for UOP\n .\n # CAD: s/p CABG. No active signs of ischemia.\n - transfuse for HCT > 27\n - will hold asa in the setting of GIB.\n .\n # AAA: Needs out patient follow up. Stable on recent abdominal\n ultrasound.\n - better control of blood pressure as above.\n .\n # Hyperlipidemia:\n - continue home simvastatin\n .\n # B12 deficiency:\n - cont home B12\n .\n # FEN: NPO for now, replete lytes prn\n .\n # Prophylaxis: Supratherapeutic INR. Pneumoboots. PPI IV BID.\n .\n # Contact: Daughter, \n .\n # Access: PIV\n .\n # Code: Full Code\n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin, s/p 10 mg vitamin K)\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 CRITICAL CARE STAFF ADDENDUM\n I saw and examined Ms. with the ICU team. The note above\n reflects my input. I would add/emphasize that this 86-year-old woman\n with CAD (+p thal after CABG) and 4-5 cm aortic aneurysm now presents\n with melena and possible maroon stool. Although she has been\n hemodynamically stable, her fall in hct has been quite impressive and\n has not yet abated: baseline high 30s-low 40s\n 29\n 23. Immediate\n trigger is probably elevated INR (>7) though would suspect an anatomic\n lesion. She has declined urgent EGD and seems to have capacity to do\n so.\n We will plan:\n 1) PPI\n 2) Maintain IV access\n 3) Appreciate GIs help\n 4) Transfuse\n 5) Ensure coagulopathy reversed (has already received vit K and\n FFP)\n 6) Given the marked fall in Hct and relatively small amount of\n clinical bleeding, will evaluate for other causes: check hemolysis labs\n and CT for RP bleed\n Other issues as per the ICU team note above. Discussed with Dr. \n from GI. Also discussed with patient, who does not want family called\n at this point.\n She is critically ill: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 17:22 ------\n" }, { "category": "Physician ", "chartdate": "2155-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356855, "text": "Chief Complaint:\n 24 Hour Events:\n -transfused 2U for hct 22.7\n -CT A/P to r/o RP bleed prelim- negative\n 10mg Po hydral for sbps to 180s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 78) bpm\n BP: 157/62(85) {140/48(77) - 197/74(123)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,009 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 866 mL\n Total out:\n 575 mL\n 300 mL\n Urine:\n 575 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 434 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 178 K/uL\n 11.2 g/dL\n 98 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 106 mEq/L\n 139 mEq/L\n 32.1 %\n 7.1 K/uL\n [image002.jpg]\n 11:51 AM\n 01:13 PM\n 09:20 PM\n 02:00 AM\n WBC\n 5.6\n 7.1\n Hct\n 22.7\n 23.6\n 29.3\n 32.1\n Plt\n 239\n 178\n Cr\n 1.0\n 1.0\n Glucose\n 92\n 98\n Other labs: PT / PTT / INR:16.1/29.1/1.4, ALT / AST:13/16, Alk Phos / T\n Bili:/1.1, LDH:164 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2155-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356856, "text": "Chief Complaint:\n 24 Hour Events:\n -transfused 2U for hct 22.7\n -CT A/P to r/o RP bleed prelim- negative\n 10mg Po hydral for sbps to 180s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 78) bpm\n BP: 157/62(85) {140/48(77) - 197/74(123)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,009 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 866 mL\n Total out:\n 575 mL\n 300 mL\n Urine:\n 575 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 434 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 178 K/uL\n 11.2 g/dL\n 98 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 106 mEq/L\n 139 mEq/L\n 32.1 %\n 7.1 K/uL\n [image002.jpg]\n 11:51 AM\n 01:13 PM\n 09:20 PM\n 02:00 AM\n WBC\n 5.6\n 7.1\n Hct\n 22.7\n 23.6\n 29.3\n 32.1\n Plt\n 239\n 178\n Cr\n 1.0\n 1.0\n Glucose\n 92\n 98\n Other labs: PT / PTT / INR:16.1/29.1/1.4, ALT / AST:13/16, Alk Phos / T\n Bili:/1.1, LDH:164 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 62 y/o lady with CAD, HTN, and atrial fibrillation presents with\n gastrointestinal bleed.\n .\n # anemia: Likely lower GIB given guaic positive dark maroon stool in\n rectal volt in ED although reported melena at home. Hemodynamically\n stable currently. Refusing scope at this time.\n - GI notified. Appreciate input\n - Transfuse 2 units PRBCs given Hct drop to 22\n - PIV x 2\n - already 2 units of FFP in ED to reverse INR of 7.4\n - Vit K to reverse INR, already received 10 mg IV in ED\n - trend Hct and coags\n - send for CT noncontrast to eval for spontaneous RP hematoma given sig\n Hct drop without persistent GIB\n - send hemolysis labs\n - if Hct continues to drop and above evaluation negative, must consider\n possibility of herald bleed from aortoenteric fistula\n .\n # Hypertension: Hypertensive in ED. No signs or symptoms of infection\n or ischemia.\n - hold off on beta blockade for now\n - continue HCTZ\n - needs better control of BP given AAA, could consider starting\n amlodipine. Will monitor for now\n .\n # Atrial fibrillation: Currently in sinus.\n - will switch to short acting metoprolol when restarting\n - continue amiodarone for now. Needs 200 mg x 1 month\n - hold coumadin in acute GI bleed. not be good candidate in future\n .\n # : Her BUN is elevated to 40 with Cr relatively elevated to 1.1.\n Her BUN is most likely due to GIB. However she may have some prerenal\n insufficiency.\n - already received 1L NS\n - monitor I&O\n - consider renal lytes if her function worsens\n - IVF and PRBCs for UOP\n .\n # CAD: s/p CABG. No active signs of ischemia.\n - transfuse for HCT > 27\n - will hold asa in the setting of GIB.\n .\n # AAA: Needs out patient follow up. Stable on recent abdominal\n ultrasound.\n - better control of blood pressure as above.\n .\n # Hyperlipidemia:\n - continue home simvastatin\n .\n # B12 deficiency:\n - cont home B12\n .\n # FEN: NPO for now, replete lytes prn\n .\n # Prophylaxis: Supratherapeutic INR. Pneumoboots. PPI IV BID.\n .\n # Contact: Daughter, \n .\n # Access: PIV\n .\n # Code: Full Code\n .\n # Dispo: ICU for now\n HYPERTENSION, BENIGN\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2155-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356908, "text": "Chief Complaint:\n 24 Hour Events:\n -transfused 2U for hct 22.7\n -CT A/P to r/o RP bleed prelim- negative\n 10mg Po hydral for sbps to 180s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 78) bpm\n BP: 157/62(85) {140/48(77) - 197/74(123)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,009 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 866 mL\n Total out:\n 575 mL\n 300 mL\n Urine:\n 575 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 434 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 178 K/uL\n 11.2 g/dL\n 98 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 106 mEq/L\n 139 mEq/L\n 32.1 %\n 7.1 K/uL\n [image002.jpg]\n 11:51 AM\n 01:13 PM\n 09:20 PM\n 02:00 AM\n WBC\n 5.6\n 7.1\n Hct\n 22.7\n 23.6\n 29.3\n 32.1\n Plt\n 239\n 178\n Cr\n 1.0\n 1.0\n Glucose\n 92\n 98\n Other labs: PT / PTT / INR:16.1/29.1/1.4, ALT / AST:13/16, Alk Phos / T\n Bili:/1.1, LDH:164 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 62 y/o lady with CAD, HTN, and atrial fibrillation presents with\n gastrointestinal bleed.\n .\n # anemia: Likely lower GIB given guaic positive dark maroon stool in\n rectal volt in ED although reported melena at home. Hemodynamically\n stable currently. Refusing scope at this time.\n - GI notified. Appreciate input\n - Transfuse 2 units PRBCs given Hct drop to 22\n - PIV x 2\n - already 2 units of FFP in ED to reverse INR of 7.4\n - Vit K to reverse INR, already received 10 mg IV in ED\n - trend Hct and coags\n - send for CT noncontrast to eval for spontaneous RP hematoma given sig\n Hct drop without persistent GIB\n - send hemolysis labs\n - if Hct continues to drop and above evaluation negative, must consider\n possibility of herald bleed from aortoenteric fistula\n .\n # Hypertension: Hypertensive in ED. No signs or symptoms of infection\n or ischemia.\n - hold off on beta blockade for now\n - continue HCTZ\n - needs better control of BP given AAA, could consider starting\n amlodipine. Will monitor for now\n .\n # Atrial fibrillation: Currently in sinus.\n - will switch to short acting metoprolol when restarting\n - continue amiodarone for now. Needs 200 mg x 1 month\n - hold coumadin in acute GI bleed. not be good candidate in future\n .\n # : Her BUN is elevated to 40 with Cr relatively elevated to 1.1.\n Her BUN is most likely due to GIB. However she may have some prerenal\n insufficiency.\n - already received 1L NS\n - monitor I&O\n - consider renal lytes if her function worsens\n - IVF and PRBCs for UOP\n .\n # CAD: s/p CABG. No active signs of ischemia.\n - transfuse for HCT > 27\n - will hold asa in the setting of GIB.\n .\n # AAA: Needs out patient follow up. Stable on recent abdominal\n ultrasound.\n - better control of blood pressure as above.\n .\n # Hyperlipidemia:\n - continue home simvastatin\n .\n # B12 deficiency:\n - cont home B12\n .\n # FEN: NPO for now, replete lytes prn\n .\n # Prophylaxis: Supratherapeutic INR. Pneumoboots. PPI IV BID.\n .\n # Contact: Daughter, \n .\n # Access: PIV\n .\n # Code: Full Code\n .\n # Dispo: ICU for now\n HYPERTENSION, BENIGN\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2155-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 356910, "text": "Chief Complaint:\n 24 Hour Events:\n -transfused 2U for hct 22.7\n -CT A/P to r/o RP bleed prelim- negative\n 10mg Po hydral for sbps to 180s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 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 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 78) bpm\n BP: 157/62(85) {140/48(77) - 197/74(123)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,009 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 866 mL\n Total out:\n 575 mL\n 300 mL\n Urine:\n 575 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 434 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: Thin, elderly\n HEENT: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: S1S2 no m/r/g\n Peripheral 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: clear\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 178 K/uL\n 11.2 g/dL\n 98 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 106 mEq/L\n 139 mEq/L\n 32.1 %\n 7.1 K/uL\n [image002.jpg]\n 11:51 AM\n 01:13 PM\n 09:20 PM\n 02:00 AM\n WBC\n 5.6\n 7.1\n Hct\n 22.7\n 23.6\n 29.3\n 32.1\n Plt\n 239\n 178\n Cr\n 1.0\n 1.0\n Glucose\n 92\n 98\n Other labs: PT / PTT / INR:16.1/29.1/1.4, ALT / AST:13/16, Alk Phos / T\n Bili:/1.1, LDH:164 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 62 y/o lady with CAD, HTN, and atrial fibrillation presents with\n gastrointestinal bleed.\n .\n # anemia: s/p 2U prbc, hct stable at low 30s. will repeat once more\n prior to call-out to ensure she is not dropping again.\n - f/u GI input, needs follow up\n - f/u hct and INR\n - trend Hct and coags\n - f/u ct final read\n - if Hct continues to drop and above evaluation negative, must consider\n possibility of herald bleed from aortoenteric fistula\n .\n # Hypertension: Hypertensive in ED. No signs or symptoms of infection\n or ischemia.\n - restart hctz, consider amlodipine\n - needs better control of BP given AAA as outpatient\n .\n # Atrial fibrillation: Currently in sinus.\n - continue amiodarone for now. Needs 200 mg x 1 month\n - hold coumadin in acute GI bleed. not be good candidate in future\n .\n # : Now resolved. Likely pre-renal etiology.\n - monitor I&O\n - consider renal lytes if her function worsens\n - IVF and PRBCs for UOP\n .\n # CAD: s/p CABG. No active signs of ischemia.\n - transfuse for HCT > 27\n - will hold asa in the setting of GIB.\n .\n # AAA: Needs out patient follow up. Stable on recent abdominal\n ultrasound.\n - better control of blood pressure as above.\n .\n # Hyperlipidemia:\n - continue home simvastatin\n .\n # B12 deficiency:\n - cont home B12\n .\n # FEN: clears, replete lytes prn\n .\n # Prophylaxis: hold for GI bleed. Pneumoboots. PPI IV BID.\n .\n # Contact: Daughter, \n .\n # Access: PIV\n .\n # Code: Full Code\n .\n # Dispo: c/o to floor\n HYPERTENSION, BENIGN\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2155-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356783, "text": "Pt is an 86 year old woman admitted after developing weakness for past\n few day and dark tarry stools. Hct 29.9 in ew, and INR ~7. Pt recently\n restarted on coumadin for afib.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt. with supratheraputic INR and c/o tarry stools on admission. Recived\n 2 units FFP and Vit. K 10mg IV in ED. No stools since admission. Repeat\n Labs show INR down to 1.6 and Hct. 22.7 with repeat 23.6. No s/s of\n bleeding. Denies pain. BP 150\ns-170\ns systolic and HR 60\ns-70\ns NSR.\n Action:\n Ordered for 2 units of PRBC. First unit up at 1547. CT of abd. and\n pelvis done to r/o RP bleed. GI team in to see Pt. Will not scope\n until INR corrected and Pt. cont to have hct. Drop.\n Response:\n CT results pending. VSS. Tolerating PRBC transfusion well.\n Plan:\n f/u CT results. Monitor VS. F/U labs post transfusion.\n" }, { "category": "Physician ", "chartdate": "2155-11-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 356786, "text": "Chief Complaint: Dark stool\n PCP: , , Gerontology\n HPI:\n 86 y/o lady with CAD s/p CABG, HTN, Afib on coumadin has experienced\n generlaized weakness. Patient experienced dark stool yesterday for the\n first time. No stools since then. Did not notice any other bleeding\n including hematuria. She denies any fever, chills, cough, cold, chest\n pain, abdominal pain, shortness of breath, orhtopnea, PND, lower\n extremity swelling, nausea, vomitting, dizzenss, numbness, tingling,\n dizziness, change in vision, change in hearing, headache,\n neckstiffness, and or backpain. No focal weakness but has generalized\n weakness. She was restarted on coumadin on admission and also\n restarted on amiodarone given the presentation with aftrial\n fibrillation with rapid ventricular response.\n In ED her vitals were 97.1 62 192/75 16 95% RA. She received\n NS 1 L, Vitamin 10 units IV, and FFP 2 units once. She was transfered\n to the MICU for possible scope.\n On arrival to MICU her vitals were T 98.1 HR 70 BP 197/55 RR 27\n 2LNC 100% oxygen saturation. Her blood pressure improved to 154/66.\n Otherwise she is asymptomatic. She currently refused upper endoscopy\n or colonscopy. She is able to walk 1.5 blocks five times a week\n without any limiting symtpoms.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 AM\n Other medications:\n Aspirin 81 mg daily\n Toprol XL 100 mg daily\n Hydrochlorothiazide 12.5 mg daily\n Amiodarone 200 mg for one month (written on )\n Cyanocobalamin 500 mcg daily\n Simvastatin 10 mg daily\n Coumadin 3 mg daily\n Past medical history:\n Family history:\n Social History:\n - CAD s/p 3V CABG LIMA->LAD, reversed SVG to Marginal and PDA.\n - H/o Afib priorly treated with coumadin and amiodarone. Stopped\n in and had been in sinus (in theory) since then.\n - AAA 4.5 x 4.7 cm\n - Spinal infarct 7 yrs ago. Patient now has partial numbness in\n right leg, vagina and perineum.\n - Appy, pancreatitis.\n - Hyperlipidemia -\n - Depression - no meds\n - B12 deficiency - on replacement; pt does not know what the\n diagnosis was.\n - Status post gallstone pancreatitis\n Her father died at 77 from bleeding pud, and her mother, who had\n a history of HTN, died in her early 90's from old age. She had a\n sister who died at 59 of colon cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is widowed and lives alone, indepedent in her ADLs. She has\n an involved daughter who lives in and a son in .\n She's smoked 2-3packs per week for 30-40 yrs, quit 15 to 18 yrs ago.\n She drinks wine but never heavily, just with meals.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, melena, maroon stools\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 05:05 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 72 (65 - 78) bpm\n BP: 174/48(81) {154/48(81) - 197/74(123)} mmHg\n RR: 24 (17 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 554 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 412 mL\n Total out:\n 0 mL\n 275 mL\n Urine:\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 279 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Thin, elderly\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, JVP low sitting upright\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 Crackles : fine, bibasilar)\n Abdominal: Soft, Non-tender, Bowel sounds present, midabdominal bruit\n heard. Aorta not enlarged by palpation\n Extremities: Right: Absent, Left: Absent\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 239 K/uL\n 8.0 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 39 mg/dL\n 28 mEq/L\n 105 mEq/L\n 3.2 mEq/L\n 141 mEq/L\n 23.6 %\n 5.6 K/uL\n [image002.jpg]\n \n 2:33 A12/20/ 11:51 AM\n \n 10:20 P12/20/ 01:13 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 5.6\n Hct\n 22.7\n 23.6\n Plt\n 239\n Cr\n 1.0\n Glucose\n 92\n Other labs: PT / PTT / INR:17.4/31.1/1.6, Ca++:8.1 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n Imaging: P-MIBI : No anginal type symptoms or ischemic EKG\n changes. Nuclear report is sent separately.\n 1. Reversible, medium sized, moderate severity perfusion defect\n involving the LAD territory.\n 2. Normal left ventricular cavity size and systolic function.\n .\n Abdomen US :\n 1. Small gallbladder stone, without evidence of acute cholecystitis.\n 2. Limited study with only a small portion of pancreas visible which\n grossly\n appears unremarkable.\n 3. Unchanged appearance abdominal aortic aneurysm measuring\n approximately 4.5\n x 4.7 cm.\n ECG: NSR, rate 70s, qwaves in III and aVF, TW flattening V3-5. LVH\n with R wave in aVL greater than 11 mm. Compared to , patient\n is currently in sinus rhythm without any significant ST-T changes.\n Assessment and Plan\n 62 y/o lady with CAD, HTN, and atrial fibrillation presents with\n gastrointestinal bleed.\n .\n # anemia: Likely lower GIB given guaic positive dark maroon stool in\n rectal volt in ED although reported melena at home. Hemodynamically\n stable currently. Refusing scope at this time.\n - GI notified. Appreciate input\n - Transfuse 2 units PRBCs given Hct drop to 22\n - PIV x 2\n - already 2 units of FFP in ED to reverse INR of 7.4\n - Vit K to reverse INR, already received 10 mg IV in ED\n - trend Hct and coags\n - send for CT noncontrast to eval for spontaneous RP hematoma given sig\n Hct drop without persistent GIB\n - send hemolysis labs\n - if Hct continues to drop and above evaluation negative, must consider\n possibility of herald bleed from aortoenteric fistula\n .\n # Hypertension: Hypertensive in ED. No signs or symptoms of infection\n or ischemia.\n - hold off on beta blockade for now\n - continue HCTZ\n - needs better control of BP given AAA, could consider starting\n amlodipine. Will monitor for now\n .\n # Atrial fibrillation: Currently in sinus.\n - will switch to short acting metoprolol when restarting\n - continue amiodarone for now. Needs 200 mg x 1 month\n - hold coumadin in acute GI bleed. not be good candidate in future\n .\n # : Her BUN is elevated to 40 with Cr relatively elevated to 1.1.\n Her BUN is most likely due to GIB. However she may have some prerenal\n insufficiency.\n - already received 1L NS\n - monitor I&O\n - consider renal lytes if her function worsens\n - IVF and PRBCs for UOP\n .\n # CAD: s/p CABG. No active signs of ischemia.\n - transfuse for HCT > 27\n - will hold asa in the setting of GIB.\n .\n # AAA: Needs out patient follow up. Stable on recent abdominal\n ultrasound.\n - better control of blood pressure as above.\n .\n # Hyperlipidemia:\n - continue home simvastatin\n .\n # B12 deficiency:\n - cont home B12\n .\n # FEN: NPO for now, replete lytes prn\n .\n # Prophylaxis: Supratherapeutic INR. Pneumoboots. PPI IV BID.\n .\n # Contact: Daughter, \n .\n # Access: PIV\n .\n # Code: Full Code\n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin, s/p 10 mg vitamin K)\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": "Physician ", "chartdate": "2155-11-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 356886, "text": "TITLE:\n 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 Transfusions\n CT abd/pelvis pending\n Hypertension treated\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:30 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 Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Gastrointestinal: bloating\n Heme / Lymph: Anemia\n Flowsheet Data as of 08:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 78) bpm\n BP: 157/62(85) {140/48(77) - 187/74(123)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,009 mL\n PO:\n 60 mL\n TF:\n IVF:\n 83 mL\n Blood products:\n 866 mL\n Total out:\n 575 mL\n 300 mL\n Urine:\n 575 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 434 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n 11.2 g/dL\n 178 K/uL\n 98 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 106 mEq/L\n 139 mEq/L\n 32.1 %\n 7.1 K/uL\n [image002.jpg]\n 11:51 AM\n 01:13 PM\n 09:20 PM\n 02:00 AM\n WBC\n 5.6\n 7.1\n Hct\n 22.7\n 23.6\n 29.3\n 32.1\n Plt\n 239\n 178\n Cr\n 1.0\n 1.0\n Glucose\n 92\n 98\n Other labs: PT / PTT / INR:16.1/29.1/1.4, ALT / AST:13/16, Alk Phos / T\n Bili:/1.1, LDH:164 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n GI bleed\n Hypertension\n Coagulopathy 2ndary to warfarin\n resolved\n Atrial fibrillation\n Abdominal aortic aneurysm (chronic)\n 86-year-old woman with GI bleed in the setting of a markedly elevated\n INR (> 7). She has had no further clinical bleeding, and Hct increased\n about 9 points with 2 units PRBCs. She has declined endoscopy at this\n point; per prior notes this is consistent with her prior wishes as\n well.\n We will continue PPI and maintain IV access. Will continue to discuss\n the options of diagnostic (and possibly therapeutic) procedures with\n her. Will also collaborate with geriatrics, who have known her well in\n the past.\n For her atrial fibrillation, will hold anticoagulation today. Will\n defer the decision about resuming warfarin to her longer-term providers\n and her.\n For her hypertension, will titrate up HCTZ given prior history of ACEI\n intolerance\n To floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:30 AM\n 22 Gauge - 08:30 AM\n 20 Gauge - 01:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2155-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 356780, "text": "Pt is an 86 year old woman admitted after developing weakness for past\n few day and dark tarry stools. Hct 29.9 in ew, and INR ~7. Pt recently\n restarted on coumadin for afib.\n" }, { "category": "Nursing", "chartdate": "2155-11-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 356981, "text": "Pt is an 86 year old woman admitted after developing weakness x a few\n days and dark tarry stools. PMH sig for: CAD, HTN, AAA, AFib (on\n Coumadin). Hct 29.9 in ew, and INR ~7. Of note, pt was recently\n restarted on Coumadin for her AFib. Pt received Vit K and 2units FFP in\n transferred to MICU 6 for further management. -- Serial Hcts\n ~ 22-23 >> Pt received 2units PRBC on the eve of . HCT this am\n (post blood tx) = 32.1, followed by 34.1, at 09:00 this am. Pt had an\n ABD CT on to r/o RP bleed\n prelim negative. Pt is now stable for\n transfer to medical floor.\n Hypertension, benign\n Assessment:\n NIBP ranging 140\ns-190\ns / 40\ns-70\ns. HR 60\ns-70\ns, NSR. Pt w/o\n complaints.\n Action:\n Pt started on HCTZ (25 mg PO Daily), BP monitored closely.\n Response:\n BP now ranging 140\ns-150\ns / 50\ns-70\n Plan:\n Continue BP meds; ? need for further agents.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt w/o N/V/D, abd exam benign. No bm today. HCT this am = 32.1, post\n blood-tx last eve.\n Action:\n Repeat HCT sent later this am (approx 6 hrs after last HCT of 32.1).\n Pt started on clear liquid diet.\n Response:\n Repeat HCT = 34.1; no bm thus far; pt continues to deny n/v/abd pain;\n pt tolerated clear liquids well.\n Plan:\n Follow HCTs and coags; transfuse prn for HCT < 27; hold ASA and\n Coumadin; f/u GI recs.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LOWER GI BLEED\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 53 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: Contact, Additional Precautions\n PMH:\n CV-PMH: CAD, Hypertension\n Additional history: CABG, AAA, spinal infarct, depression,\n pancreatitis, appe\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:159\n D:73\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 250 mL\n 24h total out:\n 600 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 09:20 PM\n Potassium:\n 4.2 mEq/L\n 09:20 PM\n Chloride:\n 106 mEq/L\n 09:20 PM\n CO2:\n 26 mEq/L\n 09:20 PM\n BUN:\n 32 mg/dL\n 09:20 PM\n Creatinine:\n 1.0 mg/dL\n 09:20 PM\n Glucose:\n 98 mg/dL\n 09:20 PM\n Hematocrit:\n 34.1 %\n 09:19 AM\n Finger Stick Glucose:\n 96\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: jacket, 1 bag of clothes\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: n/a\n Credit Cards: n/a\n Cash / Credit cards sent home with:\n Jewelry: n/a\n Transferred from: MICU 686\n Transferred to: F 223\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Radiology", "chartdate": "2155-11-08 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1052386, "text": " 2:20 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? retroperitoneal bleed\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with dropping hematocrit, supratherapeutic INR, concern for\n RP bleed\n REASON FOR THIS EXAMINATION:\n ? retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dropping hematocrit, supratherapeutic INR, concern for\n retroperitoneal bleed.\n\n TECHNIQUE: Helical acquisition through the abdomen and pelvis was performed\n without contrast material.\n\n FINDINGS:\n\n ABDOMEN: There is minimal dependent atelectasis at the bilateral bases, with\n minimal left pleural thickening. The visualized heart is within normal\n limits. There is a simple left renal cyst. Small areas of dense material are\n noted within the stomach and proximal small bowel, likely consistent with\n ingested material. Duodenal diverticula are noted at the second and third\n portions. Mild colonic diverticulosis is noted. There is a bilobed infrarenal\n abdominal aortic aneurysm, measuring 5.1 x 4.7 cm in size within the upper\n portion of the aneurysm and 4.3 x 4.3 cm in size within the lower portion of\n the aneurysm. There are degenerative changes and prominent scoliosis of the\n lumbar spine.\n\n PELVIS: There is no free pelvic fluid. There is no evidence of\n retroperitoneal hematoma, as questioned. Small uterine calcifications are\n noted, likely representing tiny fibroids. The urinary bladder is somewhat\n distended. Mild colonic diverticulosis is noted. A pessary is in place.\n There are atherosclerotic calcifications of the distal abdominal aorta and\n iliac arteries. There are degenerative changes and prominent scoliosis of the\n lumbar spine.\n\n IMPRESSION:\n\n 1. No evidence of retroperitoneal hematoma, as questioned.\n\n 2. Bilobed infrarenal abdominal aortic aneurysm, measuring up to 5.1 cm in\n diameter.\n\n 3. Mild colonic diverticulosis.\n\n (Over)\n\n 2:20 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? retroperitoneal bleed\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2155-11-08 00:00:00.000", "description": "Report", "row_id": 150827, "text": "Sinus rhythm. Left ventricular hypertrophy. Inferior myocardial infarction.\nPoor R wave progression is consistent with old anterior myocardial infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing of \natrial fibrillation with rapid ventricular rate is no longer seen.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505021, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Rd the on 80% high flow neb.Sating 98-100%.LS clear with occasional\n rhonchi at bases.Pt awake and follows command.\n Action:\n Weaned O2 to 60%.Bld gases.Encouraged cough and deep breaths.\n Response:\n Sating well.No SOB.Bld gases acceptable.\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. Trend ABG.Cont\n with cough and deep breath.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, pt\n stillhas HD line .\n Action:\n BUN and Cr trending down.Renal following.\n Response:\n UOP cont be ok.\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABP ranges from 155-`80 occasinonaly upto 200.\n Action:\n Given standing BP meds as ordered. Bp cont stayed high.Clonidine\n patch 0.3mcg on.NBP 20 points lower than ABP.\n Response:\n BP comes down with Sleep and rest.\n Plan:\n Monitor BP, Titrate BP meds as needed.\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505090, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505108, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Cont. to produce fevers intermittently Tmax 100.5 oral recent sputum\n growing pseudomonas\n Action:\n Monitoring fevers, contact precautions, started on cefepime this night\n Response:\n As above\n Plan:\n Monitor fevers, cont. cefepine\n Impaired Skin Integrity\n Assessment:\n Healing wound on coccyx, yeast rash on coccyx and perianal area non\n raised limited area\n Action:\n Open to air, ointments , flexiseal in, discussed with HO potential need\n for peg in prep for rehab as too weak to ensure adequate calorie base\n is met\n Response:\n Healing wounds, body rash resolved, yeast improving and limited\n Plan:\n Cont. skin care plan, consider Peg tube for adequate nutrition needs\n in prep for rehab\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n On 36% high flow mash for sats in mid 90\ns, room air sats 88%, 3 liters\n nasal cannula 91-93% , fair cough effort, lung fields coarse\n Action:\n Titrated oxygen to maintain sats above 90%\n Response:\n Stable on current min. oxygen need\n Plan:\n Titrate oxygen to off when able, mobilize with PT, to chair, plan for\n rehab soon\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cont. to have edema generally, pp intact, HD and central line out.\n Urine output large and clear\n Action:\n Gave 40 mgm lasix IV for response of 500 cc in hr with cont.\n autodiuresis though night\n Response:\n Achieved negative goal today of 3.5 liters\n Plan:\n Follow total body balance, cont. to diures\n Muscle Performace, Impaired\n Assessment:\n Wiggles toes to command bil. Not able to lift any extremety to command,\n slight right hand grasp, none on left. Not able to lift neck or move\n independently.\n Action:\n ROM, mobilize with PT OOb to , rehab eval\n Response:\n Weak all extremeties as noted above\n Plan:\n Mobilize, plan to rehab soon\n" }, { "category": "Physician ", "chartdate": "2117-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505178, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Holding HD, per Renal: keep R IJ if possible in case needs HD but can\n pull if needed\n - Another bcx of GPC in pairs and clusters in 1 anaerobic bottle from\n (second positive bottle)\n - coag negative staph from , will do sensitivities given 2 days of\n coag positive staph --> MRSA\n - Per renal, goal negative 3-4L today\n - Lasix 20mg IV x1, then lasix 40mg IV to reach I&O goal\n - Hydral 10mg IV a6h prn started\n - Pulled a-line, temp HD line (IJ), will pull subclavian line when PICC\n is repositioned\n - Klonipin prn agitation started\n - sputum grew Klebsiella, which in the past was resistant to , \n was started on Cefepime\n DIALYSIS CATHETER - STOP 02:00 PM\n ARTERIAL LINE - STOP 03:00 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Meropenem - 08:15 PM\n Cefipime - 10:12 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:11 PM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 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: 37.8\nC (100.1\n HR: 94 (76 - 94) bpm\n BP: 107/50(63) {107/50(63) - 156/95(110)} mmHg\n RR: 30 (22 - 70) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 773 mL\n 335 mL\n PO:\n TF:\n 128 mL\n 300 mL\n IVF:\n 570 mL\n 35 mL\n Blood products:\n Total out:\n 4,070 mL\n 900 mL\n Urine:\n 4,070 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,297 mL\n -565 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 414 K/uL\n 8.8 g/dL\n 217 mg/dL\n 3.8 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.3 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n WBC\n 6.8GEN: NAD, speaks short phrases of words, alert, appears anxious.\n CV: RRR, no m/r/g\n PULM: CTAB\n ABD: soft, nt, nd, +BS\n EXTR: no edema\n 7.3\n 8.5\n 8.0\n Hct\n 23.4\n 23.5\n 26.3\n 27.3\n Plt\n 277\n 318\n 352\n 414\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 28\n 27\n 27\n 27\n 27\n Glucose\n 186\n 226\n 138\n 217\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.5 mg/dL, PO4:6.0 mg/dL\n Imaging: CXR Newly inserted PICC line over the left upper\n extremity. The line is still\n positioned in the left internal jugular vein. There is no evidence of\n changes. Unchanged distribution and density of the pre-existing\n parenchymal\n bilateral opacities.\n \n Microbiology: and B cxrs grew coag neg COCCUS in pairs and\n clusters, MRSA in \n sputum - PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n catheter tip pending\n Assessment and Plan\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic /Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - Added vancomycin on for GPC\n - get cultures daily from all possible lines (until cultures negative\n x48 hours, per ID)\n - pull as many lines today as possible (aline, HD line, TLC)\n - Requested speciation and sensitivities of GNRs in sputum cxr, as\n concern for treatment failure given growth while pt on appropriate abx\n therapy; also spec/ of GPC\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - ask renal if we can pull HD line today given positive blood cultures\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - add 10mg IV hydral q6h prn SBP >140\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Glargine increased to 40 QD, and continue ISS\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, start tube feeds (place NG tube), HD schedule\n per renal\n hold for now\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: pending clinical improvement, stay in ICU\n" }, { "category": "Physician ", "chartdate": "2117-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505181, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Holding HD, per Renal: keep R IJ if possible in case needs HD but can\n pull if needed\n - Another bcx of GPC in pairs and clusters in 1 anaerobic bottle from\n (second positive bottle)\n - coag negative staph from , will do sensitivities given 2 days of\n coag positive staph --> MRSA\n - Per renal, goal negative 3-4L today\n - Lasix 20mg IV x1, then lasix 40mg IV to reach I&O goal\n - Hydral 10mg IV a6h prn started\n - Pulled a-line, temp HD line (IJ), will pull subclavian line when PICC\n is repositioned\n - Klonipin prn agitation started\n - sputum grew Klebsiella, which in the past was resistant to , \n was started on Cefepime\n DIALYSIS CATHETER - STOP 02:00 PM\n ARTERIAL LINE - STOP 03:00 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Meropenem - 08:15 PM\n Cefipime - 10:12 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:11 PM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.8\nC (100.1\n HR: 94 (76 - 94) bpm\n BP: 107/50(63) {107/50(63) - 156/95(110)} mmHg\n RR: 30 (22 - 70) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 773 mL\n 335 mL\n PO:\n TF:\n 128 mL\n 300 mL\n IVF:\n 570 mL\n 35 mL\n Blood products:\n Total out:\n 4,070 mL\n 900 mL\n Urine:\n 4,070 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,297 mL\n -565 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: NAD, speaks short phrases of words, alert\n CV: RRR, no m/r/g\n PULM: CTAB\n ABD: soft, nt, nd, +BS\n EXTR: no edema\n Labs / Radiology\n 414 K/uL\n 8.8 g/dL\n 217 mg/dL\n 3.8 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.3 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n WBC\n 6.8\n 7.3\n 8.5\n 8.0\n Hct\n 23.4\n 23.5\n 26.3\n 27.3\n Plt\n 277\n 318\n 352\n 414\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 28\n 27\n 27\n 27\n 27\n Glucose\n 186\n 226\n 138\n 217\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.5 mg/dL, PO4:6.0 mg/dL\n Imaging: CXR Newly inserted PICC line over the left upper\n extremity. The line is still positioned in the left internal jugular\n vein. There is no evidence of changes. Unchanged distribution and\n density of the pre-existing parenchymal bilateral opacities.\n CXR improved L infiltrates\n Microbiology: and B cxrs grew coag neg COCCUS in pairs and\n clusters, MRSA in \n sputum - PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n catheter tip pending\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n Has gone into SVT (wide complex) in the past, resolved with adenosine.\n .\n # Septic /Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 12. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - Added vancomycin on for GPC\n - Now pt is on cefepime, meropenem and Vanc\n - get cultures daily from all possible lines (until cultures negative\n x48 hours, per ID)\n - pull as many lines today as possible (aline, HD line, TLC)\n - Requested speciation and sensitivities of GNRs in sputum cxr, as\n concern for treatment failure given growth while pt on appropriate abx\n therapy; also spec/ of GPC\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - pulled HD line today given positive blood cultures\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - also written for 10mg IV hydral q6h prn SBP >140\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - also written for 10mg IV hydral q6h prn SBP >140\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Glargine increased to 40 QD, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, start tube feeds (place NG tube), HD schedule\n per renal\n hold for now\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: pending clinical improvement, stay in ICU\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505089, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 505265, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n UPDATE: Fairly quiet day for with improving renal fxn,\n low supplemental oxygen support and no acute c/o pain or anxiety. The\n pt worked with PT this AM for general ROM and was moved OOB to chair\n for 60 minutes this AM.\n Pneumonia, other\n Assessment:\n Pt received/maintained on 35% cold steam face tent with sats in the\n low/mid 90\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Case Management ", "chartdate": "2117-11-12 00:00:00.000", "description": "Initial Assessment", "row_id": 505277, "text": "The patient is a 37 y/o with DM who transferred from OSH after\n presenting in septic shock with Staph PNA / bacteria with a course\n complicated by ARF and tachycardia. The patient has been called out to\n the floor.\n This nurse case manager spoke with the MICU attending regarding this\n patient\ns potential post-acute care needs, and it seems likely that the\n patient will need some level of rehab, possibly in at an LTACH given\n his medical needs as well. The patient does not currently have a\n viable payer for any post-acute care as he is currently uninsured.\n \ns office has been consulted per PAS notes in CCC. The lack of\n coverage severly limits the patient\ns options. or \n may be options but even those facilities have been declininig to offer\n beds to patients without a payer of late. At this point it seems to\n make sense to have the patient transfer to the floor and see what kind\n of progress he can make.\n This nurse case manager will continue to follow for discharge planning\n purposes while the patient is in the ICU. Please feel free to page for\n further case management assistance at any time.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Page: \n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505400, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Pneumonia, other\n Assessment:\n Pt received/maintained on 35% cold steam face tent LS are fairly\n clear in upper lobes and more diminished @ bases. No cough efforts.\n Pt continued to have abdominal breathing with RR in 30\n WBC 8.1\n Action:\n MD notified on pts increased to WOB\n ABG 7.49/37 /97/4 on above mentioned O@ supplement\n CXray\n.started on NIV\n Response:\n Pt resp status continued to be the same,denies any pain ,not agitated.\n Sats always maintained 95-97%\n RR 20-25 on BIPAP.\n Off the NIV and back on high flow now\n Plan:\n Cont to monitor resp fxn, coach pt to CDB, antibx as ordered .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt now recovering from ARF, pt making approx 100ml/hr clear yellow\n urine per hour.\n Action:\n Following Q1 hour urine output. Following serum kidney fxn tests\n Qday.\n Response:\n Pts kidney fxn cont to improve daily.\n Plan:\n Cont to follow kidney fxn/urine output daily.\n Muscle Performace, Impaired\n Assessment:\n Pt profoundly weak/flaccid. Pt opens eyes on verbal commands no other\n response noted at this shift. Mute voice, pt has difficulty\n articulating needs. Pt has denied c/o pain but does not appears\n anxious or agitated.\n Action:\n Repositioned Q2hr .\n Response:\n Pt remains with significantly impaired muscle weakness and will cont to\n require aggressive PT to assist with return of fxn.\n Plan:\n Pt is uninsured and will have diff transferring to a rehab facility\n and thus will likely stay in and receive his PT here and thus\n will be as aggressively as poss to deliver optimal/freq PT\n interventions.\n" }, { "category": "Physician ", "chartdate": "2117-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505501, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - increased glargine\n - thinking, once ARF improves, to d/c hydral and start ACEi (maybe in\n days)\n - per renal: goal 1-2 L out today (met goal without extra lasix)\n - hypernatremic from 142 to 146 to 150\n - tachypneic last night, so wasn\nt called out, as with belly\n breathing/effort too\n - GPR in blood culture; consistent with corynebacterium or\n proprionyebacterium\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:12 PM\n Vancomycin - 10:09 AM\n Meropenem - 08:52 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:21 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: 37.6\nC (99.6\n HR: 101 (80 - 106) bpm\n BP: 160/88(105) {109/43(60) - 165/89(136)} mmHg\n RR: 23 (23 - 40) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,941 mL\n 92 mL\n PO:\n TF:\n 871 mL\n IVF:\n 670 mL\n 92 mL\n Blood products:\n Total out:\n 3,010 mL\n 1,200 mL\n Urine:\n 3,010 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,069 mL\n -1,108 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV+ApnVol\n PS : 15 cmH2O\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 95%\n ABG: 7.49/37/96./24/4\n Ve: 13.3 L/min\n PaO2 / FiO2: 242\n Physical Examination\n GEN\n nad, alert, tracks, does not speak, shakes head to\nno pain\n CV\n rrr, no murmurs auscultated\n PULM\n clear\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 390 K/uL\n 8.3 g/dL\n 145 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 57 mg/dL\n 114 mEq/L\n 150 mEq/L\n 26.4 %\n 8.1 K/uL\n [image002.jpg]\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n WBC\n 7.3\n 8.5\n 8.0\n 8.1\n Hct\n 23.5\n 26.3\n 27.3\n 26.4\n Plt\n 90\n Cr\n 3.4\n 4.3\n 3.8\n 2.7\n 2.0\n TCO2\n 27\n 27\n 27\n 27\n 29\n Glucose\n 45\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:6.4 mg/dL\n CXR: persistent haze at left base\n Assessment and Plan\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 12. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to \n - given improving Cr, investigate re-dosing meropenem perhaps\n - s/p removal of aline, HD line, TLC\n - Added vancomycin on for GPC\n - F/u ID recs\n - consider GPR (corynebacterium) as skin contaminant in bld cx\n - get cultures daily (until cultures negative x48 hours, per ID)\n - f/u daily CXR, sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Tachypnea on , unclear etiology\n (positional, AMS, PE). Improving, not de-satting, but still with incr\n work of breathing.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation as well as ongoing infection, think pt\ns MS is likely due to\n toxic-metabolic encephalopathy. Will cont to monitor for 2-3 days\n (from ), and if no improvement can consider head CT, EEG\n monitoring and AMS w/u. Monitor for now.\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - pulled HD line () given positive blood cultures\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider dc\ning and starting\n ACEI in days when stable improved kidney fxn\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - consider starting ACEi tomorrow instead of hydralazine\n .\n # DM: Blood sugars previously poorly controlled.\n - Glargine 50 QD and continue ISS\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5 days\n as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n OTHER STABLE ISSUES\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: ICU given tenuous respiratory status.\n ICU Care\n Lines:\n PICC Line - 04:30 PM\n Code status: Full code\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505372, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Pneumonia, other\n Assessment:\n Pt received/maintained on 35% cold steam face tent LS are fairly\n clear in upper lobes and more diminished @ bases. No cough efforts.\n Pt continued to have abdominal breathing with RR in 30\n WBC 8.1\n Action:\n MD notified on pts increased to WOB\n ABG 7.49/37 /97/4 on above mentioned O@ supplement\n CXray\n.started on NIV\n Response:\n Pt resp status continued to be the same,denies any pain ,not agitated.\n Sats always maintained 95-97%\n RR 20-25 on BIPAP.\n Off the NIV and back on face mask.\n Plan:\n Cont to monitor resp fxn, coach pt to CDB, antibx as ordered .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt now recovering from ARF, pt making approx 100ml/hr clear yellow\n urine per hour.\n Action:\n Following Q1 hour urine output. Following serum kidney fxn tests\n Qday.\n Response:\n Pts kidney fxn cont to improve daily.\n Plan:\n Cont to follow kidney fxn/urine output daily.\n Muscle Performace, Impaired\n Assessment:\n Pt profoundly weak/flaccid. Pt opens eyes on verbal commands no other\n response noted at this shift. Mute voice, pt has difficulty\n articulating needs. Pt has denied c/o pain but does not appears\n anxious or agitated.\n Action:\n Repositioned Q2hr .\n Response:\n Pt remains with significantly impaired muscle weakness and will cont to\n require aggressive PT to assist with return of fxn.\n Plan:\n Pt is uninsured and will have diff transferring to a rehab facility\n and thus will likely stay in and receive his PT here and thus\n will be as aggressively as poss to deliver optimal/freq PT\n interventions.\n" }, { "category": "Physician ", "chartdate": "2117-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505459, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - increased glargine\n - thinking, once ARF improves, to d/c hydral and start ACEi\n - per renal: goal 1-2 L out today (met goal without extra lasix)\n - hypernatremic from 142 to 146 to 150\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:12 PM\n Vancomycin - 10:09 AM\n Meropenem - 08:52 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:21 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: 37.6\nC (99.6\n HR: 101 (80 - 106) bpm\n BP: 160/88(105) {109/43(60) - 165/89(136)} mmHg\n RR: 23 (23 - 40) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,941 mL\n 92 mL\n PO:\n TF:\n 871 mL\n IVF:\n 670 mL\n 92 mL\n Blood products:\n Total out:\n 3,010 mL\n 1,200 mL\n Urine:\n 3,010 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,069 mL\n -1,108 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV+ApnVol\n PS : 15 cmH2O\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 95%\n ABG: 7.49/37/96./24/4\n Ve: 13.3 L/min\n PaO2 / FiO2: 242\n Physical Examination\n GEN\n CV\n PULM\n ABD\n EXTR\n Labs / Radiology\n 390 K/uL\n 8.3 g/dL\n 145 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 57 mg/dL\n 114 mEq/L\n 150 mEq/L\n 26.4 %\n 8.1 K/uL\n [image002.jpg]\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n WBC\n 7.3\n 8.5\n 8.0\n 8.1\n Hct\n 23.5\n 26.3\n 27.3\n 26.4\n Plt\n 90\n Cr\n 3.4\n 4.3\n 3.8\n 2.7\n 2.0\n TCO2\n 27\n 27\n 27\n 27\n 29\n Glucose\n 45\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:6.4 mg/dL\n CXR: persistent haze at left base\n Assessment and Plan\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 12. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - s/p removal of aline, HD line, TLC\n - Added vancomycin on for GPC\n - F/u ID recs for: double coverage of ? pseudomonal PNA, also re: abx\n coverage for coag pos staph bacteremia, duration of therapy\n - get cultures daily (until cultures negative x48 hours, per ID)\n - f/u daily CXR, sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation as well as ongoing infection, think pt\ns MS is likely due to\n toxic-metabolic encephalopathy. Will cont to monitor for 2-3 days\n (from ), and if no improvement can consider head CT, EEG\n monitoring and AMS w/u.\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - pulled HD line yesterday () given positive blood cultures\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider dc\ning and starting\n ACEI in days when stable improved kidney fxn\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n .\n # DM: Blood sugars poorly controlled.\n - Glargine increased to 50 QD and continue ISS\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5 days\n as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n OTHER STABLE ISSUES\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, started tube feeds, speech & swallow and PT\n consults, HD per renal\n holding for now given improved renal fxn\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: call out to floor\n ICU Care\n Lines:\n PICC Line - 04:30 PM\n Code status: Full code\n" }, { "category": "Nursing", "chartdate": "2117-11-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505649, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Early in shift pt noted to be working very hard to breath while on\n Bipap. RR high 30\ns, abd and accessory muscles being used, LS very\n diminished, o2sat remained in mid-90\ns. MD\ns notified.\n Action:\n Started w/ PO clonazepam via NGT, RT increased , MD\ns ordered\n CXR, 40mg IV lasix and 1mg IV Ativan. ABG done as well. Repositioned\n pt in bed to 90degrees and supine.\n Response:\n Pt calmed w/ meds but still working to breath. CXR was improved\n compared to AM CXR. Put out very well to the lasix. Attempted pt off\n bipap and given albuterol/atrovent nebs. Placed back on 50% high flow\n face-tent but soon required 60%. Pt eventually settled and looked much\n more comfortable breathing w/ o2 sat high 90\ns. Later had difficulty\n again after bathing and turning, desat to 88-90, required nebs again\n and 95% high flow face tent. Given seroquel PRN w/ good calming\n effect. Pt eventually back down to 60% on highflow face-tent.\n Plan:\n Cont PRN nebs and clonazepam and/or seroquel for comfort. f/u w/ AM\n cxr.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak but able to wiggle toes/fingers consistently\n to verbal command. Not attempting to speak even when asked. The pt\n requires extra time to process questions. Extremities are flaccid with\n pt unable to hold extremity up against gravity. Pt inconsistent when\n asked to nod to yes and no questions.\n Action:\n ROM provided to all extremities.\n Response:\n Pt remains profoundly weak @ this time with minimal/no obvious\n improvement from .\n Plan:\n Pt will cont to require aggressive PT and needs to be mobilized OOB to\n chair daily.\n Hypernatremia (high sodium)\n Assessment:\n AM serum sodium value of 150 noted. Pt finishing 2L IV d5 @ 240cc/hr\n and getting 200cc FWB via NGT Q6H.\n Action:\n Repeat Na level sent from PICC but results ?\nd (116) so sent peripheral\n lab and was (146). Finished w/ D5 fluids but still giving 200cc FWB\n Q6H.\n Response:\n AM Na level (???).\n Plan:\n Cont 200cc FWB via NGT Q6H, discuss on rounds whether to continue FWB\n or if addition interventions needed.\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506118, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt Rd on 40% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%. Follow commands cont be very\n weak,inconsistently nodding head to yes/ no questions\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.Weaned O2 6L Pt\n .pt tolerated sitting up in chair >4 hrs. Pt came and worked with him.\n Response:\n Weak cough.No more episodes of desating.\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely. rehab screening.\n Hypernatremia (high sodium)\n Assessment:\n AM sodium 146.\n Action:\n Cont FWB at 300cc q4hrs. Cont with D5W at 150cc/hr for 2000cc.sent\n evening lytes.\n Response:\n PM sodium 145,Mag 1.1 getting 1^st bag Mag,needs 1 more bag .\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505556, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n UPDATE:\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n AM serum sodium value of 150 noted.\n Action:\n Pt now receiving 200ml free water boluses via NGT Q 6 hrs. Pt also\n receiving two liters of D5W infusing @ 240ml/hr via PICC.\n Response:\n Plan:\n Will check next lytes with 12/13 AM labs.\n" }, { "category": "Physician ", "chartdate": "2117-11-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 505479, "text": "Chief Complaint: Respiratory Failure, Klebsiella pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Had evidence of accessory muscle use and tachypnea last night and this\n AM. Currently on mask ventilation\n 24 Hour Events:\n BLOOD CULTURED - At 04:24 PM\n CALLED OUT\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:12 PM\n Meropenem - 08:22 AM\n Vancomycin - 08:23 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 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: NIPPV\n Genitourinary: Foley\n Heme / Lymph: Anemia\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: 38\nC (100.4\n Tcurrent: 37.6\nC (99.6\n HR: 90 (78 - 106) bpm\n BP: 160/82(98) {109/43(60) - 165/92(136)} mmHg\n RR: 25 (20 - 40) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,941 mL\n 779 mL\n PO:\n TF:\n 871 mL\n 123 mL\n IVF:\n 670 mL\n 456 mL\n Blood products:\n Total out:\n 3,010 mL\n 1,500 mL\n Urine:\n 3,010 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,069 mL\n -721 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV+ApnVol\n Vt (Spontaneous): 316 (316 - 316) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: 7.49/37/96./24/4\n Ve: 3.3 L/min\n PaO2 / FiO2: 323\n Physical Examination\n General Appearance: Overweight / Obese, on NIPPV with abd muscle use\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: Non-tender, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 390 K/uL\n 145 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 57 mg/dL\n 114 mEq/L\n 150 mEq/L\n 26.4 %\n 8.1 K/uL\n [image002.jpg]\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n WBC\n 7.3\n 8.5\n 8.0\n 8.1\n Hct\n 23.5\n 26.3\n 27.3\n 26.4\n Plt\n 90\n Cr\n 3.4\n 4.3\n 3.8\n 2.7\n 2.0\n TCO2\n 27\n 27\n 27\n 27\n 29\n Glucose\n 45\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:6.4 mg/dL\n Microbiology: : corynebacterium\n Assessment and Plan\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n ESBL klebs bacteremia/pneumonia: Cont meropenem\n Acute respiratory failure: Has had onset of abdominal muscle use -\n will continue with bipap prn.\n GPC bacteremia: coag neg staph/cornynebacterium - now de-lined except\n for new PICC line. Cont vanc.\n Hypertension: dilt and metoprolol, clonidine. prn hydralazine\n Tachcardia/SVT: dilt and metoprolol\n ARF - Renal function continues to improve\n MS - continues to be impaired though he does follow commands\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 08:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506191, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was complicated by ARF, and\n was started on H/D hyperkalemia.Renal function is now fully\n recovered.\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Hypernatremia (high sodium)\n Assessment:\n Sodium level has been consistently high oveer the past few days.\n Action:\n Has been and is receiving D5W and free water boluses for high sodium.\n Response:\n Sodium this am 143.\n Plan:\n Team to re evaluate pt re sodium level.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak and unable to lift UE/LE to gravity. Pt\n consistently follows commands (wiggle toes/ fingers). Pt nodding head\n appropriately to yes/no questions.\n Action:\n PROM provided to all extremities.\n Response:\n No appreciable change noted in muscle strengthover the last two days..\n Plan:\n Cont to provide PROM to all extemities and mobilize pt OOB to chair\n daily. PT consult in place to facilitate muscle strength.\n Dyspnea (Shortness of breath)\n Assessment:\n No episodes on 40% high flow neb.RR in 20\ns. sating >95% on\n the current settings.\n Action:\n Weaned O2 to 35%.Turn and chest PT Q2hrs.\n Response:\n No resp distress overnight.\n Plan:\n Monitor resp status.Frequent cheat PT.\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505554, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505555, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505557, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n UPDATE:\n Dyspnea (Shortness of breath)\n Assessment:\n Pt\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n AM serum sodium value of 150 noted.\n Action:\n Pt now receiving 200ml free water boluses via NGT Q 6 hrs. Pt also\n receiving two liters of D5W infusing @ 240ml/hr via PICC.\n Response:\n Plan:\n Will check next lytes with 12/13 AM labs.\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505564, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n UPDATE: Pt was SOB this AM requiring the return of CPAP/PS this AM with\n improve resp fxn. Profound muscle weakness was unchanged today. The\n pts mother calls daily and kept up to date with POC.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt received mildly dyspneic on 50% cold steam face tent with RR in the\n 20-30\ns, accessory muscle recruitment/abd breathing and sats in the low\n 90\ns. LS are diminished in all fields, seems to be clear in upper\n lobes. Weak non-prod cough.\n Action:\n Pt returned to CPAP/PS 10/5 with 30% FiO2 this AM. Pt weaned back onto\n 50% CSFM later this afternoon. Pt coached to CDB.\n Response:\n Pt appears more comfortable now on CSFM than earlier this AM with nl\n sats, RR but is again recruiting accessories muscles to facilitate gas\n exchange.\n Plan:\n Pt will likely require the return of CPAP/PS later this evening and\n overnight to ensure optimal gas exchange/pt comfort.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n AM Serum Creatinine value dropped to 2.0 this AM with likely nl GFR per\n team. Urine is yellow and clear. The pt is net input 300ml today and\n is net input five liters for LOS.\n Action:\n Following hourly/daily urine output. Following daily renal fxn labs.\n Response:\n Pt renal fxn cont to improve as reflected in normalizing cr values and\n excellent hourly urine output.\n Plan:\n Cont to follow urine output, daily renal fxn lab values.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak but able to wiggle toes/fingers consistently\n to verbal command. Voice remains essentially mute. The pt requires\n extra time to process questions. Extremities are flaccid with pt\n unable to hold extremity up against gravity. Pt able to nod head\n appropriately to some simple yes/no questions.\n Action:\n ROM provided to all extremities. Pt moved OOB to chair for one hour\n this afternoon.\n Response:\n Pt remains profoundly weak @ this time with minimal/no obvious\n improvement from .\n Plan:\n Pt will cont to require aggressive PT and needs to be mobilized OOB to\n chair daily for one hour.\n Hypernatremia (high sodium)\n Assessment:\n AM serum sodium value of 150 noted.\n Action:\n Pt now receiving 200ml free water boluses via NGT Q 6 hrs. Pt also\n receiving two liters of D5W infusing @ 240ml/hr via PICC.\n Response:\n Plan:\n Will check next lytes with 12/13 AM labs.\n" }, { "category": "Nursing", "chartdate": "2117-11-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505643, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt received mildly dyspneic on 50% cold steam face tent with RR in the\n 20-30\ns, accessory muscle recruitment/abd breathing and sats in the low\n 90\ns. LS are diminished in all fields, seems to be clear in upper\n lobes. Weak non-prod cough.\n Action:\n Pt returned to CPAP/PS 10/5 with 30% FiO2 this AM. Pt weaned back onto\n 50% CSFM later this afternoon. Pt coached to CDB.\n Response:\n Pt appears more comfortable now on CSFM than earlier this AM with nl\n sats, RR but is again recruiting accessories muscles to facilitate gas\n exchange.\n Plan:\n Pt will likely require the return of CPAP/PS later this evening and\n overnight to ensure optimal gas exchange/pt comfort.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n AM Serum Creatinine value dropped to 2.0 this AM with likely nl GFR per\n team. Urine is yellow and clear. The pt is net input 300ml today and\n is net input five liters for LOS.\n Action:\n Following hourly/daily urine output. Following daily renal fxn labs.\n Response:\n Pt renal fxn cont to improve as reflected in normalizing cr values and\n excellent hourly urine output.\n Plan:\n Cont to follow urine output, daily renal fxn lab values.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak but able to wiggle toes/fingers consistently\n to verbal command. Voice remains essentially mute. The pt requires\n extra time to process questions. Extremities are flaccid with pt\n unable to hold extremity up against gravity. Pt able to nod head\n appropriately to some simple yes/no questions.\n Action:\n ROM provided to all extremities. Pt moved OOB to chair for one hour\n this afternoon.\n Response:\n Pt remains profoundly weak @ this time with minimal/no obvious\n improvement from .\n Plan:\n Pt will cont to require aggressive PT and needs to be mobilized OOB to\n chair daily for one hour.\n Hypernatremia (high sodium)\n Assessment:\n AM serum sodium value of 150 noted.\n Action:\n Pt now receiving 200ml free water boluses via NGT Q 6 hrs. Pt also\n receiving two liters of D5W infusing @ 240ml/hr via PICC.\n Response:\n Plan:\n Will check next lytes with 12/13 AM labs.\n" }, { "category": "Nursing", "chartdate": "2117-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506311, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 143\n Action:\n D5w infusion stopped and free h2o bolus decreased to 200cc q4\n Plans to change tube feeds to pulmonary formula\n Phos binder d/c\n Response:\n Normal NA\n Plan:\n Free h2o bolus as ordered\n Pm lytes\n Muscle Performace, Impaired\n Assessment:\n Profoundly weak\n Action:\n Pt able to lift hands off bed, and wiggle toes, but unable to assist\n with any moving or care\n Weak cough, but able to exprectorate secretions\n O2 weaned to 2l NC\n Awaiting Mass health approval to be rehab screening process\n Response:\n Weaning o2\n Remains weak\n Plan:\n OOB to chair daily\n CPT prn\n Wean o2 as tolerated\n Screen for rehab when insurance issues resolved\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n BP wnl\n Action:\n Hydralizine decreased to 25mg po qid, then d/c\nd due to lower bp\n Plans to titrate BP meds and decrease when possible\n Response:\n Slow wean of antihypertensives\n Plan:\n Antihypertensives as ordered\n" }, { "category": "Physician ", "chartdate": "2117-11-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505689, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory distress, altered mental status\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 06:00 PM\n - once ARF improves, will d/c hydral and start ACEi\n - one episode of respiratory distress this PM--tachypnic to 30s, O2sats\n low 90s on bipap. CXR taken (unchanged), ABG sent (also relatively\n unchanged, O2 97->79)). Pt given neb, ativan 1mg, lasix 40mg IV, and\n re-posititioned, with significant improvement--within 1 hour, on shovel\n face mask at 97%O2.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:12 PM\n Vancomycin - 09:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Furosemide (Lasix) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.3\nC (99.2\n HR: 101 (76 - 102) bpm\n BP: 147/75(90) {120/56(69) - 160/92(105)} mmHg\n RR: 32 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,058 mL\n 1,065 mL\n PO:\n TF:\n 630 mL\n 299 mL\n IVF:\n 2,828 mL\n 216 mL\n Blood products:\n Total out:\n 4,255 mL\n 875 mL\n Urine:\n 4,255 mL\n 875 mL\n NG:\n Stool:\n Drains:\n Balance:\n -197 mL\n 190 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV+ApnVol\n Vt (Spontaneous): 420 (316 - 793) mL\n PS : 14 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n SpO2: 94%\n ABG: 7.47/39/78./25/4\n Ve: 11 L/min\n PaO2 / FiO2: 132\n Physical Examination\n GEN\n NAD, alert, tracks, does not speak, shakes head to\nno pain\n CV\n RRR, no murmurs\n PULM\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 373 K/uL\n 8.0 g/dL\n 210 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 46 mg/dL\n 112 mEq/L\n 148 mEq/L\n 24.7 %\n 8.8 K/uL\n [image002.jpg]\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n Plt\n 73\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n TCO2\n 27\n 27\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.4 mg/dL, PO4:6.1 mg/dL\n Imaging: CXR LLL infiltrate, improving LUL\n CXR LLL infiltrate, improving LUL\n Microbiology: None new\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 12. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to \n - Meropenem re-dosed for pt\ns renal function\n - s/p removal of aline, HD line, TLC\n - Added vancomycin on for GPC\n - F/u ID recs\n - get cultures daily (until cultures negative x48 hours, per ID)\n - f/u daily CXR, sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Tachypnea on , unclear etiology\n (positional, AMS, PE). Improving, not de-satting, but still with incr\n work of breathing.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation as well as ongoing infection, think pt\ns MS is likely due to\n toxic-metabolic encephalopathy. Will cont to monitor for 2-3 days\n (from ), and if no improvement can consider head CT, EEG\n monitoring and AMS w/u. Monitor for now.\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - pulled HD line () given positive blood cultures\n .\n # Hypernatremia\n - improved with 1/2D5 at 240 ml/hr overnight.\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider dc\ning and starting\n ACEI in days when stable improved kidney fxn\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - consider starting ACEi tomorrow instead of hydralazine\n .\n # DM: Blood sugars previously poorly controlled.\n - Glargine 50 QD and continue ISS\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5 days\n as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n OTHER STABLE ISSUES\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status.\n" }, { "category": "Physician ", "chartdate": "2117-11-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 505741, "text": "Chief Complaint: Klebsiella pneumonia, 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 Still not conversant\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 06:00 PM\n Had episode of respiratory distress/hypoxemia last PM that resolved\n with nebs, repositioning\n CXR this AM consitent with L mainstem mucous plugging\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:12 PM\n Vancomycin - 09:00 PM\n Meropenem - 07:55 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Furosemide (Lasix) - 07:50 PM\n Famotidine (Pepcid) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 07:55 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 Cardiovascular: No(t) Tachycardia\n Respiratory: Tachypnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 84 (76 - 102) bpm\n BP: 142/68(84) {120/56(69) - 156/83(98)} mmHg\n RR: 29 (17 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,058 mL\n 1,636 mL\n PO:\n TF:\n 630 mL\n 496 mL\n IVF:\n 2,828 mL\n 460 mL\n Blood products:\n Total out:\n 4,255 mL\n 1,535 mL\n Urine:\n 4,255 mL\n 1,535 mL\n NG:\n Stool:\n Drains:\n Balance:\n -197 mL\n 102 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV+ApnVol\n Vt (Spontaneous): 420 (389 - 420) mL\n PS : 14 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n SpO2: 95%\n ABG: 7.47/39/78./25/4\n Ve: 11 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: throughout)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 373 K/uL\n 210 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 46 mg/dL\n 112 mEq/L\n 148 mEq/L\n 24.7 %\n 8.8 K/uL\n [image002.jpg]\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n Plt\n 73\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n TCO2\n 27\n 27\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.4 mg/dL, PO4:6.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n ESBL klebs bacteremia/pneumonia: Cont meropenem\n Acute respiratory failure: Had episode of mucous plugging seen on CXR\n this AM - exam no longer constent after chest PT --> will repeat CXR\n GPC bacteremia: Cont vanc\n Hypertension: dilt and metoprolol, clonidine. Start ACE-I. prn\n hydralazine\n Tachcardia/SVT: dilt and metoprolol\n ARF - Renal function continues to improve\n MS - still has poor mental status - will hold off on head imaging,\n suspect ongoing ICU delerium\n DM - sugars elevated but getting D5W for hypernatremia\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 11:20 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2117-11-15 00:00:00.000", "description": "Swallowing Follow-Up", "row_id": 506020, "text": "TITLE: SWALLOWING FOLLOW-UP\nWe returned to follow-up with patient regarding swallowing.\nPatient with worsening respiratory status over the weekend and\ncontinues to be unstable and weak. PO trials deferred at this\ntime. Please continue NPO status with tube feeds. Please\nreconsult once patient's overall medical/respiratory status\nimproves and we will be happy to return.\n_______________________________\n , MS, CCC-SLP\nPager #\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504613, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Intubated, CPAP 8 + 6, 40%. RR 20s-32, sats >95%. Breath sounds clear,\n diminished at bases. Sx several times for small amts thick bright\n yellow secretions. Strong cough. Presedex @ .2mcg/k/hr. Pt denies pain\n but nods yes when asked if feeling anxious.\n Action:\n Increased PS-> 14 in effort to decrease RR from 30s. Increased presedex\n to .3mcg d/t pts c/o feeling anxious, emotional support given\n Response:\n RR 17-32, mostly in low 20s but occ ^^ 30 while sleeping. AM ABG\n 7.47/36/126/27.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 PO. Pt diaphoretic.\n Action:\n HO aware, UC sent. BC sent with AM labs. Tylenol via OGT. Meropenum as\n ordered.\n Response:\n T decreased to 99.4 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Physician ", "chartdate": "2117-11-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505745, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory distress, altered mental status\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 06:00 PM\n - once ARF improves, will d/c hydral and start ACEi\n - one episode of respiratory distress this PM--tachypnic to 30s, O2sats\n low 90s on bipap. CXR taken (unchanged), ABG sent (also relatively\n unchanged, O2 97->79)). Pt given neb, ativan 1mg, lasix 40mg IV, and\n re-posititioned, with significant improvement--within 1 hour, on shovel\n face mask at 97%O2.\n - improved resp status this AM on 60% on high flow face-tent.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 10:12 PM\n Vancomycin - 09:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Furosemide (Lasix) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.3\nC (99.2\n HR: 101 (76 - 102) bpm\n BP: 147/75(90) {120/56(69) - 160/92(105)} mmHg\n RR: 32 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,058 mL\n 1,065 mL\n PO:\n TF:\n 630 mL\n 299 mL\n IVF:\n 2,828 mL\n 216 mL\n Blood products:\n Total out:\n 4,255 mL\n 875 mL\n Urine:\n 4,255 mL\n 875 mL\n NG:\n Stool:\n Drains:\n Balance:\n -197 mL\n 190 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV+ApnVol\n Vt (Spontaneous): 420 (316 - 793) mL\n PS : 14 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n SpO2: 94%\n ABG: 7.47/39/78./25/4\n Ve: 11 L/min\n PaO2 / FiO2: 132\n Physical Examination\n GEN\n NAD, alert, tracks, does not speak, shakes head to\nno pain\n CV\n RRR, no murmurs\n PULM\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 373 K/uL\n 8.0 g/dL\n 210 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 46 mg/dL\n 112 mEq/L\n 148 mEq/L\n 24.7 %\n 8.8 K/uL\n [image002.jpg]\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n Plt\n 73\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n TCO2\n 27\n 27\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.4 mg/dL, PO4:6.1 mg/dL\n Imaging: CXR LLL infiltrate, improving LUL\n CXR LLL infiltrate, improving LUL, 4am CXR white out of\n L lung w. likely mucous plug\n Microbiology: None new\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function, also added\n vancomycin on for GPC\n - s/p removal of aline, HD line, TLC\n - F/u ID recs\n - get cultures daily (until cultures negative x48 hours, per ID)\n - daily CXR\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n - Frequent suctioning and CPT as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point.\n - F/u renal recs, no HD and HD line removed\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Hypernatremia\n - improved with 1/2D5 at 240 ml/hr overnight but then worsened\n after lasix given for resp distress\n - - will add free H20 flushes\n - Re check electrolytes this pm\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider decreasing when ACEI\n uptitrated.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - star lisinopril and titrate to effect\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, will readdress in AM\n .\n OTHER STABLE ISSUES\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status.\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504722, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Intubated, CPAP 8 + 6, 40%. RR 20s-32, sats >95%. Breath sounds clear,\n diminished at bases. Sx several times for small amts thick bright\n yellow secretions. Strong cough. Presedex @ .2mcg/k/hr. Pt denies pain\n but nods yes when asked if feeling anxious.\n Action:\n Increased PS-> 14 in effort to decrease RR from 30s. Increased presedex\n to .3mcg d/t pts c/o feeling anxious, emotional support given\n Response:\n RR 17-32, mostly in low 20s but occ ^^ 30 while sleeping. AM ABG\n 7.47/36/126/27. RSBI 31, SBT for 20\n and pt became hypertensive, using\n abdominal muscles to breath. Pt c/o difficulty breathing so SBT\n aborted. Placed back on CPAP 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine 4.3\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 PO. Pt diaphoretic.\n Action:\n HO aware, UC sent. BC sent with AM labs. Sputum Cx sent this AM.\n Tylenol via OGT. Meropenum as ordered.\n Response:\n T decreased to 99.4 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506104, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt Rd on 40% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%. Follow commands cont be very\n weak,inconsistently nodding head to yes/ no questions\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.Weaned O2 6L Pt\n .pt tolerated sitting up in chair >4 hrs. Pt came and worked with him.\n Response:\n Weak cough.No more episodes of desating.\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely. rehab screening.\n Hypernatremia (high sodium)\n Assessment:\n AM sodium 146.\n Action:\n Cont FWB at 300cc q4hrs. Cont with D5W at 150cc/hr for 2000cc.sent\n evening lytes.\n Response:\n PM sodium 145,Mag 1.1 getting 1^st bag Mag,needs 1 more bag .\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n" }, { "category": "Nursing", "chartdate": "2117-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506298, "text": "Hypernatremia (high sodium)\n Assessment:\n NA 143\n Action:\n D5w infusion stopped and free h2o bolus decreased to 200cc q4\n Continues on renal formula TF at goal\n Response:\n Normal NA\n Plan:\n Free h2o bolus as ordered\n Pm lytes\n Muscle Performace, Impaired\n Assessment:\n Profoundly weak\n Action:\n Pt able to lift hands off bed, and wiggle toes, but unable to assist\n with any moving or care\n Weak cough, but able to exprectorate secretions\n O2 weaned to 2l NC\n Awaiting Mass health approval to be rehab screening process\n Response:\n Weaning o2\n Remains weak\n Plan:\n OOB to chair daily\n CPT prn\n Wean o2 as tolerated\n Screen for rehab when insurance issues resolved\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n BP wnl\n Action:\n Hydralizine decreased to 25mg po qid\n Plans to titrate BP meds and decrease when possible\n Response:\n Slow wean of antihypertensives\n Plan:\n Antihypertensives as ordered\n" }, { "category": "Nutrition", "chartdate": "2117-11-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 506304, "text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 159 mg/dL\n 03:20 AM\n Glucose Finger Stick\n 246\n 10:00 AM\n BUN\n 31 mg/dL\n 03:20 AM\n Creatinine\n 1.0 mg/dL\n 03:20 AM\n Sodium\n 143 mEq/L\n 03:20 AM\n Potassium\n 3.4 mEq/L\n 03:20 AM\n Chloride\n 110 mEq/L\n 03:20 AM\n TCO2\n 23 mEq/L\n 03:20 AM\n PO2 (arterial)\n 78. mm Hg\n 07:49 PM\n PCO2 (arterial)\n 39 mm Hg\n 07:49 PM\n pH (arterial)\n 7.47 units\n 07:49 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 07:49 PM\n Albumin\n 2.7 g/dL\n 03:20 AM\n Calcium non-ionized\n 8.0 mg/dL\n 03:20 AM\n Phosphorus\n 4.4 mg/dL\n 03:20 AM\n Magnesium\n 1.5 mg/dL\n 03:20 AM\n ALT\n 29 IU/L\n 03:20 AM\n Alkaline Phosphate\n 83 IU/L\n 03:20 AM\n AST\n 28 IU/L\n 03:20 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:20 AM\n WBC\n 8.9 K/uL\n 03:20 AM\n Hgb\n 7.9 g/dL\n 03:20 AM\n Hematocrit\n 24.7 %\n 03:20 AM\n Current diet order / nutrition support: Novasource Renal @ 45mL/hr\n (2160 kcals/80 grams protein)\n GI: Abd:soft/obese\n Assessment of Nutritional Status\n Specifics:\n Patient continues on full tube feeds via NGT. Repeat swallow eval\n deferred yesterday d/t respiratory status. Feeds well tolerated @ goal\n per discussion c/ RN. Renal function continues to improve-patient no\n longer requires renal tube feeds New formula will provide more volume\n as well as more K and Mg- hopefully this will decrease need for D5W as\n well as K and Mg repletions. New formula remains low .\n Medical Nutrition Therapy Plan - Recommend the Following\n Change tube feeds to Nutren Pulmonary @45mL/hr to increase\n 15 mL p/ 6 hr to goal 60mL/hr (2160 kcals/98 gr protein)\n Continue to check residuals q4, hold if >200mL\n Replete free water deficit per renal as you are\n Glucose control as you are\n Following #\n" }, { "category": "Nursing", "chartdate": "2117-11-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505787, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n UPDATE: AM CXR revealed complete opacification of L side 2^nd mucous\n plug which improved s/p chest PT, turning/ repositioning & pt cough per\n f/u afternoon CXR. Pt with another episode of dyspnea @ 14:00 with\n near resp arrest\n remedied with chest PT, NTS, repositioning and pt\n cough for large amounts of thich tan sec and a single large mucous plug\n (over 5cm in length).\n Dyspnea (Shortness of breath)\n Assessment:\n As noted above the pt developed L sided opacification on CXR 2^nd\n mucous plug. Pt became acutely dyspneic with accessory muscle\n recruitment this afternoon with decreased breath sounds on the L and\n diffuse coarse rhonchi appreciated in all lung fields. Pt desatted to\n the 80\ns with RR in the 30/40\n Action:\n Pt repositioned freq, chest PT provided, NTS provided, pt encouraged to\n CDB\n large thick tan sec evacuated along with giant mucous plug.\n Response:\n Pt now respirating more comfortably on 60% cold steam face tent.\n Repeat afternoon CXR revealed restored aeration on L side.\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely.\n Hypernatremia (high sodium)\n Assessment:\n AM serum sodium value of 148 noted.\n Action:\n Pt is s/p two liters D5W and 800ml FWB on . Team increasing FWB\n schedule @ this time awaiting recs.\n Response:\n Sodium serum value dropped from 150 on to 148 today.\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak and unable to lift UE/LE to gravity. Pt\n consistently follows commands (wiggle toes/ fingers). Pt nodding head\n appropriately to yes/no questions inconsistently.\n Action:\n PROM provided to all extremities today. Pt moved OOB to chair for one\n hour today.\n Response:\n No appreciable change noted in muscle strength today.\n Plan:\n Cont to provide PROM to all extemities and mobilize pt OOB to chair\n daily. PT consult in place to facilitate muscle strength.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504615, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 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:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: VERY THICK\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 Comments: RSBI-38, SBT trial was initiated but terminated after approx\n 30 min due to pt agitation (active exhalation which was resolved by\n returning to original peep and pt claimed discomfort) and a significant\n increase in BP (151/70- 178/89)\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504619, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Intubated, CPAP 8 + 6, 40%. RR 20s-32, sats >95%. Breath sounds clear,\n diminished at bases. Sx several times for small amts thick bright\n yellow secretions. Strong cough. Presedex @ .2mcg/k/hr. Pt denies pain\n but nods yes when asked if feeling anxious.\n Action:\n Increased PS-> 14 in effort to decrease RR from 30s. Increased presedex\n to .3mcg d/t pts c/o feeling anxious, emotional support given\n Response:\n RR 17-32, mostly in low 20s but occ ^^ 30 while sleeping. AM ABG\n 7.47/36/126/27. RSBI 31, SBT for 20\n and pt became hypertensive, using\n abdominal muscles to breath. Pt c/o difficulty breathing so SBT\n aborted. Placed back on CPAP 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine 4.3\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 PO. Pt diaphoretic.\n Action:\n HO aware, UC sent. BC sent with AM labs. Sputum Cx sent this AM.\n Tylenol via OGT. Meropenum as ordered.\n Response:\n T decreased to 99.4 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504798, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received Intubated on CPAP 40%/. RR 20s-32, sats >95%. RSBI this\n morning was 38. Bilateral Breath sounds Rhonchorus. ON Presedex @\n .6mcg/k/hr. widw eawake.following commands,appeared to be anxious.\n Action:\n Placed him on SBT this morning,5 minutes later became hypertensive\n upyo 180,Abd breathing And diaphoretic,ABG 1 hr after SBT was\n 7.49/34/68,Put back on * of ppep to help rest. Extubated afternoon\n around 1420.SPO2 94-95% o 80%,RR cont be 25-30,Post extubation looked\n Ook and it was 7.49/39/108 Stopped Presedex after 1hr of extubation.\n Response:\n RR comes down with sleeping, weak cough. Currently he is on 80% FIO2\n . SPO2 94-96%.\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. Trend ABG.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, pt\n stillhas HD line on her side\n Action:\n Cr up from yesterday 4.3 ( 4). Renal following.\n Response:\n UOP cont be ok.\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABP ranges from 155-`80 occasinonaly upto 200. With SBT trial BP went\n upto !80-200.\n Action:\n Given standing BP meds as ordered. Bp cont stayed high. Changed\n Clonidine dose from 0.2 to 0.3 . Changed Metoprolol 125 to 150.\n Response:\n BP comes down with Sleep and rest Pt also got seroquil for anxiety.\n Plan:\n Monitor BP, Titrate BP meds as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.6. Pt cont be diaphoretic.\n Action:\n Pan cultured. Sent Bc this afternoon,Given Tylenol 100mg PRN as\n ordered. Started on Vanc and Cont meropenem.\n Response:\n Given one time dose of Tylenol.\n Plan:\n Follow twmp curve.Cont abx.Follow with culture data. Meropenum for\n Klebsiella PNA.\n" }, { "category": "Nursing", "chartdate": "2117-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506174, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was complicated by ARF, and\n was started on H/D hyperkalemia.Renal function is now fully\n recovered.\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Hypernatremia (high sodium)\n Assessment:\n Sodium level has been consistently high oveer the past few days.\n Action:\n Has been and is receiving D5W and free water boluses for high sodium.\n Response:\n Sodium this am 143.\n Plan:\n Team to re evaluate pt re sodium level.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak and unable to lift UE/LE to gravity. Pt\n consistently follows commands (wiggle toes/ fingers). Pt nodding head\n appropriately to yes/no questions.\n Action:\n PROM provided to all extremities.\n Response:\n No appreciable change noted in muscle strengthover the last two days..\n Plan:\n Cont to provide PROM to all extemities and mobilize pt OOB to chair\n daily. PT consult in place to facilitate muscle strength.\n Dyspnea (Shortness of breath)\n Assessment:\n No episodes on 40% high flow neb.RR in 20\ns. sating >95% on\n the current settings.\n Action:\n Weaned O2 to 35%.Turn and chest PT Q2hrs.\n Response:\n No resp distress overnight.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505782, "text": "TITLE:\n" }, { "category": "Physician ", "chartdate": "2117-11-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504662, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory failure\n 24 Hour Events:\n - per ID, treat with 14 total days Meropenem since first negative blood\n culture = course should be from to \n - renal recommends starting epogen 10,000 units SQ twice a week\n - on presedex\n -good UO\n - febrile to 101 o/n, tachypneic in that setting with decreased tidal\n volumes - pan cultured\n - very uncomfortable when went down on pressure support\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 07:58 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:08 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: 37.7\nC (99.8\n HR: 95 (71 - 95) bpm\n BP: 181/86(114) {123/43(64) - 181/89(115)} mmHg\n RR: 26 (15 - 31) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,858 mL\n 468 mL\n PO:\n TF:\n 1,082 mL\n 288 mL\n IVF:\n 1,225 mL\n 151 mL\n Blood products:\n Total out:\n 1,170 mL\n 1,320 mL\n Urine:\n 1,170 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,688 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 573 (428 - 688) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.47/36/126/26/3\n Ve: 14 L/min\n PaO2 / FiO2: 315\n Physical Examination\n GEN: Sedated, tracking, PERRL 2->1mm\n CV: regular rate, no m/r/g\n PULM: fairly clear, few crackles bilat bases w. few scattered wheezes,\n mod amt of white/yello purulent sputum suctioned by resp\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema, puffy hands/face\n Labs / Radiology\n 318 K/uL\n 8.1 g/dL\n 226 mg/dL\n 4.3 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 59 mg/dL\n 103 mEq/L\n 139 mEq/L\n 23.5 %\n 7.3 K/uL\n [image002.jpg]\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n WBC\n 7.7\n 6.8\n 7.3\n Hct\n 23.8\n 23.4\n 23.5\n Plt\n 277\n 277\n 318\n Cr\n 6.4\n 4.0\n 3.4\n 4.3\n TCO2\n 24\n 25\n 28\n 29\n 28\n 27\n Glucose\n 193\n 163\n 186\n 226\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR done\n CXR Persistent pneumonic infiltrate mostly in left lower lung\n field.\n No pneumothorax or other abnormalities.\n Microbiology: B cxrs , , , , pending\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8.\n - Increasing propofol to help with hypertension/tachycardia (see\n below).\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n - Will decrease fentanyl, propofol and start precedex x 24 hours to\n attempt to extubate tomorrow\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD on Monday.\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 500 mL.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increased Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 40 QD, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement\n" }, { "category": "Nursing", "chartdate": "2117-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506410, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. He was started on\n naficillin. His hospital course was complicated by ARF for which he\n underwent HD hyperkalemia, and wide complex tachycardia w/\n subsequent cardioversion and adenosine and amiodarone infusuin. Renal\n function is now fully recovered.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Events overnight: Lytes were repleted. Renal function stable.\n Hypernatremia (high sodium)\n Assessment:\n Na levels elevated to 146 in the last 3 days. On pm Na noted to\n be 142.\n Action:\n Cont FWB via TF at 200 ml q 4 h. UOP 70-175 ml/hr, clear yellow urine.\n Response:\n Na level this AM 144. UOP sable.\n Plan:\n Cont FWB, trend lytes.\n Impaired Skin Integrity\n Assessment:\n Pt has deep tissue injury on R lg toe and healing stage II decubitus\n ulcer on coccyx.\n Action:\n Freq reposition, pt is on bariatric air mattress. Redress mepilex to\n coccyx, keep toe free from pressure.\n Response:\n Skin issues stable, coccyx area improving.\n Plan:\n Cont skin magt.\n Hyperglycemia\n Assessment:\n Pt has hx of hyperglycemia this admission.\n Action:\n Admin standing dose glargine 50 units HS and cover w/ RISS.\n Response:\n BG overnight 196 / 106.\n Plan:\n Cont long acting insulin and q 6 h SS.\n Muscle Performace, Impaired\n Assessment:\n Pt able to minimally assist w/ lifting head and turns. Pt able to lift\n arms below elbow and squeeze hands bilat. Pt able to wiggle toes when\n asked. Pt has strong cough, adequate respiratory function, Sp02\n 93-100% on 2 L NC. Pt has good sensation bilat UE and LE. Pt failed\n speech and swallow eval.\n Action:\n Encourage to TCDB, encourage pt to help w/ turns.\n Response:\n Stable.\n Plan:\n Pt has active PT consult and will get OOB daily. Pt would benefit from\n OT consult also. Pt will go to rehab facility once MASS health\n insurance is cleared.\n Knowledge, Impaired\n Assessment:\n Pt asking for something to eat / drink. Stating that he is at \n hospital.\n Action:\n pt frequently.\n Response:\n Pt easily re-oriented, is free from anxiety.\n Plan:\n Cont to orient and update pt of surroundings, plan of care, and his\n progress.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt has hx of HTN this admission, has been recently taking up to 4\n different PO meds for HTN. Lopressor was held during day on .\n Action:\n NBPs overnight are 109/57\n 148/49. This RN held 1 dose diltiazem\n overnight.\n Response:\n NBPs stable.\n Plan:\n Re-address antihypertensive med dosing in rounds today.\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504602, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Intubated, CPAP 8 + 6, 40%. RR 20s-32, sats >95%. Breath sounds clear,\n diminished at bases. Sx several times for small amts thick bright\n yellow secretions. Strong cough. Presedex @ .2mcg/k/hr. Pt denies pain\n but nods yes when asked if feeling anxious.\n Action:\n Increased PS-> 14 in effort to decrease RR from 30s. Increased presedex\n to .3mcg d/t pts c/o feeling anxious, emotional support given\n Response:\n RR 17-32, mostly in low 20s but occ ^^ 30 while sleeping. AM ABG\n 7.47/36/126/27.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 PO. Pt diaphoretic.\n Action:\n HO aware, UC sent. BC sent with AM labs. Tylenol via OGT. Meropenum as\n ordered.\n Response:\n T decreased to 98.3 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Physician ", "chartdate": "2117-11-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 504684, "text": "Chief Complaint: Respiratory Failure, ESBL Klebsiella pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Precidex started yesterday\n 24 Hour Events:\n RSBI in 30s today but does have paradoxical breathing and diaphoresis\n on SBT.\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 07:58 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n per ICU rsdient 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\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:00 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: 37.7\nC (99.8\n HR: 95 (71 - 95) bpm\n BP: 181/86(114) {123/43(64) - 181/89(115)} mmHg\n RR: 26 (15 - 31) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,858 mL\n 617 mL\n PO:\n TF:\n 1,082 mL\n 407 mL\n IVF:\n 1,225 mL\n 180 mL\n Blood products:\n Total out:\n 1,170 mL\n 1,320 mL\n Urine:\n 1,170 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,688 mL\n -703 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 537 (428 - 688) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.49/34/68/26/2\n Ve: 11.8 L/min\n PaO2 / FiO2: 170\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, Obese\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, able to\n be aroused, but not tracking\n Labs / Radiology\n 8.1 g/dL\n 318 K/uL\n 226 mg/dL\n 4.3 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 59 mg/dL\n 103 mEq/L\n 139 mEq/L\n 23.5 %\n 7.3 K/uL\n [image002.jpg]\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n WBC\n 7.7\n 6.8\n 7.3\n Hct\n 23.8\n 23.4\n 23.5\n Plt\n 277\n 277\n 318\n Cr\n 6.4\n 4.0\n 3.4\n 4.3\n TCO2\n 25\n 28\n 29\n 28\n 27\n 27\n Glucose\n 193\n 163\n 186\n 226\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n Septic shock with ESBL klebs bacteremia: Cont meropenem\n Acute respiratory failure: Has accessory muscle use on SBT but will\n try to extubate with prn NIPPV if needed\n Hypertension: c/w dilt and metoprolol, clonidine\n Tachcardia/SVT: dilt and metoprolol\n ARF - HD per renal. Now producing urine.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:47 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504788, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received Intubated on CPAP 40%/. RR 20s-32, sats >95%. RSBI this\n morning was 38. Bilateral Breath sounds Rhonchorus. ON Presedex @\n .6mcg/k/hr. widw eawake.following commands,appeared to be anxious.\n Action:\n Placed him on SBT this morning,5 minutes later became hypertensive\n upyo 180,Abd breathing And diaphoretic,ABG 1 hr after SBT was\n 7.49/34/68,Put back on * of ppep to help rest. Extubated afternoon\n around 1420.SPO2 94-95% o 80%,RR cont be 25-30,Post extubation looked\n Ook and it was 7.49/39/108 Stopped Presedex after 1hr of extubation.\n Response:\n RR comes down with sleeping, weak cough. AM ABG 7.47/36/126/27. RSBI\n 31, SBT for 20\n and pt became hypertensive, using abdominal muscles to\n breath. Pt c/o difficulty breathing so SBT aborted. Placed back on CPAP\n 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, pt\n stillhas HD line on her side\n Action:\n Cr up from yesterday 4.3 ( 4). Renal following.\n Response:\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.6. Pt cont be diaphoretic.\n Action:\n Pan cultured. Sent Bc this afternoon,Given Tylenol 100mg PRN as\n ordered. Started on Vanc and Cont meropenem.\n Response:\n Given one time dose of Tylenol.\n Plan:\n Follow twmp curve.Cont abx.Follow with culture data. Meropenum for\n Klebsiella PNA.\n" }, { "category": "Rehab Services", "chartdate": "2117-11-11 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 504956, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 37 y/o male with a h/o DM, HTN,\nobesity, and CKD who initially presented to OSH on after\na syncopal episode. There was a question of a seizure in the\nfield prior to arrival. Per family patient had URI with sneezing,\ncough for 7-10 days, decreased PO intake, and general malasie\nprior to presentation. Patient arrived to OSH in shock with 105\nfever and was intubated. Flu swab was negative. OSH course c/b\nMSSA, ARF requiring HD for hyperkalemia, intermittant afib, and\ntachycardia. Patient was transferred to on for\nfurther management. Patient treated for septic shock and\nmulti-focal Staph pna. Patient was extubated successfully on\n and we were consulted to evaluate patient's oral and\npharyngeal swallowing function and r/o aspiration while eating\nand drinking.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the MICU with full face mask in place.\nCognition, language, speech, voice: Patient was awake and alert,\noriented to self only with repetitive questioning and delayed\nresponse time. Patient did not follow commands. Speech was\nmarkedly unintelligible with hoarse, wet vocal quality and low\nvocal volume.\nTeeth: present dentition from what I could see\nSecretions: normal oral secretions from what I could see\nORAL MOTOR EXAM:\nPatient did not follow commands to participate in oral motor\nexam.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp/straw), nectar\nthick liquids via straw. Oral phase was grossly wfl. Laryngeal\nelevation was difficult to palpate excess tissue. Patient was\nnoted with consistent throat clearing, mild coughing, and\nincreased WOB on all PO trials. O2 sats remained stable in the\nupper 90s as face mask was only briefly removed for spoon\npresentation.\nSUMMARY / IMPRESSION:\nMr. presents with appearance of generalized weakness\nand confusion. He presented with s/sx of aspiration on limited PO\ntrials as evidenced by consistent throat clearing, delayed mild\ncoughing, and increased WOB with all trials with full face mask\nin place. Recommend patient remain NPO at this time with\ncontinued alternate means of nutrition, hydration, and\nmedications. We will continue to follow.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 1 out of 7.\nRECOMMENDATIONS:\n1. NPO status with alternate means of nutrition, hydration, and\nmedications.\n2. Q4 oral care.\n3. We will continue to follow.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1030-1040\nTotal time: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504759, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received Intubated on CPAP 40%/. RR 20s-32, sats >95%. RSBI this\n morning was 38. Bilateral Breath sounds Rhonchorus. ON Presedex @\n .6mcg/k/hr. widw eawake.following commands,appeared to be anxious.\n Action:\n Placed him on SBT this morning,5 minutes later became hypertensive\n upyo 180,Abd breathing And diaphoretic,ABG 1 hr after SBT was\n 7.49/34/68,Put back on * of ppep to help rest. Extubated afternoon\n around 1420.SPO2 94-95% o 80%,RR cont be 25-30,Post extubation looked\n Ook and it was 7.49/39/108 Stopped Presedex after 1hr of extubation.\n Response:\n RR comes down with sleeping, weak cough. AM ABG 7.47/36/126/27. RSBI\n 31, SBT for 20\n and pt became hypertensive, using abdominal muscles to\n breath. Pt c/o difficulty breathing so SBT aborted. Placed back on CPAP\n 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine 4.3\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 PO. Pt diaphoretic.\n Action:\n HO aware, UC sent. BC sent with AM labs. Sputum Cx sent this AM.\n Tylenol via OGT. Meropenum as ordered.\n Response:\n T decreased to 99.4 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504760, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received Intubated on CPAP 40%/. RR 20s-32, sats >95%. RSBI this\n morning was 38. Bilateral Breath sounds Rhonchorus. ON Presedex @\n .6mcg/k/hr. widw eawake.following commands,appeared to be anxious.\n Action:\n Placed him on SBT this morning,5 minutes later became hypertensive\n upyo 180,Abd breathing And diaphoretic,ABG 1 hr after SBT was\n 7.49/34/68,Put back on * of ppep to help rest. Extubated afternoon\n around 1420.SPO2 94-95% o 80%,RR cont be 25-30,Post extubation looked\n Ook and it was 7.49/39/108 Stopped Presedex after 1hr of extubation.\n Response:\n RR comes down with sleeping, weak cough. AM ABG 7.47/36/126/27. RSBI\n 31, SBT for 20\n and pt became hypertensive, using abdominal muscles to\n breath. Pt c/o difficulty breathing so SBT aborted. Placed back on CPAP\n 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine 4.3\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.6. Pt cont be diaphoretic.\n Action:\n Pan cultured. Sputum Cx sent this AM. Tylenol via OGT. Meropenum as\n ordered.\n Response:\n T decreased to 99.4 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504761, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received Intubated on CPAP 40%/. RR 20s-32, sats >95%. RSBI this\n morning was 38. Bilateral Breath sounds Rhonchorus. ON Presedex @\n .6mcg/k/hr. widw eawake.following commands,appeared to be anxious.\n Action:\n Placed him on SBT this morning,5 minutes later became hypertensive\n upyo 180,Abd breathing And diaphoretic,ABG 1 hr after SBT was\n 7.49/34/68,Put back on * of ppep to help rest. Extubated afternoon\n around 1420.SPO2 94-95% o 80%,RR cont be 25-30,Post extubation looked\n Ook and it was 7.49/39/108 Stopped Presedex after 1hr of extubation.\n Response:\n RR comes down with sleeping, weak cough. AM ABG 7.47/36/126/27. RSBI\n 31, SBT for 20\n and pt became hypertensive, using abdominal muscles to\n breath. Pt c/o difficulty breathing so SBT aborted. Placed back on CPAP\n 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine 4.3\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.6. Pt cont be diaphoretic.\n Action:\n Pan cultured. Sent Bc this afternoon,Given Tylenol 100mg PRN as\n ordered. Started on Vanc and Cont meropenem.\n Response:\n Given one time dose of Tylenol.\n Plan:\n Follow twmp curve.Cont abx.Follow with culture data. Meropenum for\n Klebsiella PNA.\n" }, { "category": "Physician ", "chartdate": "2117-11-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504790, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory failure\n 24 Hour Events:\n - per ID, treat with 14 total days Meropenem since first negative blood\n culture = course should be from to \n - renal recommends starting epogen 10,000 units SQ twice a week\n - on presedex x 1 ay to decr sedation in preparation for extubation\n -good UO\n - febrile to 101 o/n, tachypneic in that setting with decreased tidal\n volumes - pan cultured\n - very uncomfortable when went down on pressure support\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 07:58 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:08 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: 37.7\nC (99.8\n HR: 95 (71 - 95) bpm\n BP: 181/86(114) {123/43(64) - 181/89(115)} mmHg\n RR: 26 (15 - 31) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,858 mL\n 468 mL\n PO:\n TF:\n 1,082 mL\n 288 mL\n IVF:\n 1,225 mL\n 151 mL\n Blood products:\n Total out:\n 1,170 mL\n 1,320 mL\n Urine:\n 1,170 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,688 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 573 (428 - 688) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.47/36/126/26/3\n Ve: 14 L/min\n PaO2 / FiO2: 315\n Physical Examination\n GEN: PERRL 2->1mm, following commands, tracking to name\n CV: regular rate, no m/r/g\n PULM: few crackles bilat bases\n ABD: obese, +BS, soft, nt, mild distension but no rigidity\n EXTR; 2+ b/l U&LE\n Labs / Radiology\n 318 K/uL\n 8.1 g/dL\n 226 mg/dL\n 4.3 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 59 mg/dL\n 103 mEq/L\n 139 mEq/L\n 23.5 %\n 7.3 K/uL\n [image002.jpg]\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n WBC\n 7.7\n 6.8\n 7.3\n Hct\n 23.8\n 23.4\n 23.5\n Plt\n 277\n 277\n 318\n Cr\n 6.4\n 4.0\n 3.4\n 4.3\n TCO2\n 24\n 25\n 28\n 29\n 28\n 27\n Glucose\n 193\n 163\n 186\n 226\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR done\n CXR Persistent pneumonic infiltrate mostly in left lower lung\n field.\n No pneumothorax or other abnormalities.\n Microbiology: B cxrs , , , , pending\n Sputum gram stain - + GNRs,\n Cxr - pending\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic /Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - Requested speciation and sensitivities of GNRs in sputum cxr, as\n concern for treatment failure given growth while pt on appropriate abx\n therapy.\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Now intubated 18 days\n ().\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n - Will decrease fentanyl, propofol and start precedex x 24 hours to\n attempt to extubate today.\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD on Monday.\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 500 mL.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increased Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 40 QD, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement\n" }, { "category": "Physician ", "chartdate": "2117-11-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504925, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:20 PM\n - BCx from line showed GPC in pairs and clusters (anaerobic bottle\n drawn from A-line). Added vanco.\n - Renal recs: 1. Off HD since , overall Cr stable w. only mild\n worsening, decent UO. Cont to monitor off HD. If sig incr in volume\n status, can consider increased diuresis. Keep RIJ in place for now. 2.\n Hyper phos - cont phoslo, add A1OH for additional day.\n - Pt with good UOP without additional lasix, was negative 1,187 mL for\n 0000-2200p period.\n - Pt extubated. Hypertensive in PM after extubation, incr clonidine\n patch to 0.3 and incr Metop to 150 TID. ? anxiety component, could\n consider benzo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:15 PM\n Meropenem - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 03:05 PM\n Heparin Sodium (Prophylaxis) - 11:57 PM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 82 (75 - 101) bpm\n BP: 194/99(125) {117/58(77) - 194/99(125)} mmHg\n RR: 25 (12 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,196 mL\n 138 mL\n PO:\n TF:\n 330 mL\n IVF:\n 702 mL\n 138 mL\n Blood products:\n Total out:\n 2,525 mL\n 800 mL\n Urine:\n 1,625 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,329 mL\n -662 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 389 (389 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 33\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: 7.47/36/151/26/3\n Ve: 12.8 L/min\n PaO2 / FiO2: 252\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 352 K/uL\n 8.4 g/dL\n 138 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:42 AM\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n WBC\n 6.8\n 7.3\n 8.5\n Hct\n 23.4\n 23.5\n 26.3\n Plt\n 277\n 318\n 352\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 29\n 28\n 27\n 27\n 27\n 27\n Glucose\n 163\n 186\n 226\n 138\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL, PO4:6.3 mg/dL\n CXR: today with decreased opacity at LUL versus yesterday\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic /Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - Added vancomycin on for GPC\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - Requested speciation and sensitivities of GNRs in sputum cxr, as\n concern for treatment failure given growth while pt on appropriate abx\n therapy.\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n -Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 500 mL.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Glargine increased to 40 QD, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement\n ICU Care\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504827, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Rd the on 80% high flow neb.Sating 98-100%.LS clear with occasional\n rhonchi at bases.Pt awake and follows command.\n Action:\n Remains on 80%.Bld gases.Encouraged cough and deep breaths.\n Response:\n Sating well.No SOB.Bld gases.\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. Trend ABG.Cont\n with cough and deep breath.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, pt\n stillhas HD line .\n Action:\n Cr up from yesterday 4.3 ( 4). Renal following.\n Response:\n UOP cont be ok.\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABP ranges from 155-`80 occasinonaly upto 200. With SBT trial BP went\n upto !80-200.\n Action:\n Given standing BP meds as ordered. Bp cont stayed high.Clonidine\n patch 0.3mcg on.\n Response:\n BP comes down with Sleep and rest Pt also got seroquil for anxiety.\n Plan:\n Monitor BP, Titrate BP meds as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max99.9. Pt cont be diaphoretic.\n Action:\n Pan cultured yesterday. No Tylenol.\n Response:\n Cont to have low grade fevers.\n Plan:\n Follow twmp curve.Cont abx.Follow with culture data. Meropenum for\n Klebsiella PNA.\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504901, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Rd the on 80% high flow neb.Sating 98-100%.LS clear with occasional\n rhonchi at bases.Pt awake and follows command.\n Action:\n Weaned O2 to 60%.Bld gases.Encouraged cough and deep breaths.\n Response:\n Sating well.No SOB.Bld gases acceptable.\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. Trend ABG.Cont\n with cough and deep breath.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, pt\n stillhas HD line .\n Action:\n BUN and Cr trending down.Renal following.\n Response:\n UOP cont be ok.\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABP ranges from 155-`80 occasinonaly upto 200.\n Action:\n Given standing BP meds as ordered. Bp cont stayed high.Clonidine\n patch 0.3mcg on.NBP 20 points lower than ABP.\n Response:\n BP comes down with Sleep and rest.\n Plan:\n Monitor BP, Titrate BP meds as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max99.9. Pt cont be diaphoretic.\n Action:\n Pan cultured yesterday. No Tylenol.2^nd set of Bld culture sent this\n am.\n Response:\n Cont to have low grade fevers.\n Plan:\n Follow twmp curve.Cont abx.Follow with culture data. Meropenum for\n Klebsiella PNA. PICC today if possible.\n" }, { "category": "Rehab Services", "chartdate": "2117-11-11 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 505029, "text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: 038.9 / sepsis\n Reason of : eval and treat\n History of Present Illness / Subjective Complaint: 37 m with hx of DM\n adm from OSH after presenting there with syncopal episode. Per\n family he had URI 7 days prior. He was in shock on admission and\n intubated and started on Levophed and Tamiflu. He remained on\n vasopressors until . Course c/b ARF with Cr up to 7.2 thought to\n be ATN and requiring HD and tachycardia. Transferred to on \n paralyzed and ventilated. Pt treated for septic shock and multifocal\n pna. Extubated .\n Past Medical / Surgical History: DM, HTN\n Medications: Heparin Glucagon\n Diltiazem\n HydrALAzine\n Amlodipine\n Insulin SC\n Meropenem\n Clonidine Patch Metoprolol Tartrate\n Vancomycin\n HydrALAzine\n Furosemide\n Clonazepam\n Radiology:\n Labs:\n 26.3\n 8.4\n 352\n 8.5\n [image002.jpg]\n Other labs:\n Activity Orders: OOB ok'd by MICU team and RN\n Social / Occupational History: supportive family\n Living Environment: unclear\n Functional Status / Activity Level: presumed I\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert. Responds to\n name. Answers some questions, follows simple commands 50% of the time.\n Not oriented. Low voice. Tracking.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 80\n 142/82\n 30\n 98% on 50%fm\n Rest\n /\n Sit\n 80\n 143/97\n 30\n 98 % on 50%fm\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Shallow breathing pattern, decreased breath sounds\n Integumentary / Vascular: Mild edema t/o 1+ all extremities\n Sensory Integrity: difficult to assess decreased mental status.\n Pain / Limiting Symptoms: denies pain, limited by mental status\n Posture: received supine in bed\n Range of Motion\n Muscle Performance\n wfl\n grasp B, no other UE movement noted. B hip flex, knee ext and ankle\n dorsiflexion grossly .\n Motor Function: no abnormal tone noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: total A x 2 to EOB, total A x 2 to maintain eob\n dependent transfer to stretcher chair.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: total A to maintain eob. unable to support head upright. no\n postural responses.\n Education / Communication: pt/family ed: role of PT, importance of oob\n case discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Muscle Performace, Impaired\n 4.\n Transfers, Impaired\n Clinical impression / Prognosis: 37 m with complex medical course\n presents with above impairments assoc with PNS d/o. Given the length of\n time on sedatives and mechanical ventilation, it is likely that ICU\n polyneuropathy coupled with deconditioniing accounts for his profound\n weakness. Eval is somewhat limited given his current confusion as well.\n He will require extensive rehab to maximize return of function.\n Prognosis is good based on age and PLOF but may be limited by extent of\n illness and current weakness.\n Goals\n Time frame: 1 week\n 1.\n roll max a x1\n 2.\n sit at eob with mod a x 2 x 5 minutes\n 3.\n follow 100% simple commands with BLE\n 4.\n inc strength mmt BLE grade\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk x 1wk\n therex/strengthening in bed with coop student, transfer training, eob\n activity.\n recommend nsg use Airpal to transfer patient to stretcher chair daily.\n time: 11:45-12:30\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505937, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Rd on 60% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%.\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.Weaned O2 to\n 40%.\n Response:\n Improved coughing.No more episodes of desating.RR in 20\ns with\n occasionally going upto 30\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely.\n Hypernatremia (high sodium)\n Assessment:\n PM sodium 150.\n Action:\n Increased FWB to 300cc q4hrs. cont with D5W at 150cc/hr.\n Response:\n AM sodium pending.\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak and unable to lift UE/LE to gravity. Pt\n consistently follows commands (wiggle toes/ fingers). Pt nodding head\n appropriately to yes/no questions inconsistently.\n Action:\n PROM provided to all extremities today.\n Response:\n No appreciable change noted in muscle strength today.\n Plan:\n Cont to provide PROM to all extemities and mobilize pt OOB to chair\n daily. PT consult in place to facilitate muscle strength.\n" }, { "category": "Physician ", "chartdate": "2117-11-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505956, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - CXR urgent\n - Lisinopril 10mg\n - Episode of desat; suctioned 5cm dark brown mucus ball, started on\n mucomyst nebs\n - 2L D5W per renal recs to give 4L free water\n - PM hypernatremia worse, Cr improved. Renal recommended 4L free water\n intake/day, so increased tube feed free water flushes from 200cc to\n 200cc q4h.\n - Pilonidal cyst vs. hemorrhoid perirectally\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 85 (78 - 99) bpm\n BP: 135/75(87) {112/60(75) - 161/91(105)} mmHg\n RR: 26 (12 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,641 mL\n 1,731 mL\n PO:\n TF:\n 1,147 mL\n 338 mL\n IVF:\n 2,000 mL\n 763 mL\n Blood products:\n Total out:\n 3,425 mL\n 1,110 mL\n Urine:\n 3,425 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,216 mL\n 621 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN\n NAD, alert, tracks, does not speak, shakes head to\nno pain\n CV\n RRR, no murmurs\n PULM\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 339 K/uL\n 8.0 g/dL\n 210 mg/dL\n 1.4 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 112 mEq/L\n 150 mEq/L\n 24.9 %\n 7.6 K/uL\n [image002.jpg]\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n 7.6\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n 24.9\n Plt\n 73\n 339\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n TCO2\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.7 mg/dL, PO4:6.1 mg/dL\n Imaging: CXR - slightly increased diffuse infiltrates, continued\n widened mediasteinum, continued blunting of left costrophrenic angle\n Microbiology: , , , - bcx ntd\n ( bcx pseudomonas, klebsiella)\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function, also added\n vancomycin on for GPC\n - s/p removal of aline, HD line, TLC\n - F/u ID recs\n - get cultures daily (until cultures negative x48 hours, per ID)\n - daily CXR\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n - Frequent suctioning and CPT as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point.\n - F/u renal recs, no HD and HD line removed\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Hypernatremia\n - improved with 1/2D5 at 240 ml/hr overnight but then worsened after\n lasix given for resp distress\n - Increased free H20 flushes to 300cc q4h\n - Re check electrolytes this pm\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider decreasing when ACEI\n uptitrated.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - star lisinopril and titrate to effect\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, will readdress in AM\n .\n OTHER STABLE ISSUES\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2117-11-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 506256, "text": "Chief Complaint: Respiratory Failure, Klebsiella pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n No complaints today\n 24 Hour Events:\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 AM\n Vancomycin - 09:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:08 AM\n Heparin Sodium (Prophylaxis) - 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: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 75 (69 - 91) bpm\n BP: 109/63(75) {109/54(72) - 155/85(99)} mmHg\n RR: 20 (16 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 6,625 mL\n 2,823 mL\n PO:\n TF:\n 1,085 mL\n 502 mL\n IVF:\n 3,710 mL\n 1,302 mL\n Blood products:\n Total out:\n 2,910 mL\n 1,950 mL\n Urine:\n 2,910 mL\n 1,950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,715 mL\n 873 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered)\n Abdominal: Soft, Non-tender, Obese\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\n Labs / Radiology\n 7.9 g/dL\n 305 K/uL\n 159 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 31 mg/dL\n 110 mEq/L\n 143 mEq/L\n 24.7 %\n 8.9 K/uL\n [image002.jpg]\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n WBC\n 8.0\n 8.1\n 8.8\n 7.6\n 8.9\n Hct\n 27.3\n 26.4\n 24.7\n 24.9\n 24.7\n Plt\n 39\n 305\n Cr\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n TCO2\n 29\n 29\n Glucose\n \n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L, Ca++:8.0 mg/dL, Mg++:1.5 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n ESBL klebs bacteremia/pneumonia: Cont meropenem - 14 day course. CXR\n improved.\n Acute respiratory failure: Cont aggressive pulmonary toilet\n GPC bacteremia: Cont vanc for 7 day course - will be complete after PM\n dose today\n Weakness: He appears to have a significant ICU myopathy but has shown\n some slow improvements at least in streength of voice. MS also appears\n to be improving\n Hypertension: dilt and metoprolol, clonidine. ACE-I. Decrease\n hydralazine\n Tachcardia/SVT: dilt and metoprolol\n Hypernatremia: improving continue to replete fH20\n Rehab screening if possible\n will discuss with case management\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:59 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 506258, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - 4L deficit per renal; getting D5W\n - per renal, if still with large urine output for another 2 days plus\n hyperNa, check lytes to consider diabetes insipidus as potentially\n causative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:58 PM\n Meropenem - 12:21 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 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 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.1\nC (97\n HR: 81 (71 - 91) bpm\n BP: 122/67(81) {111/54(72) - 155/81(97)} mmHg\n RR: 17 (17 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 6,625 mL\n 1,351 mL\n PO:\n TF:\n 1,085 mL\n 339 mL\n IVF:\n 3,710 mL\n 353 mL\n Blood products:\n Total out:\n 2,910 mL\n 1,250 mL\n Urine:\n 2,910 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,715 mL\n 101 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n GEN\n Alert, interactive, verbal, NAD\n CV\n RRR, no murmurs\n PULM\n CTAB, equal BS\n ABD\n obese, soft, nt\n EXTR\n 2+ pitting edema b/l\n Labs / Radiology\n 305 K/uL\n 7.9 g/dL\n 159 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 31 mg/dL\n 110 mEq/L\n 143 mEq/L\n 24.7 %\n 8.9 K/uL\n [image002.jpg]\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n WBC\n 8.0\n 8.1\n 8.8\n 7.6\n 8.9\n Hct\n 27.3\n 26.4\n 24.7\n 24.9\n 24.7\n Plt\n 39\n 305\n Cr\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n TCO2\n 29\n 29\n Glucose\n \n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L, Ca++:8.0 mg/dL, Mg++:1.5 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR - improved aeration b/l with decreased haziness and\n improved left lung base opacity\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of aline, HD line, TLC\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function\n - Continue vancomycin, started on for GPC, 7 day course, d/c \n - F/u ID recs\n - hold on daily CXR given continued improvement\n - d/c daily cultures given negative x48 hours, per ID\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n NAC nebs x1 day to help prevent mucus plugging.\n -Meropenem as above\n - Wean O2 as tolerated\n - Frequent suctioning and CPT as tolerated\n .\n # Volume Status: Hypernatremia improved with 1/2D5 at 240 ml/hr\n overnight but then worsened after lasix given for resp distress.\n Resolved, now becoming hyponatremic.\n - Hold IVF today; no D5W\n - Decrease free H20 flushes from 300cc q4h PM of to 200cc q4h\n - Consider U lytes if hyponatremia worsens, though likely volume\n overload\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L; f/u\n Renal recs\n - Assess I/O and use Lasix for diuresis if necessary in PM\n - Re check electrolytes this pm\n .\n # Hypertension\n - Decrease Hydralazine from 50mg Q6 hrs to 25mg q6h\n - Consider increasing Lisinopril from 10mg to 20mg daily tomorrow if\n patient\ns BP high with decrease of Hydral\n - Continue clonidine patch 0.3; titrate down once Hydralazine is weaned\n off\n - Continue Amlodipine 10 mg PO daily.\n - Cont Dilt and Metoprolol\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - Consider initiating Celexa 20mg daily for anxiety with goal of\n d/c\ning Clonazepam once SSRI becomes effective\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, increase SSI for sugars in 200\n .\n OTHER STABLE ISSUES\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point. Resolved Cr, HD line\n removed.\n - F/u renal recs\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU for today as profoundly weak; ideally discharge\n directly to rehab if possible given patient\ns insurance\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:59 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2117-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 506471, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory distress, AMS\n 24 Hour Events:\n - Relative hypotension: SBP was in 100-110's in early evening and pt\n had meds held (pm metoprolol, amlodipine and dilt), clonidine patch was\n dc'ed, after which his blood pressures were 130s - 140s when awake,\n 100s when asleep.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 PM\n Meropenem - 12:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:16 AM\n Other medications:\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\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 72 (66 - 86) bpm\n BP: 125/76(86) {97/41(55) - 148/85(99)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,888 mL\n 1,040 mL\n PO:\n TF:\n 1,089 mL\n 312 mL\n IVF:\n 2,029 mL\n 268 mL\n Blood products:\n Total out:\n 3,180 mL\n 660 mL\n Urine:\n 3,180 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,708 mL\n 380 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD, alert, talking, following commands\n CV: RRR no m\n Pulm: fairly CTA bilat\n Abd: obese, + BS, soft, nd, non-tender\n Ext: trace edema bilat LE, 2+ pitting edema bilat hands\n Labs / Radiology\n 270 K/uL\n 7.5 g/dL\n 81 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 23.3 %\n 7.3 K/uL\n [image002.jpg]\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n 03:46 PM\n 02:48 AM\n WBC\n 8.1\n 8.8\n 7.6\n 8.9\n 7.3\n Hct\n 26.4\n 24.7\n 24.9\n 24.7\n 23.3\n Plt\n 390\n 373\n 339\n 305\n 270\n Cr\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 145\n 243\n 210\n \n 81\n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L,\n Ca++:7.9 mg/dL (corrected 8.9), Mg++:1.6 mg/dL, PO4:4.1 mg/dL\n Imaging: None new\n Microbiology: sputum - pseudomonas ( to ), klebsiella\n ( to )\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), Klebsiella in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of A.line, HD line, TLC\n - On meropenem; per ID consult: should treat with 14 total days\n Meropenem since first negative blood culture = course should be from\n to (coag neg staph on and likely staph epi and a\n contaminant).\n - Completed 7 day course of vancomycin on \n - F/u ID recs\n - CXR tomorrow (Qod CXRs)\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n NAC nebs x1 day to help prevent mucus plugging.\n -Meropenem as above\n - Wean O2 as tolerated\n doing well on 2L NC\n - Frequent suctioning and CPT as tolerated\n .\n # Volume Status: Monitoring hypernatremia. No D5 yesterday.\n - Cont free water flushes 200cc q4h\n - Consider U lytes if hyponatremia worsens, though likely volume\n overload\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L; f/u\n Renal recs\n - Assess I/O and use Lasix for diuresis if necessary in PM\n - Re check electrolytes this pm\n .\n # Hypertension\n currently overly well-controlled. Will discontinue\n Dilt.\n - Hydralazine and clonidine patch discontinued yesterday.\n - Continue Lisinopril 10mg Qday, Metop 150 TID\n .\n # DM: Blood sugars better controlled with CBGs 120-150s\n - Glargine 50 QD and continue ISS,\n .\n OTHER STABLE ISSUES\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns AMS was\n likely due to toxic-metabolic encephalopathy. If no improvement or\n worsening of encephalopathy, can consider head CT, EEG monitoring and\n LP.\n - Overall, much improved today (), and pt is oriented,\n interactive, verbal, appropriate.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point. Resolved Cr, HD line\n removed.\n - F/u renal recs\n - Cr stabilizing at 0.9 to 1 with excellent UOP.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - dc Dilt today\n - Continue metoprolol at 150 tid\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds for now, will re-consult speech & swallow\n given pt\ns improved strength and mental status\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: With the patient and his Mother, \n . HCP name/number (ICU RN) on whiteboard in room.\n Disposition: Call out to floor today\n" }, { "category": "Nursing", "chartdate": "2117-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506395, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. He was started on\n naficillin. His hospital course was complicated by ARF for which he\n underwent HD hyperkalemia, and wide complex tachycardia w/\n subsequent cardioversion and adenosine and amiodarone infusuin. Renal\n function is now fully recovered.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Events overnight: Lytes were repleted.\n Hypernatremia (high sodium)\n Assessment:\n Na levels elevated to 146 in the last 3 days. On pm Na noted to\n be 142.\n Action:\n Cont FWB via TF at 200 ml q 4 h. UOP 70-175 ml/hr, clear yellow urine.\n Response:\n Na level this AM 144. UOP sable.\n Plan:\n Cont FWB, trend lytes.\n Impaired Skin Integrity\n Assessment:\n Pt has deep tissue injury on R lg toe and healing stage II decubitus\n ulcer on coccyx.\n Action:\n Freq reposition, pt is on bariatric air mattress. Redress mepilex to\n coccyx, keep toe free from pressure.\n Response:\n Skin issues stable, coccyx area improving.\n Plan:\n Cont skin magt.\n Hyperglycemia\n Assessment:\n Pt has hx of hyperglycemia this admission.\n Action:\n Admin standing dose glargine 50 units HS and cover w/ RISS.\n Response:\n BG overnight 196 / 106.\n Plan:\n Cont long acting insulin and q 6 h SS.\n Muscle Performace, Impaired\n Assessment:\n Pt able to minimally assist w/ lifting head and turns. Pt able to lift\n arms below elbow and squeeze hands bilat. Pt able to wiggle toes when\n asked. Pt has strong cough, adequate respiratory function, Sp02\n 93-100% on 2 L NC. Pt has good sensation bilat UE and LE. Pt failed\n speech and swallow eval.\n Action:\n Encourage to TCDB, encourage pt to help w/ turns.\n Response:\n Stable.\n Plan:\n Pt has active PT consult and will get OOB daily.\n Knowledge, Impaired\n Assessment:\n Pt asking for something to eat / drink. Stating that he is at \n hospital.\n Action:\n pt frequently.\n Response:\n Pt easily re-oriented, is free from anxiety.\n Plan:\n Cont to orient and update pt of surroundings, plan of care, and his\n progress.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt has hx of HTN this admission, has been recently taking up to 4\n different PO meds for HTN. Lopressor was held during day on .\n Action:\n NBPs overnight are 109/57\n 148/49. This RN held 1 dose diltiazem\n overnight.\n Response:\n NBPs stable.\n Plan:\n Re-address antihypertensive med dosing in rounds today.\n" }, { "category": "Rehab Services", "chartdate": "2117-11-17 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 506485, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: CXR - Extensive left lung consolidation\n has somewhat decreased\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 76\n 123/67\n 100% on 2L\n Activity\n Sit\n 80\n 114/66\n 100% on 2L\n Recovery\n Sit\n 75\n /\n Total distance walked: 0\n Minutes:\n Gait: not assessed\n Balance: max A to maintain static sitting at edge of chair, L lateral\n and posterior bias, able to initiate weight shift anteriorly and to the\n right, max A to shift weight, mod A to maintain in midline for 5\n seconds at a time.\n Education / Communication: Reviewed PT , communicated with nsg re:\n status.\n Other: Patient presented seated in shuttle chair\n Following all simple commands, moving all extremities volitionally,\n mostly distally.\n Fair head control but unable to maintain\n Minimally verbal\n Assessment: 37 yo M with pneumonia making slow steady progress in PT\n with strength and balance, continues to be limited by profound weakness\n and deconditioning. Would continue to recommend rehab when medically\n appropriate, anticipate fair-good potential given his age and prior\n level. PT to continue to follow to progress as able, pt being seen\n daily for therex by rehab aide.\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Nursing", "chartdate": "2117-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 506479, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. He was started on\n naficillin. His hospital course was complicated by ARF for which he\n underwent HD hyperkalemia, and wide complex tachycardia w/\n subsequent cardioversion and adenosine and amiodarone infusuin. Renal\n function is now fully recovered.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Events overnight: Lytes were repleted. Renal function stable.\n Hypernatremia (high sodium)\n Assessment:\n Na levels elevated to 146 in the last 3 days. On pm Na noted to\n be 142.\n Action:\n Cont FWB via TF at 200 ml q 4 h. UOP 70-175 ml/hr, clear yellow urine.\n Response:\n Na level this AM 144. UOP sable.\n Plan:\n Cont FWB, trend lytes.\n Impaired Skin Integrity\n Assessment:\n Pt has deep tissue injury on R lg toe and healing stage II decubitus\n ulcer on coccyx. Pt also has thrombosed haemorroids .\n Action:\n Freq reposition, pt is on bariatric air mattress. Redress mepilex to\n coccyx, keep toe free from pressure. Tucks Ointment for rexctal\n discomfort.Pt tolerated sitting up in chair for couple of hrs.\n Response:\n Skin issues stable, coccyx area improving.\n Plan:\n Cont skin magt.\n Hyperglycemia\n Assessment:\n Pt has hx of hyperglycemia this admission.\n Action:\n Admin standing dose glargine 50 units HS and cover w/ RISS.\n Response:\n BG overnight 196 / 106.\n Plan:\n Cont long acting insulin and q 6 h SS.\n Muscle Performace, Impaired\n Assessment:\n Pt able to minimally assist w/ lifting head and turns. Pt able to lift\n arms below elbow and squeeze hands bilat. Pt able to wiggle toes when\n asked. Pt has strong cough, adequate respiratory function, Sp02\n 93-100% on 2 L NC. Pt has good sensation bilat UE and LE. Pt failed\n speech and swallow eval.\n Action:\n Encourage to TCDB, encourage pt to help w/ turns.\n Response:\n Stable.\n Plan:\n Pt has active PT consult and will get OOB daily. Pt would benefit from\n OT consult also. Pt will go to rehab facility once MASS health\n insurance is cleared.\n Knowledge, Impaired\n Assessment:\n Pt asking for something to eat / drink. Stating that he is at \n hospital.\n Action:\n pt frequently. Emotional support.Family visited him tocday.\n Response:\n Pt easily re-oriented, is free from anxiety.\n Plan:\n Cont to orient and update pt of surroundings, plan of care, and his\n progress.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DIABETES MELLITUS;SEPTIC SHOCK\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 119 kg\n Daily weight:\n 113 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Droplet\n PMH: Diabetes - Insulin, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:73\n Temperature:\n 98.4\n Arterial BP:\n S:174\n D:87\n Respiratory rate:\n 50 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,685 mL\n 24h total out:\n 1,310 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 02:48 AM\n Potassium:\n 3.6 mEq/L\n 02:48 AM\n Chloride:\n 112 mEq/L\n 02:48 AM\n CO2:\n 25 mEq/L\n 02:48 AM\n BUN:\n 26 mg/dL\n 02:48 AM\n Creatinine:\n 0.9 mg/dL\n 02:48 AM\n Glucose:\n 81 mg/dL\n 02:48 AM\n Hematocrit:\n 23.3 %\n 02:48 AM\n Finger Stick Glucose:\n 120\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: MICU 684\n Transferred to:\n Date & time of Transfer: \n" }, { "category": "Rehab Services", "chartdate": "2117-11-17 00:00:00.000", "description": "Repeat Bedside Swallowing Evaluation", "row_id": 506487, "text": "TITLE: REPEAT BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 37 y/o male with a h/o DM, HTN,\nobesity, and CKD who initially presented to OSH on after\na syncopal episode. There was a question of a seizure in the\nfield prior to arrival. Per family patient had URI with sneezing,\ncough for 7-10 days, decreased PO intake, and general malasie\nprior to presentation. Patient arrived to OSH in shock with 105\nfever and was intubated. Flu swab was negative. OSH course c/b\nMSSA, ARF requiring HD for hyperkalemia, intermittant afib, and\ntachycardia. Patient was transferred to on for\nfurther management. Patient treated for septic shock and\nmulti-focal Staph pna. Patient was extubated successfully on\n and we were consulted to evaluate patient's oral and\npharyngeal swallowing function and r/o aspiration while eating\nand drinking.\nPatient was seen for initial bedside swallowing evaluation on\n and was recommended to remain NPO s/sx of aspiration\non all consistencies. We returned on however patient\ncontinued with weakness and respiratory distress. We agreed to\nreturn today to repeat the bedside swallowing evaluation \npatient with improvement in alertness and mental status.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair on the MICU.\nCognition, language, speech, voice: Patient was awake and alert,\noriented to self and hospital. He continues with delayed\nprocessing and response time and mild inattention. Patient was\nable to follow a few basic commands with cues and models and\nparticipate in PO trials. Speech was fluent when produced. Voice\nis weak and low in volume.\nTeeth: present dentition from what I could see\nSecretions: normal oral secretions from what I could see\nORAL MOTOR EXAM:\nTongue protruded weakly and remained within mouth. Patient with\npersistent weakness and did not follow further commands to\nparticipate in oral motor exam.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp/straw), nectar\nthick liquids via straw, puree, ground solids, and \ncracker. Oral phase was remarkable for mildly reduced mastication\nof regular solid with mild to moderate oral residue remaining.\nAppearance of reduced bolus control of initial straw sips of thin\nliquids. Laryngeal elevation felt mildly reduced to palpation.\nPatient was noted with intermittent coughing on thin liquids and\nthroat clearing and coughing noted on regular solid. Patient\ndenied the sensation of food or liquid stuck in his throat or\ngoing down the wrong way. He did report that the nectar thick\nliquid was \"easier\".\nSUMMARY / IMPRESSION:\nMr. presents with persistent generalized weakness and\ns/sx of aspiration on thin liquids and reduced mastication and\ndifficulty with regular solids as evidenced by reflexive coughing\nand throat clearing. Recommend initiating a PO diet of nectar\nthick liquids and ground solids in small amounts with 1:1\nsupervision. Suggest continuing tube feeds at this time to ensure\nadequate caloric intake and patient is able to safely tolerate\nPOs as his weakness may impact his ability to eat a full meal. We\nwill continue to follow while patient remains inhouse. Recommend\ncontinued follow-up and repeat evaluation at acute rehab.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 5 out of 7.\nRECOMMENDATIONS:\n1. Continue tube feeds as primary means of nutrition, hydration,\nand medications at this time.\n2. Initiate PO intake of nectar thick liquids and ground solids\nin small amounts as tolerated.\n3. 1:1 supervision with all POs.\n4. Patient seated upright for all POs.\n5. Q6 oral care.\n6. We will continue to follow while patient remains inhouse.\n7. Recommend continued follow-up and repeat evaluation at acute\nrehab.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1045-1100\nTotal time: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2117-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 506495, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. He was started on\n naficillin. His hospital course was complicated by ARF for which he\n underwent HD hyperkalemia, and wide complex tachycardia w/\n subsequent cardioversion and adenosine and amiodarone infusuin. Renal\n function is now fully recovered.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Events overnight: Lytes were repleted. Renal function stable.\n Impaired Skin Integrity\n Assessment:\n Pt has deep tissue injury on R lg toe and healing stage II decubitus\n ulcer on coccyx. Pt also has thrombosed haemorroids .\n Action:\n Freq reposition, pt is on bariatric air mattress. Redress mepilex to\n coccyx, keep toe free from pressure. Tucks Ointment for rexctal\n discomfort.Pt tolerated sitting up in chair for couple of hrs. Wound\n care following.\n Response:\n Skin issues stable, coccyx area improving.\n Plan:\n Cont skin mgmt.\n Hyperglycemia\n Assessment:\n Pt has hx of hyperglycemia this admission.\n Action:\n Admin standing dose glargine 50 units HS and cover w/ RISS.\n Response:\n BG overnight 196 / 106.\n Plan:\n Cont long acting insulin and q 6 h SS.\n Muscle Performace, Impaired\n Assessment:\n Pt seems better than yesterday able to assist w/ lifting head and\n turns. Pt able to lift arms below elbow and squeeze hands bilat. Pt\n able to wiggle toes when asked. Pt has strong cough, adequate\n respiratory function, Sp02 93-100% on 2 L NC.\n Action:\n Encourage to TCDB, encourage pt to help w/ turns. Speech and swallow\n came and evaluated,recommended Nectar thick & pureed solid with 1:1\n supervision. Cont TF with Novsource renal through NGT. PT following\n Response:\n Pt looks stable,waiting for bed.\n Plan:\n Encourage passive and active range of motion. Pt will go to rehab\n facility once MASS health insurance is cleared.\n Knowledge, Impaired\n Assessment:\n Pt asking for something to eat / drink. Stating that he is at \n hospital.\n Action:\n pt frequently. Emotional support.Family visited him today.\n Response:\n Pt easily re-oriented, is free from anxiety.\n Plan:\n Cont to orient and update pt of surroundings, plan of care, and his\n progress.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DIABETES MELLITUS;SEPTIC SHOCK\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 119 kg\n Daily weight:\n 113 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Droplet\n PMH: Diabetes - Insulin, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:73\n Temperature:\n 98.4\n Arterial BP:\n S:174\n D:87\n Respiratory rate:\n 50 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,685 mL\n 24h total out:\n 1,310 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 02:48 AM\n Potassium:\n 3.6 mEq/L\n 02:48 AM\n Chloride:\n 112 mEq/L\n 02:48 AM\n CO2:\n 25 mEq/L\n 02:48 AM\n BUN:\n 26 mg/dL\n 02:48 AM\n Creatinine:\n 0.9 mg/dL\n 02:48 AM\n Glucose:\n 81 mg/dL\n 02:48 AM\n Hematocrit:\n 23.3 %\n 02:48 AM\n Finger Stick Glucose:\n 120\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: MICU 684\n Transferred to:\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2117-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 506437, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory distress, AMS\n 24 Hour Events:\n - Relative hypotension: SBP was in 100-110's in early evening and pt\n had meds held (pm metoprolol, amlodipine and dilt), clonidine patch was\n dc'ed, pt's blood pressures were in 130s - 140s after when awake, 100s\n when asleep.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 PM\n Meropenem - 12:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:16 AM\n Other medications:\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\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 72 (66 - 86) bpm\n BP: 125/76(86) {97/41(55) - 148/85(99)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,888 mL\n 1,040 mL\n PO:\n TF:\n 1,089 mL\n 312 mL\n IVF:\n 2,029 mL\n 268 mL\n Blood products:\n Total out:\n 3,180 mL\n 660 mL\n Urine:\n 3,180 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,708 mL\n 380 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD, alert, talking, following commands\n CV: RRR no m\n Pulm:\n Abd: obese, + BS, soft, nd, non-tender\n Ext:\n Labs / Radiology\n 270 K/uL\n 7.5 g/dL\n 81 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 23.3 %\n 7.3 K/uL\n [image002.jpg]\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n 03:46 PM\n 02:48 AM\n WBC\n 8.1\n 8.8\n 7.6\n 8.9\n 7.3\n Hct\n 26.4\n 24.7\n 24.9\n 24.7\n 23.3\n Plt\n 390\n 373\n 339\n 305\n 270\n Cr\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 145\n 243\n 210\n \n 81\n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L,\n Ca++:7.9 mg/dL (corrected 8.9), Mg++:1.6 mg/dL, PO4:4.1 mg/dL\n Imaging: None new\n Microbiology: sputum - pseudomonas ( to ), klebsiella\n ( to )\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), Klebsiella in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of aline, HD line, TLC\n - On meropenem\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Completed 7 day course of vancomycin on \n - F/u ID recs\n - hold on daily CXR given continued improvement (Qod CXRs)\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n NAC nebs x1 day to help prevent mucus plugging.\n -Meropenem as above\n - Wean O2 as tolerated\n - Frequent suctioning and CPT as tolerated\n .\n # Volume Status: Monitoring hypernatremia. No D5 yesterday.\n - Cont free water flushes 200cc q4h\n - Consider U lytes if hyponatremia worsens, though likely volume\n overload\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L; f/u\n Renal recs\n - Assess I/O and use Lasix for diuresis if necessary in PM\n - Re check electrolytes this pm\n .\n # Hypertension\n - Hydralazine and clonidine patch discontinued\n - Lisinopril 10mg Qday, Dilt 30 QID, Metop 150 TID\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam PRN anxiety (started on )\n - Consider initiating Celexa 20mg daily for anxiety with goal of\n d/c\ning Clonazepam once SSRI becomes effective\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, increase SSI for sugars in 200\n .\n OTHER STABLE ISSUES\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point. Resolved Cr, HD line\n removed.\n - F/u renal recs\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 150 tid\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, pt failed\n S&S, will likely need dobhoff placement\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU for today as profoundly weak; ideally discharge\n directly to rehab if possible given patient\ns insurance\n" }, { "category": "Physician ", "chartdate": "2117-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 506453, "text": "TITLE:\n Chief Complaint: pneumonia, respiratory distress, AMS\n 24 Hour Events:\n - Relative hypotension: SBP was in 100-110's in early evening and pt\n had meds held (pm metoprolol, amlodipine and dilt), clonidine patch was\n dc'ed, after which his blood pressures were 130s - 140s when awake,\n 100s when asleep.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 PM\n Meropenem - 12:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:16 AM\n Other medications:\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\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 72 (66 - 86) bpm\n BP: 125/76(86) {97/41(55) - 148/85(99)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,888 mL\n 1,040 mL\n PO:\n TF:\n 1,089 mL\n 312 mL\n IVF:\n 2,029 mL\n 268 mL\n Blood products:\n Total out:\n 3,180 mL\n 660 mL\n Urine:\n 3,180 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,708 mL\n 380 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD, alert, talking, following commands\n CV: RRR no m\n Pulm: fairly CTA bilat\n Abd: obese, + BS, soft, nd, non-tender\n Ext: trace edema bilat LE, 2+ pitting edema hands\n Labs / Radiology\n 270 K/uL\n 7.5 g/dL\n 81 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 23.3 %\n 7.3 K/uL\n [image002.jpg]\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n 03:46 PM\n 02:48 AM\n WBC\n 8.1\n 8.8\n 7.6\n 8.9\n 7.3\n Hct\n 26.4\n 24.7\n 24.9\n 24.7\n 23.3\n Plt\n 390\n 373\n 339\n 305\n 270\n Cr\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 145\n 243\n 210\n \n 81\n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L,\n Ca++:7.9 mg/dL (corrected 8.9), Mg++:1.6 mg/dL, PO4:4.1 mg/dL\n Imaging: None new\n Microbiology: sputum - pseudomonas ( to ), klebsiella\n ( to )\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), Klebsiella in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of A.line, HD line, TLC\n - On meropenem; per ID consult: should treat with 14 total days\n Meropenem since first negative blood culture = course should be from\n to (coag neg staph on and likely staph epi and a\n contaminant).\n - Completed 7 day course of vancomycin on \n - F/u ID recs\n - hold on daily CXR given continued improvement (Qod CXRs)\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n NAC nebs x1 day to help prevent mucus plugging.\n -Meropenem as above\n - Wean O2 as tolerated\n - Frequent suctioning and CPT as tolerated\n .\n # Volume Status: Monitoring hypernatremia. No D5 yesterday.\n - Cont free water flushes 200cc q4h\n - Consider U lytes if hyponatremia worsens, though likely volume\n overload\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L; f/u\n Renal recs\n - Assess I/O and use Lasix for diuresis if necessary in PM\n - Re check electrolytes this pm\n .\n # Hypertension\n - Hydralazine and clonidine patch discontinued\n - Lisinopril 10mg Qday, Dilt 30 QID, Metop 150 TID\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam PRN anxiety (started on )\n - Consider initiating Celexa 20mg daily for anxiety with goal of\n d/c\ning Clonazepam once SSRI becomes effective\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, increase SSI for sugars in 200\n .\n OTHER STABLE ISSUES\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point. Resolved Cr, HD line\n removed.\n - F/u renal recs\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 150 tid\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, pt failed\n S&S, will likely need dobhoff placement\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU for today as profoundly weak; ideally discharge\n directly to rehab if possible given patient\ns insurance\n" }, { "category": "Physician ", "chartdate": "2117-11-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 506464, "text": "Chief Complaint: Respiratory Failure, Klebsiella pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Only complaint is rectal discomfort\n 24 Hour Events:\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 PM\n Meropenem - 08:15 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:16 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: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: No(t) Dyspnea\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: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.4\n HR: 75 (66 - 86) bpm\n BP: 129/74(86) {97/41(55) - 148/77(91)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,888 mL\n 1,560 mL\n PO:\n TF:\n 1,089 mL\n 468 mL\n IVF:\n 2,029 mL\n 403 mL\n Blood products:\n Total out:\n 3,180 mL\n 1,070 mL\n Urine:\n 3,180 mL\n 1,070 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,708 mL\n 490 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, conversive\n Labs / Radiology\n 7.5 g/dL\n 270 K/uL\n 81 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 23.3 %\n 7.3 K/uL\n [image002.jpg]\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n 03:46 PM\n 02:48 AM\n WBC\n 8.1\n 8.8\n 7.6\n 8.9\n 7.3\n Hct\n 26.4\n 24.7\n 24.9\n 24.7\n 23.3\n Plt\n 390\n 373\n 339\n 305\n 270\n Cr\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n 0.9\n 0.9\n TCO2\n 29\n Glucose\n 145\n 243\n 210\n \n 81\n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n ESBL klebs bacteremia/pneumonia: Cont meropenem - 14 day course.\n Acute respiratory failure: Cont aggressive pulmonary toilet\n Weakness: Slowly improving\n Hypertension: clonidine d/c'd. d/c dilt. cont lisinopril, metoprolol.\n Tachcardia/SVT: dilt and metoprolol\n Rehab screening. Call ou to the floor.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 05:08 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506097, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt Rd on 40% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%. Follow commands cont be very\n weak,inconsistently nodding head to yes/ no questions\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.Weaned O2 6L Pt\n .pt tolerated sitting up in chair >4 hrs. Pt came and worked with him.\n Response:\n Weak cough.No more episodes of desating.\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely.\n Hypernatremia (high sodium)\n Assessment:\n AM sodium 146.\n Action:\n Cont FWB at 300cc q4hrs. Cont with D5W at 150cc/hr for 2000cc.sent\n evening lytes.\n Response:\n PM sodium pending.\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n" }, { "category": "Physician ", "chartdate": "2117-11-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505996, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Lisinopril 10mg\n - Episode of desat and tachypnea; suctioned 5cm dark brown mucus ball,\n started on mucomyst nebs\n - PM hypernatremia worse, Cr improved. Renal recommended 4L free water\n intake/day, so increased tube feed free water flushes from 200cc to\n 200cc q4h.\n - 2L D5W per renal recs to give 4L free water\n - Pilonidal cyst vs. hemorrhoid perirectally\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 85 (78 - 99) bpm\n BP: 135/75(87) {112/60(75) - 161/91(105)} mmHg\n RR: 26 (12 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,641 mL\n 1,731 mL\n PO:\n TF:\n 1,147 mL\n 338 mL\n IVF:\n 2,000 mL\n 763 mL\n Blood products:\n Total out:\n 3,425 mL\n 1,110 mL\n Urine:\n 3,425 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,216 mL\n 621 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN\n NAD, alert, tracks, does not speak, shakes head to\nno pain\n CV\n RRR, no murmurs\n PULM\n CTAB, equal BS\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 339 K/uL\n 8.0 g/dL\n 210 mg/dL\n 1.4 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 112 mEq/L\n 150 mEq/L\n 24.9 %\n 7.6 K/uL\n [image002.jpg]\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n 7.6\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n 24.9\n Plt\n 73\n 339\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n TCO2\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.7 mg/dL, PO4:6.1 mg/dL\n Imaging: CXR\n (my read) slightly increased diffuse infiltrates,\n continued widened mediasteinum, continued blunting of left\n costrophrenic angle\n Microbiology: , , , - bcx ntd\n ( bcx pseudomonas, klebsiella)\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of aline, HD line, TLC\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function, also added\n vancomycin on for GPC\n -\n - F/u ID recs\n - daily CXR\n - d/c daily cultures given negative x48 hours, per ID\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n -Meropenem, vancomycin as above\n - Wean O2 as tolerated\n - NAC nebs x1 day to help prevent mucus plugging\n - Frequent suctioning and CPT as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point.\n - F/u renal recs, no HD and HD line removed\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Hypernatremia\n - improved with 1/2D5 at 240 ml/hr overnight but then worsened after\n lasix given for resp distress\n - Increased free H20 flushes to 300cc q4h\n - Re check electrolytes this pm\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider decreasing when ACEI\n uptitrated.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - star lisinopril and titrate to effect\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, will readdress in AM\n .\n OTHER STABLE ISSUES\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2117-11-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 506001, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Lisinopril 10mg\n - Episode of desat and tachypnea; suctioned 5cm dark brown mucus ball,\n started on mucomyst nebs\n - PM hypernatremia worse, Cr improved. Renal recommended 4L free water\n intake/day, so increased tube feed free water flushes from 200cc to\n 200cc q4h.\n - 2L D5W per renal recs to give 4L free water\n - Pilonidal cyst vs. hemorrhoid perirectally\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 85 (78 - 99) bpm\n BP: 135/75(87) {112/60(75) - 161/91(105)} mmHg\n RR: 26 (12 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,641 mL\n 1,731 mL\n PO:\n TF:\n 1,147 mL\n 338 mL\n IVF:\n 2,000 mL\n 763 mL\n Blood products:\n Total out:\n 3,425 mL\n 1,110 mL\n Urine:\n 3,425 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,216 mL\n 621 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN\n NAD, alert, tracks, does not speak, shakes head to\nno pain\n CV\n RRR, no murmurs\n PULM\n CTAB, equal BS\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 339 K/uL\n 8.0 g/dL\n 210 mg/dL\n 1.4 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 112 mEq/L\n 150 mEq/L\n 24.9 %\n 7.6 K/uL\n [image002.jpg]\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n 7.6\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n 24.9\n Plt\n 73\n 339\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n TCO2\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.7 mg/dL, PO4:6.1 mg/dL\n Imaging: CXR\n (my read) slightly increased diffuse infiltrates,\n continued widened mediasteinum, continued blunting of left\n costrophrenic angle\n Microbiology: , , , - bcx ntd\n ( bcx pseudomonas, klebsiella)\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of aline, HD line, TLC\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function, also added\n vancomycin on for GPC\n - F/u ID recs\n - daily CXR\n - d/c daily cultures given negative x48 hours, per ID\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n -Meropenem, vancomycin as above\n - Wean O2 as tolerated\n - NAC nebs x1 day to help prevent mucus plugging\n - Frequent suctioning and CPT as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point.\n - F/u renal recs, no HD and HD line removed\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Hypernatremia/Volume Status: Improved with 1/2D5 at 240 ml/hr\n overnight but then worsened after lasix given for resp distress.\n - D5W x2L\n - Increased free H20 flushes to 300cc q4h PM of ; continue\n - f/u Renal recs\n - Assess I/O and use Lasix for diuresis if necessary in PM\n - Re check electrolytes this pm\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider decreasing when ACEI\n uptitrated.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - star lisinopril and titrate to effect\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, increase SSI for sugars in 200\n .\n OTHER STABLE ISSUES\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506103, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Pt Rd on 40% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%. Follow commands cont be very\n weak,inconsistently nodding head to yes/ no questions\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.Weaned O2 6L Pt\n .pt tolerated sitting up in chair >4 hrs. Pt came and worked with him.\n Response:\n Weak cough.No more episodes of desating.\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely.\n Hypernatremia (high sodium)\n Assessment:\n AM sodium 146.\n Action:\n Cont FWB at 300cc q4hrs. Cont with D5W at 150cc/hr for 2000cc.sent\n evening lytes.\n Response:\n PM sodium 145,Mag 1.1 getting 1^st bag Mag,needs 1 more bag .\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n" }, { "category": "Physician ", "chartdate": "2117-11-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505981, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Lisinopril 10mg\n - Episode of desat and tachypnea; suctioned 5cm dark brown mucus ball,\n started on mucomyst nebs\n - PM hypernatremia worse, Cr improved. Renal recommended 4L free water\n intake/day, so increased tube feed free water flushes from 200cc to\n 200cc q4h.\n - 2L D5W per renal recs to give 4L free water\n - Pilonidal cyst vs. hemorrhoid perirectally\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:48 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 85 (78 - 99) bpm\n BP: 135/75(87) {112/60(75) - 161/91(105)} mmHg\n RR: 26 (12 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,641 mL\n 1,731 mL\n PO:\n TF:\n 1,147 mL\n 338 mL\n IVF:\n 2,000 mL\n 763 mL\n Blood products:\n Total out:\n 3,425 mL\n 1,110 mL\n Urine:\n 3,425 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,216 mL\n 621 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN\n NAD, alert, tracks, does not speak, shakes head to\nno pain\n CV\n RRR, no murmurs\n PULM\n CTAB, equal BS\n ABD\n obese, soft, nt\n EXTR\n no edema\n Labs / Radiology\n 339 K/uL\n 8.0 g/dL\n 210 mg/dL\n 1.4 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 112 mEq/L\n 150 mEq/L\n 24.9 %\n 7.6 K/uL\n [image002.jpg]\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n 7.6\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n 24.9\n Plt\n 73\n 339\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n TCO2\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.7 mg/dL, Mg++:1.7 mg/dL, PO4:6.1 mg/dL\n Imaging: CXR\n (my read) slightly increased diffuse infiltrates,\n continued widened mediasteinum, continued blunting of left\n costrophrenic angle\n Microbiology: , , , - bcx ntd\n ( bcx pseudomonas, klebsiella)\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function, also added\n vancomycin on for GPC\n - s/p removal of aline, HD line, TLC\n - F/u ID recs\n - daily CXR\n - d/c daily cultures given negative x48 hours, per ID\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n -Meropenem, vancomycin as above\n - Wean O2 as tolerated\n - NAC nebs x1 day to help prevent mucus plugging\n - Frequent suctioning and CPT as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point.\n - F/u renal recs, no HD and HD line removed\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Hypernatremia\n - improved with 1/2D5 at 240 ml/hr overnight but then worsened after\n lasix given for resp distress\n - Increased free H20 flushes to 300cc q4h\n - Re check electrolytes this pm\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider decreasing when ACEI\n uptitrated.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - star lisinopril and titrate to effect\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, will readdress in AM\n .\n OTHER STABLE ISSUES\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505852, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Rd on 60% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%.\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.\n Response:\n Improved coughing.No more episodes of desating.RR in 20\ns with\n occasionally going upto 30\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely.\n Hypernatremia (high sodium)\n Assessment:\n PM sodium 150.\n Action:\n Increased FWB to 300cc q4hrs. cont with D5W at 150cc/hr.\n Response:\n AM sodium\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak and unable to lift UE/LE to gravity. Pt\n consistently follows commands (wiggle toes/ fingers). Pt nodding head\n appropriately to yes/no questions inconsistently.\n Action:\n PROM provided to all extremities today.\n Response:\n No appreciable change noted in muscle strength today.\n Plan:\n Cont to provide PROM to all extemities and mobilize pt OOB to chair\n daily. PT consult in place to facilitate muscle strength.\n" }, { "category": "Nursing", "chartdate": "2117-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 506081, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Rd on 40% high flow neb.LS clear with diminished LLL. Got very weak\n cough.RR in 20\ns with sats >95%.\n Action:\n Encouraged with coughing and deep breathing.Q2 chest PT.Weaned O2 6L Pt\n .pt tolerated sitting up in chair >4 hrs.\n Response:\n Weak cough.No more episodes of desating.RR in 20\ns with occasionally\n going upto 30\n Plan:\n Pt will cont to require aggressive chest PT. Will cont to encourage\n CDB. Cont to follow resp fxn closely.\n Hypernatremia (high sodium)\n Assessment:\n AM sodium 146.\n Action:\n Cont FWB at 300cc q4hrs. cont with D5W at 150cc/hr for 2000cc.sent\n evening lytes.\n Response:\n PM sodium pending.\n Plan:\n Cont to follow daily sodium values and adjust FWB accordingly.\n Muscle Performace, Impaired\n Assessment:\n Pt remains profoundly weak and unable to lift UE/LE to gravity. Pt\n consistently follows commands (wiggle toes/ fingers). Pt nodding head\n appropriately to yes/no questions inconsistently.\n Action:\n PROM provided to all extremities today.\n Response:\n No appreciable change noted in muscle strength today.\n Plan:\n Cont to provide PROM to all extemities and mobilize pt OOB to chair\n daily. PT consult in place to facilitate muscle strength.\n" }, { "category": "Physician ", "chartdate": "2117-11-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 505973, "text": "Chief Complaint: Klebsiella pneumonia, 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 No NIPPV overnight\n 24 Hour Events:\n Large mucous plug suctioned yesterday\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:48 PM\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: No(t) Tachycardia\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 85 (78 - 99) bpm\n BP: 135/75(87) {112/60(75) - 161/91(105)} mmHg\n RR: 26 (12 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,641 mL\n 2,124 mL\n PO:\n TF:\n 1,147 mL\n 429 mL\n IVF:\n 2,000 mL\n 1,065 mL\n Blood products:\n Total out:\n 3,425 mL\n 1,110 mL\n Urine:\n 3,425 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,216 mL\n 1,014 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///23/\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 throughout)\n Abdominal: Soft, Non-tender\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, still not\n interacting/speaking significantly\n Labs / Radiology\n 8.0 g/dL\n 339 K/uL\n 246 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 37 mg/dL\n 112 mEq/L\n 146 mEq/L\n 24.9 %\n 7.6 K/uL\n [image002.jpg]\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n 7.6\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n 24.9\n Plt\n 73\n 339\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n TCO2\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n 246\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 505975, "text": "Chief Complaint: Klebsiella pneumonia, 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 No NIPPV overnight\n 24 Hour Events:\n Large mucous plug suctioned yesterday\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:48 PM\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: No(t) Tachycardia\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 85 (78 - 99) bpm\n BP: 135/75(87) {112/60(75) - 161/91(105)} mmHg\n RR: 26 (12 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 4,641 mL\n 2,124 mL\n PO:\n TF:\n 1,147 mL\n 429 mL\n IVF:\n 2,000 mL\n 1,065 mL\n Blood products:\n Total out:\n 3,425 mL\n 1,110 mL\n Urine:\n 3,425 mL\n 1,110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,216 mL\n 1,014 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///23/\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 throughout)\n Abdominal: Soft, Non-tender\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, still not\n interacting/speaking significantly\n Labs / Radiology\n 8.0 g/dL\n 339 K/uL\n 246 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 37 mg/dL\n 112 mEq/L\n 146 mEq/L\n 24.9 %\n 7.6 K/uL\n [image002.jpg]\n 03:16 AM\n 03:47 AM\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n WBC\n 8.5\n 8.0\n 8.1\n 8.8\n 7.6\n Hct\n 26.3\n 27.3\n 26.4\n 24.7\n 24.9\n Plt\n 73\n 339\n Cr\n 3.8\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n TCO2\n 27\n 29\n 29\n Glucose\n 138\n 217\n 145\n 243\n 210\n 246\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:26 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n ------ Protected Section ------\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n ESBL klebs bacteremia/pneumonia: Cont meropenem\n Acute respiratory failure: Ongoing mucous plugging\n aggressive\n pulmonary toilet\n GPC bacteremia: Cont vanc\n Hypertension: dilt and metoprolol, clonidine. ACE-I.\n Tachcardia/SVT: dilt and metoprolol\n ARF - resolved\n MS\n on reexam, somewhat improved. Does appear to have significant\n weakness diffusely as well\n Hypernatremia: improving continue to replete fH20\n Remainder of issues per ICU team.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:43 AM ------\n" }, { "category": "Nursing", "chartdate": "2117-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 506518, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. He was started on\n naficillin. His hospital course was complicated by ARF for which he\n underwent HD hyperkalemia, and wide complex tachycardia w/\n subsequent cardioversion and adenosine and amiodarone infusuin. Renal\n function is now fully recovered.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Events overnight: Lytes were repleted. Renal function stable.\n Impaired Skin Integrity\n Assessment:\n Pt has deep tissue injury on R lg toe and healing stage II decubitus\n ulcer on coccyx. Pt also has thrombosed haemorroids .\n Action:\n Freq reposition, pt is on bariatric air mattress. Redress mepilex to\n coccyx, keep toe free from pressure. Tucks Ointment for rexctal\n discomfort.Pt tolerated sitting up in chair for couple of hrs. Wound\n care following.\n Response:\n Skin issues stable, coccyx area improving.\n Plan:\n Cont skin mgmt.\n Hyperglycemia\n Assessment:\n Pt has hx of hyperglycemia this admission.\n Action:\n Admin standing dose glargine 50 units HS and cover w/ RISS.\n Response:\n BG 120 and 219 today covered with Sliding scale.\n Plan:\n Cont long acting insulin and q 6 h SS.\n Muscle Performace, Impaired\n Assessment:\n Pt seems better than yesterday able to assist w/ lifting head and\n turns. Pt able to lift arms below elbow and squeeze hands bilat. Pt\n able to wiggle toes when asked. Pt has strong cough, adequate\n respiratory function, Sp02 93-100% on 2 L NC.\n Action:\n Encourage to TCDB, encourage pt to help w/ turns. Speech and swallow\n came and evaluated,recommended Nectar thick & pureed solid with 1:1\n supervision. Cont TF with Novsource renal through NGT. PT following\n Response:\n Pt looks stable,waiting for bed.\n Plan:\n Encourage passive and active range of motion. Pt will go to rehab\n facility once MASS health insurance is cleared.\n Knowledge, Impaired\n Assessment:\n Pt asking for something to eat / drink. Stating that he is at \n hospital.\n Action:\n pt frequently. Emotional support.Family visited him today.\n DCd seroquil and klonopin.\n Response:\n Pt easily re-oriented, is free from anxiety.\n Plan:\n Cont to orient and update pt of surroundings, plan of care, and his\n progress.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DIABETES MELLITUS;SEPTIC SHOCK\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 119 kg\n Daily weight:\n 113 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Droplet\n PMH: Diabetes - Insulin, ETOH\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:73\n Temperature:\n 98.4\n Arterial BP:\n S:174\n D:87\n Respiratory rate:\n 50 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,685 mL\n 24h total out:\n 1,310 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 02:48 AM\n Potassium:\n 3.6 mEq/L\n 02:48 AM\n Chloride:\n 112 mEq/L\n 02:48 AM\n CO2:\n 25 mEq/L\n 02:48 AM\n BUN:\n 26 mg/dL\n 02:48 AM\n Creatinine:\n 0.9 mg/dL\n 02:48 AM\n Glucose:\n 81 mg/dL\n 02:48 AM\n Hematocrit:\n 23.3 %\n 02:48 AM\n Finger Stick Glucose:\n 120\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: MICU 684\n Transferred to: cc726\n Date & time of Transfer: \n" }, { "category": "Respiratory ", "chartdate": "2117-11-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504136, "text": "Demographics\n Day of mechanical ventilation: 12\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Known difficult intubation: Unknown\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: 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 Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously, Frequent failed\n trigger efforts\n RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Physician ", "chartdate": "2117-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503693, "text": "TITLE:\n Chief Complaint: sepsis\n 24 Hour Events:\n FEVER - 101.6\nF - 06:00 PM\n - glargine increased to 18\n - lopressor increased to 37.5TID\n - LFT's per ID for cholangitis/cholecystitis continue to trend down\n from arrival\n - Changed to pressure support at noon and tolerated this well.\n Continued to wean --> \n - taken off midaz and given propofol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 10:13 PM\n Meropenem - 08:26 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 05:00 PM\n Fentanyl - 10:45 PM\n Propofol - 11:14 PM\n Famotidine (Pepcid) - 03:14 AM\n Insulin - Regular - 05:07 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.3\nC (100.9\n HR: 84 (81 - 100) bpm\n BP: 152/61(83) {126/47(70) - 173/78(99)} mmHg\n RR: 32 (23 - 32) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,895 mL\n 622 mL\n PO:\n TF:\n 1,083 mL\n 297 mL\n IVF:\n 572 mL\n 325 mL\n Blood products:\n Total out:\n 2,227 mL\n 80 mL\n Urine:\n 227 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -332 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (455 - 490) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 21 cmH2O\n Plateau: 21 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/43/139/23/3\n Ve: 11.3 L/min\n PaO2 / FiO2: 278\n Physical Examination\n Labs / Radiology\n 239 K/uL\n 7.7 g/dL\n 228 mg/dL\n 7.0 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 63 mg/dL\n 100 mEq/L\n 138 mEq/L\n 23.6 %\n 7.9 K/uL\n [image002.jpg]\n 02:55 AM\n 03:24 AM\n 05:01 PM\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n WBC\n 8.8\n 8.9\n 7.9\n Hct\n 26.8\n 25.1\n 23.6\n Plt\n 255\n 282\n 239\n Cr\n 9.4\n 8.4\n 7.0\n TCO2\n 28\n 32\n 31\n 31\n 32\n 29\n 29\n Glucose\n 137\n 187\n 228\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/47, Alk Phos / T Bili:166/1.1,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:239 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Fluid analysis / Other labs: GGT: 429\n Imaging:\n CXR\n Comparison is made with prior study performed a day earlier.\n ET tube is in the standard position. Right IJ and NG tube remain in\n place.\n There is opacity in the left perihilar region and left lower lobe have\n minimally improved. There are low lung volumes. Cardiac size is top\n normal.\n Widened mediastinum is unchanged. There is no pneumothorax or enlarging\n pleural effusion.\n Left subclavian catheter tip is in unchanged position in the left\n brachiocephalic vein/in the junction of the brachiocephalic veins.\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 6\n - f/u cultures\n - f/u daily CXR\n - send c.diff\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 50% and now with PEEP of 8.\n - SBT today; wean peep and PS as tolerated.\n - Check PM ABG\n - Fentanyl and propofol for sedation\n wean down as patient was\n minimally responsive this morning, use boluses for agitation rather\n than uptitrating the dose, that is preferred.\n - HD today\n -Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today due to clot; renal will place\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear.\n - Dilt stopped and lopressor started again according to cardiology recs\n - lopressor dose at 37.5mg TID and consider using dilt since patient is\n responsive to this tomorrow if lopressor does not work\n - 24 hour amiodarone has completed\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Increase glargine and increase ISS\n - Glargine increase from 18 to 25\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; change standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line. Renal to re-adjust lines\n today for HD.\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Physician ", "chartdate": "2117-11-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504986, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:20 PM\n - BCx from line showed GPC in pairs and clusters (anaerobic bottle\n drawn from A-line). Added vanco.\n - Renal recs: 1. Off HD since , overall Cr stable w. only mild\n worsening, decent UO. Cont to monitor off HD. If sig incr in volume\n status, can consider increased diuresis. Keep RIJ in place for now. 2.\n Hyper phos - cont phoslo, add A1OH for additional day.\n - Pt with good UOP without additional lasix, was negative 1,187 mL for\n 0000-2200p period.\n - Pt extubated. Hypertensive in PM after extubation, incr clonidine\n patch to 0.3 and incr Metop to 150 TID. ? anxiety component, could\n consider benzo.\n - GPC again grew in blood culture\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:15 PM\n Meropenem - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 03:05 PM\n Heparin Sodium (Prophylaxis) - 11:57 PM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 82 (75 - 101) bpm\n BP: 194/99(125) {117/58(77) - 194/99(125)} mmHg\n RR: 25 (12 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,196 mL\n 138 mL\n PO:\n TF:\n 330 mL\n IVF:\n 702 mL\n 138 mL\n Blood products:\n Total out:\n 2,525 mL\n 800 mL\n Urine:\n 1,625 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,329 mL\n -662 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 389 (389 - 537) mL\n PS : 5 cmH2O\n RR (Spontaneous): 33\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: 7.47/36/151/26/3\n Ve: 12.8 L/min\n PaO2 / FiO2: 252\n Physical Examination\n GEN: NAD, speaks short phrases of words, alert, appears anxious.\n CV: RRR, no m/r/g\n PULM: CTAB\n ABD: soft, nt, nd, +BS\n EXTR: no edema\n Labs / Radiology\n 352 K/uL\n 8.4 g/dL\n 138 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:42 AM\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n WBC\n 6.8\n 7.3\n 8.5\n Hct\n 23.4\n 23.5\n 26.3\n Plt\n 277\n 318\n 352\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 29\n 28\n 27\n 27\n 27\n 27\n Glucose\n 163\n 186\n 226\n 138\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL, PO4:6.3 mg/dL\n CXR: today with decreased opacity at LUL versus yesterday\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic /Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - Added vancomycin on for GPC\n - get cultures daily from all possible lines (until cultures negative\n x48 hours, per ID)\n - pull as many lines today as possible (aline, HD line, TLC)\n - Requested speciation and sensitivities of GNRs in sputum cxr, as\n concern for treatment failure given growth while pt on appropriate abx\n therapy; also spec/ of GPC\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - ask renal if we can pull HD line today given positive blood cultures\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - add 10mg IV hydral q6h prn SBP >140\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Glargine increased to 40 QD, and continue ISS\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, start tube feeds (place NG tube), HD schedule\n per renal\n hold for now\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: pending clinical improvement, stay in ICU\n ICU Care\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n" }, { "category": "Respiratory ", "chartdate": "2117-11-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503496, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route:\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/Plan\n Remains on AC mode ventilation, no changes made overnight. Performed\n sedation/weaning protocol w/ pt failed SBT secondary to RR>35.\n Placed back on AC. RSBI=46. See flowsheet for further pt data. Will\n follow.\n 06:31\n" }, { "category": "Physician ", "chartdate": "2117-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503502, "text": "TITLE:\n Chief Complaint: Sepsis and acute renal failure\n 24 Hour Events:\n - Had HD (R IJ TLC changed to HD cath; L subclavian placed)\n - ABG's post-dialysis showed alkalosis (resp and metabolic mixed);\n decreased RR from 30 to 24 (although he's overbreathing at times) to\n try to correct the metabolic side, also increased sedation to try to\n help slow RR and HR and BP. next gas = improved.\n - BP in 160s 170s around 11pm and HR 100 - increased sedation.\n - renal plan: daily HD\n - 3AM, while being turned, HR bumped to 170s narrow-complex\n tachycardia, SBP held steady in 110's, no change to respiration, also\n febrile. 5 lopressor given without effect, 10 dilt given and then\n spontaneously broke to HR 80s-90s and BP stable in 110's.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 03:18 PM\n Nafcillin - 10:13 PM\n Meropenem - 08:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Metoprolol - 03:30 AM\n Diltiazem - 03:37 AM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38\nC (100.4\n HR: 96 (89 - 171) bpm\n BP: 134/57(79) {108/44(64) - 176/84(109)} mmHg\n RR: 27 (17 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.8 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 13 (11 - 13)mmHg\n Total In:\n 1,752 mL\n 724 mL\n PO:\n TF:\n 533 mL\n 302 mL\n IVF:\n 859 mL\n 242 mL\n Blood products:\n Total out:\n 509 mL\n 27 mL\n Urine:\n 109 mL\n 27 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,243 mL\n 697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 95%\n ABG: 7.44/45/90./28/5\n Ve: 14.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n Gen: sedated and intubated\n Eyes: pupils 3mm and 4mm, reactive to light. Likely normal variation\n Heart: NRRR; no murmurs\n Chest: CTAB\n Abdomen: ND; bowel sounds hypoactive\n Ext: no edema; warm and well perfused\n Labs / Radiology\n 282 K/uL\n 8.3 g/dL\n 187 mg/dL\n 8.4 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 75 mg/dL\n 98 mEq/L\n 139 mEq/L\n 25.1 %\n 8.9 K/uL\n [image002.jpg]\n 02:25 PM\n 09:21 PM\n 09:39 PM\n 02:55 AM\n 03:24 AM\n 05:01 PM\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n WBC\n 8.8\n 8.9\n Hct\n 26.8\n 25.1\n Plt\n 255\n 282\n Cr\n 9.1\n 9.4\n 8.4\n TCO2\n 27\n 26\n 28\n 32\n 31\n 31\n 32\n Glucose\n 146\n 137\n 187\n Other labs: PT / PTT / INR:13.9/34.0/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:39/60, Alk Phos / T Bili:197/1.6,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:265 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:6.9 mg/dL\n Imaging: CXR \n IMPRESSION:\n 1. Stable mediastinal widening, at least in part reflecting mediastinal\n lymphadenopathy.\n 2. Persistent consolidative opacities throughout much of the left lung,\n worrisome for pneumonia.\n 3. Better aeration of the right lung, which may be due to improvement\n in\n pulmonary vascular congestion.\n Microbiology: 10:48 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n Commensal Respiratory Flora Absent.\n KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.\n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #\n 286-2926K\n .\n PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n SENSITIVITIES PERFORMED ON CULTURE # 286-4033K .\n CDiff pending\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ).\n - f/u cultures\n - f/u daily CXR\n - send c.diff\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 50% and now with PEEP of 8.\n - Pressure support trial today\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning, use boluses for agitation rather than\n uptitrating the dose, that is preferred.\n - HD today\n -Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today due to clot; renal will place\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear.\n - Dilt stopped and lopressor started again according to cardiology recs\n - Increase lopressor dose to 25mg TID and consider using dilt since\n patient is responsive to this.\n - 24 hour amiodarone has completed\n - Watch hemodynamics and rhythm; on telemetry\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Continue glargine; continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; change standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line. Renal to re-adjust lines\n today for HD.\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Respiratory ", "chartdate": "2117-11-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503788, "text": "Demographics\n Day of mechanical ventilation: 10\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Known difficult intubation: Unknown\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\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 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:\n" }, { "category": "Nursing", "chartdate": "2117-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504307, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n : Pt placed on SBT this am, developed SVT rate 170-175, remains\n febrile 100-101, no HD.\n : VERY HTN, started on hydralazine and clonidine patch, propofol\n up to 40 to help HTN, no weaning, U/O UP!\n : PEEP weaned to 8, changed to PSV tol well, b/p improved,\n amlodipine added, HD done 1 kilo off, tol well.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABPs 160/70- 180\ns/90\ns. MAPs 76-113. Pt remains sedated on 40\n mcg/kg/min propofol and 25 mcg/hr fentanyl gtts. Pt opens eyes\n spontaneously but unable to follow commands. Intermittently MAEs but\n not to command.\n Action:\n Cont on clonidine patch which was added , lopressor, dilt and\n hydral. Amlodipine added.\n Response:\n ABP improved prior to 1^st dose of amlodipine, currently 150/64.\n Plan:\n Cont w/ PO med mgt for HTN cont to increase medication doses until HTN\n better controlled.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 99.8 this shift.\n Action:\n Blood cx\ns x 2 sent to lab for analysis last shift. Cont meropenum.\n Response:\n ongoing.\n Plan:\n Cont ABX and follow temp curve. f/u bld cx w/ am labs.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt on AC 40%/600x18/10. Sp02 98%. LSCTAB, scant secretions\n w/ ETT suction.\n Action:\n PEEP weaned to 8, tol well, propofol weaned to 30\n Response:\n ABG on PEEP 8 7.54/32/78, placed on PSV 10/8\n Plan:\n Cont to wean vent/ sedation as tol.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n This AM: BUN / Cre 85 / 6.4. K 4.6. UOP improved\n Action:\n HD done, 1 kilo taken off, tol well.\n Response:\n UOP cont to improve\n Plan:\n Monitor UOP, cont HD as needed.\n Impaired Skin Integrity\n Assessment:\n Stage II on coccyx and R buttock. Sm amt excoriation noted near\n flexiseal.\n Action:\n Seen by wound care RN, new mepilex applied. Barimax bed, freq\n reposition. Xeroform around flexiseal.\n Response:\n Stable.\n Plan:\n Cont wound mgt.\n" }, { "category": "Nursing", "chartdate": "2117-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504376, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Patient SBP 160\ns at start of shift a-line in place good wave form\n Action:\n Responded to blood pressure medication sbp < 160 until propofol shut\n off then sbp increased to high of 188 ,\n Response:\n Patient moves legs slightly with propofol off, not moving arms at all\n even off propofol for 2 hours restarted propofol at half the dose due\n to sbp > 180 Fentanyl remained on at 25mcg\n Plan:\n Continue sedation as indicated, continue diltazem, lopressor and\n hydralazine, monitor HR, discomfort and B/P treat as indicated.\n Hyperglycemia\n Assessment:\n Patient FS 224 at 2200\n Action:\n Glargine 30unit given and 5 unit regular insulin per sliding scale for\n Fs of 224\n Response:\n Patient BS 163 at 0130\n Plan:\n Q 6 hours FS treat per Sliding scale\n Impaired Skin Integrity\n Assessment:\n Edema in extremities, dressing on coccyx intact, heels pinkish, groin\n slightly red, skin fold in abd pink, back red , edges of mouth with\n scabbing\n Action:\n Turn patient , barrier cream to back and heels, groin and axillia,\n lotramin cream and hydrocortisone cream as ordered, ointment to abd as\n ordered, frequent mouth care\n Response:\n Skin red but no breaks in skin, tolerated turns and mouth care\n Plan:\n Continue mouth care ,and skin care as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient urine lytes improved urine initially amber now yellow with\n sediment, urine out put 20-40 an hour\n Action:\n Urine lytes sent and serum lytes, NS 500 cc given,\n Response:\n Urine out put with out change initially,\n Plan:\n Monitor labs and urine output, due am labs with creatinine and BUN\n Pneumonia, other\n Assessment:\n Suction for thick yellow sputum, copious oral secretions lungs coarse\n to decrease in longs with rhonchi throughout lung fields when\n suctioning needed. Sputum thick\n Action:\n Suctioned orally and down ET, turned q3-4 hours, ABG sent\n Response:\n Sputum production decreased and less thick, tolerated suctioning oral\n and ET, vent changes Decreased PS and peep,\n Plan:\n Wean as able. extubate in am if able, shut off sedation at 0400\n" }, { "category": "Physician ", "chartdate": "2117-11-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 504971, "text": "Chief Complaint: Klebsiella pneumonia, 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 Extubated yesterday and doing well.\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:20 PM\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:15 PM\n Meropenem - 08:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 03:05 PM\n Heparin Sodium (Prophylaxis) - 11:57 PM\n Famotidine (Pepcid) - 04:00 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: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: No(t) Dyspnea\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 79 (75 - 101) bpm\n BP: 182/95(119) {117/58(77) - 194/99(125)} mmHg\n RR: 32 (12 - 41) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,196 mL\n 160 mL\n PO:\n TF:\n 330 mL\n IVF:\n 702 mL\n 160 mL\n Blood products:\n Total out:\n 2,525 mL\n 1,400 mL\n Urine:\n 1,625 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,329 mL\n -1,240 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 389 (389 - 389) mL\n PS : 5 cmH2O\n RR (Spontaneous): 33\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.47/36/151/26/3\n Ve: 12.8 L/min\n PaO2 / FiO2: 302\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: scattered)\n Abdominal: Soft, Non-tender, Obese\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\n Labs / Radiology\n 8.4 g/dL\n 352 K/uL\n 138 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 105 mEq/L\n 141 mEq/L\n 26.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:42 AM\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n WBC\n 6.8\n 7.3\n 8.5\n Hct\n 23.4\n 23.5\n 26.3\n Plt\n 277\n 318\n 352\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 29\n 28\n 27\n 27\n 27\n 27\n Glucose\n 163\n 186\n 226\n 138\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL, PO4:6.3 mg/dL\n Microbiology: 128, blood cultures - GPCs\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n Septic shock with ESBL klebs bacteremia: Cont meropenem\n Acute respiratory failure: Now extubated - doing well\n GPC bacteremia: vancomycin. Will d/c central line, HD line, a-line\n Hypertension: continues to be hypertensive. dilt and metoprolol,\n clonidine. prn hydralazine\n Tachcardia/SVT: dilt and metoprolol\n ARF - HD per renal. Now producing urine.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505071, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received on 60% high flow neb,SPO2 96-98%,RR in 20\ns,BLS clear to\n diminish at the bases. Weak cough. Alert,Able to follow commands,\n moving all extrimities.\n Action:\n Weaned O2 to 36%.Encouraged cough and deep breaths.. Failed bedside\n picc,went to IR for Picc line. Pt out to chair for couple of hrs,still\n weak. Failed Bedside speech and swallow, started on TF.\n Response:\n SPO2 stable, Denies any pain. DCd Aline,HD line and central line\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. Encourage cough\n and deep breath. Advance TfF as tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be improved.,Foley draining clear yellow urine 50-60cc/hr.\n Action:\n BUN and Cr trending down.Renal following,no need of dialysis as per\n renal . Given 20 mg Lasix,Goal neg 2L.\n Response:\n UOP cont be ok. DCd HD line.\n Plan:\n Monitor UOP, and renal function. Follow up with renal.\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505072, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received on 60% high flow neb,SPO2 96-98%,RR in 20\ns,BLS clear to\n diminish at the bases. Weak cough. Alert,Able to follow commands,\n moving all extrimities.\n Action:\n Weaned O2 to 36%.Encouraged cough and deep breaths.. Failed bedside\n picc,went to IR for Picc line. Pt out to chair for couple of hrs,still\n weak. Failed Bedside speech and swallow, started on TF.\n Response:\n SPO2 stable, Denies any pain. DCd Aline,HD line and central line\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. Encourage cough\n and deep breath. Advance TfF as tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be improved.,Foley draining clear yellow urine 50-60cc/hr.\n Action:\n BUN and Cr trending down.Renal following,no need of dialysis as per\n renal . Given 20 mg Lasix,Goal neg 2L.\n Response:\n UOP cont be ok. DCd HD line.\n Plan:\n Monitor UOP, and renal function. Follow up with renal.\n" }, { "category": "Nutrition", "chartdate": "2117-11-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 503778, "text": "Subjective\n Patient remains intubated/sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 228 mg/dL\n 01:22 AM\n Glucose Finger Stick\n 186\n 10:00 AM\n BUN\n 31 mg/dL\n 01:08 PM\n Creatinine\n 7.0 mg/dL\n 01:22 AM\n Sodium\n 138 mEq/L\n 01:22 AM\n Potassium\n 4.5 mEq/L\n 01:22 AM\n Chloride\n 100 mEq/L\n 01:22 AM\n TCO2\n 23 mEq/L\n 01:22 AM\n PO2 (arterial)\n 139 mm Hg\n 02:14 AM\n PCO2 (arterial)\n 43 mm Hg\n 02:14 AM\n pH (arterial)\n 7.42 units\n 02:14 AM\n CO2 (Calc) arterial\n 29 mEq/L\n 02:14 AM\n Albumin\n 1.9 g/dL\n 02:16 AM\n Calcium non-ionized\n 8.2 mg/dL\n 01:22 AM\n Phosphorus\n 6.2 mg/dL\n 01:22 AM\n Ionized Calcium\n 0.97 mmol/L\n 02:14 AM\n Magnesium\n 2.0 mg/dL\n 01:22 AM\n Total Bilirubin\n 1.1 mg/dL\n 01:22 AM\n Current diet order / nutrition support: Novasource Renal @ 45mL/hr\n (2160 kcals/80 gr protein)\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Specifics:\n 37 year old male c/ severe Kleb sepsis c/b ARF, remains intubated and\n sedated. Sedation changed to propofol in hopes of extubation soon.\n Patient being dialyzed daily per renal. Patient receiving tube feeds @\n goal c/ good tolerance per discussion c/ RN. Patient receiving an\n additional 350 kcals from propfol at current rate. Propofol and tube\n feeds meeting higher end of estimated nutrition needs-remains ok given\n daily dialysis. Glargine being increased prn for better glucose\n control. Phos remains elevated on phos binder.Ca repletion noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n Continue feeds @ goal\n Continue to adjust insulin regimen prn\n Lyte management as you are\n Following #\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503784, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Events: remains febrile 100.2-101.0, HD with 3l removed, received\n 1unit RBC\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp has been 100.2-101.0, WBC 7.9.\n Action:\n Continues on meropenem, Blood cultures drawn from the HD catheter and\n from the triple lumen.\n Response:\n Continues with low grade temp despite correct antibotics.\n Plan:\n Continue to monitor temp, give meropenem as ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt continue with minimal U/O, U/O very variable, 10-40cc/hr, creat 7.0\n Action:\n Pt had 3\n hours of HD today with 3l fluid removed. He continues to be\n very edematous. He received a unit of RBC\ns during dialysis and the\n volume was removed.\n Response:\n He tolerated HD with no drop in B/P.\n Plan:\n Continue to monitor I&O. HD when renal fellow orders.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings from A/C were changed to PSV 8/Peep 8, FiO2 50 %. O2\n sats 98-100%, pt has a strong cough but minimal to non existent gag.\n Action:\n Vent settings changed to 40%, , suctioning out a large amount of\n creamy secretions, q2h.\n Response:\n ABG 7.42/42/83\n Plan:\n Continue to suction PRN, monitor O2 sats, ??? attempt to extubate, turn\n off propofol at 6am with SBT planned at 730am.\n Hyperglycemia\n Assessment:\n Blood sugar 186-195 continues on tube feedings at goal rate of 45cc/hr.\n Action:\n Pt was covered with 2units of regular at 10am and 3 units of\n regular at 1600 after the doctors increased the to be\n given on the sliding scale. The HS glargine dose was also increased to\n 25 units.\n Response:\n Blood sugars are slightly better but will monitor following increased\n glargine.\n Plan:\n Continue to monitor blood sugar q6h and cover with according to\n sliding scale.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503856, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\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 IPS5/5 overnoc. ABG acceptable. RSBI\n 67 this am. Plan SBT early am.\n" }, { "category": "Nursing", "chartdate": "2117-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504127, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n : Pt placed on SBT this am, developed SVT rate 170-175, remains\n febrile 100-101, no HD.\n Events: VERY HTN, started on hydralazine and clonidine patch, propofol\n up to 40 to help HTN, no weaning, U/O UP!\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504417, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Patient SBP 160\ns at start of shift a-line in place good wave form\n Action:\n Responded to blood pressure medication sbp < 160 until propofol shut\n off then sbp increased to high of 188 ,\n Response:\n Patient moves legs slightly with propofol off, not moving arms at all\n even off propofol for 2 hours restarted propofol at half the dose due\n to sbp > 180 Fentanyl remained on at 25mcg\n Plan:\n Continue sedation as indicated, continue diltazem, lopressor and\n hydralazine, monitor HR, discomfort and B/P treat as indicated.\n Hyperglycemia\n Assessment:\n Patient FS 224 at 2, TF at goal 45 tolerated well\n residual < 30\n Action:\n Glargine 30unit given and 5 unit regular insulin per sliding scale at\n 0500 3 unit Regular insulin given\n Response:\n Patient BS 163 at 0130\n Plan:\n Q 6 hours FS treat per Sliding scale\n Impaired Skin Integrity\n Assessment:\n Edema in extremities, dressing on coccyx intact, heels pinkish, groin\n slightly red, skin fold in abd pink, back red , edges of mouth with\n scabbing\n Action:\n Turn patient , barrier cream to back and heels, groin and axillia,\n lotramin cream and hydrocortisone cream as ordered, ointment to abd as\n ordered, frequent mouth care\n Response:\n Skin red but no breaks in skin, tolerated turns and mouth care\n Plan:\n Continue mouth care ,and skin care as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient urine lytes improved urine initially amber now yellow with\n sediment, urine out put 20-40 an hour\n Action:\n Urine lytes sent and serum lytes, NS 500 cc given,\n Response:\n Urine out put with out change initially,\n Plan:\n Monitor labs and urine output, due am labs with creatinine and BUN\n Pneumonia, other\n Assessment:\n Suction for thick yellow sputum, copious oral secretions lungs coarse\n to decrease in longs with rhonchi throughout lung fields when\n suctioning needed. Sputum thick\n Action:\n Suctioned orally and down ET, turned q3-4 hours, ABG sent\n Response:\n Sputum production decreased and less thick, tolerated suctioning oral\n and ET, vent changes Decreased PS and peep,\n Plan:\n Wean as able. extubate in am if able, shut off sedation at 0400\n" }, { "category": "Nursing", "chartdate": "2117-11-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505067, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received on 60% high flow neb,SPO2 96-98%,RR in 20\ns,BLS clear to\n diminish at the bases. Weak cough. Alert,Able to follow commands,\n moving all extrimities.\n Action:\n Weaned O2 to 36%.Encouraged cough and deep breaths.. Failed bedside\n picc,went to IR for Picc line. Pt out to chair for couple of hrs,still\n weak. Failed Bedside speech and swallow, started on TF.\n Response:\n SPO2 stable, Denies any pain. DCd Aline,HD line and central line\n Plan:\n Closely monitor Resp status, Wean oxygen as needed. encourage cough\n and deep breath. Advance Tf as tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be improved.,Foley draining clear yellow urine 50-60cc/hr.\n Action:\n BUN and Cr trending down.Renal following,accordinh .\n Response:\n UOP cont be ok.\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABP ranges from 155-`80 occasinonaly upto 200.\n Action:\n Given standing BP meds as ordered. Bp cont stayed high.Clonidine\n patch 0.3mcg on.NBP 20 points lower than ABP.\n Response:\n BP comes down with Sleep and rest.\n Plan:\n Monitor BP, Titrate BP meds as needed.\n" }, { "category": "Nursing", "chartdate": "2117-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503841, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Shift Events:\n Initiated labetol gtt for maps under 90\n Decreased Propofol to 15 mgm hr\n Blood cultures done, one peripheral , one from a line\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 100.9, responsive to Tylenol x 1\n Action:\n Tylenol 1000 mgm x 1 pngt\n Response:\n Temp to 100.1 oral\n Plan:\n Monitor temps, respond with Tylenol, mobilize asap\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Coarse breath sounds throughout, diminished slightly LLL, large prod.\n Of yellow creamy sputum, large oral blood tinged subglottal, cont. on\n 40% ps 5/5 with sats 94-97%, rsbi acceptable this am, does increase rr\n above 35 with sedation lightened.\n Action:\n Cont. meropenum, follow temps q 2-4 hrs, pulm care\n Response:\n Improved tolerance of cpap with min support. Increase ETT secretions\n this night\n Plan:\n Pulm care and support, wean to extubate\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 25-30 cc drk amber cloudy urine q 2 hrs. HD yesterday.\n Tol well, remains 3 -4 liters positive body balance\n Action:\n Follow renal labs, urine output\n Response:\n Urine output with little improvement over prev.\n Plan:\n Monitor labs, LOC, I/O\n Impaired Skin Integrity\n Assessment:\n Resolving light pink patch rash on abd, groin and axillae healing, not\n red, chest wound wnl, mepilex on coccyx\n Action:\n Multiple skin ointment applied to sites as ordered, keep areas dry,\n tube feedings\n Response:\n Improved skin, healing wounds\n Plan:\n Cont. skin care plan, barimax bed with turns and rotation\n Hyperglycemia\n Assessment:\n Fsbs cont. to be in the 200\n Action:\n Glargine increased to 25 units at HS, cont. sliding scale for added\n coverage\n Response:\n Con.t bs over 200\n Plan:\n need to increase glargine again today if needed due to bs over 200,\n cont. tube feeds, sliding scale\n" }, { "category": "Nursing", "chartdate": "2117-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503843, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Shift Events:\n Initiated labetol gtt for maps under 90\n Decreased Propofol to 15 mgm hr\n Blood cultures done, one peripheral , one from a line\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 100.9, responsive to Tylenol x 1\n Action:\n Tylenol 1000 mgm x 1 pngt\n Response:\n Temp to 100.1 oral\n Plan:\n Monitor temps, respond with Tylenol, mobilize asap\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Coarse breath sounds throughout, diminished slightly LLL, large prod.\n Of yellow creamy sputum, large oral blood tinged subglottal, cont. on\n 40% ps 5/5 with sats 94-97%, rsbi acceptable this am, does increase rr\n above 35 with sedation lightened.\n Action:\n Cont. meropenum, follow temps q 2-4 hrs, pulm care\n Response:\n Improved tolerance of cpap with min support. Increase ETT secretions\n this night\n Plan:\n Pulm care and support, wean to extubate\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output 25-30 cc drk amber cloudy urine q 2 hrs. HD yesterday.\n Tol well, remains 3 -4 liters positive body balance\n Action:\n Follow renal labs, urine output\n Response:\n Urine output with little improvement over prev.\n Plan:\n Monitor labs, LOC, I/O\n Impaired Skin Integrity\n Assessment:\n Resolving light pink patch rash on abd, groin and axillae healing, not\n red, chest wound wnl, mepilex on coccyx\n Action:\n Multiple skin ointment applied to sites as ordered, keep areas dry,\n tube feedings\n Response:\n Improved skin, healing wounds\n Plan:\n Cont. skin care plan, barimax bed with turns and rotation\n Hyperglycemia\n Assessment:\n Fsbs cont. to be in the 200\n Action:\n Glargine increased to 25 units at HS, cont. sliding scale for added\n coverage\n Response:\n Con.t bs over 200\n Plan:\n need to increase glargine again today if needed due to bs over 200,\n cont. tube feeds, sliding scale\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Maps to 135 with cough. Not responding to pain stim. But clearly has\n pain response to cough.\n Action:\n Medicated for pain with good response transiently, started labetol gtt\n for map goal >90\n Response:\n Started at .5 now at .9 with consistant maps under 90. with cough\n cont. to increase map transiently to 100\n Plan:\n Maps goal for gtt in >90, consider po meds for bp control. Increase\n lopressor as able, ensure pain control adequate, may consider fentanyl\n patch vs gtt for pain\n" }, { "category": "Physician ", "chartdate": "2117-11-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 503922, "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 37 yr old, DM, influenza, ESBL sputum and blood, pseud, MSSA in blood\n and sputum. Daily fevers\n 24 Hour Events:\n FEVER - 101.2\nF - 08:00 PM\n Daily fevers\n MS - still unresponsive, withdraws to pain\n Started on labetolol in addition to lopressor\n On rounds, SVT to 160 - given adenosine 5 IV\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 PM\n Infusions:\n Labetalol - 0.1 mg/min\n Fentanyl - 50 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:25 AM\n Fentanyl - 04:27 AM\n Other medications:\n Reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.4\nC (101.1\n HR: 88 (84 - 105) bpm\n BP: 145/63(85) {125/51(72) - 183/93(118)} mmHg\n RR: 24 (0 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,643 mL\n 1,152 mL\n PO:\n TF:\n 1,084 mL\n 408 mL\n IVF:\n 1,010 mL\n 624 mL\n Blood products:\n 350 mL\n Total out:\n 4,065 mL\n 130 mL\n Urine:\n 415 mL\n 130 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n -1,422 mL\n 1,022 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 676 (390 - 676) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 12 cmH2O\n SpO2: 96%\n ABG: 7.46/39/84./25/3\n Ve: 13.4 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, BS faint\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm, Rash: , rash on abd improved\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.2 g/dL\n 244 K/uL\n 193 mg/dL\n 5.5 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 49 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.1 %\n 8.2 K/uL\n [image002.jpg]\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n WBC\n 8.9\n 7.9\n 8.2\n Hct\n 25.1\n 23.6\n 25.1\n Plt\n 282\n 239\n 244\n Cr\n 8.4\n 7.0\n 5.5\n TCO2\n 31\n 31\n 32\n 29\n 29\n 28\n 29\n Glucose\n 187\n 228\n 193\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:28/46, Alk Phos / T Bili:153/1.0,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:217 IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:6.0 mg/dL\n Microbiology: c diff neg\n BC from HD line - GNR (pre-line change). 4 surveill cultures\n negative so far\n CXR reviewed. ETT, OG okay. HD line appears in good position\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Septic shock with ESBL klebs bacteremia: has another positive blood cx\n from . It was from the same line, which has now been changed to\n the HD cath. Four surveill cultures (taken from CVL, HD and periph\n sources) all negative so far.\n Acute respiratory failure: wean his peep, did well on PS 5/5. Main\n barrier to extubation is SVT and mental status. Will stop prop and wean\n fent. Try to wake up with bolus sedation prn.\n Tachcardia: doing well on lopressor, off labetolol. responded to\n adenosine this am for SVT. Will combine increased lopressor and start\n diltiazem.\n ARF - HD on Monday\n DM: glargine 25.\n increased LFTs: are all decreasing. Likely from shock liver.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 10:14 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504124, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2117-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505232, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Holding HD, per Renal: keep R IJ if possible in case needs HD but can\n pull if needed\n - Per renal, goal negative 3-4L today, Lasix 20mg IV x1, then lasix\n 40mg IV to reach I&O goal\n - Another bcx of GPC in pairs and clusters in 1 anaerobic bottle from\n (second positive bottle)\n - speciation from pos BCXR on showed coag negative GPC, will do\n sensitivities given 2 days of coag positive staph --> oxacillin\n resistant coag neg GPC\n - Pulled a-line, temp HD line (IJ), subclavian line\n - sputum grew pseudomonas, which in the past was resistant to , \n was started on Cefepime overnight to double cover for pseudomonal PNA\n - Hydral 10mg IV 6h started for HTN control\n - PICC placed\n - Klonipin prn agitation started\n - on 36% high flow mask with sats in mid-90s, rA sats 88%, NC 91-93%\n DIALYSIS CATHETER - STOP 02:00 PM\n ARTERIAL LINE - STOP 03:00 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Meropenem - 08:15 PM\n Cefipime - 10:12 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:11 PM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.8\nC (100.1\n HR: 94 (76 - 94) bpm\n BP: 107/50(63) {107/50(63) - 156/95(110)} mmHg\n RR: 30 (22 - 70) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 773 mL\n 335 mL\n PO:\n TF:\n 128 mL\n 300 mL\n IVF:\n 570 mL\n 35 mL\n Blood products:\n Total out:\n 4,070 mL\n 900 mL\n Urine:\n 4,070 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,297 mL\n -565 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: NAD, alert but non-vernbal, nods yes and no to questions\n CV: RRR, no m/r/g\n PULM: + crackles bilat bases\n ABD: soft, nt, nd, +BS\n EXTR: no edema\n Labs / Radiology\n 414 K/uL\n 8.8 g/dL\n 217 mg/dL\n 3.8 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.3 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n WBC\n 6.8\n 7.3\n 8.5\n 8.0\n Hct\n 23.4\n 23.5\n 26.3\n 27.3\n Plt\n 277\n 318\n 352\n 414\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 28\n 27\n 27\n 27\n 27\n Glucose\n 186\n 226\n 138\n 217\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.5 mg/dL, PO4:6.0 mg/dL\n Imaging: CXR Newly inserted PICC line over the left upper\n extremity. The line is still positioned in the left internal jugular\n vein. There is no evidence of changes. Unchanged distribution and\n density of the pre-existing parenchymal bilateral opacities.\n CXR improved L infiltrates\n Microbiology: and B cxrs grew coag neg COCCUS in pairs and\n clusters, oxacillin resistant\n sputum - PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n Requested Tigacycline sensitivities.\n catheter tip pending\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 12. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - s/p removal of aline, HD line, TLC\n - Added vancomycin on for GPC\n - Cefepime was added to meropenem and Vanc overnight as coverage for\n -resistant Pseudomonas (given + sputum cxrf from ). Will dc\n cefepime for now, as Pseudomonas is likely contaminate.\n - F/u ID recs for: double coverage of ? pseudomonal PNA, also re: abx\n coverage for coag pos staph bacteremia, duration of therapy\n - get cultures daily (until cultures negative x48 hours, per ID)\n - f/u daily CXR, sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - pulled HD line yesterday () given positive blood cultures\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider dc\ning and starting\n ACEI in days when stable improved kidney fxn\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n .\n # DM: Blood sugars poorly controlled.\n - Glargine increased to 50 QD and continue ISS\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5 days\n as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n OTHER STABLE ISSUES\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, started tube feeds, speech & swallow and PT\n consults, HD per renal\n holding for now given improved renal fxn\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2117-11-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 505234, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Holding HD, per Renal: keep R IJ if possible in case needs HD but can\n pull if needed\n - Per renal, goal negative 3-4L today, Lasix 20mg IV x1, then lasix\n 40mg IV to reach I&O goal\n - Another bcx of GPC in pairs and clusters in 1 anaerobic bottle from\n (second positive bottle)\n - speciation from pos BCXR on showed coag negative GPC, will do\n sensitivities given 2 days of coag positive staph --> oxacillin\n resistant coag neg GPC\n - Pulled a-line, temp HD line (IJ), subclavian line\n - sputum grew pseudomonas, which in the past was resistant to , \n was started on Cefepime overnight to double cover for pseudomonal PNA\n - Hydral 10mg IV 6h started for HTN control\n - PICC placed\n - Klonipin prn agitation started\n - on 36% high flow mask with sats in mid-90s, rA sats 88%, NC 91-93%\n DIALYSIS CATHETER - STOP 02:00 PM\n ARTERIAL LINE - STOP 03:00 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 05:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Meropenem - 08:15 PM\n Cefipime - 10:12 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:11 PM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.8\nC (100.1\n HR: 94 (76 - 94) bpm\n BP: 107/50(63) {107/50(63) - 156/95(110)} mmHg\n RR: 30 (22 - 70) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 773 mL\n 335 mL\n PO:\n TF:\n 128 mL\n 300 mL\n IVF:\n 570 mL\n 35 mL\n Blood products:\n Total out:\n 4,070 mL\n 900 mL\n Urine:\n 4,070 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,297 mL\n -565 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n GEN: NAD, alert but non-vernbal, nods yes and no to questions\n CV: RRR, no m/r/g\n PULM: + crackles bilat bases\n ABD: soft, nt, nd, +BS\n EXTR: no edema\n Labs / Radiology\n 414 K/uL\n 8.8 g/dL\n 217 mg/dL\n 3.8 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 65 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.3 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n WBC\n 6.8\n 7.3\n 8.5\n 8.0\n Hct\n 23.4\n 23.5\n 26.3\n 27.3\n Plt\n 277\n 318\n 352\n 414\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n TCO2\n 28\n 27\n 27\n 27\n 27\n Glucose\n 186\n 226\n 138\n 217\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.5 mg/dL, PO4:6.0 mg/dL\n Imaging: CXR Newly inserted PICC line over the left upper\n extremity. The line is still positioned in the left internal jugular\n vein. There is no evidence of changes. Unchanged distribution and\n density of the pre-existing parenchymal bilateral opacities.\n CXR improved L infiltrates\n Microbiology: and B cxrs grew coag neg COCCUS in pairs and\n clusters, oxacillin resistant\n sputum - PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n Requested Tigacycline sensitivities.\n catheter tip pending\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 12. Will treat with\n 14 total days Meropenem since first negative blood culture = course\n should be from to .\n - s/p removal of aline, HD line, TLC\n - Added vancomycin on for GPC\n - Cefepime was added to meropenem and Vanc overnight as coverage for\n -resistant Pseudomonas (given + sputum cxrf from ). Will dc\n cefepime for now, as Pseudomonas is likely contaminate.\n - F/u ID recs for: double coverage of ? pseudomonal PNA, also re: abx\n coverage for coag pos staph bacteremia, duration of therapy\n - get cultures daily (until cultures negative x48 hours, per ID)\n - f/u daily CXR, sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving.\n -Meropenem, vancomycin as above\n - Daily CXR\n - Wean O2 as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation as well as ongoing infection, think pt\ns MS is likely due to\n toxic-metabolic encephalopathy. Will cont to monitor for 2-3 days\n (from ), and if no improvement can consider head CT, EEG\n monitoring and AMS w/u.\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, holding on HD for now\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n - pulled HD line yesterday () given positive blood cultures\n .\n # Hypertension\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - Continue Amlodipine 10 mg PO daily.\n - Continue hydralazine 500mg Q6 hrs, can consider dc\ning and starting\n ACEI in days when stable improved kidney fxn\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n .\n # DM: Blood sugars poorly controlled.\n - Glargine increased to 50 QD and continue ISS\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5 days\n as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n OTHER STABLE ISSUES\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, started tube feeds, speech & swallow and PT\n consults, HD per renal\n holding for now given improved renal fxn\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this AM at bedside\n ().\n Disposition: call out to floor\n" }, { "category": "Nutrition", "chartdate": "2117-11-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 505238, "text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 217 mg/dL\n 05:12 AM\n Glucose Finger Stick\n 278\n 10:00 AM\n BUN\n 63 mg/dL\n 05:12 AM\n Creatinine\n 2.7 mg/dL\n 05:12 AM\n Sodium\n 146 mEq/L\n 05:12 AM\n Potassium\n 3.5 mEq/L\n 05:12 AM\n Chloride\n 108 mEq/L\n 05:12 AM\n TCO2\n 24 mEq/L\n 05:12 AM\n Albumin\n 2.5 g/dL\n 05:12 AM\n Calcium non-ionized\n 8.1 mg/dL\n 05:12 AM\n Phosphorus\n 6.0 mg/dL\n 05:12 AM\n Magnesium\n 1.5 mg/dL\n 05:12 AM\n WBC\n 8.0 K/uL\n 05:12 AM\n Hgb\n 8.8 g/dL\n 05:12 AM\n Hematocrit\n 27.3 %\n 05:12 AM\n Current diet order / nutrition support: Nutren Renal @ 45mL/hr (2160\n kcals/80 gramsn protein)\n GI: Abd: soft/obese/hyp bowel sounds\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Patient extubated. NGT placed p/ failed swallow eval. Tube feeds\n resumed and currently infusing @ goal s/ problems per discussion c/\n RN. Renal function continues to improve. Now requiring K and Mg\n repletions. PO4 remains elevated- on Ca acetate. Can change tube feed\n formula to similar formula c/ slightly more K and Mg. FSBG\ns remain\n elevated/ Glargine increased to 50 units from 40 for tonight.\n Medical Nutrition Therapy Plan - Recommend the Following\n Change tube feeds to Nutren 2.0 @45mL/hr (2160 kcals/86 gr\n protein)\n Continue c/ Phos binder\n Continue to adjust insulin regimen prn\n Lyte management as you are\n Following #\n" }, { "category": "Physician ", "chartdate": "2117-11-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503898, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 08:00 PM\n - increased glargine\n - daily bcx until neg cx for 48hr\n - increased BB to 50mg\n - plan to use zyprexa and BB for high HR, BP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 15 mcg/Kg/min\n Labetalol - 0.4 mg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:25 AM\n Fentanyl - 04:27 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.3\nC (100.9\n HR: 85 (84 - 105) bpm\n BP: 125/51(72) {125/51(72) - 187/93(118)} mmHg\n RR: 33 (0 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,643 mL\n 976 mL\n PO:\n TF:\n 1,084 mL\n 336 mL\n IVF:\n 1,010 mL\n 579 mL\n Blood products:\n 350 mL\n Total out:\n 4,065 mL\n 130 mL\n Urine:\n 415 mL\n 130 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n -1,422 mL\n 846 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (390 - 497) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.46/39/84./25/3\n Ve: 14.8 L/min\n PaO2 / FiO2: 210\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 244 K/uL\n 8.2 g/dL\n 193 mg/dL\n 5.5 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 49 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.1 %\n 8.2 K/uL\n [image002.jpg]\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n WBC\n 8.9\n 7.9\n 8.2\n Hct\n 25.1\n 23.6\n 25.1\n Plt\n 282\n 239\n 244\n Cr\n 8.4\n 7.0\n 5.5\n TCO2\n 31\n 31\n 32\n 29\n 29\n 28\n 29\n Glucose\n 187\n 228\n 193\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:28/46, Alk Phos / T Bili:153/1.0,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:217 IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:6.0 mg/dL\n C.diff negative\n No other new micro data\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 7\n - get culture today from HD line and triple lumen (cultured yesterday\n too)\n - consider abdominal CT to look for source of infection\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 5. Too altered for SBT at this\n time despite adequate RSBI\n - SBT today; pressure support trial as tolerated\n - Fentanyl and propofol for sedation\n wean down as patient was\n minimally responsive this morning, use boluses for agitation rather\n than uptitrating the dose, that is preferred.\n -Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed after SVT/VT/\n - Dilt stopped and lopressor started again according to cardiology recs\n - Increase lopressor dose to 50 mg TID and consider using dilt since\n patient is responsive to this tomorrow if lopressor does not work\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Continue glargine 25 and ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 10:14 PM 45 mL/hour\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n" }, { "category": "Physician ", "chartdate": "2117-11-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504019, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 08:00 PM\n - increased glargine\n - daily bcx until neg cx for 48hr, per ID\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 15 mcg/Kg/min\n Labetalol - 0.4 mg/min\n Other ICU medications:\n Famotidine (Pepcid) - 04:25 AM\n Fentanyl - 04:27 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.3\nC (100.9\n HR: 85 (84 - 105) bpm\n BP: 125/51(72) {125/51(72) - 187/93(118)} mmHg\n RR: 33 (0 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,643 mL\n 976 mL\n PO:\n TF:\n 1,084 mL\n 336 mL\n IVF:\n 1,010 mL\n 579 mL\n Blood products:\n 350 mL\n Total out:\n 4,065 mL\n 130 mL\n Urine:\n 415 mL\n 130 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n -1,422 mL\n 846 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 480 (390 - 497) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.46/39/84./25/3\n Ve: 14.8 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GEN: Sedated, NAD\n CV: Tachycardic, no murmurs, regular rate\n PULM: CTAB\n ABD: no BS, soft, obese, NT\n EXTR: no edema\n Labs / Radiology\n 244 K/uL\n 8.2 g/dL\n 193 mg/dL\n 5.5 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 49 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.1 %\n 8.2 K/uL\n [image002.jpg]\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n WBC\n 8.9\n 7.9\n 8.2\n Hct\n 25.1\n 23.6\n 25.1\n Plt\n 282\n 239\n 244\n Cr\n 8.4\n 7.0\n 5.5\n TCO2\n 31\n 31\n 32\n 29\n 29\n 28\n 29\n Glucose\n 187\n 228\n 193\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:28/46, Alk Phos / T Bili:153/1.0,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:217 IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:6.0 mg/dL\n C.diff negative\n No other new micro data\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 7\n - get culture today from HD line and triple lumen (cultured yesterday\n too), and culture tomorrow (until cultures negative x48 hours, per ID)\n - consider abdominal CT to look for source of infection\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 5. Too altered for SBT at this\n time despite adequate RSBI\n - SBT today; pressure support trial as tolerated\n - Fentanyl and propofol for sedation\n wean down as patient was\n minimally responsive this morning, use boluses for agitation rather\n than uptitrating the dose, that is preferred. Stop Propofol, wean down\n fentanyl; if then mental status appropriate, consider repeat SBT.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - No HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed after SVT/VT/\n - Restart diltiazem 30mg qid\n - Increase metoprolol from 50mg tid to 75 mg tid\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; put adenosine at bedside\n - d/c labetalol gtt\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Increase glargine from 25 to 28, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 10:14 PM 45 mL/hour\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n" }, { "category": "Physician ", "chartdate": "2117-11-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 505221, "text": "Chief Complaint: Klesiella Pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n HD line, a-line, and CVL all pulled yesterday\n 24 Hour Events:\n DIALYSIS CATHETER - STOP 02:00 PM\n ARTERIAL LINE - STOP 03:00 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 05:00 PM\n CALLED OUT\n History obtained from Medical records, icu team\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:15 PM\n Cefipime - 10:12 PM\n Vancomycin - 10:09 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:11 PM\n Heparin Sodium (Prophylaxis) - 08:20 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 Nutritional Support: Tube feeds\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:43 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: 37.2\nC (99\n HR: 88 (76 - 98) bpm\n BP: 119/62(77) {107/50(63) - 156/95(110)} mmHg\n RR: 27 (22 - 70) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 773 mL\n 983 mL\n PO:\n TF:\n 128 mL\n 474 mL\n IVF:\n 570 mL\n 369 mL\n Blood products:\n Total out:\n 4,070 mL\n 1,295 mL\n Urine:\n 4,070 mL\n 1,295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,297 mL\n -311 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: No(t) 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, Obese\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, still confused\n Labs / Radiology\n 8.8 g/dL\n 414 K/uL\n 217 mg/dL\n 2.7 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 63 mg/dL\n 108 mEq/L\n 146 mEq/L\n 27.3 %\n 8.0 K/uL\n [image002.jpg]\n 03:43 AM\n 03:01 PM\n 04:38 PM\n 02:44 AM\n 02:46 AM\n 09:27 AM\n 03:14 PM\n 03:16 AM\n 03:47 AM\n 05:12 AM\n WBC\n 6.8\n 7.3\n 8.5\n 8.0\n Hct\n 23.4\n 23.5\n 26.3\n 27.3\n Plt\n 277\n 318\n 352\n 414\n Cr\n 4.0\n 3.4\n 4.3\n 3.8\n 2.7\n TCO2\n 28\n 27\n 27\n 27\n 27\n Glucose\n 186\n 226\n 138\n 217\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:2.5 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.5 mg/dL, PO4:6.0 mg/dL\n Microbiology: , - coag neg staph\n Assessment and Plan\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n Septic shock with ESBL klebs bacteremia: Cont meropenem - redose for\n improving renal function. Got a dose of cefepime overnight but will\n not continue. Awaiting sensitivities on pseudomonas in sputum\n Acute respiratory failure: Now extubated - continues to do well\n GPC bacteremia: coag neg staph in blood - now de-lined except for new\n PICC line\n Hypertension: dilt and metoprolol, clonidine. prn hydralazine\n Tachcardia/SVT: dilt and metoprolol\n ARF - HD per renal. Now producing urine, Cr dropping, and\n autodiuresing\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 08:13 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2117-11-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 505295, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n UPDATE: Fairly quiet day for with improving renal fxn,\n low supplemental oxygen support and no acute c/o pain or anxiety. The\n pt worked with PT this AM for general ROM and was moved OOB to chair\n for 60 minutes this AM.\n Pneumonia, other\n Assessment:\n Pt received/maintained on 35% cold steam face tent with sats in the\n low/mid 90\ns. LS are fairly clear in upper lobes and more diminished\n @ bases. Weak/ineffective cough noted. RR generally in the high\n 20\ns. Pt cont to receive IV Antibx as timed.\n Action:\n Random AM Vanco value of 16.9 today, pt subsequently infused with 1gm\n IV Vanco. IV Meropenem dosing increased to 1gm Q12 hrs infused over\n two hours. Pt couched to CDB with minimal effort noted on pts part.\n Pt moved OOB to chair sat upright 90 degrees to optimize resp fxn.\n Response:\n Pt resp fxn appears to be stable/slowly improving.\n Plan:\n Cont to monitor resp fxn, coach pt to CDB, move pt OOB to chair for one\n hour intervals, admin antibx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt now recovering from ARF with falling Cr values now down to 2.7 and\n pt making approx 100ml/hr clear yellow urine per hour. The pt is\n currently net output 600ml today and is net input five liters for LOS.\n Action:\n Following Q1 hour urine output. Following serum kidney fxn tests\n Qday.\n Response:\n Pts kidney fxn cont to improve daily.\n Plan:\n Cont to follow kidney fxn/urine output daily.\n Muscle Performace, Impaired\n Assessment:\n Pt MAE to command but is profoundly weak/flaccid. Pt follows\n commands. Mute voice, pt has difficulty articulating needs. Pt is \n time one, diff to assess 2^nd mute voice. Pt has denied c/o pain but\n appears anxious.\n Action:\n PT worked with pt ROM this AM. Pt mobilized OOB to chair for one hour\n (stage II pressure ulcer on coccyx prevents longer stay in chair).\n Response:\n Pt remains with significantly impaired muscle weakness and will cont to\n require aggressive PT to assist with return of fxn.\n Plan:\n Pt is uninsured and will have diff transferring to a rehab facility\n and thus will likely stay in and receive his PT here and thus\n will be as aggressively as poss to deliver optimal/freq PT\n interventions.\n" }, { "category": "Nursing", "chartdate": "2117-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504063, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n : Pt placed on SBT this am, developed SVT rate 170-175, remains\n febrile 100-101, no HD.\n Events overnight: Pt opening eyes to voice and looking toward sound of\n voice. Pt unable to track, however in early AM pt spontaneously moving\n all extremities (!!) When asked to wiggles his toes he did so on\n command both feet, but was unable to squeeze to grasp w/ hands when\n asked. Propofol increased overnight to 20 mcg/kg/min.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Received pt on PO meds for HTN, ABPs 150-160/70.\n Action:\n Admin lopressor and diltiazem but increase lopressor dose d/t\n borderline high ABPs.\n Response:\n ABPs cont to drift up toward AM, MAPs > 100, current ABP 175/85 (105).\n Team notified.\n Plan:\n ? increase standing doses or give 1x dose to control HTN.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max overnight 100.6 F oral. WBC WNL.\n Action:\n Admin abx: Meropenem.\n Response:\n Temp stable (100.1\n 100.6 F). WBC unchanged at 8.2.\n Plan:\n Cont abx tx for identified infections and monitor.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt on CPAP 40% / PS 8 / PEEP 8. Sp02 97%. RR 30 up to 35 at\n times. LS clear, scant secretions w/ in line suction. Intermittent\n bronchospasm and coughing noted, not associated w/ movt or turning.\n Action:\n Perform RSBI in AM, admin nebs PRN.\n Response:\n LS remain clear, ABG this AM 7.41/36/86. RSBI score 78. No arrhythmia\n noted during RSBI.\n Plan:\n Poss SBT again today pending MS, hemodynamic stability, resp status.\n" }, { "category": "Physician ", "chartdate": "2117-11-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 504089, "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 FEVER - 101.1\nF - 08:00 AM\n Tachy tx with dilt/adenosine\n Metoprolol doubled last night for hypertension\n Dilt added to regimen\n Daily BCs per ID\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:32 AM\n Famotidine (Pepcid) - 05:00 AM\n Other medications:\n reviewed\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:19 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: 37.8\nC (100\n HR: 84 (80 - 94) bpm\n BP: 180/88(108) {144/54(78) - 183/94(117)} mmHg\n RR: 33 (22 - 38) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,252 mL\n 872 mL\n PO:\n TF:\n 1,036 mL\n 494 mL\n IVF:\n 875 mL\n 258 mL\n Blood products:\n Total out:\n 530 mL\n 400 mL\n Urine:\n 530 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,722 mL\n 472 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 417 (417 - 540) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 17 cmH2O\n SpO2: 99%\n ABG: 7.41/36/86/22/0\n Ve: 13.3 L/min\n PaO2 / FiO2: 215\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Crackles : )\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, Moving toes spontaneously\n Labs / Radiology\n 8.3 g/dL\n 248 K/uL\n 172 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 74 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.2 %\n 8.2 K/uL\n [image002.jpg]\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n WBC\n 8.9\n 7.9\n 8.2\n 8.2\n Hct\n 25.1\n 23.6\n 25.1\n 25.2\n Plt\n 282\n 239\n 244\n 248\n Cr\n 8.4\n 7.0\n 5.5\n 6.5\n TCO2\n 32\n 29\n 29\n 28\n 29\n 24\n Glucose\n 187\n 228\n 193\n 172\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Septic shock with ESBL klebs bacteremia: has another positive blood cx\n from . It was from the same line, which has now been changed to\n the HD cath. Multiple surveill cultures (taken from CVL, HD and periph\n sources) all negative so far. Cont with meropenem\n Acute respiratory failure: wean his peep, did well on PS 5/5. Main\n barrier to extubation is mental status, volume. Will stop prop and wean\n fent. Try to wake up with bolus sedation prn.\n Hypertension: c/w dilt and metoprolol, add clonidine\n Tachcardia/SVT: doing well on lopressor, off labetolol. responded to\n adenosine this am for SVT. Will combine increased lopressor and start\n diltiazem.\n ARF - HD tomorrow\n DM: glargine 25.\n increased LFTs: almost normalized. Likely from shock liver.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 08:28 AM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: Increase\n glargine, last BS 173\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504096, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.1\nF - 08:00 AM\n - had another run of tachycardia, bp held steady, given 10 dilt and\n then adenosine and then he broke to HR 80s\n - added back dilt and increased metoprolol\n - daily blood cultures until negative, per ID\n - tachy and hypertensive, given 10 IV labetalol early morning, without\n significant effect noted\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Diltiazem - 09:05 AM\n Adenosine - 09:10 AM\n Heparin Sodium (Prophylaxis) - 12:32 AM\n Famotidine (Pepcid) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 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: 37.9\nC (100.3\n HR: 86 (80 - 165) bpm\n BP: 174/87(108) {128/54(78) - 177/87(111)} mmHg\n RR: 38 (17 - 38) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,252 mL\n 578 mL\n PO:\n TF:\n 1,036 mL\n 331 mL\n IVF:\n 875 mL\n 186 mL\n Blood products:\n Total out:\n 530 mL\n 220 mL\n Urine:\n 530 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,722 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (475 - 676) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: 7.41/36/86/22/0\n Ve: 13.3 L/min\n PaO2 / FiO2: 215\n Physical Examination\n GEN: Sedated, does not open eyes to command, spontaneously moving legs\n (and arms a bit).\n CV: Tachycardic, regular rate, no m/r/g\n PULM: Mild rales b/l anteriorly\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema\n Labs / Radiology\n 248 K/uL\n 8.3 g/dL\n 172 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 74 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.2 %\n 8.2 K/uL\n [image002.jpg]\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n WBC\n 8.9\n 7.9\n 8.2\n 8.2\n Hct\n 25.1\n 23.6\n 25.1\n 25.2\n Plt\n 282\n 239\n 244\n 248\n Cr\n 8.4\n 7.0\n 5.5\n 6.5\n TCO2\n 32\n 29\n 29\n 28\n 29\n 24\n Glucose\n 187\n 228\n 193\n 172\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:8.2 mg/dL\n CXR: pneumonia improving (my read)\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 8. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get culture today from HD line and triple lumen (cultured yesterday\n too), and culture tomorrow (until cultures negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Too altered for SBT at this\n time despite adequate RSBI\n - Increasing propofol to help with hypertension/tachycardia (see\n below); so will postpone doing an SBT today as feel that increased\n sedation will result in an SBT failure\n - Continue pressure support for today\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs\n - No HD today, next planned for Monday\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Watch hemodynamics and rhythm; on telemetry\n - Apply clonidine patch 0.2 (know that there will be a delay before it\n starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too\n - d/c labetalol gtt\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Increase glargine from 28 to 30, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated this morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 09:24 PM 45 mL/hour\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Code status: Full code\n" }, { "category": "Physician ", "chartdate": "2117-11-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 504301, "text": "Chief Complaint: Kelbsiella pneumonia, respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 04:16 AM\n Heparin Sodium (Prophylaxis) - 08:00 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: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\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: 38.2\nC (100.8\n Tcurrent: 37.7\nC (99.8\n HR: 79 (76 - 94) bpm\n BP: 169/72(94) {142/54(76) - 180/83(106)} mmHg\n RR: 23 (19 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,262 mL\n 1,016 mL\n PO:\n TF:\n 1,086 mL\n 565 mL\n IVF:\n 806 mL\n 422 mL\n Blood products:\n Total out:\n 1,105 mL\n 795 mL\n Urine:\n 1,105 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,157 mL\n 221 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/35/86/22/0\n Ve: 15 L/min\n PaO2 / FiO2: 215\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: 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\n Labs / Radiology\n 7.8 g/dL\n 277 K/uL\n 193 mg/dL\n 6.4 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 23.8 %\n 7.7 K/uL\n [image002.jpg]\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n WBC\n 7.9\n 8.2\n 8.2\n 7.7\n Hct\n 23.6\n 25.1\n 25.2\n 23.8\n Plt\n 77\n Cr\n 7.0\n 5.5\n 6.5\n 6.4\n TCO2\n 29\n 29\n 28\n 29\n 24\n 25\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:1.7 mg/dL, PO4:8.4 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n Septic shock with ESBL klebs bacteremia: Cont meropenem\n Acute respiratory failure: Will try to wean PEEP today, on FIO2 of\n .4. Weaning sedation barrier to extubation.\n Hypertension: c/w dilt and metoprolol, clonidine\n Tachcardia/SVT: dilt and metoprolol\n ARF - HD today\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:33 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504003, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Shift Events:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504010, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Shift Events: Placed on SBT this am, developed SVT rate 170-175,\n remains febrile 100-101, no HD.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt place on SBT this am, The propofol was stopped and the fentanyl was\n turned down to 50 mcg/hr. at 9am he developed SVT (see below).\n Action:\n He was placed back on PSV 8/8 to let him rest. He has required frequent\n suctioning for thick creamy white secretions. Most of the day when his\n B/P increased he needed suctioning but at 1430 he became tachycardic,\n HTN, and tachypnic.\n Response:\n The propofol was restarted at 8mg/hr and he settled right out.\n Plan:\n Maintain vent settings overnight, keep propofol during the night, will\n try to wean in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O very slowly picking up, U/P 10-30cc/hr.\n Action:\n No HD done today\n Response:\n Slowly improving renal status\n Plan:\n Continue to monitor I&O closely.\n Cardiac dysrhythmia other\n Assessment:\n While pt was on SBT he developed SVT 170-175, B/P 125/66.\n Action:\n He was given dilt 10mg with no effect, then given adenosine 6mg.\n Response:\n Within a minute of getting the adenosine he converted back to sinus\n rhythm. His blood pressure following that was 170-180/80\nhe was\n started on diltazem 30mg qid and the lopressor was increased to 75mg\n tid.\n Plan:\n Continue meds as ordered, monitor vital signs.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Continues to have fevers in 100-101.\n Action:\n Continues on antibiotic meropenem, foley and NGT changed.\n Response:\n No change in fever.\n Plan:\n Continue as planned.\n Hyperglycemia\n Assessment:\n Blood sugars remain ~200\n Action:\n Glargine amount was increased to 28, sliding scale unchanged. He was\n given 5 units of regular insulin at 10am and 1600.\n Response:\n Blood sugars are unchaged.\n Plan:\n Continue to monitor and give sliding scale regular insulin as ordered.\n" }, { "category": "Physician ", "chartdate": "2117-11-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504069, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.1\nF - 08:00 AM\n - had another run of tachycardia, bp held steady, given 10 dilt and\n then adenosine and then he broke to HR 80s\n - added back dilt and increased metoprolol\n - daily blood cultures until negative, per ID\n - tachy to 170s, given 10 IV labetalol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:00 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Diltiazem - 09:05 AM\n Adenosine - 09:10 AM\n Heparin Sodium (Prophylaxis) - 12:32 AM\n Famotidine (Pepcid) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 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: 37.9\nC (100.3\n HR: 86 (80 - 165) bpm\n BP: 174/87(108) {128/54(78) - 177/87(111)} mmHg\n RR: 38 (17 - 38) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,252 mL\n 578 mL\n PO:\n TF:\n 1,036 mL\n 331 mL\n IVF:\n 875 mL\n 186 mL\n Blood products:\n Total out:\n 530 mL\n 220 mL\n Urine:\n 530 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,722 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 540 (475 - 676) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 72\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: 7.41/36/86/22/0\n Ve: 13.3 L/min\n PaO2 / FiO2: 215\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 248 K/uL\n 8.3 g/dL\n 172 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 74 mg/dL\n 103 mEq/L\n 138 mEq/L\n 25.2 %\n 8.2 K/uL\n [image002.jpg]\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n WBC\n 8.9\n 7.9\n 8.2\n 8.2\n Hct\n 25.1\n 23.6\n 25.1\n 25.2\n Plt\n 282\n 239\n 244\n 248\n Cr\n 8.4\n 7.0\n 5.5\n 6.5\n TCO2\n 32\n 29\n 29\n 28\n 29\n 24\n Glucose\n 187\n 228\n 193\n 172\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 7\n - get culture today from HD line and triple lumen (cultured yesterday\n too), and culture tomorrow (until cultures negative x48 hours, per ID)\n - consider abdominal CT to look for source of infection\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 5. Too altered for SBT at this\n time despite adequate RSBI\n - SBT today; pressure support trial as tolerated\n - Fentanyl and propofol for sedation\n wean down as patient was\n minimally responsive this morning, use boluses for agitation rather\n than uptitrating the dose, that is preferred. Stop Propofol, wean down\n fentanyl; if then mental status appropriate, consider repeat SBT.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - No HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed after SVT/VT/\n - Restart diltiazem 30mg qid\n - Increase metoprolol from 50mg tid to 75 mg tid\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; put adenosine at bedside\n - d/c labetalol gtt\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Increase glargine from 25 to 28, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 09:24 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2117-11-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504407, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI-38, however when pt was placed on RSBI he became very\n hypertensive. MAPS rose from 90's to 120's within 5 minutes so SBT was\n stopped. Pt also had pronounced active exhalation. Pt was also weaned\n from 8 to 5 of peep which was not tolerated again by HTN so peep was\n increased back to 8.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503403, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. SaO2 92-96%. Cough/gag weak. LS clear w/diminished bases. O2 sat\n 94-98%. Opening eyes with turning. Not following commands. Not moving\n extremities. Occasionally withdraws to pain. PERRLA. Tmax 101.6 PO.\n Action:\n No vent changes made during shift. Continued meropenum. Continued\n Tylenol and cooling blanket. Continued on fentanyl and versed gtts.\n Response:\n Plan:\n will cont the current abx,follow fever curve off cooling blanket,follow\n cx and sensitivities,daily wake up and SBT.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt essentially anuric,(16cc in this shift),HD line was changed over the\n wire last day high access pressure,confirmed the line placement but\n unable to flush the new line,so didn\nt have HD yesterday,bun/s.cr\n trending up,Ionised ca running on the low side,CVP was 13.\n Action:\n Plan for new HD line today(possibly in the IR),and HD\n afterwards,received 6gm of calcium gluconate in this shift,\n Response:\n Pending. I ca was 1.08 after the 4gm of ca.received a total of 6gm in\n this shift,bun/s.cr worsening.\n Plan:\n New HD line placement and HD.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing. One of the port of the HD cath was found coiled under the\n dsg,\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n novasource renal at goal(held since 0400am for possible IR HD line\n placement,\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition as needed,contd\n enteral nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 505356, "text": "TITLE: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures), , noted pseudomonas in sputum culture\n Pneumonia, other\n Assessment:\n Pt received/maintained on 35% cold steam face tent LS are fairly\n clear in upper lobes and more diminished @ bases. No cough efforts.\n Pt continued to have abdominal breathing with RR in 30\n Action:\n MD notified on pts increased to WOB\n ABG 7.49/37 /97/4 on above mentioned O@ supplement\n CXray\n.started on NIV\n Response:\n Pt resp status continued to be in the same,denies any pain ,not\n agitated.\n Sats always maintained 95-97%\n RR 20-25 on BIPAP.\n Plan:\n Cont to monitor resp fxn, coach pt to CDB, antibx as ordered .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt now recovering from ARF with falling Cr values now down to 2.7 and\n pt making approx 100ml/hr clear yellow urine per hour. The pt is\n currently net output 600ml today and is net input five liters for LOS.\n Action:\n Following Q1 hour urine output. Following serum kidney fxn tests\n Qday.\n Response:\n Pts kidney fxn cont to improve daily.\n Plan:\n Cont to follow kidney fxn/urine output daily.\n Muscle Performace, Impaired\n Assessment:\n Pt profoundly weak/flaccid. Pt opens eyes on verbal commands no other\n response noted at this shift. Mute voice, pt has difficulty\n articulating needs. Pt has denied c/o pain but does not appears\n anxious or agitated.\n Action:\n Repositioned Q2hr .\n Response:\n Pt remains with significantly impaired muscle weakness and will cont to\n require aggressive PT to assist with return of fxn.\n Plan:\n Pt is uninsured and will have diff transferring to a rehab facility\n and thus will likely stay in and receive his PT here and thus\n will be as aggressively as poss to deliver optimal/freq PT\n interventions.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 505422, "text": "Demographics\n :\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 :\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation; Comments: paradoxical respirations\n Non-invasive ventilation assessment: Tolerated well\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High min. ventilation)\n Apply NIV for pt\ns comfort and ease of breathing\n" }, { "category": "Physician ", "chartdate": "2117-11-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504238, "text": "TITLE:\n Chief Complaint: septic , ARDS\n 24 Hour Events:\n - surveillance cultures on not drawn for some reason- rechecked\n that order was in. Cultures from and negative. Make sure\n cultures get drawn \n - started on clonidine patch and hydral bridge\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 PM\n Famotidine (Pepcid) - 04:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 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: 37.9\nC (100.3\n HR: 86 (76 - 94) bpm\n BP: 167/65(89) {142/54(76) - 192/99(122)} mmHg\n RR: 24 (19 - 40) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,262 mL\n 617 mL\n PO:\n TF:\n 1,086 mL\n 295 mL\n IVF:\n 806 mL\n 292 mL\n Blood products:\n Total out:\n 1,105 mL\n 375 mL\n Urine:\n 1,105 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,157 mL\n 242 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 388) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/35/86/22/0\n Ve: 12 L/min\n PaO2 / FiO2: 215\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 277 K/uL\n 7.8 g/dL\n 193 mg/dL\n 6.4 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 23.8 %\n 7.7 K/uL\n [image002.jpg]\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n WBC\n 7.9\n 8.2\n 8.2\n 7.7\n Hct\n 23.6\n 25.1\n 25.2\n 23.8\n Plt\n 77\n Cr\n 7.0\n 5.5\n 6.5\n 6.4\n TCO2\n 29\n 29\n 28\n 29\n 24\n 25\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:1.7 mg/dL, PO4:8.4 mg/dL\n Imaging:\n CXR done\n CXR : In comparison with the study of , there is probably\n little\n overall change. Monitoring and support devices remain in place.\n Extensive\n opacification in the lower half of the left lung is again seen. Again\n this is\n probably consistent with pneumonia and pleural effusion. Small amount\n of\n opacification at the right base most likely represents atelectasis.\n Microbiology: B Cxrs from , , pending\n 10:47 am BLOOD CULTURE Source: Line- CVP. Blood Culture,\n Routine (Final ): KLEBSIELLA PNEUMONIAE. ESBL.\n 10:48 am SPUTUM Source: Endotracheal. KLEBSIELLA\n PNEUMONIAE. ESBL. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get culture today from HD line and triple lumen (cultured the prior\n two days too), and culture tomorrow (until cultures negative x48 hours,\n per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Too altered for SBT at this\n time despite adequate RSBI\n - Increasing propofol to help with hypertension/tachycardia (see\n below); so will postpone doing an SBT today as feel that increased\n sedation will result in an SBT failure\n - Continue pressure support for today\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs\n - No HD today, next planned for Monday\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Watch hemodynamics and rhythm; on telemetry\n - Apply clonidine patch 0.2 (know that there will be a delay before it\n starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too\n - d/c labetalol gtt\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Increase glargine from 28 to 30, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Physician ", "chartdate": "2117-11-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 504284, "text": "Chief Complaint: Kelbsiella pneumonia, respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 06:11 AM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 04:16 AM\n Heparin Sodium (Prophylaxis) - 08:00 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: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\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: 38.2\nC (100.8\n Tcurrent: 37.7\nC (99.8\n HR: 79 (76 - 94) bpm\n BP: 169/72(94) {142/54(76) - 180/83(106)} mmHg\n RR: 23 (19 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,262 mL\n 1,016 mL\n PO:\n TF:\n 1,086 mL\n 565 mL\n IVF:\n 806 mL\n 422 mL\n Blood products:\n Total out:\n 1,105 mL\n 795 mL\n Urine:\n 1,105 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,157 mL\n 221 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n Plateau: 22 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/35/86/22/0\n Ve: 15 L/min\n PaO2 / FiO2: 215\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: 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\n Labs / Radiology\n 7.8 g/dL\n 277 K/uL\n 193 mg/dL\n 6.4 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 23.8 %\n 7.7 K/uL\n [image002.jpg]\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n WBC\n 7.9\n 8.2\n 8.2\n 7.7\n Hct\n 23.6\n 25.1\n 25.2\n 23.8\n Plt\n 77\n Cr\n 7.0\n 5.5\n 6.5\n 6.4\n TCO2\n 29\n 29\n 28\n 29\n 24\n 25\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:1.7 mg/dL, PO4:8.4 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Septic shock with ESBL klebs bacteremia: Cont meropenem\n Acute respiratory failure: Will try to wean PEEP today, on FIO2 of\n .4. Sedation an issue\n Hypertension: c/w dilt and metoprolol, clonidine\n Tachcardia/SVT: dilt and metoprolol\n ARF - HD today\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:33 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503593, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. Has blood tinged oral secretions. O2 sats 95-97%. Cough/gag\n weak. LS clear w/diminished bases. Opening eyes with turning,\n occasionally w/o stimulation. Not following commands. Not moving\n extremities. Not tracking. Occasionally withdraws to pain. PERRLA, R\n pupil >L. Tmax 99.1 PO.\n Action:\n Placed on PS , 50%. Continued meropenum. Continued Tylenol.\n Continued on fentanyl and versed gtts, occasionally given fentanyl and\n versed boluses.\n Response:\n ABG 7.47/39/96 while on dialysis. Tcurrent 98.9 PO with cooling blanket\n off.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 75cc for shift.\n Action:\n UOP monitored. HD done, 2L removed. TF continued. FS covered by ISS.\n Response:\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\ns. Plan for\n Ultrafiltration tomorrow and Sat.\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF continued. Repositioned q2-3 hours.\n Response:\n Rash appears to be improving. No change of stage II noted.\n Plan:\n Will cont the current management, turn and reposition q2-3hrs, continue\n nutrition. F/U wound care consult.\n" }, { "category": "Nursing", "chartdate": "2117-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503602, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. Has blood tinged oral secretions. O2 sats 95-97%. Cough/gag\n weak. LS clear w/diminished bases. Opening eyes with turning,\n occasionally w/o stimulation. Not following commands. Not moving\n extremities. Not tracking. Occasionally withdraws to pain. PERRLA, R\n pupil >L. Tmax 101.6 PO.\n Action:\n Placed on PS , 50%. Continued meropenum. Continued Tylenol.\n Continued on fentanyl and versed gtts, occasionally given fentanyl and\n versed boluses.\n Response:\n ABG 7.47/39/96 while on dialysis. Tcurrent 101.6 PO with cooling\n blanket on.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 125cc for shift.\n Action:\n UOP monitored. HD done, 2L removed. TF continued. FS covered by ISS.\n Response:\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\ns. Plan for\n Ultrafiltration tomorrow and Sat.\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF continued. Repositioned q2-3 hours.\n Response:\n Rash appears to be improving. No change of stage II noted.\n Plan:\n Will cont the current management, turn and reposition q2-3hrs, continue\n nutrition. F/U wound care consult.\n" }, { "category": "Nursing", "chartdate": "2117-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503603, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. Has blood tinged oral secretions. O2 sats 95-97%. Cough/gag\n weak. LS clear w/diminished bases. Opening eyes with turning,\n occasionally w/o stimulation. Not following commands. Not moving\n extremities. Not tracking. Occasionally withdraws to pain. PERRLA, R\n pupil >L. Tmax 101.6 PO.\n Action:\n Placed on PS , 50%. Continued meropenum. Continued Tylenol.\n Continued on fentanyl and versed gtts, occasionally given fentanyl and\n versed boluses.\n Response:\n ABG 7.47/39/96 while on dialysis. Tcurrent 101.6 PO with cooling\n blanket and fan on.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated, plan to change versed gtt to propofol gtt.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 125cc for shift.\n Action:\n UOP monitored. HD done, 2L removed. TF continued. FS covered by ISS.\n Response:\n No significant change in UOP.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\ns. Plan for\n Ultrafiltration tomorrow and Sat.\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF continued. Repositioned q2-3 hours.\n Response:\n Rash appears to be improving. No change of stage II noted.\n Plan:\n Will cont the current management, turn and reposition q2-3hrs, continue\n nutrition. F/U wound care consult.\n" }, { "category": "Nursing", "chartdate": "2117-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504225, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n : Pt placed on SBT this am, developed SVT rate 170-175, remains\n febrile 100-101, no HD.\n : VERY HTN, started on hydralazine and clonidine patch, propofol\n up to 40 to help HTN, no weaning, U/O UP!\n : Stable overnight.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABPs 170/80\n 160/70. MAPs 76-103. Pt remains sedated on 40\n mcg/kg/min propofol and 25 mcg/hr fentanyl gtts. Pt opens eyes\n spontaneously and intermittently overnight, inconsistenly opens eyes to\n command. Intermittently MAEs but not to command.\n Action:\n Stat dose 25 mg hydralazine given overnight. Standing hydralazine dose\n increased from 25 mg to 50 mg TID. Lopressor and diltiazem given\n asdir. Cont sedation for comfort and hemodynamic mgt while intubated\n and pt conts to wake up.\n Response:\n Current ABP this AM 166/61 (86).\n Plan:\n Cont w/ PO med mgt for HTN. ? cont to increase medication doses until\n HTN better controlled.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max overnight 100.8. WBC 8.2.\n Action:\n Blood cx\ns x 2 sent to lab for analysis. Cont meropenum.\n Response:\n Pending. WBC this AM 7.7.\n Plan:\n Conr ABX and follow temp curve.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt on AC 40%/600/18/10. Sp02 98%. LSCTAB, scant secretions\n w/ ETT suction. SRR 6 bpm.\n Action:\n Keep pt on AC overnight. RSBI deferred (PEEP >=10).\n Response:\n Resp status stable.\n Plan:\n Attempt to wean vent / change back to CPAP as HTN is better managed and\n ? anxiety issues are addressed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN / Cre 74 / 6.5. K 4.7. UOP 30-85 ml/hr.\n Action:\n Monitor UOP.\n Response:\n This AM: BUN / Cre 85 / 6.4. K 4.6. UOP stable.\n Plan:\n Pt to get HD today.\n Impaired Skin Integrity\n Assessment:\n Stage II on coccyx and R buttock.\n Action:\n Clean w/ NS and new mepilex applied. Barimax bed, freq reposition.\n Response:\n Stable.\n Plan:\n Cont wound mgt.\n Hyperglycemia\n Assessment:\n BG has been elevated most recently to 200s. Overnight 226, 230.\n Action:\n Admin standing glargine dose 30 units at 10pm and cover w/ RISS.\n Response:\n Pending.\n Plan:\n Re-assess BG mgt daily.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503595, "text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\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 / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt weaned to PSV 8/8 today; has tolerated well & continues on\n these settings at this time.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2117-11-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 505531, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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 source/amount: / None\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment: Tolerated well\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt is on and off mask ventilation tol well. See respiratory page of\n meta vision for more information.\n" }, { "category": "Physician ", "chartdate": "2117-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504487, "text": "TITLE:\n Chief Complaint: pneumonia, speptic \n 24 Hour Events:\n - Started Amlodipine 5mg to improve HTN control. Now on Propofol drip,\n Dilt, Metoprolol, Clonidine patch, Hydralazine and Amlodipine.\n - dialyzed yesterday\n - On pressure support ventilation\n - pt has had increasing urine output, which began to drop off so\n received 500cc NS (30-40cc/hour)\n - per respiratory, RSBI-38, however when pt was placed on RSBI he\n became very hypertensive. MAPS rose from 90's to 120's within 5 minutes\n so SBT was stopped. Pt also had pronounced active exhalation. Pt was\n also weaned from 8 to 5 of peep which was not tolerated again by HTN so\n peep was increased back to 8.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n ISS 20U insulin given in 24 hrs\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.9\n HR: 83 (77 - 90) bpm\n BP: 153/69(90) {123/43(65) - 185/89(113)} mmHg\n RR: 28 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,891 mL\n 1,068 mL\n PO:\n TF:\n 1,087 mL\n 319 mL\n IVF:\n 775 mL\n 600 mL\n Blood products:\n Total out:\n 1,090 mL + 1L taken off by HD\n 275 mL\n Urine:\n 1,090 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 801mL\n 1L from HD (199 mL neg)\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 616 (410 - 674) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 17 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.48/37/120/26/5\n Ve: 12 L/min\n PaO2 / FiO2: 300\n Physical Examination\n GEN: Sedated, tracking, PERRL 2->1mm\n CV: regular rate, no m/r/g\n PULM: fairly clear, few crackles bilat bases w. few scattered wheezes,\n mod amt of white/yello purulent sputum suctioned by resp\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema, puffy hands/face\n Labs / Radiology\n 277 K/uL\n 7.5 g/dL\n 186 mg/dL\n 4.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 51 mg/dL\n 100 mEq/L\n 139 mEq/L\n 23.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n WBC\n 8.2\n 8.2\n 7.7\n 6.8\n Hct\n 25.1\n 25.2\n 23.8\n 23.4\n Plt\n 244\n 248\n 277\n 277\n Cr\n 5.5\n 6.5\n 6.4\n 4.0\n TCO2\n 28\n 29\n 24\n 25\n 28\n 29\n Glucose\n 193\n 172\n 193\n 163\n 186\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR No significant change of the left lower lobe\n opacification or right basilar\n atalectasis.\n Microbiology: B cxrs , , , pending\n B cxr KLEBSIELLA PNEUMONIAE.\n Legionella urine negative\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8.\n - Increasing propofol to help with hypertension/tachycardia (see\n below).\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n - Will decrease fentanyl, propofol and start precedex x 24 hours to\n attempt to extubate tomorrow\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD yesterday.\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 500 mL.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increase amlodipine to 10mg daily.\n - Continue hydralazine 500mg Q6 hrs\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increase Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 40 QD, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Nursing", "chartdate": "2117-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504495, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Hypertensive most of night with intermittent effect of antihypertensive\n meds\n Action:\n Amlodipine increased to 10 mg QD; continued on hydralazine, lopressor,\n cardiazem as wel las clonidine patch\n Response:\n SBP<170 most of shift. SBP 120-130 while sleeping\n Plan:\n Cont to closely monitor BP. Begin on precedex and d/c propofol/fent\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD yesterday with removal of 1L. Received 500cc bolus IVF last night\n for decreased u/o\n Action:\n u/o monitored, renal continuing to consult\n Response:\n u/o 30-45cc/hr most of shift without lasix/bolus. ATN appears to be\n resolving.\n Plan:\n I/O. Cont with TF at goal. Hold on further HD for now. Monitor Cr/Bun\n QD\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Am RSBI 38, failed SBT d/t hypertension/tachypnea\n Action:\n ATN resolving; suctioned Q3-4hrs; weaned PSV to 8/6PEEP wth 40%.\n Afternoon CXR/ABG\n Response:\n Scant to no secretions; tol PSV wean.\n Plan:\n Anticipate extubation over next 24hrs. hold TF within 6-8hrs\n extubation.\n" }, { "category": "Nursing", "chartdate": "2117-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504557, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2117-11-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503732, "text": "TITLE:\n Chief Complaint: sepsis\n 24 Hour Events:\n FEVER - 101.6\nF - 06:00 PM\n - glargine increased to 18\n - lopressor increased to 37.5TID\n - LFT's per ID for cholangitis/cholecystitis continue to trend down\n from arrival\n - Changed to pressure support at noon and tolerated this well.\n Continued to wean --> \n - taken off midaz and given propofol\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 10:13 PM\n Meropenem - 08:26 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 05:00 PM\n Fentanyl - 10:45 PM\n Propofol - 11:14 PM\n Famotidine (Pepcid) - 03:14 AM\n Insulin - Regular - 05:07 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.3\nC (100.9\n HR: 84 (81 - 100) bpm\n BP: 152/61(83) {126/47(70) - 173/78(99)} mmHg\n RR: 32 (23 - 32) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,895 mL\n 622 mL\n PO:\n TF:\n 1,083 mL\n 297 mL\n IVF:\n 572 mL\n 325 mL\n Blood products:\n Total out:\n 2,227 mL\n 80 mL\n Urine:\n 227 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -332 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (455 - 490) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 21 cmH2O\n Plateau: 21 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/43/139/23/3\n Ve: 11.3 L/min\n PaO2 / FiO2: 278\n Physical Examination\n Gen: sedated and intubated, but opening eyes to voice. Not following\n commands\n Heart: NRRR; no murmurs\n Chest: Coarse BS b/l\n Abdomen: distended, hypoactive BS\n Ext: 1+ edema; warm and well perfused.\n Labs / Radiology\n 239 K/uL\n 7.7 g/dL\n 228 mg/dL\n 7.0 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 63 mg/dL\n 100 mEq/L\n 138 mEq/L\n 23.6 %\n 7.9 K/uL\n [image002.jpg]\n 02:55 AM\n 03:24 AM\n 05:01 PM\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n WBC\n 8.8\n 8.9\n 7.9\n Hct\n 26.8\n 25.1\n 23.6\n Plt\n 255\n 282\n 239\n Cr\n 9.4\n 8.4\n 7.0\n TCO2\n 28\n 32\n 31\n 31\n 32\n 29\n 29\n Glucose\n 137\n 187\n 228\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/47, Alk Phos / T Bili:166/1.1,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:239 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Fluid analysis / Other labs: GGT: 429\n Blood cultures:\n Gram negative rods\n Imaging:\n CXR\n Comparison is made with prior study performed a day earlier.\n ET tube is in the standard position. Right IJ and NG tube remain in\n place.\n There is opacity in the left perihilar region and left lower lobe have\n minimally improved. There are low lung volumes. Cardiac size is top\n normal.\n Widened mediastinum is unchanged. There is no pneumothorax or enlarging\n pleural effusion.\n Left subclavian catheter tip is in unchanged position in the left\n brachiocephalic vein/in the junction of the brachiocephalic veins.\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n Gram negative rods in blood culture from \n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 6\n - get culture today from HD line and triple lumen and again tomorrow am\n - consider abdominal CT to look for source of infection\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 50% and now with PEEP of 8. Too altered for SBT at this\n time despite adequate RSBI\n - SBT today; wean peep and PS as tolerated.\n - Check PM ABG\n - Fentanyl and propofol for sedation\n wean down as patient was\n minimally responsive this morning, use boluses for agitation rather\n than uptitrating the dose, that is preferred.\n - HD today\n -Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today due to clot; renal will place\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed after SVT/VT/\n - Dilt stopped and lopressor started again according to cardiology recs\n - increase lopressor dose to 50 mg TID and consider using dilt since\n patient is responsive to this tomorrow if lopressor does not work\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Increase glargine and increase ISS\n - Glargine increase from 18 to 25\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; change standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line. Renal to re-adjust lines\n today for HD.\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Respiratory ", "chartdate": "2117-11-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504220, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: less sputum\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Comments: Pt. remains on A/C overnoc, no vent changes. RSBI not done\n due to peep level.\n" }, { "category": "Nursing", "chartdate": "2117-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504492, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504506, "text": "37 yr old w/ PMHX of DM (newly dx) and ETOH. Adm to on after syncopal episode. ?seizure activity. Family\n reports pt had sneezing and coughing for 10 days with decreased po\n intake. On admission he was in shock and intubated. Vasopressin and\n levophed required; begun on tamiflu as well as levaquin and vanco. Neg\n for flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Hypertensive most of night with intermittent effect of antihypertensive\n meds\n Action:\n Amlodipine increased to 10 mg QD; continued on hydralazine, lopressor,\n cardiazem as wel las clonidine patch\n Response:\n SBP<170 most of shift. SBP 120-130 while sleeping\n Plan:\n Cont to closely monitor BP. Begin on precedex and d/c propofol/fent\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD yesterday with removal of 1L. Received 500cc bolus IVF last night\n for decreased u/o\n Action:\n u/o monitored, renal continuing to consult\n Response:\n u/o 30-45cc/hr most of shift without lasix/bolus. ATN appears to be\n resolving.\n Plan:\n I/O. Cont with TF at goal. Hold on further HD for now. Monitor Cr/Bun\n QD\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Am RSBI 38, failed SBT d/t hypertension/tachypnea; treatment for\n klebsiella pna\n Action:\n Q3-4hrs; weaned PSV to 8/6PEEP wth 40%. Afternoon CXR/ABG\n Response:\n Scant to no secretions; tol PSV wean.\n Plan:\n Anticipate extubation over next 24hrs. hold TF within 6-8hrs\n extubation.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503391, "text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\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: 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 response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503812, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504328, "text": "HPI: The patient is a 37y/o male with a PMH of DM, ETOH. He admitted\n to on after syncopal episode. There was a\n question of him having a seizure. Per his family, he had sneezing and\n coughing for 10 days with a decrease in his PO intake. On admission he\n was shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n : Pt placed on SBT this am, developed SVT rate 170-175, remains\n febrile 100-101, no HD.\n : VERY HTN, started on hydralazine and clonidine patch, propofol\n up to 40 to help HTN, no weaning, U/O UP!\n : PEEP weaned to 8, changed to PSV tol well, b/p improved,\n amlodipine added, HD done 1 kilo off, tol well.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n ABPs 160/70- 180\ns/90\ns. MAPs 76-113. Pt remains sedated on 40\n mcg/kg/min propofol and 25 mcg/hr fentanyl gtts. Pt opens eyes\n spontaneously but unable to follow commands. Intermittently MAEs but\n not to command.\n Action:\n Cont on clonidine patch which was added , lopressor, dilt and\n hydral. Amlodipine added.\n Response:\n ABP improved prior to 1^st dose of amlodipine, currently 150/64.\n Plan:\n Cont w/ PO med mgt for HTN cont to increase medication doses until HTN\n better controlled.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 100.2 this shift.\n Action:\n Blood cx\ns x 2 sent to lab for analysis last shift. Cont meropenum.\n Response:\n ongoing.\n Plan:\n Cont ABX and follow temp curve. f/u bld cx w/ am labs.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt on AC 40%/600x18/10. Sp02 98%. LSCTAB, scant secretions\n w/ ETT suction.\n Action:\n PEEP weaned to 8, tol well, propofol weaned to 30\n Response:\n ABG on PEEP 8 7.54/32/78, placed on PSV 10/8\n Plan:\n Cont to wean vent/ sedation as tol.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n This AM: BUN / Cre 85 / 6.4. K 4.6. UOP improved\n Action:\n HD done, 1 kilo taken off, tol well.\n Response:\n UOP cont to improve\n Plan:\n Monitor UOP, cont HD as needed.\n Impaired Skin Integrity\n Assessment:\n Stage II on coccyx and R buttock. Sm amt excoriation noted near\n flexiseal.\n Action:\n Seen by wound care RN, new mepilex applied. Barimax bed, freq\n reposition. Xeroform around flexiseal.\n Response:\n Stable.\n Plan:\n Cont wound mgt.\n" }, { "category": "Physician ", "chartdate": "2117-11-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 503358, "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 37 yo man with MSSA bactermia/respiratory failure/ARF/VAP\n 24 Hour Events:\n FEVER - 101.8\nF - 08:00 AM\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 03:18 PM\n Meropenem - 08:01 PM\n Nafcillin - 10:13 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Famotidine (Pepcid) - 04:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.6\nC (101.5\n HR: 89 (77 - 99) bpm\n BP: 135/63(83) {110/45(65) - 169/81(101)} mmHg\n RR: 17 (17 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 13 (8 - 19)mmHg\n Total In:\n 2,563 mL\n 922 mL\n PO:\n 240 mL\n TF:\n 955 mL\n 173 mL\n IVF:\n 1,188 mL\n 509 mL\n Blood products:\n Total out:\n 427 mL\n 459 mL\n Urine:\n 27 mL\n 59 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,136 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 4\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 68\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 45.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.41/42/112/24/1\n Ve: 10.7 L/min\n PaO2 / FiO2: 224\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\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 8.5 g/dL\n 255 K/uL\n 137 mg/dL\n 9.4 mg/dL\n 24 mEq/L\n 5.0 mEq/L\n 96 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n 09:15 AM\n 02:25 PM\n 09:21 PM\n 09:39 PM\n 02:55 AM\n 03:24 AM\n WBC\n 9.5\n 8.8\n Hct\n 26.5\n 26.8\n Plt\n 261\n 255\n Cr\n 8.8\n 9.1\n 9.4\n TCO2\n 28\n 29\n 28\n 28\n 27\n 26\n 28\n Glucose\n 172\n 146\n 137\n Other labs: PT / PTT / INR:13.9/34.0/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:39/60, Alk Phos / T Bili:197/1.6,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:265 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:7.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Respiratory failure: continue to wean as tolerated. Try and switch to\n PSV\n sedation: try and reduce sedation.\n renal: needs new HD catheter\n fever: now on meropenem only for klebsiella.\n tachcardia: up titrate the lopressor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Pharmacy", "chartdate": "2117-11-03 00:00:00.000", "description": "Sedation", "row_id": 503359, "text": "Pharmacy Note\n Sedation\n Assessment:\n Currently undergoing slow wean from fentanyl and versed; now on\n fentanyl 50 mcg/hr and versed 2 mg/hr.\n Recommendation:\n Given the duration of sedation/time on ventilator, if there are plans\n in the near future to extubate or do SBT, please consider a transition\n to propofol to allow time for midazolam to clear and make wakeup more\n meaningful. To transition this patient shut off the midazolam drip and\n begin propofol infusion, titrating to goal sedation and assessing\n response when awake.\n If there is breakthrough agitation, consider bolusing from the drip\n rather than escalating the infusion dose. Also, consider haldol,\n olanzepine or seroquel to supplement the sedative drip.\n Contact pharmacy with questions if need.\n , PharmD \n Unit-based PharmD \n" }, { "category": "Respiratory ", "chartdate": "2117-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503980, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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 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 Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Waiting for pt to clear sedation and follow commands before\n extubating\n" }, { "category": "Physician ", "chartdate": "2117-11-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503563, "text": "TITLE:\n Chief Complaint: Sepsis and acute renal failure\n 24 Hour Events:\n - Had HD (R IJ TLC changed to HD cath; L subclavian placed); 3L off\n - ABG's post-dialysis showed alkalosis (resp and metabolic mixed);\n decreased RR from 30 to 24 (although he's overbreathing at times) to\n try to correct the metabolic side, also increased sedation to try to\n help slow RR and HR and BP. next gas = improved.\n - BP in 160s 170s around 11pm and HR 100 - increased sedation.\n - renal plan: daily HD\n - 3AM, while being turned, HR bumped to 170s narrow-complex\n tachycardia, SBP held steady in 110's, no change to respiration, also\n febrile. 5 lopressor given without effect, 10 dilt given and then\n spontaneously broke to HR 80s-90s and BP stable in 110's.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 03:18 PM\n Nafcillin - 10:13 PM\n Meropenem - 08:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Metoprolol - 03:30 AM\n Diltiazem - 03:37 AM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38\nC (100.4\n HR: 96 (89 - 171) bpm\n BP: 134/57(79) {108/44(64) - 176/84(109)} mmHg\n RR: 27 (17 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.8 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 13 (11 - 13)mmHg\n Total In:\n 1,752 mL\n 724 mL\n PO:\n TF:\n 533 mL\n 302 mL\n IVF:\n 859 mL\n 242 mL\n Blood products:\n Total out:\n 509 mL\n 27 mL\n Urine:\n 109 mL\n 27 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,243 mL\n 697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 95%\n ABG: 7.44/45/90./28/5\n Ve: 14.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n Gen: sedated and intubated\n Eyes: pupils 3mm and 4mm, reactive to light. Likely normal variation\n Heart: NRRR; no murmurs\n Chest: CTAB\n Abdomen: ND; bowel sounds hypoactive\n Ext: no edema; warm and well perfused\n Labs / Radiology\n 282 K/uL\n 8.3 g/dL\n 187 mg/dL\n 8.4 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 75 mg/dL\n 98 mEq/L\n 139 mEq/L\n 25.1 %\n 8.9 K/uL\n [image002.jpg]\n 02:25 PM\n 09:21 PM\n 09:39 PM\n 02:55 AM\n 03:24 AM\n 05:01 PM\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n WBC\n 8.8\n 8.9\n Hct\n 26.8\n 25.1\n Plt\n 255\n 282\n Cr\n 9.1\n 9.4\n 8.4\n TCO2\n 27\n 26\n 28\n 32\n 31\n 31\n 32\n Glucose\n 146\n 137\n 187\n Other labs: PT / PTT / INR:13.9/34.0/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:39/60, Alk Phos / T Bili:197/1.6,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:265 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:6.9 mg/dL\n Imaging: CXR \n IMPRESSION:\n 1. Stable mediastinal widening, at least in part reflecting mediastinal\n lymphadenopathy.\n 2. Persistent consolidative opacities throughout much of the left lung,\n worrisome for pneumonia.\n 3. Better aeration of the right lung, which may be due to improvement\n in\n pulmonary vascular congestion.\n Microbiology: 10:48 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n Commensal Respiratory Flora Absent.\n KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.\n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #\n 286-2926K\n .\n PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n SENSITIVITIES PERFORMED ON CULTURE # 286-4033K .\n CDiff pending\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ).\n - f/u cultures\n - f/u daily CXR\n - send c.diff\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 50% and now with PEEP of 8.\n - Pressure support trial today\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning, use boluses for agitation rather than\n uptitrating the dose, that is preferred.\n - HD today\n -Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today due to clot; renal will place\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear.\n - Dilt stopped and lopressor started again according to cardiology recs\n - Increase lopressor dose to 25mg TID and consider using dilt since\n patient is responsive to this tomorrow if lopressor does not work\n - 24 hour amiodarone has completed\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Increase glargine and increase ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; change standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line. Renal to re-adjust lines\n today for HD.\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503644, "text": "37y/o male with a PMH of DM, ETOH. He admitted to on\n after syncopal episode. There was a question of a seizure. Per\n his family, he had sneezing and coughing for 10 days with a decrease in\n his PO intake. On admission he was shocked and intubated. Started on\n vasopresson, levophed and tamiflu,levaquin and vanco. Flu swab were\n negative. Blood cultures and sputum were positive for MSSA, and also\n has GNR from blood. He was started on naficillin. His hospital course\n was than completed by ARF, and was started on H/D hyperkalemia.\n When the H/D line was placed he had intermittent episode of A-fib\n which was treated with cardize. He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Shift Events:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n IMpaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2117-11-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504040, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Not applicable\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: White / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\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 manage secretions, Underlying illness not\n resolved\n Comments: Pt. remains intubated on IPS overnoc. RR low 30\n Suctioned less sputum. RSBI 72 this am, plan SBT early am.\n" }, { "category": "Nursing", "chartdate": "2117-11-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504744, "text": "old w/ PMHX of DM (newly dx) and ETOH. Adm to \n on after syncopal episode. ?seizure activity. Family reports pt\n had sneezing and coughing for 10 days with decreased po intake. On\n admission he was in shock and intubated. Vasopressin and levophed\n required; begun on tamiflu as well as levaquin and vanco. Neg for\n flu. Bld and sputum cx +for MSSA; GNR in blood. Naficillin begun.\n Hospital course further complicated with ARF and HD begun \n hyperkalemia. During HD line placement, brief A-fib responsive to\n cardiazem. Transferred to MICU 6 . On wide complex\n tachycardia with HR 180\ns, cardioverted, begun on amiodarone, and\n adenosine was given. Pt converted to sinus and begun on amio gtt. Pt\n has continued to have hypertension and begun on multiple agents. Pt\n has begun weaning of vent support.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received Intubated on CPAP 40%/. RR 20s-32, sats >95%. RSBI this\n morning was 38. Bilateral Breath sounds Rhonchorus. ON Presedex @\n .6mcg/k/hr. widw eawake.following commands,appeared to be anxious.\n Action:\n Increased PS-> 14 in effort to decrease RR from 30s. Increased presedex\n to .3mcg d/t pts c/o feeling anxious, emotional support given\n Response:\n RR 17-32, mostly in low 20s but occ ^^ 30 while sleeping. AM ABG\n 7.47/36/126/27. RSBI 31, SBT for 20\n and pt became hypertensive, using\n abdominal muscles to breath. Pt c/o difficulty breathing so SBT\n aborted. Placed back on CPAP 5 + 5, 40%\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-90cc/hr clear yellow urine. +2 edema in hands and feet, lines\n leaving pressure marks on skin\n Action:\n AM labs sent\n Response:\n Creatinine 4.3\n Plan:\n Monitor UOP, labs. Renal following re: whether pt will need further\n dialysis\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Awake at beginning of shift. ABP gradually increasing from 130s->\n 180s/100s. NSR 70s-80s.\n Action:\n BP meds as ordered\n Response:\n BP 120s-130s/ after meds and pt asleep.\n Plan:\n Monitor BP, BP meds as ordered. Monitor effect of meds.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 PO. Pt diaphoretic.\n Action:\n HO aware, UC sent. BC sent with AM labs. Sputum Cx sent this AM.\n Tylenol via OGT. Meropenum as ordered.\n Response:\n T decreased to 99.4 Ax.\n Plan:\n Follow culture data. Meropenum for Klebsiella PNA.\n" }, { "category": "Physician ", "chartdate": "2117-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503437, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 08:00 AM\n -Altepase given for HD catheter placed today which was not flushing\n (per renal), but HD catheter still not flush so could not receive HD\n today; hope to change lines and do HD today\n - EP recs: uptitrate metoprolol as necessary. d/c amiodarone after\n initial 1g\n this happened yesterday. signing off.\n - Gent and Nafcillin d/c'ed per ID, initiated Meropenem for ESBL\n Klebsiella.\n - febrile (ie: 100.2 to 100.7) through most of the night, and 99.5-100\n this morning\n - LFT\ns downtrending\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 03:18 PM\n Meropenem - 08:01 PM\n Nafcillin - 10:13 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Famotidine (Pepcid) - 04:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 37.8\nC (100\n HR: 93 (77 - 93) bpm\n BP: 153/64(87) {109/42(62) - 169/81(101)} mmHg\n RR: 28 (21 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 12 (5 - 19)mmHg\n Total In:\n 2,563 mL\n 733 mL\n PO:\n 240 mL\n TF:\n 955 mL\n 173 mL\n IVF:\n 1,188 mL\n 440 mL\n Blood products:\n Total out:\n 427 mL\n 409 mL\n Urine:\n 27 mL\n 9 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,136 mL\n 324 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 3\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 68\n PIP: 22 cmH2O\n Plateau: 21 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 92%\n ABG: 7.41/42/112/24/1\n Ve: 14.3 L/min\n PaO2 / FiO2: 224\n Physical Examination\n GEN: NAD, non-responsive to verbal stimuli\n CV: II/VI SEM, tachycardic, irregularly irregular\n PULM: CTAB\n ABD: obese, +BS, non-tender\n EXTR: 1+ pedal and hand edema\n SKIN: abdominal rash improved, less erythematous.\n Labs / Radiology\n 255 K/uL\n 8.5 g/dL\n 137 mg/dL\n 9.4 mg/dL\n 24 mEq/L\n 5.0 mEq/L\n 96 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n 09:15 AM\n 02:25 PM\n 09:21 PM\n 09:39 PM\n 02:55 AM\n 03:24 AM\n WBC\n 9.5\n 8.8\n Hct\n 26.5\n 26.8\n Plt\n 261\n 255\n Cr\n 8.8\n 9.1\n 9.4\n TCO2\n 28\n 29\n 28\n 28\n 27\n 26\n 28\n Glucose\n 172\n 146\n 137\n Other labs: PT / PTT / INR:13.9/34.0/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:39/60, Alk Phos / T Bili:197/1.6,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:265 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:7.6 mg/dL\n CXR: increased effusion (decreased visualization of right\n hemidiaphragm) on the right.\n Sputum :\nKLEBSIELLA PNEUMONIAE. MODERATE GROWTH.\n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 286-2926K\n .\n GRAM NEGATIVE ROD #2. SPARSE GROWTH. SUGGESTING PSEUDOMONAS.\n Blood culture:\nBlood Culture, Routine (Preliminary):\n KLEBSIELLA PNEUMONIAE.\n WARNING! This isolate is an extended-spectrum beta-lactamase\n (ESBL) producer and should be considered resistant to all\n penicillins, cephalosporins, and aztreonam. Consider Infectious\n Disease consultation for serious infections caused by\n ESBL-producing species.\n Anaerobic Bottle Gram Stain (Final ):\n REPORTED BY PHONE TO @ 0340 ON - CC6D.\n GRAM NEGATIVE ROD(S).\n Aerobic Bottle Gram Stain (Final ): GRAM NEGATIVE ROD(S).\n Assessment and Plan\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ).\n - f/u cultures\n - f/u daily CXR\n - send c.diff\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n - Weaned FiO2 to 50% and now with PEEP of 8.\n - Pressure support trial today\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning, use boluses for agitation rather than\n uptitrating the dose, that is preferred.\n - HD today\n - Meropenem as above\n - Daily CXR\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today due to clot; renal will place\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear.\n - Dilt stopped and lopressor started again according to cardiology recs\n - Dose of lopressor 12.5 TID, will increase today if needed for\n tachycardia.\n - 24 hour amiodarone has completed\n - Watch hemodynamics and rhythm; on telemetry\n .\n # DM: Blood sugars were elevated, now better controlled.\n - Continue glargine; continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; change standing Tylenol to PRN\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line. Renal to re-adjust lines\n today for HD.\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 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": "2117-11-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 503544, "text": "Chief Complaint: repiratory 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 37 yo man with ARDS/PNA/Septic shock/ARF. Had new HD catheter and new\n central line placed yesterday. SVT yesterday broke with diltiazem.\n 24 Hour Events:\n DIALYSIS CATHETER - START 02:00 PM\n MULTI LUMEN - START 02:00 PM\n MULTI LUMEN - STOP 02:01 PM\n DIALYSIS CATHETER - STOP 02:03 PM\n catheter with side port.\n EKG - At 03:21 AM\n FEVER - 102.1\nF - 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 03:18 PM\n Nafcillin - 10:13 PM\n Meropenem - 08:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Metoprolol - 03:30 AM\n Diltiazem - 03:37 AM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n hydrocort\n lopressor 12.5po tid\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 11:25 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: 37.3\nC (99.1\n HR: 93 (84 - 171) bpm\n BP: 159/78(99) {108/44(64) - 176/84(109)} mmHg\n RR: 27 (17 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.8 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 13 (13 - 13)mmHg\n Total In:\n 1,752 mL\n 1,030 mL\n PO:\n TF:\n 533 mL\n 493 mL\n IVF:\n 859 mL\n 297 mL\n Blood products:\n Total out:\n 509 mL\n 27 mL\n Urine:\n 109 mL\n 27 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,243 mL\n 1,003 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n RR (Set): 20\n RR (Spontaneous): 2\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 95%\n ABG: 7.44/45/90./28/5\n Ve: 10.7 L/min\n PaO2 / FiO2: 180\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed, opens\n eyes to voice\n Labs / Radiology\n 8.3 g/dL\n 282 K/uL\n 187 mg/dL\n 8.4 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 75 mg/dL\n 98 mEq/L\n 139 mEq/L\n 25.1 %\n 8.9 K/uL\n [image002.jpg]\n 02:25 PM\n 09:21 PM\n 09:39 PM\n 02:55 AM\n 03:24 AM\n 05:01 PM\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n WBC\n 8.8\n 8.9\n Hct\n 26.8\n 25.1\n Plt\n 255\n 282\n Cr\n 9.1\n 9.4\n 8.4\n TCO2\n 27\n 26\n 28\n 32\n 31\n 31\n 32\n Glucose\n 146\n 137\n 187\n Other labs: PT / PTT / INR:13.9/34.0/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:39/60, Alk Phos / T Bili:197/1.6,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:265 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Respiratory failure: Will try another PSV.\n VAP: On meropenem for Klebs and PSA\n MSSA bacteremia: covered with meropenem\n SVT: Increase lopessor\n DM increase sliding scale.\n ARF: continue daily HD to remove fluid.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:00 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 40 minutes\n Critically ill.\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503642, "text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503643, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n IMpaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2117-11-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504738, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Comments: Pt extubated to 80% hi setup to maintain spo2 >92%. Good\n cuff leak noted prior to extubation. Will cont to monitor for\n signs/symptoms of fatigue and assist with mask ventilation as needed.\n Will wean fio2 accordingly.\n" }, { "category": "Nursing", "chartdate": "2117-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503628, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. Has blood tinged oral secretions. O2 sats 95-97%. Cough/gag\n weak. LS clear w/diminished bases. Opening eyes with turning,\n occasionally w/o stimulation. Not following commands. Not moving\n extremities. Not tracking. Occasionally withdraws to pain. PERRLA, R\n pupil >L. Tmax 101.6 PO.\n Action:\n Placed on PS , 50%. Continued meropenum. Continued Tylenol.\n Continued on fentanyl and versed gtts, occasionally given fentanyl and\n versed boluses.\n Response:\n ABG 7.47/39/96 while on dialysis. Tcurrent 101.6 PO with cooling\n blanket and fan on.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated, plan to change versed gtt to propofol gtt.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 125cc for shift.\n Action:\n UOP monitored. HD done, 2L removed. TF continued. FS covered by ISS.\n Response:\n No significant change in UOP.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\ns. Plan for\n Ultrafiltration tomorrow and Sat.\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF continued. Repositioned q2-3 hours.\n Response:\n Rash appears to be improving. No change of stage II noted.\n Plan:\n Will cont the current management, turn and reposition q2-3hrs, continue\n nutrition. F/U wound care consult.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503685, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24cm at teeth\n Route:\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: light yellow / loose\n Sputum source/amount: suctioned / moderate\n Comments/Plan\n Pt remains vent supported. Placed on AC overnight to rest, now back on\n PSV/CPAP for RSBI of 76. See flowsheet for further pt data. Will\n follow.\n 06:17\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503686, "text": "37y/o male with a PMH of DM, ETOH. He admitted to on\n after syncopal episode. There was a question of a seizure. Per\n his family, he had sneezing and coughing for 10 days with a decrease in\n his PO intake. On admission he was shocked and intubated. Started on\n vasopresson, levophed and tamiflu,levaquin and vanco. Flu swab were\n negative. Blood cultures and sputum were positive for MSSA, and also\n has GNR from blood. He was started on naficillin. His hospital course\n was than completed by ARF, and was started on H/D hyperkalemia.\n When the H/D line was placed he had intermittent episode of A-fib\n which was treated with cardize. He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Shift Events:\n Tylenol/cooling blanket used for temp 101\n Replaced versed with propofol gtt\n Repleted calcium for Ica .9 with 4 gms\n .rec\nd on PS returned to cmv for increase hr, rr and bp\n Added pm dose metoprol, change order to increase daily dosing\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Cont. to be febrile T101 , skin dry warm\n Action:\n .tylenol, cooling blanket\n Response:\n Cont. supportive care, contact precautions\n :\n Tylenol to 4 gms day, cooling blanket prn\n IMpaired Skin Integrity\n Assessment:\n Rash on torso light, patchy, axillae rash, small skin tear under chin\n on chest and left buttock\n Action:\n Derm consulted, ointments avail., wick moisture in axillae and groin,\n mepilex to tears, turning with bed and manual tilts, barimax bed\n Response:\n New skin issues, resolving rash on torso\n Plan:\n Cont. skin care regime. Support nutrition\n Hyperglycemia\n Assessment:\n Blood sugars remain elevated to mid 200\ns despite glargine/insulin\n fixed dose sliding scale\n Action:\n Consider insulin gtt for tighter control\n Response:\n Cont. to have elevated blood sugars on goal novasource full strength at\n 45 cc hr. no residuals\n Plan:\n Discuss insulin gtt with team.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine out below 20 cc hr. HD pt. 6 liters positive\n Action:\n Noted to HO, plan for HD\n Response:\n Unchanged from prev. exam\n Plan:\n Plan HD\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Rec\nd pressure support, breath sounds diminished, bronchial, secretions\n light yellow mod amt ETT, subglottal large amt blood tinged sputum. Rr\n increased over 1 hr to 40 gradually, hr increased, bp increased\n returned to CMV 50%, peep 8, pt not responding to pain stim at nail\n bed. Eyes open appears to gaze fix, no movement of any kind to pain\n stim.\n Action:\n Pulm care, morning trial pt rsbi 76\n Response:\n peep sensitive when ps again gradual increase in vs and rr am\n abg p02 over 100. returns to cmv for night with trial in am noted\n above.\n Plan:\n Wean to extubate\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503432, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. Has blood tinged oral secretions. SaO2 92-96%. Cough/gag weak.\n LS clear w/diminished bases. O2 sat 94-98%. Opening eyes with\n turning. Not following commands. Not moving extremities. Occasionally\n withdraws to pain. PERRLA. Tmax 101.6 PO.\n Action:\n No vent changes made during shift. Continued meropenum. Continued\n Tylenol and cooling blanket. Continued on fentanyl and versed gtts.\n Stool sample sent for r/o C-Diff.\n Response:\n ABG 7.53/37/77 while on dialysis. Tcurrent 100.5 PO with cooling\n blanket off while on dialysis.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 90cc for shift. Ica 1.01.\n Action:\n New triple lumen placed L subclavian and HD line rewired over prior\n triple lumen in R IJ. Both confirmed via x-ray. HD done. TF\n restarted after line placements.\n Response:\n Due for 2gm calcium IV when dialysis done.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF, novasource renal, restarted- held 0400 to 1600 for line\n placement. Repositioned q2-3 hours.\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition q2-3hrs, continue\n nutrition.\n ------ Protected Section ------\n Barimaxx II bed ordered for patient.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:57 ------\n" }, { "category": "Respiratory ", "chartdate": "2117-11-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503298, "text": "Demographics\n Day of intubation: 8\n Day of mechanical ventilation: 8\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 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: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No 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": "Physician ", "chartdate": "2117-10-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 502251, "text": "Chief Complaint: Sepsis\n HPI:\n 37 y/o with a h/o DM presents to on \n after a syncopal episode. There was a question of a seizure in the\n field prior to arrival. Per family he had a upper respiratory illness\n (starting ) with sneezing, cough for 7-10 days with decreased PO\n intake and general malasie prior to presentation. He was in shock on\n admission, was intubated and started on levophed and Tamiflu, Levaquin,\n and vacnomycin. He had fevers as high as 105 on admission. H1N1 was\n originally suspected, however Flu swab has remained negative. He\n developed MSSA in the blood cult and abx were narrowed to naficillin.\n He remained on vasopressors until .\n His course was complicated by ARF with Cr of 1.9 worsening to 7.2\n thought to be ATN and requiring HD for hyperkalemia to 6. He had a\n HD line placed on . He also had intermittant Afib treated with\n Cardizem as well as a wide complex tachycardia. Echo showed a preserved\n EF without evidence of vegitation.\n On transport he was paralysized and given boluses of versed and\n fentanyl. HR remained tachycardic in the 140s.\n On arrival, initial vs were: T 100.6 P 147 BP152/90 O2 sat. 92% on CMV\n 500/20/12/70%\n .\n Review of systems: via mother. + Anorexia, malagia, sneezing, cough,\n mild dyspnea, diarrhea x1. No stiff neck or photophobia, no F/C/S. No\n CP or abd pain. NO N/V, constipation. No sick contacts or travel\n History obtained from Family / Medical records\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 02:45 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DM - diet controled\n HTN\n DMII. Father CAD. Mom RA, CVA, DM. Two brothers with CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Chef. lives in with parents. No tobacco or\n illicts. Heavy drinker.\n Review of systems:\n Constitutional: Fever\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Dyspnea\n Gastrointestinal: Diarrhea\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Seizure, ? seizure prior to presentation\n Flowsheet Data as of 03:31 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 125 (125 - 149) bpm\n BP: 95/48(65) {95/48(65) - 100/53(70)} mmHg\n RR: 17 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n CVP: 13 (13 - 15)mmHg\n Mixed Venous O2% Sat: 84 - 84\n Total In:\n 12 mL\n 161 mL\n PO:\n TF:\n IVF:\n 12 mL\n 161 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 161 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 109 (109 - 109) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 29 cmH2O\n Compliance: 34.6 cmH2O/mL\n SpO2: 96%\n ABG: ///25/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube,\n No(t) OG tube\n Cardiovascular: tachycardic\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: Rhonchorous: left base > left\n apex)\n Abdominal: Soft, Non-tender, Bowel sounds present, tympanic to\n percussion. Flex-seal in place\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mottled\n Skin: Cool, mottled\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Decreased\n Labs / Radiology\n 214 K/uL\n 12.8 g/dL\n 147 mg/dL\n 5.4 mg/dL\n 39 mg/dL\n 25 mEq/L\n 104 mEq/L\n 4.6 mEq/L\n 144 mEq/L\n 42\n 12.5 K/uL\n [image002.jpg]\n \n 2:33 A11/25/ 11:09 PM\n \n 10:20 P11/25/ 11:28 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.5\n Hct\n 37.9\n 42\n Plt\n 214\n Cr\n 5.4\n TropT\n 0.20\n Glucose\n 147\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.2 g/dL, LDH:437 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: Urine Tox neg \n BNP 1155 on \n ABG: on Bilevel FIOx 50%, TV 450, 7.34/39.6/69.8. pH ranging\n 7.21 to 7.34 on to .\n .\n LFTs: AST 93, alk 117, tbili 3.4, ALT 56, alb 2.2\n CE: Trop I peak 2.44, CK 1467, CKMP 9.2 on \n Chem : glu 216, BUN 58, Cr 7.26, NA 141, K 4.2, Cl 101, CO2 23\n CBC WBC 7.7 hgb 15, HCT 46, plt 139. N62, Band 16, L 16, M5, B 1\n WBC 10.5, hgb 11.4, HCT 32.9 plt\n Imaging: Images: CXR: : per me, dense consolidation of LLL\n with likely collapse and effusion. small consolidation in LUL and RLL.\n OSH CXR : multip focal infiltrates are suggested in the left\n midlung zone and pleural consolidation is noted at the left lung base.\n This does not appear signficicantly changed. Multi focal infiltrates\n are also noted within the RLL.\n head CT : no acute brain abnormailty on a study limited by\n motion artifact. small amount of fluid in the left sphenoid sinsu\n likely reflecting inflammatory sinus disease.\n Echo OSH: date unclear: normal LV function with EF of 60%, no\n significant valvular dz. no obvious valvular vegiation although there\n was some shadowing in the area of the tricuspid vale and endocarditis\n could not be ruled out.\n Microbiology: : Blood, staphy aureus in anaeroic bottle. MSSA\n Urine Legionella neg.\n Blood NGTD x2\n Blood cult NGTD\n sputum GS: 3+ GPC in pairs / clusters, 1+ GPR,\n cult: 4+ staph aureus, 3+ normal flora\n Clinda, erythromycin, oxacillin, tetracycline, Bactrim, vanco,\n cefazolin, levo, unasyn, gent sensitive. Resistant to penicillin G and\n ampicillin.\n Rapid Influenza Flu B and A negative.\n Rapid Influenza Flu B and A negative.\n ECG: . Sinus tachy at 147, RAD. NL QRS. TWI in II, III, aVF,\n V3 to V6. < depressions in II, III, aVF. NO q wave. Qtc 448\n OSH: Sinus tachy at 100. RAD. QRS 160 ms. RBBB with TWI opposite\n to QRS and ST depression in II, III, aVF. no Q waves\n Assessment and Plan\n Assessment and Plan: 37 y/o with DM presents from OSH after presenting\n in septic shock with Staph PNA / bacteria with a course complicated by\n ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CXRs with L > R\n infiltrates. Remains presistently febrile on narrowed abx coverage.\n Treated for flu although DFA neg x 2 in OSH. Elevated Mixed venous Sat\n elevated at 84% and mottled appearance most suggestive of Septic\n etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high Mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given fever and mottled appears broadly\n cover for VAP with vanco and Cefepime given consolidation on CXR. Given\n neg Urine legionalla and Prolonged QTc at times avoid FQ. Over likely\n sources include line infection, urine, or sinus (given sinusitus on CT\n head). Drug fever also possible. Fevers to 105 may also be a\n central CNS process.\n - monitor BP for MAP goal > 60\n - CVP goal \n - mixed venous sat goal > 70\n - monitor fever curve\n - Blood, urine, sputum, stool (c diff) cultures.\n - Repeat DFA\n - trend lactate (1.0 currently)\n - replace naficillin for Vanco and Cefepime for HAP\n - Given convincing viral prodrome continue Tamiflu until repeat DFA\n here.\n - f/u final read CXR\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS.\n - ARDS net protocol with TV at 6cc/kg\n - monitor plateau, titrate up PEEP for plateus in low 30s.\n - wean FiO2 as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oligouric\n - check UA, U cult, U lytes\n - contact Renal in am\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Tachycardia: appears sinus on arrival. Records state Afib, however\n apears sinus on all tracings. OSH EKG with RBBB as recently as .\n This would be an odd presentation of rate related IVCD given the slower\n rate on EKGs with QRS widing. Ddx for sinus tachy includes fever vs\n pain vs agitation vs withdrawl (possible Etoh history).\n - titrate sedation to aggitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL colapse.\n - dialsis per renal\n - maximize minute ventilation\n - trend ABG.\n # mild LFT elevation: likely prolonged hypotension.\n - trend\n - limit tylenol to 2 gm daily\n # DM: BG stable on SS\n - continue Reg SS\n #: FEN; no IVF, lytes prn, nutrition consult for TF in am\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin, PPI\n .\n Access: left subclavian. R fem HD line. Resite when possible. A line.\n .\n Code: Full code confirmed\n .\n Communication: Mother, \n .\n Disposition: pending clinical improvement\n PGY2\n \n ICU Care\n Nutrition:\n Comments: NPO, consult Nutriition for TF recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:01 PM\n Multi Lumen - 11:02 PM\n Arterial Line - 02:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2117-10-28 00:00:00.000", "description": "Physician Attending/Resident Admission Note - MICU", "row_id": 502252, "text": "Chief Complaint: Sepsis\n HPI:\n 37 y/o with a h/o DM presents to on \n after a syncopal episode. There was a question of a seizure in the\n field prior to arrival. Per family he had a upper respiratory illness\n (starting ) with sneezing, cough for 7-10 days with decreased PO\n intake and general malasie prior to presentation. He was in shock on\n admission, was intubated and started on levophed and , Levaquin,\n and vacnomycin. He had fevers as high as 105 on admission. H1N1 was\n originally suspected, however Flu swab has remained negative. He\n developed MSSA in the blood cult and abx were narrowed to naficillin.\n He remained on vasopressors until .\n His course was complicated by ARF with Cr of 1.9 worsening to 7.2\n thought to be ATN and requiring HD for hyperkalemia to 6. He had a\n HD line placed on . He also had intermittant Afib treated with\n Cardizem as well as a wide complex tachycardia. Echo showed a preserved\n EF without evidence of vegitation.\n On transport he was paralysized and given boluses of versed and\n fentanyl. HR remained tachycardic in the 140s.\n On arrival, initial vs were: T 100.6 P 147 BP152/90 O2 sat. 92% on CMV\n 500/20/12/70%\n .\n Review of systems: via mother. + Anorexia, malagia, sneezing, cough,\n mild dyspnea, diarrhea x1. No stiff neck or photophobia, no F/C/S. No\n CP or abd pain. NO N/V, constipation. No sick contacts or travel\n History obtained from Family / Medical records\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 02:45 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DM - diet controled\n HTN\n DMII. Father CAD. Mom RA, CVA, DM. Two brothers with CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Chef. lives in with parents. No tobacco or\n illicts. Heavy drinker.\n Review of systems:\n Constitutional: Fever\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Dyspnea\n Gastrointestinal: Diarrhea\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Seizure, ? seizure prior to presentation\n Flowsheet Data as of 03:31 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 125 (125 - 149) bpm\n BP: 95/48(65) {95/48(65) - 100/53(70)} mmHg\n RR: 17 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n CVP: 13 (13 - 15)mmHg\n Mixed Venous O2% Sat: 84 - 84\n Total In:\n 12 mL\n 161 mL\n PO:\n TF:\n IVF:\n 12 mL\n 161 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 161 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 109 (109 - 109) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 29 cmH2O\n Compliance: 34.6 cmH2O/mL\n SpO2: 96%\n ABG: ///25/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube,\n No(t) OG tube\n Cardiovascular: tachycardic\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: Rhonchorous: left base > left\n apex)\n Abdominal: Soft, Non-tender, Bowel sounds present, tympanic to\n percussion. Flex-seal in place\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mottled\n Skin: Cool, mottled\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Decreased\n Labs / Radiology\n 214 K/uL\n 12.8 g/dL\n 147 mg/dL\n 5.4 mg/dL\n 39 mg/dL\n 25 mEq/L\n 104 mEq/L\n 4.6 mEq/L\n 144 mEq/L\n 42\n 12.5 K/uL\n [image002.jpg]\n \n 2:33 A11/25/ 11:09 PM\n \n 10:20 P11/25/ 11:28 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.5\n Hct\n 37.9\n 42\n Plt\n 214\n Cr\n 5.4\n TropT\n 0.20\n Glucose\n 147\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.2 g/dL, LDH:437 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: Urine Tox neg \n BNP 1155 on \n ABG: on Bilevel FIOx 50%, TV 450, 7.34/39.6/69.8. pH ranging\n 7.21 to 7.34 on to .\n .\n LFTs: AST 93, alk 117, tbili 3.4, ALT 56, alb 2.2\n CE: Trop I peak 2.44, CK 1467, CKMP 9.2 on \n Chem : glu 216, BUN 58, Cr 7.26, NA 141, K 4.2, Cl 101, CO2 23\n CBC WBC 7.7 hgb 15, HCT 46, plt 139. N62, Band 16, L 16, M5, B 1\n WBC 10.5, hgb 11.4, HCT 32.9 plt\n Imaging: Images: CXR: : per me, dense consolidation of LLL\n with likely collapse and effusion. small consolidation in LUL and RLL.\n OSH CXR : multip focal infiltrates are suggested in the left\n midlung zone and pleural consolidation is noted at the left lung base.\n This does not appear signficicantly changed. Multi focal infiltrates\n are also noted within the RLL.\n head CT : no acute brain abnormailty on a study limited by\n motion artifact. small amount of fluid in the left sphenoid sinsu\n likely reflecting inflammatory sinus disease.\n Echo OSH: date unclear: normal LV function with EF of 60%, no\n significant valvular dz. no obvious valvular vegiation although there\n was some shadowing in the area of the tricuspid vale and endocarditis\n could not be ruled out.\n Microbiology: : Blood, staphy aureus in anaeroic bottle. MSSA\n Urine Legionella neg.\n Blood NGTD x2\n Blood cult NGTD\n sputum GS: 3+ GPC in pairs / clusters, 1+ GPR,\n cult: 4+ staph aureus, 3+ normal flora\n Clinda, erythromycin, oxacillin, tetracycline, Bactrim, vanco,\n cefazolin, levo, unasyn, gent sensitive. Resistant to penicillin G and\n ampicillin.\n Rapid Influenza Flu B and A negative.\n Rapid Influenza Flu B and A negative.\n ECG: . Sinus tachy at 147, RAD. NL QRS. TWI in II, III, aVF,\n V3 to V6. < depressions in II, III, aVF. NO q wave. Qtc 448\n OSH: Sinus tachy at 100. RAD. QRS 160 ms. RBBB with TWI opposite\n to QRS and ST depression in II, III, aVF. no Q waves\n Assessment and Plan\n Assessment and Plan: 37 y/o with DM presents from OSH after presenting\n in septic shock with Staph PNA / bacteria with a course complicated by\n ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CXRs with L > R\n infiltrates. Remains presistently febrile on narrowed abx coverage.\n Treated for flu although DFA neg x 2 in OSH. Elevated Mixed venous Sat\n elevated at 84% and mottled appearance most suggestive of Septic\n etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high Mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given fever and mottled appears broadly\n cover for VAP with vanco and Cefepime given consolidation on CXR. Given\n neg Urine legionalla and Prolonged QTc at times avoid FQ. Over likely\n sources include line infection, urine, or sinus (given sinusitus on CT\n head). Drug fever also possible. Fevers to 105 may also be a\n central CNS process.\n - monitor BP for MAP goal > 60\n - CVP goal \n - mixed venous sat goal > 70\n - monitor fever curve\n - Blood, urine, sputum, stool (c diff) cultures.\n - Repeat DFA\n - trend lactate (1.0 currently)\n - replace naficillin for Vanco and Cefepime for HAP\n - Given convincing viral prodrome continue until repeat DFA\n here.\n - f/u final read CXR\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS.\n - ARDS net protocol with TV at 6cc/kg\n - monitor plateau, titrate up PEEP for plateus in low 30s.\n - wean FiO2 as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oligouric\n - check UA, U cult, U lytes\n - contact Renal in am\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Tachycardia: appears sinus on arrival. Records state Afib, however\n apears sinus on all tracings. OSH EKG with RBBB as recently as .\n This would be an odd presentation of rate related IVCD given the slower\n rate on EKGs with QRS widing. Ddx for sinus tachy includes fever vs\n pain vs agitation vs withdrawl (possible Etoh history).\n - titrate sedation to aggitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL colapse.\n - dialsis per renal\n - maximize minute ventilation\n - trend ABG.\n # mild LFT elevation: likely prolonged hypotension.\n - trend\n - limit tylenol to 2 gm daily\n # DM: BG stable on SS\n - continue Reg SS\n #: FEN; no IVF, lytes prn, nutrition consult for TF in am\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin, PPI\n .\n Access: left subclavian. R fem HD line. Resite when possible. A line.\n .\n Code: Full code confirmed\n .\n Communication: Mother, \n .\n Disposition: pending clinical improvement\n PGY2\n \n ICU Care\n Nutrition:\n Comments: NPO, consult Nutriition for TF recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:01 PM\n Multi Lumen - 11:02 PM\n Arterial Line - 02:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Attending Note: I saw and examined the patient, and was physically\n present with Dr. the key portions of the services provided. I agree\n with the note above, including the assessment and plan. I would\n emphasize and add the following points:\n 37 yr old hx of HTN and diet controlled DM2, with URI sx since \n (malaise, decreased PO intake and on , day of admission to\n had seizure per family). On admission he decompensated with\n shock, intubated in ED and started on Levophed. Given , but\n eventually had two neg flu swabs. BC and sputum grew out MSSA on .\n BC on and NGTD. WBC 7.7 with 15% bands on admit. Creat 1.9,\n peaked at 7.2, was started on HD on ~. Hep C neg. HIV status\n unknown, no hx of IVDU.\n Has been intermittently tachycardic requiring dilt drip. EKG\n significant for RBBB which resolved but now with inverted T waves. Trop\n increased in context of ARF, but CKMB was increased. Treated for ACS\n but suspect this was demand ischemia.\n Brought to MICU paralysed, ventilated. Currently a/c 450 x 26,\n 80% peep 16. Exam significant for high fever T 105 F, mottling,\n cyanotic toes, no sig LE edema, abd soft, lungs clear ant/lat, HS reg\n no murmurs.\n CXR shows consolidation +/- atelectasis of LLL. RN there was an ET\n cuff leak on arrival. Recruitment maneuvers resulted in improved\n oxygenation. Most recent ABG 7.23/57/115. Lactate was ~3 at OSH, now\n 1.0.\n CT head showed fluid left sphenoid sinus, otherwise unremarkable but\n limited. No CT chest or abdomen. TTE x 2 - EF 60%, shadowing\n on tricuspic ? endocarditis.\n Impression - septic shock, treated for MSSA bacteremia, flu essentially\n ruled out by two swabs, likely now VAP but may have other source of\n infection. High fever also concerning for a neurologic process. CVP\n goal , MAP >65, agree with Vanc/Cefepime/, renally dose\n meds. Given high fever, will do LP and if stable, will send for CT\n head/chest/abd. Will start low dose pressors for hypotension. Will need\n renal consult for HD. Would consider checking HIV status once awake.\n Very difficult to monitor end organ damage given oliguria. Family\n updated. Full code.\n Patient is critically ill. Total time 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 04:48 ------\n" }, { "category": "Physician ", "chartdate": "2117-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 502976, "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 37 yo man with MSSA PNA and ARF. Sputum and blood with GNRs. Sputum\n has ESBL klebs.\n AF with RVR during HD.\n 24 Hour Events:\n BLOOD CULTURED - At 02:31 PM\n SPUTUM CULTURE - At 02:31 PM\n EKG - At 08:30 PM\n FEVER - 102.2\nF - 12:00 PM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Meropenem - 10:30 PM\n Nafcillin - 06:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n chlordex\n diltiazem\n phoslo\n famotidine\n SSI\n lopressor\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 09:56 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: 39.1\nC (102.3\n HR: 103 (83 - 118) bpm\n BP: 104/55(70) {97/48(65) - 173/64(89)} mmHg\n RR: 30 (23 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 11 (3 - 139)mmHg\n Total In:\n 2,246 mL\n 970 mL\n PO:\n TF:\n 964 mL\n 380 mL\n IVF:\n 1,072 mL\n 410 mL\n Blood products:\n Total out:\n 350 mL\n 20 mL\n Urine:\n 50 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,896 mL\n 950 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.41/39/116/21/0\n Ve: 16.4 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Bronchial: left base, Rhonchorous:\n )\n Abdominal: Soft, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Warm, Rash: diffuse drug rash over trunk\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 9.7 g/dL\n 292 K/uL\n 199 mg/dL\n 9.4 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 91 mg/dL\n 102 mEq/L\n 139 mEq/L\n 30.0 %\n 10.3 K/uL\n [image002.jpg]\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n 02:15 PM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n WBC\n 10.4\n 9.7\n 10.3\n Hct\n 30.3\n 29.1\n 30.0\n Plt\n \n Cr\n 7.4\n 7.8\n 9.4\n TropT\n 0.21\n TCO2\n 24\n 25\n 24\n 26\n 26\n 25\n 26\n Glucose\n 227\n 215\n 199\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:53/90, Alk Phos / T Bili:259/3.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.1 g/dL,\n LDH:347 IU/L, Ca++:7.3 mg/dL, Mg++:2.5 mg/dL, PO4:5.5 mg/dL\n Microbiology: sputum\n blood cx \n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Fevers: GNRs in blood, ESBL klebsiella in sputum. Now on meropenem.\n continue nafcillin, and add gentimicin.\n Repeat cx.\n ? of emboli on CXR, so will get TTE.\n Respiratory failure: on FiO2 of 0.6. Needs more fluid off before we\n can wean down. Can reduce FiO2.\n rash: likely due to cefepime. now stopped.\n Acute renal failure: To get HD today.\n AFib: better controlled on dilt. Can stop the lopressor\n DM: high blood sugars, increase glargine, increase sliding scale.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:31 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n ------ Protected Section ------\n Patient with ventricular tachycardia during HD, towards the end.\n Received a synchronized defibrillation once, and then went into an SVT\n which then responded to a bolus of IV adenosine. He then retured to\n NSR. Amiodarone drip started and EP consult called.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:51 ------\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503423, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. SaO2 92-96%. Cough/gag weak. LS clear w/diminished bases. O2 sat\n 94-98%. Opening eyes with turning. Not following commands. Not moving\n extremities. Occasionally withdraws to pain. PERRLA. Tmax 101.6 PO.\n Action:\n No vent changes made during shift. Continued meropenum. Continued\n Tylenol and cooling blanket. Continued on fentanyl and versed gtts.\n Response:\n ABG 7.53/37/77 while on dialysis. Tcurrent 100.5 PO with cooling\n blanket off while on dialysis.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 90cc for shift. Ica 1.01.\n Action:\n New triple lumen placed L subclavian and HD line rewired over prior\n triple lumen in R IJ. Both confirmed via x-ray. HD done. TF\n restarted after line placements.\n Response:\n Due for 2gm calcium IV when dialysis done.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF, novasource renal, restarted- held 0400 to 1600 for line\n placement.\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition q2hrs, continue\n nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503424, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. SaO2 92-96%. Cough/gag weak. LS clear w/diminished bases. O2 sat\n 94-98%. Opening eyes with turning. Not following commands. Not moving\n extremities. Occasionally withdraws to pain. PERRLA. Tmax 101.6 PO.\n Action:\n No vent changes made during shift. Continued meropenum. Continued\n Tylenol and cooling blanket. Continued on fentanyl and versed gtts.\n Response:\n ABG 7.53/37/77 while on dialysis. Tcurrent 100.5 PO with cooling\n blanket off while on dialysis.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 90cc for shift. Ica 1.01.\n Action:\n New triple lumen placed L subclavian and HD line rewired over prior\n triple lumen in R IJ. Both confirmed via x-ray. HD done. TF\n restarted after line placements.\n Response:\n Due for 2gm calcium IV when dialysis done.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF, novasource renal, restarted- held 0400 to 1600 for line\n placement. Repositioned q2-3 hours.\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition q2-3hrs, continue\n nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503426, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. SaO2 92-96%. Cough/gag weak. LS clear w/diminished bases. O2 sat\n 94-98%. Opening eyes with turning. Not following commands. Not moving\n extremities. Occasionally withdraws to pain. PERRLA. Tmax 101.6 PO.\n Action:\n No vent changes made during shift. Continued meropenum. Continued\n Tylenol and cooling blanket. Continued on fentanyl and versed gtts.\n Stool sample sent for r/o C-Diff.\n Response:\n ABG 7.53/37/77 while on dialysis. Tcurrent 100.5 PO with cooling\n blanket off while on dialysis.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 90cc for shift. Ica 1.01.\n Action:\n New triple lumen placed L subclavian and HD line rewired over prior\n triple lumen in R IJ. Both confirmed via x-ray. HD done. TF\n restarted after line placements.\n Response:\n Due for 2gm calcium IV when dialysis done.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF, novasource renal, restarted- held 0400 to 1600 for line\n placement. Repositioned q2-3 hours.\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition q2-3hrs, continue\n nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503428, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Breathing over\n vent. Small to moderate amts of thick, yellow sputum suctioned from ET\n tube. Has blood tinged oral secretions. SaO2 92-96%. Cough/gag weak.\n LS clear w/diminished bases. O2 sat 94-98%. Opening eyes with\n turning. Not following commands. Not moving extremities. Occasionally\n withdraws to pain. PERRLA. Tmax 101.6 PO.\n Action:\n No vent changes made during shift. Continued meropenum. Continued\n Tylenol and cooling blanket. Continued on fentanyl and versed gtts.\n Stool sample sent for r/o C-Diff.\n Response:\n ABG 7.53/37/77 while on dialysis. Tcurrent 100.5 PO with cooling\n blanket off while on dialysis.\n Plan:\n Continue antibiotics. Monitor temp curve. Cooling blanket as needed.\n F/U cultures. Daily wake up and SBT. Wean vent as tolerated. Wean\n sedation as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 90cc for shift. Ica 1.01.\n Action:\n New triple lumen placed L subclavian and HD line rewired over prior\n triple lumen in R IJ. Both confirmed via x-ray. HD done. TF\n restarted after line placements.\n Response:\n Due for 2gm calcium IV when dialysis done.\n Plan:\n Monitor UOP. Monitor BUN/creat. F/u Renal rec\n Impaired Skin Integrity\n Assessment:\n HD and central line dressings intact, oozing. 2 small blisters noted\n near HD line. Flexiseal in place draining loose brown stool. Skin\n appearing pink\n repositioning of Flexiseal importants @ this time.\n Mepilex dsg in place. 2 stage II wounds noted beneath dsg. Pt cont to\n have drug rash\n notable on torso, abd & part of extremities. Groin,\n axilla & neck folds are excoriated and yeast appearing.\n Action:\n Mepilex dsg changed on coccyx area, currently dry, intact. Multiple\n topical creams/ointments ordered and continued (please see for\n details). TF, novasource renal, restarted- held 0400 to 1600 for line\n placement. Repositioned q2-3 hours.\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition q2-3hrs, continue\n nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502683, "text": "Pt is a 37yo male with a h/o of diabetes and alcohol abuse who\n presented to Hosp on w/ flu-like symptoms,\n including temp 105. In ED had seizure and was intubated. CXR showing\n PNA. Initially was on pressors and was not urinating (new renal\n failure). Thought to be in and out of a.fib w/ RBBB and increasing\n troponin so started on heparin gtt as well. ECHO for ? myocarditis.\n Heparin has been off since, pressors off, tolerating HD w/ goal\n 1-1.5L per treatment. EEG done to f/u w/ seizure activity (? results\n from OSH). MSSA in sputum and blood from OSH. Transported to \n ICU via Med flight, arrived unresponsive from bolus sedation and\n bolus paralytic.\n Events overnight: Tolerated 2hrs hemodialysis with removal of 1L of\n fluid. U/O minimal. Cont\ns to spike, Tylenol, and cooling blanket, IV\n abx. New red blotchy rash noted on trunk. Given benedryl prior to\n infusing vanco at a slower rate, ? of a drug rash. Family friend \n calling for updates.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Con\nts to spike. Received pt at 1900 with low grade temp. Cooling\n blanket removed for several hours. By 12am, temp con\nt to rise to\n 101.5. Random vanco level 9, received 1gm vanco post dialysis\n Action:\n Cooling blanket placed back on, Tylenol 650mg per NGT\n Response:\n Temp improving\n Plan:\n Con\nt to monitor temp and place cooling blanket as appropriate, Tylenol\n PRN. Vanco and cefepime as ordered\n Cardiac dysrhythmia other\n Assessment:\n Without episodes of AFib. One episode of a 5 beat run of VTach\n immediately after dialysis was completed.\n Action:\n Diltiazem 30mg po qid\n Response:\n HR has been in the 80\ns SR with minimal ectopy\n Plan:\n Con\nt to assess, con\nt with po diltiazem\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr con\nt to rise, minimal urine output.\n Action:\n Dialysis\n Response:\n Tolerating removal of 1 liter over 2 hr dialysis treatment\n Plan:\n Con\nt to monitor lab values, assess for improved renal status, urine\n output\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n No vent changes made overnight. Remains on A/C 50%/500/x30 with 10\n peep. Suctioning q2-3 hrs for think brown secretions. ABG:\n Action:\n Suction prn\n Response:\n Maintaining o2 sats,\n Plan:\n Con\nt to pulmonary toilet, assess resp status, assess ability to wean\n peep when able\n" }, { "category": "Nursing", "chartdate": "2117-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503486, "text": "Impaired Skin Integrity\n Assessment:\n CVL bleeding. Small blisters near HD line dressing. Cont w/ Rash on\n abdomen and BLEs. Flexiseal in place. in place at coccyx.\n Pt w/ a stage II. Groin and axilla w/ yeast like appearance.\n Action:\n Miconazole powder applied to groin and axilla. Ointments applied to\n skin. Repositioned q 2-3 hrs & placed on barimax II bed. CVL dsg\n changed and surgiceal applied.\n Response:\n Plan:\n Cont w/ ointments, frequent repositioning.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Max temp of 102.1 orally\n.assumed pt on cooling blanket. Pt\n hypertensive into the 170s-180s systolic w/ HR in the 90s-100s and\n breathing 6-10 breaths over the vent earlier in shift\n.versed & fent ^^\n to 3mg/75mcg respectively. At 0330, pt went into a SVT w/ HR up to 170\n (SVT) while turning and remained there, sbp in the 1-teens-120s. O2\n sats 91-93%. Assumed pt on AC @ 50%/500x24/8+. ABG @ --\n 7.49/40/84/31.\n Action:\n Given scheduled po dose of lopressor @ 0200 and given 5mg of IV\n lopressor x 1w/o much effect on HR. Then given 10mg of IV dilt x 1 w/\n good effect. Given 1000mg po tyelenol x 2 and 400mg of po ibuprofen.\n RR changed to 20 on vent.\n Response:\n HR now in the 80s and BP in the 1 teens to 120s following diltiazem\n dose. ABG now 7.44/45/90/32 on RR of 20. O2 sats of 96%. Temp now\n 101.1 orally.\n Plan:\n Wean vent as tolerated, ? increase po lopressor dose\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n AM Ica 1.03. UOP 10-12 cc every 2-3 hrs. Pt received HD yesterday.\n Action:\n Given 2gm of calcium gluconate this am.\n Response:\n Plan:\n Cont to monitor and replete Ionized Calcium according to scale. Monitor\n BUN/creat.\n" }, { "category": "Physician ", "chartdate": "2117-10-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 502246, "text": "Chief Complaint: Sepsis\n HPI:\n 37 y/o with a h/o DM presents to on \n after a syncopal episode. There was a question of a seizure in the\n field prior to arrival. Per family he had a upper respiratory illness\n (starting ) with sneezing, cough for 7-10 days with decreased PO\n intake and general malasie prior to presentation. He was in shock on\n admission, was intubated and started on levophed and Tamiflu, Levaquin,\n and vacnomycin. He had fevers as high as 105 on admission. H1N1 was\n originally suspected, however Flu swab has remained negative. He\n developed MSSA in the blood cult and abx were narrowed to naficillin.\n He remained on vasopressors until .\n His course was complicated by ARF with Cr of 1.9 worsening to 7.2\n thought to be ATN and requiring HD for hyperkalemia to 6. He had a\n HD line placed on . He also had intermittant Afib treated with\n Cardizem as well as a wide complex tachycardia. Echo showed a preserved\n EF without evidence of vegitation.\n On transport he was paralysized and given boluses of versed and\n fentanyl. HR remained tachycardic in the 140s.\n On arrival, initial vs were: T 100.6 P 147 BP152/90 O2 sat. 92% on CMV\n 500/20/12/70%\n .\n Review of systems: via mother. + Anorexia, malagia, sneezing, cough,\n mild dyspnea, diarrhea x1. No stiff neck or photophobia, no F/C/S. No\n CP or abd pain. NO N/V, constipation. No sick contacts or travel\n History obtained from Family / Medical records\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 02:45 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DM - diet controled\n HTN\n DMII. Father CAD. Mom RA, CVA, DM. Two brothers with CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Chef. lives in with parents. No tobacco or\n illicts. Heavy drinker.\n Review of systems:\n Constitutional: Fever\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Dyspnea\n Gastrointestinal: Diarrhea\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Seizure, ? seizure prior to presentation\n Flowsheet Data as of 03:31 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 125 (125 - 149) bpm\n BP: 95/48(65) {95/48(65) - 100/53(70)} mmHg\n RR: 17 (17 - 26) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 69 Inch\n CVP: 13 (13 - 15)mmHg\n Mixed Venous O2% Sat: 84 - 84\n Total In:\n 12 mL\n 161 mL\n PO:\n TF:\n IVF:\n 12 mL\n 161 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 161 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 109 (109 - 109) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 29 cmH2O\n Compliance: 34.6 cmH2O/mL\n SpO2: 96%\n ABG: ///25/\n Ve: 12.1 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube,\n No(t) OG tube\n Cardiovascular: tachycardic\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: Rhonchorous: left base > left\n apex)\n Abdominal: Soft, Non-tender, Bowel sounds present, tympanic to\n percussion. Flex-seal in place\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mottled\n Skin: Cool, mottled\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Decreased\n Labs / Radiology\n 214 K/uL\n 12.8 g/dL\n 147 mg/dL\n 5.4 mg/dL\n 39 mg/dL\n 25 mEq/L\n 104 mEq/L\n 4.6 mEq/L\n 144 mEq/L\n 42\n 12.5 K/uL\n [image002.jpg]\n \n 2:33 A11/25/ 11:09 PM\n \n 10:20 P11/25/ 11:28 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.5\n Hct\n 37.9\n 42\n Plt\n 214\n Cr\n 5.4\n TropT\n 0.20\n Glucose\n 147\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.2 g/dL, LDH:437 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: Urine Tox neg \n BNP 1155 on \n ABG: on Bilevel FIOx 50%, TV 450, 7.34/39.6/69.8. pH ranging\n 7.21 to 7.34 on to .\n .\n LFTs: AST 93, alk 117, tbili 3.4, ALT 56, alb 2.2\n CE: Trop I peak 2.44, CK 1467, CKMP 9.2 on \n Chem : glu 216, BUN 58, Cr 7.26, NA 141, K 4.2, Cl 101, CO2 23\n CBC WBC 7.7 hgb 15, HCT 46, plt 139. N62, Band 16, L 16, M5, B 1\n WBC 10.5, hgb 11.4, HCT 32.9 plt\n Imaging: Images: CXR: : per me, dense consolidation of LLL\n with likely collapse and effusion. small consolidation in LUL and RLL.\n OSH CXR : multip focal infiltrates are suggested in the left\n midlung zone and pleural consolidation is noted at the left lung base.\n This does not appear signficicantly changed. Multi focal infiltrates\n are also noted within the RLL.\n head CT : no acute brain abnormailty on a study limited by\n motion artifact. small amount of fluid in the left sphenoid sinsu\n likely reflecting inflammatory sinus disease.\n Echo OSH: date unclear: normal LV function with EF of 60%, no\n significant valvular dz. no obvious valvular vegiation although there\n was some shadowing in the area of the tricuspid vale and endocarditis\n could not be ruled out.\n Microbiology: : Blood, staphy aureus in anaeroic bottle. MSSA\n Urine Legionella neg.\n Blood NGTD x2\n Blood cult NGTD\n sputum GS: 3+ GPC in pairs / clusters, 1+ GPR,\n cult: 4+ staph aureus, 3+ normal flora\n Clinda, erythromycin, oxacillin, tetracycline, Bactrim, vanco,\n cefazolin, levo, unasyn, gent sensitive. Resistant to penicillin G and\n ampicillin.\n Rapid Influenza Flu B and A negative.\n Rapid Influenza Flu B and A negative.\n ECG: . Sinus tachy at 147, RAD. NL QRS. TWI in II, III, aVF,\n V3 to V6. < depressions in II, III, aVF. NO q wave. Qtc 448\n OSH: Sinus tachy at 100. RAD. QRS 160 ms. RBBB with TWI opposite\n to QRS and ST depression in II, III, aVF. no Q waves\n Assessment and Plan\n Assessment and Plan: 37 y/o with DM presents from OSH after presenting\n in septic shock with Staph PNA / bacteria with a course complicated by\n ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CXRs with L > R\n infiltrates. Remains presistently febrile on narrowed abx coverage.\n Treated for flu although DFA neg x 2 in OSH. Elevated Mixed venous Sat\n elevated at 84% and mottled appearance most suggestive of Septic\n etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high Mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given fever and mottled appears broadly\n cover for VAP with vanco and Cefepime given consolidation on CXR. Given\n neg Urine legionalla and Prolonged QTc at times avoid FQ. Over likely\n sources include line infection, urine, or sinus (given sinusitus on CT\n head). Drug fever also possible. Fevers to 105 may also be a\n central CNS process.\n - monitor BP for MAP goal > 60\n - CVP goal \n - mixed venous sat goal > 70\n - monitor fever curve\n - Blood, urine, sputum, stool (c diff) cultures.\n - Repeat DFA\n - trend lactate (1.0 currently)\n - replace naficillin for Vanco and Cefepime for HAP\n - Given convincing viral prodrome continue Tamiflu until repeat DFA\n here.\n - f/u final read CXR\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS.\n - ARDS net protocol with TV at 6cc/kg\n - monitor plateau, titrate up PEEP for plateus in low 30s.\n - wean FiO2 as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oligouric\n - check UA, U cult, U lytes\n - contact Renal in am\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Tachycardia: appears sinus on arrival. Records state Afib, however\n apears sinus on all tracings. OSH EKG with RBBB as recently as .\n This would be an odd presentation of rate related IVCD given the slower\n rate on EKGs with QRS widing. Ddx for sinus tachy includes fever vs\n pain vs agitation vs withdrawl (possible Etoh history).\n - titrate sedation to aggitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL colapse.\n - dialsis per renal\n - maximize minute ventilation\n - trend ABG.\n # mild LFT elevation: likely prolonged hypotension.\n - trend\n - limit tylenol to 2 gm daily\n # DM: BG stable on SS\n - continue Reg SS\n #: FEN; no IVF, lytes prn, nutrition consult for TF in am\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin, PPI\n .\n Access: left subclavian. R fem HD line. Resite when possible. A line.\n .\n Code: Full code confirmed\n .\n Communication: Mother, \n .\n Disposition: pending clinical improvement\n PGY2\n \n ICU Care\n Nutrition:\n Comments: NPO, consult Nutriition for TF recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 11:01 PM\n Multi Lumen - 11:02 PM\n Arterial Line - 02:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2117-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502547, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / 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: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2117-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502757, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 103.1\nF - 08:00 AM\n - started PO dilt 30 qid\n - EKG this am: TWI inferior leads, normalization of TW in lateral leads\n - stool guiac for anemia\n - OSH sensitivities/micro now in chart --> sputum with 4+ Staph, blood\n negative, flu negative\n - Renal recs: get HD today --> Vanc dose after HD. Start Phoslo 667 tid\n for hyperphosphatemia (already ordered for Ca Acetate 1334mg PO tid\n with meals)\n - CE's: Trop flat, MB flat\n - LFT's stable from this am\n - Origin of metabolic alkalosis: thought about it, only thing that made\n sense was post hypercapnia\n - ABG 8p: 7.46/36/85/26\n - Random vanc after HD and before vanc dose: 9.8\n Allergies:\n Last dose of Antibiotics:\n Tamiflu - 08:00 PM\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 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 08:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2 yesterday 11am but still febrile this am\n Tcurrent: 37.2\nC (99\n HR: 75 (75 - 102) bpm\n BP: 135/44(68) {122/39(65) - 167/64(87)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (14 - 19)mmHg\n Total In:\n 1,618 mL\n 854 mL\n PO:\n TF:\n 964 mL\n 334 mL\n IVF:\n 474 mL\n 430 mL\n Blood products:\n Total out:\n 1,540 mL\n 305 mL\n Urine:\n 40 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 78 --> 3.9L positive through LOS mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/36/85/25/1 YESTERDAY PM\n Ve: 15.1 L/min\n PaO2 / FiO2: 170\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 280 K/uL\n 9.9 g/dL\n 215 mg/dL\n 7.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 103 mEq/L\n 142 mEq/L\n 29.1 %\n 9.7 K/uL\n [image002.jpg]\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n WBC\n 12.5\n 10.4\n 9.7 DOWN\n Hct\n 31.2\n 30.3\n 29.1 DOWN\n Plt\n STABLE\n Cr\n 7.7\n 6.3\n 7.4\n 7.8\n TropT\n 0.21\n TCO2\n 20\n 19\n 24\n 25\n 24\n 26\n Glucose\n 15\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:62/138, Alk Phos / T Bili:317/2.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.1 g/dL,\n LDH:437 IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated Mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of Septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high Mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given neg Urine legionalla and\n Prolonged QTc at times avoid FQ.\n - Continue Vanco and Cefepime to cover for HAP. We will continue with\n broad coverage considering improvement, and we will treat for a 15 day\n course from yesterday (today day 3).\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS.\n Bladder pressures are lower today, suggesting we have room to wean down\n his PEEP.\n - ARDS net protocol with TV at 6cc/kg\n - wean FiO2 and PEEP as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today with trial of intermittent dialysis.\n # Tachycardia/ AFib: appeared sinus on arrival. Yesterday had a couple\n runs of tachycardia that appeared to be afib with aberrancy that were\n self-limited and well-tolerated. OSH EKG with RBBB as recently as\n , and reports of atrial fibrillation requiring treatment with\n diltiazem. Yesterday went into AFib w/ RVR during dialysis. Treated\n w/ lopressor 10, dilt 20 IV and dilt PO60. Converted back to sinus\n after 1-2 hours.\n - repeat EKG today to make sure that he does not have any acute\n ischemic changes in the setting of his Afib\n - Diltiazem 30 QID\n - titrate sedation to agitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG, is improved\n # mild LFT elevation: likely prolonged hypotension. Improving.\n Added on to today's labs because had not been drawn since \n - trend\n - limit tylenol to 2 gm daily\n # DM: Was hyperglycemic yesterday and we are starting tube feeds, so we\n will increase his sliding scale.\n - continue Reg SS\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:37 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2117-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502339, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Reduce PEEP as tolerated, Adjust\n Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1130\n uneventful\n" }, { "category": "Physician ", "chartdate": "2117-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502618, "text": "TITLE:\n Chief Complaint: ARDS and ARF\n 24 Hour Events:\n DIALYSIS CATHETER - START 01:13 PM\n catheter with side port.\n Patient went into AFib w/ RVR during dialysis yesterday and it was\n ended early (after 0.5L removed) Given 10 lopressor and 20 of dilt .\n Gave PO load of dilt. Converted back to sinus.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:10 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Metoprolol - 03:30 PM\n Diltiazem - 03:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38.2\nC (100.8\n HR: 89 (72 - 178) bpm\n BP: 128/56(78) {97/42(63) - 161/69(91)} mmHg\n RR: 30 (26 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 20 (9 - 22)mmHg\n Total In:\n 1,501 mL\n 556 mL\n PO:\n TF:\n 921 mL\n 328 mL\n IVF:\n 580 mL\n 228 mL\n Blood products:\n Total out:\n 562 mL\n 505 mL\n Urine:\n 32 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 939 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 23 cmH2O\n SpO2: 96%\n ABG: 7.43/35/78./22/0\n Ve: 16.7 L/min\n PaO2 / FiO2: 158\n Physical Examination\n Gen: sedated and intubated\n Chest: moving air well b/l\n Heart: NRRR; no murmurs\n Abd: obese, distended, normal BS\n Ext: 1+ edema, warm and well perfused.\n Labs / Radiology\n 252 K/uL\n 10.1 g/dL\n 227 mg/dL\n 7.4 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 65 mg/dL\n 102 mEq/L\n 141 mEq/L\n 30.3 %\n 10.4 K/uL\n [image002.jpg]\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n WBC\n 10.6\n 12.5\n 10.4\n Hct\n 31.7\n 31.2\n 30.3\n Plt\n 237\n 226\n 252\n Cr\n 7.2\n 7.7\n 6.3\n 7.4\n TCO2\n 21\n 20\n 19\n 24\n 25\n 24\n Glucose\n 156\n 210\n 222\n 227\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.0 mg/dL, Mg++:2.6 mg/dL, PO4:5.6 mg/dL\n Imaging: FINDINGS: As compared to the previous examination, a new\n central venous\n access line has been placed over the left internal jugular vein. The\n tip of\n the line projects over the mid SVC. There is no evidence of\n complications,\n notably no pneumothorax.\n CXR \n The other monitoring and support devices are in unchanged position.\n Also\n unchanged is the size of the cardiac silhouette as well as the right\n suprabasal atelectasis and the relatively extensive left mid lung and\n basal parenchymal opacity with air bronchograms.\n Microbiology: All cultures NTD\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated Mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of Septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high Mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given neg Urine legionalla and\n Prolonged QTc at times avoid FQ.\n - Continue Vanco and Cefepime to cover for HAP. We will continue with\n broad coverage considering improvement, and we will treat for a 15 day\n course from yesterday (today day 3).\n - f/u cultures\n - f/u read of daily CXR\n .\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS.\n Bladder pressures are lower today, suggesting we have room to wean down\n his PEEP.\n - ARDS net protocol with TV at 6cc/kg\n - wean FiO2 and PEEP as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n .\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today with trial of intermittent dialysis.\n .\n # Tachycardia/ AFib: appeared sinus on arrival. Yesterday had a couple\n runs of tachycardia that appeared to be afib with aberrancy that were\n self-limited and well-tolerated. OSH EKG with RBBB as recently as\n , and reports of atrial fibrillation requiring treatment with\n diltiazem. Yesterday went into AFib w/ RVR during dialysis. Treated\n w/ lopressor 10, dilt 20 IV and dilt PO60. Converted back to sinus\n after 1-2 hours.\n - repeat EKG today to make sure that he does not have any acute\n ischemic changes in the setting of his Afib\n - Diltiazem 30 QID\n - titrate sedation to agitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n .\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG, is improved\n .\n # mild LFT elevation: likely prolonged hypotension. Improving.\n Added on to today's labs because had not been drawn since \n - trend\n - limit tylenol to 2 gm daily\n .\n # DM: Was hyperglycemic yesterday and we are starting tube feeds, so we\n will increase his sliding scale.\n - continue Reg SS\n .\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Respiratory ", "chartdate": "2117-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502851, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 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: Green / Tenacious\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:\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 Today CXR showing L lung white out, ETT appears ~ 4.7 cm ^ carina.\n Recruitment maneuvers ordered. Done x 2 @ 2330.\n Peep ^ to 12 cm from 10. After breaths, pt coughed and was sx for\n copious tk green secretions. Spec sent during daytime today. Suggested\n bronchoscopy may be needed.\n" }, { "category": "Nursing", "chartdate": "2117-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502288, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp100.6 on admission, BP in 150\ns, MSSA in sputum and blood from OSH,\n OFF pressors since Monday . WBC 10.5, lactate 1.0, was on tamiflu\n for ? H1N1. Cool mottled extremeties.\n Action:\n Temp spike to 105.1, placed on cooling blanket and ice packs in axilla\n and groin, given 650mg PO tylenol, bld cx from a-line and TLC (OSH\n line), urine, sputum, influenza swab, LP attempted, started levophed\n gtt for BP 70\ns, getting PO contrast slowly via NGT for pending CT\n chest/abd, bladder pressure done. Given x1 doses vanco 1gram and\n ciprofloxacin 2grams.\n Response:\n Temp now 101.3, WBC 12.5, bladder pressure (23), Lactate remains 1, LP\n attempt failed, CT pending (check residuals to see if pt can tolerate\n another bottle of contrast), BP 80\ns, MAP >65 on 0.1mcg levophed.\n Plan:\n CT chest/abd, ? reattempt LP, monitor temps, f/u on cx data, still\n needs stool cx, ? KUB for increased bladder pressure if does not get\n CT. Remains on droplet precautions until neg nasal flock swab.\n Cardiac dysrhythmia other\n Assessment:\n Admitted SVT to 150\ns, ? a.fib w/ slower rates in 1teens, occasional\n pvc\ns, trop 0.4 in OSH, ECHO done in OSH, fam hx of heart disease\n Action:\n EKG showing SVT, sent trop and added on cardiac enzymes\n Response:\n ? a.fib @ times, seems to have PAC\ns and change rhythyms but mostly in\n SVT 140\ns to 120\ns. does not correlate w/ temps @ this time.\n Plan:\n ? TEE for ? myocarditis, monitor EKG, f/u on cardiac enzymes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD started @ OSH for ARF, unclear how pt tolerated or if fluid was\n removed, Last HD prior to admission. BUN/Creat 52/7\n Action:\n Fluid bolus 500cc x1\n Response:\n Anuric, BUN/Creat 39/5.4.\n Plan:\n ? HD vs. CVVH.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Admitted w/ large cuff leak, on A/C 50%, 450/20/12, started w/ o2sat\n 92%, LS diminished throughout but clear. Diagnosis of PNA from OSH, w/\n ?H1N1.\n Action:\n Multiple vent changes, ABG\ns (see metavision), CXR, cx\ns, recruitment\n done after cuff leak corrected, increased sedation for comfort w/ vent,\n plan for CT chest.\n Response:\n Fentanyl @ 250mcg, versed @ 7mg/hr, pt still overbreathing @ times d/t\n acidosis, LS unchanged, better oxygenation after recruitment. Nothing\n w/ ETT sxn. CXR initially w/ LLL down, now improved w/ better lung\n sounds.\n Plan:\n CT chest, monitor ABG\ns, adjust vent MD/RT recommendations.\n" }, { "category": "Nursing", "chartdate": "2117-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503490, "text": "Impaired Skin Integrity\n Assessment:\n CVL bleeding. Small blisters near HD line dressing. Cont w/ Rash on\n abdomen and BLEs. Flexiseal in place. in place at coccyx.\n Pt w/ a stage II. Groin and axilla w/ yeast like appearance.\n Action:\n Miconazole powder applied to groin and axilla. Ointments applied to\n skin. Repositioned q 2-3 hrs & placed on barimax II bed. CVL dsg\n changed and surgiceal applied.\n Response:\n Plan:\n Cont w/ ointments, frequent repositioning.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Max temp of 102.1 orally\n.assumed pt on cooling blanket. Pt\n hypertensive into the 170s-180s systolic w/ HR in the 90s-100s and\n breathing 6-10 breaths over the vent earlier in shift\n.versed & fent ^^\n to 3mg/75mcg respectively. At 0330, pt went into a SVT w/ HR up to 170\n (SVT) while turning and remained there, sbp in the 1-teens-120s. O2\n sats 91-93%. Assumed pt on AC @ 50%/500x24/8+. ABG @ --\n 7.49/40/84/31. Infrequently sxn\nd for thick/yellow sputum.\n Action:\n Given scheduled po dose of lopressor @ 0200 and given 5mg of IV\n lopressor x 1w/o much effect on HR. Then given 10mg of IV dilt x 1 w/\n good effect. Given 1000mg po tyelenol x 2 and 400mg of po\n ibuprofen. RR changed to 20 on vent.\n Response:\n HR now in the 80s and BP in the 1 teens to 120s following diltiazem\n dose. ABG now 7.44/45/90/32 on RR of 20. O2 sats of 96%. Temp now\n 100.4 orally.\n Plan:\n Wean vent as tolerated, ? increase po lopressor dose, follow temp\n curve, tyelenol/ibuprofen prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n AM Ica 1.03. UOP 10-12 cc every 2-3 hrs. Pt received HD yesterday.\n Action:\n Given 2gm of calcium gluconate this am.\n Response:\n Plan:\n Cont to monitor and replete Ionized Calcium according to scale. Monitor\n BUN/creat.\n" }, { "category": "Physician ", "chartdate": "2117-11-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 502938, "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 37 yo man with MSSA PNA and ARF. Sputum and blood with GNRs. Sputum\n has ESBL klebs.\n AF with RVR during HD.\n 24 Hour Events:\n BLOOD CULTURED - At 02:31 PM\n SPUTUM CULTURE - At 02:31 PM\n EKG - At 08:30 PM\n FEVER - 102.2\nF - 12:00 PM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Meropenem - 10:30 PM\n Nafcillin - 06:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Famotidine (Pepcid) - 04:00 AM\n Other medications:\n chlordex\n diltiazem\n phoslo\n famotidine\n SSI\n lopressor\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 09:56 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: 39.1\nC (102.3\n HR: 103 (83 - 118) bpm\n BP: 104/55(70) {97/48(65) - 173/64(89)} mmHg\n RR: 30 (23 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 11 (3 - 139)mmHg\n Total In:\n 2,246 mL\n 970 mL\n PO:\n TF:\n 964 mL\n 380 mL\n IVF:\n 1,072 mL\n 410 mL\n Blood products:\n Total out:\n 350 mL\n 20 mL\n Urine:\n 50 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,896 mL\n 950 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 21 cmH2O\n SpO2: 97%\n ABG: 7.41/39/116/21/0\n Ve: 16.4 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Bronchial: left base, Rhonchorous:\n )\n Abdominal: Soft, Distended\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Warm, Rash: diffuse drug rash over trunk\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 9.7 g/dL\n 292 K/uL\n 199 mg/dL\n 9.4 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 91 mg/dL\n 102 mEq/L\n 139 mEq/L\n 30.0 %\n 10.3 K/uL\n [image002.jpg]\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n 02:15 PM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n WBC\n 10.4\n 9.7\n 10.3\n Hct\n 30.3\n 29.1\n 30.0\n Plt\n \n Cr\n 7.4\n 7.8\n 9.4\n TropT\n 0.21\n TCO2\n 24\n 25\n 24\n 26\n 26\n 25\n 26\n Glucose\n 227\n 215\n 199\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:53/90, Alk Phos / T Bili:259/3.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.1 g/dL,\n LDH:347 IU/L, Ca++:7.3 mg/dL, Mg++:2.5 mg/dL, PO4:5.5 mg/dL\n Microbiology: sputum\n blood cx \n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Fevers: GNRs in blood, ESBL klebsiella in sputum. Now on meropenem.\n continue nafcillin, and add gentimicin.\n Repeat cx.\n ? of emboli on CXR, so will get TTE.\n Respiratory failure: on FiO2 of 0.6. Needs more fluid off before we\n can wean down. Can reduce FiO2.\n rash: likely due to cefepime. now stopped.\n Acute renal failure: To get HD today.\n AFib: better controlled on dilt. Can stop the lopressor\n DM: high blood sugars, increase glargine, increase sliding scale.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:31 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502940, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - patient had episode of abrupt onset narrow-complex tachycardia to\n 160s around 730pm that resolved spontaneously. Maybe a flutter with\n variable conductance vs ectopic atrial source (different p-wave\n morphology).\n - hypertensive in late afternoon so added metoprolol 25mg PO BID.\n - later in Afib with RVR with rate to 120s. Gave 5mg IV lopressor and\n noticed that right IJ was low on morning CXR so withdrew it 2-3cm.\n - CXR to confirm IJ placement showed white-out of left lung. Did\n recruitment maneouvers and increased PEEP.\n BLOOD CULTURED - At 02:31 PM\n SPUTUM CULTURE - At 02:31 PM\n EKG - At 08:30 PM\n FEVER - 102.2\nF - 12:00 PM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Meropenem - 10:30 PM\n Nafcillin - 06:00 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:26 AM\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Famotidine (Pepcid) - 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.6\nC (101.5\n HR: 97 (79 - 118) bpm\n BP: 110/53(71) {97/44(65) - 173/75(93)} mmHg\n RR: 30 (23 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (3 - 18)mmHg\n Total In:\n 2,246 mL\n 743 mL\n PO:\n TF:\n 964 mL\n 262 mL\n IVF:\n 1,072 mL\n 362 mL\n Blood products:\n Total out:\n 350 mL\n 20 mL\n Urine:\n 50 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,896 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.41/39/116/21/0\n Ve: 16.2 L/min\n PaO2 / FiO2: 193\n Physical Examination\n GEN: NAD, sedated, non-responsive to verbal stimuli\n CV: RRR, no m/r/g\n PULM: CTAB\n ABD: obese, +BS, NT, left side of the abdomen warmer than the right\n EXTR: hands very edematous, 1+ DP b/l\n SKIN: morbilliform drug rash on abdomen, without blisters\n Labs / Radiology\n 292 K/uL\n 9.7 g/dL\n 199 mg/dL\n 9.4 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 91 mg/dL\n 102 mEq/L\n 139 mEq/L\n 30.0 %\n 10.3 K/uL\n [image002.jpg]\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n 02:15 PM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n WBC\n 10.4\n 9.7\n 10.3\n Hct\n 30.3\n 29.1\n 30.0\n Plt\n \n Cr\n 7.4\n 7.8\n 9.4\n TropT\n 0.21\n TCO2\n 24\n 25\n 24\n 26\n 26\n 25\n 26\n Glucose\n 227\n 215\n 199\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:53/90, Alk Phos / T Bili:259/3.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.1 g/dL,\n LDH:347 IU/L, Ca++:7.3 mg/dL, Mg++:2.5 mg/dL, PO4:5.5 mg/dL\n Sputum 2+ GNR \n Blood culture = GNR\n Cdiff negative, DFA negative for flu, catheter tip negative x2\n Respiratory sputum culture:\n RESPIRATORY CULTURE (Preliminary):\n RARE GROWTH Commensal Respiratory Flora.\n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.\n sensitivity testing performed by Microscan.\n CEFEPIME RESISTANT, >16 MCG/ML.\n MEROPENEM SENSITIVE, <1.0 MCG/ML.\n UNASYN (AMPICILLIN/SULBACTAM) RESISTANT, >16/8 MCG/ML.\n YEAST. SPARSE GROWTH.\n GRAM NEGATIVE ROD #2. RARE GROWTH.\n CXR : Persistent parenchymal radiopacities with interval worsening\n of consolidation in the lower left lung.\n CXR : Wet read\n concern for septic abscesses (staph versus\n klebsiella) versus septic thrombophlebitis on the R lung as more\n lesions identified; continued pneumonia on the left (although white-out\n has cleared). Wide mediastinum - ?mediastinitis.\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella in sputum.\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA.\n - Would call the lab and ask them to get sensitivities for the Klebs\n culture\n - Pan Cx the pt again today\n - Get surface echo to eval for vegetations\n - Continue Nafcillin/Meropenem. The pt\ns MSSA was sensitive to\n Nafcillin at the OSH and he had been Tx\nd with it in the past. The\n Meropenem will cover the GNR (Klebs) in the sputum. Day 1 for both was\n .\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS. Did\n not have any weaning of his vent setting yesterday.\n - ARDS net protocol with TV at 6cc/kg\n - He is currently a little bit respiratory alkalotic, and with a resp\n rate of 30 implying that we can bring down his resp rate and not have\n him blow off so much CO2 and be alkalotic. We will drop his set resp\n rate to 24 with a calculated CO2 (goal CO2) of 44.\n - F/u ABG\ns later this afternoon.\n - Fentanyl and versed for sedation\n - Had 1L of fluids removed yesterday at HD and is anuric. Would ask\n renal to be more aggressive with HD tomorrow, as HD removed 1L fluids\n but pt was still net even, and approx 4L positive through LOS.\n # New rash on back, abdomen, thighs: appears consistent with a drug\n rash, could be Vanc or Cefepime, but statistically Cefepime would be\n more likely. We could continue this ABx course, given that the rash\n does not seem too bad at this point, or switch Cefepime to Ceftazadime,\n which only has 10% cross reactivity between the two, and the pt is\n critically ill and requires ABx. However, based on above ABx\n discussion, will be switching ABx anyways.\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - Had HD yesterday and will f/u with renal when to have next HD\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours.\n - Was in sinus rhythm through yesterday and currently continues in\n sinus\n - Started Diltiazem 30 QID yesterday, will continue\n - Watch hemodynamics and rhythm\n # DM: Blood sugars continue to be elevated, will need to increase his\n ISS\n OTHER STABLE ISSUES\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend\n - limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:31 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 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": "2117-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502943, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - patient had episode of abrupt onset narrow-complex tachycardia to\n 160s around 730pm that resolved spontaneously. Maybe a flutter with\n variable conductance vs ectopic atrial source (different p-wave\n morphology).\n - hypertensive in late afternoon so added metoprolol 25mg PO BID.\n - later in Afib with RVR with rate to 120s. Gave 5mg IV lopressor and\n noticed that right IJ was low on morning CXR so withdrew it 2-3cm.\n - CXR to confirm IJ placement showed white-out of left lung. Did\n recruitment maneouvers and increased PEEP.\n BLOOD CULTURED - At 02:31 PM\n SPUTUM CULTURE - At 02:31 PM\n EKG - At 08:30 PM\n FEVER - 102.2\nF - 12:00 PM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Meropenem - 10:30 PM\n Nafcillin - 06:00 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:26 AM\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Famotidine (Pepcid) - 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.6\nC (101.5\n HR: 97 (79 - 118) bpm\n BP: 110/53(71) {97/44(65) - 173/75(93)} mmHg\n RR: 30 (23 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (3 - 18)mmHg\n Total In:\n 2,246 mL\n 743 mL\n PO:\n TF:\n 964 mL\n 262 mL\n IVF:\n 1,072 mL\n 362 mL\n Blood products:\n Total out:\n 350 mL\n 20 mL\n Urine:\n 50 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,896 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.41/39/116/21/0\n Ve: 16.2 L/min\n PaO2 / FiO2: 193\n Physical Examination\n GEN: NAD, sedated, non-responsive to verbal stimuli\n CV: RRR, no m/r/g\n PULM: CTAB\n ABD: obese, +BS, NT, left side of the abdomen warmer than the right\n EXTR: hands very edematous, 1+ DP b/l\n SKIN: morbilliform drug rash on abdomen, without blisters\n Labs / Radiology\n 292 K/uL\n 9.7 g/dL\n 199 mg/dL\n 9.4 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 91 mg/dL\n 102 mEq/L\n 139 mEq/L\n 30.0 %\n 10.3 K/uL\n [image002.jpg]\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n 02:15 PM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n WBC\n 10.4\n 9.7\n 10.3\n Hct\n 30.3\n 29.1\n 30.0\n Plt\n \n Cr\n 7.4\n 7.8\n 9.4\n TropT\n 0.21\n TCO2\n 24\n 25\n 24\n 26\n 26\n 25\n 26\n Glucose\n 227\n 215\n 199\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:53/90, Alk Phos / T Bili:259/3.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.1 g/dL,\n LDH:347 IU/L, Ca++:7.3 mg/dL, Mg++:2.5 mg/dL, PO4:5.5 mg/dL\n Sputum 2+ GNR \n Blood culture = GNR\n Cdiff negative, DFA negative for flu, catheter tip negative x2\n Respiratory sputum culture:\n RESPIRATORY CULTURE (Preliminary):\n RARE GROWTH Commensal Respiratory Flora.\n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.\n sensitivity testing performed by Microscan.\n CEFEPIME RESISTANT, >16 MCG/ML.\n MEROPENEM SENSITIVE, <1.0 MCG/ML.\n UNASYN (AMPICILLIN/SULBACTAM) RESISTANT, >16/8 MCG/ML.\n YEAST. SPARSE GROWTH.\n GRAM NEGATIVE ROD #2. RARE GROWTH.\n CXR : Persistent parenchymal radiopacities with interval worsening\n of consolidation in the lower left lung.\n CXR : Wet read\n concern for septic abscesses (staph versus\n klebsiella) versus septic thrombophlebitis on the R lung as more\n lesions identified; continued pneumonia on the left (although white-out\n has cleared). Wide mediastinum - ?mediastinitis.\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella in sputum.\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA.\n - Pan-culture today\n - Order TTE: to eval for vegetations given persistent febrility and\n ?septic phenomena in lungs\n - Continue Nafcillin/Meropenem. The pt\ns MSSA was sensitive to\n Nafcillin at the OSH. The GNR (Klebsiella) in the sputum are sensitive\n to Meropenem. Day 1 for both was .\n - Add gentamycin (day #1 = ) to double-cover for GNR\ns (in sputum\n and blood).\n - f/u cultures\n - f/u daily CXR\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n - Wean down FiO2 from 60 to 50%, then wean down PEEP (PEEP had been\n increased to help recruitment)\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning.\n - HD today\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on\n gent/meropenem/nafcillin.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - HD today\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Yesterday, atrial irritation\n (believed due to IJ that was too deep, now pulled back)\n - Continue Diltiazem 30 QID\n - Monitor, telemetry, now s/p IJ repositioning\n - Watch hemodynamics and rhythm\n - Was started on metoprolol in setting of tachy/hypertensive; no longer\n occurring; discontinue metoprolol\n # DM: Blood sugars continue to be elevated\n - Increase glargine; continue ISS\n OTHER STABLE ISSUES\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend daily LFTs\n - Limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:31 AM 40 mL/hour\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503093, "text": "37 yo M with a h/o of DM & ETOH abuse who presented to on w/ flu-like symptoms, including temp 105 & seizures\n requiring intubation. CXR showing PNA. Tx to for further workup.\n + MSSA (sputum\n from OSH), + Klebsiella (sputum), GNR (blood & sputum)\n Full Code\n R IJ TLC\n L IJ HD Line\n blistered areas noted beneath dsg\n R Radial Aline\n No contact O/N with family\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 12. Scant amts of\n white sputum suctioned from ETT (significantly decreased from )\n ABG this AM 7.43/41/154. SaO2 98%. Absent gag/impaired cough noted. LS\n clear/diminished @ bases. O2 sat >95% throughout the night. Pt opening\n eyes to painful stimuli. Tmax 101.6. CXR showing complete LL\n white out. Febrile - Tmax 101.6 (oral)\n Action:\n Repeat CXR last this AM. TEE . Nafcillin, Meropenem & Gentamicin\n for broadened coverage. Cooling blanket and ice packs throughout the\n night. Ice bath given this AM. Tylenol now ordered Q6hrs via NGT. PEEP\n decreased this AM to 10.\n Response:\n ABG @ 0500 7.42/43/126 (will decrease FiO2 to 40%) Temps ranging\n 100-101.6 @ this time.\n Plan:\n Cont to assess lung function & tweak ventilator settings as warranted.\n Trend ABG\ns. F/U culture data & echo results. Cooling blanket. Ice\n Packs. Tylenol ATC.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley catheter notable for icteric/scant UOP. BUN/Creat 84/8.8 (up from\n last evening post HD 69/7.5) Pt tolerated majority of HD treatment\n yesterday. He did have a run of Vtach where he was cardioverted, given\n Adenosine & started on Amiodarone gtt. Pt has remained in SR throughout\n the night. SBP 100-120\ns. MAPS >60.\n Action:\n Plan for HD today. MICU team did discuss being somewhat aggressive with\n fluid removal if pt tolerates.\n Response:\n ? placement of new HD cath today given significant flow/clotting issues\n requiring tPA clearance.\n Plan:\n Plan for HD today & daily given ARF. Cont to follow BUN/Creat. If pt\n does not improve w/ HD or does not tolerate, ? need for CRRT. Renal\n team following.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing.\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Skin care consult today. Cont to assess for s&s of further skin\n breakdown. Pt may benefit from KinAir bed to promote healing of current\n wounds. ? need for nutrition eval to assess caloric intake.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503268, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,.placement confirmed with x\n ray,but line was unable to flush ,TPA was isnstilled but still unable\n to flush,unable to do the HD.\n Code Status: full code\n Precautions: contact klebsiella\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Scant amts of\n white sputum suctioned from ETT ABG was 7.44/34/80. SaO2 ,95 -98%.\n Absent gag/impaired cough noted. LS clear/diminished @ bases. O2 sat\n >95% throughout the night. Pt does opens eyes with stimulation,but\n doesn\nt follow commands,no movts noted in the extremity,contd to have\n low grade temp inspite of the cooling blanket was on atc and with\n standing dose of Tylenol,received the pt on triple\n abx(/nafcillin/genta),recent suptum cx with kleb,blood cx from\n osh grews MSSA.\n Action:\n No vent changes overnight,abx narrowed to meropenum,contd cooling\n blanket and Atc Tylenol,daily wake up and SBT.\n Response:\n Satting good,no episode of desatuarion,lowest sats noted 93% during\n turning(was not on 100%),.\n Plan:\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt essentially anuric,(11cc in this shift),HD line was changed over the\n wire last day high access pressure,confirmed the line placement but\n unable to flush the new line,so didn\nt have HD yesterday,bun/s.cr\n trending up,Ionised ca running on the low side\n Action:\n Plan for new HD line today(possibly in the IR),and HD\n afterwards,received 4gm of calcium gluconate in this shift,\n Response:\n Pending.\n Plan:\n New HD line placement and HD.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing.\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Skin care consult today. Cont to assess for s&s of further skin\n breakdown. Pt may benefit from KinAir bed to promote healing of current\n wounds. ? need for nutrition eval to assess caloric intake.\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503764, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2117-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502910, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - patient had episode of abrupt onset narrow-complex tachycardia to\n 160s around 730pm that resolved spontaneously. Maybe a flutter with\n variable conductance vs ectopic atrial source (different p-wave\n morphology).\n - hypertensive in late afternoon so added metoprolol 25mg PO BID.\n - later in Afib with RVR with rate to 120s. Gave 5mg IV lopressor and\n noticed that right IJ was low on morning CXR so withdrew it 2-3cm.\n - CXR to confirm IJ placement showed white-out of left lung. Did\n recruitment maneouvers and increased PEEP.\n BLOOD CULTURED - At 02:31 PM\n SPUTUM CULTURE - At 02:31 PM\n EKG - At 08:30 PM\n FEVER - 102.2\nF - 12:00 PM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Meropenem - 10:30 PM\n Nafcillin - 06:00 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:25 AM\n Fentanyl - 08:26 AM\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Famotidine (Pepcid) - 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.6\nC (101.5\n HR: 97 (79 - 118) bpm\n BP: 110/53(71) {97/44(65) - 173/75(93)} mmHg\n RR: 30 (23 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (3 - 18)mmHg\n Total In:\n 2,246 mL\n 743 mL\n PO:\n TF:\n 964 mL\n 262 mL\n IVF:\n 1,072 mL\n 362 mL\n Blood products:\n Total out:\n 350 mL\n 20 mL\n Urine:\n 50 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,896 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 19 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.41/39/116/21/0\n Ve: 16.2 L/min\n PaO2 / FiO2: 193\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 292 K/uL\n 9.7 g/dL\n 199 mg/dL\n 9.4 mg/dL\n 21 mEq/L\n 4.5 mEq/L\n 91 mg/dL\n 102 mEq/L\n 139 mEq/L\n 30.0 %\n 10.3 K/uL\n [image002.jpg]\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n 02:15 PM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n WBC\n 10.4\n 9.7\n 10.3\n Hct\n 30.3\n 29.1\n 30.0\n Plt\n \n Cr\n 7.4\n 7.8\n 9.4\n TropT\n 0.21\n TCO2\n 24\n 25\n 24\n 26\n 26\n 25\n 26\n Glucose\n 227\n 215\n 199\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:53/90, Alk Phos / T Bili:259/3.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.1 g/dL,\n LDH:347 IU/L, Ca++:7.3 mg/dL, Mg++:2.5 mg/dL, PO4:5.5 mg/dL\n Sputum 2+ GNR \n Blood culture GNR\n Cdiff negative, DFA negative for flu, catheter tip negative x2\n Respiratory sputum culture:\n RESPIRATORY CULTURE (Preliminary):\n RARE GROWTH Commensal Respiratory Flora.\n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.\n sensitivity testing performed by Microscan.\n CEFEPIME RESISTANT, >16 MCG/ML.\n MEROPENEM SENSITIVE, <1.0 MCG/ML.\n UNASYN (AMPICILLIN/SULBACTAM) RESISTANT, >16/8 MCG/ML.\n YEAST. SPARSE GROWTH.\n GRAM NEGATIVE ROD #2. RARE GROWTH.\n CXR : Persistent parenchymal radiopacities with interval worsening\n of consolidation in the lower left lung.\n Assessment and Plan\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since .\n # Septic shock: BP stable off pressors. Culture data positive only for\n MSSA in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , and radiographic\n evidence of PNA.\n - Would call the lab and ask them to get sensitivities for the Klebs\n culture\n - Pan Cx the pt again today\n - Get surface echo to eval for vegetations\n - Continue Nafcillin/Meropenem. The pt\ns MSSA was sensitive to\n Nafcillin at the OSH and he had been Tx\nd with it in the past. The\n Meropenem will cover the GNR (Klebs) in the sputum. Day 1 for both was\n .\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS. Did\n not have any weaning of his vent setting yesterday.\n - ARDS net protocol with TV at 6cc/kg\n - He is currently a little bit respiratory alkalotic, and with a resp\n rate of 30 implying that we can bring down his resp rate and not have\n him blow off so much CO2 and be alkalotic. We will drop his set resp\n rate to 24 with a calculated CO2 (goal CO2) of 44.\n - F/u ABG\ns later this afternoon.\n - Fentanyl and versed for sedation\n - Had 1L of fluids removed yesterday at HD and is anuric. Would ask\n renal to be more aggressive with HD tomorrow, as HD removed 1L fluids\n but pt was still net even, and approx 4L positive through LOS.\n # New rash on back, abdomen, thighs: appears consistent with a drug\n rash, could be Vanc or Cefepime, but statistically Cefepime would be\n more likely. We could continue this ABx course, given that the rash\n does not seem too bad at this point, or switch Cefepime to Ceftazadime,\n which only has 10% cross reactivity between the two, and the pt is\n critically ill and requires ABx. However, based on above ABx\n discussion, will be switching ABx anyways.\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - Had HD yesterday and will f/u with renal when to have next HD\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours.\n - Was in sinus rhythm through yesterday and currently continues in\n sinus\n - Started Diltiazem 30 QID yesterday, will continue\n - Watch hemodynamics and rhythm\n # DM: Blood sugars continue to be elevated, will need to increase his\n ISS\n OTHER STABLE ISSUES\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend\n - limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:31 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2117-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502427, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / 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:\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: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt has been weaned from Fio2 70% to 50%, weaning peep may be possible\n later today\n" }, { "category": "Physician ", "chartdate": "2117-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502428, "text": "TITLE:\n Chief Complaint: fevers/sepsis\n 24 Hour Events:\n MULTI LUMEN - START 02:58 PM\n MULTI LUMEN - STOP 04:30 PM\n DIALYSIS CATHETER - STOP 04:30 PM\n EKG - At 12:30 AM\n FEVER - 103.1\nF - 12:00 AM\n Abios: cefipime, vanc, tamiflu\n - Right IJ placed. Left subclavian and dialysis lines sent for\n culture. Dialysis tip touched non-sterile glove.\n - CT scan of head: no acute process. Fluid in mastoid sinuses.\n - CT scan of torso: LLL completely opacified by multifocal pneumonia,\n small amount of free fluid, abdomen otherwise benign.\n - f/u pan cultures -> respiratory culture inadequate.\n - UA w/ epi's, but pt anuric. Will f/u culture.\n - f/u LFT tomorrow to assure trending down\n - repeat ABG: 7.30/38/96, improving acidosis.\n - Started tube feeds with nutren pulmonary to goal 40ml/hour as there\n is no in-house nutrition tonight.\n - flu DFA negative, stopped oseltamivir\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.5\nC (103.1\n Tcurrent: 37.4\nC (99.4\n HR: 77 (77 - 122) bpm\n BP: 118/50(69) {84/46(62) - 123/60(77)} mmHg\n RR: 31 (28 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (12 - 19)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,448 mL\n 526 mL\n PO:\n TF:\n 89 mL\n 220 mL\n IVF:\n 1,499 mL\n 306 mL\n Blood products:\n Total out:\n 108 mL\n 10 mL\n Urine:\n 8 mL\n 10 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,340 mL\n 516 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 35 cmH2O\n Plateau: 29 cmH2O\n SpO2: 96%\n ABG: 7.32/37/116/19/-6\n Ve: 14.8 L/min\n PaO2 / FiO2: 232\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.1 g/dL\n 210 mg/dL\n 7.7 mg/dL\n 19 mEq/L\n 4.7 mEq/L\n 68 mg/dL\n 106 mEq/L\n 143 mEq/L\n 31.2 %\n 12.5 K/uL\n [image002.jpg]\n 11:09 PM\n 11:28 PM\n 04:30 AM\n 11:18 AM\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n WBC\n 12.5\n 10.6\n 12.5\n Hct\n 37.9\n 42\n 31.7\n 31.2\n Plt\n \n Cr\n 5.4\n 7.2\n 7.7\n TropT\n 0.20\n TCO2\n 25\n 19\n 21\n 20\n Glucose\n 147\n 156\n 210\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:6.4 mg/dL\n Imaging: CXR: ET tube high? continued left-sided opacity\n CXR: widespread left mid and lower lobe consolidations as well as\n right basal consolidation. Small amount of bilateral pleural effusion\n is present.\n Micro: Flu DFA negative. Urine and blood cx pending.\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CXRs with L > R\n infiltrates. We broadened antibiotics empirically yesterday with vanc\n and cefepime. CT scan did show fluid in sinuses and multi-focal\n pneumonia but no other clear source.\n Treated for flu although DFA neg x 2 in OSH. Elevated Mixed venous Sat\n elevated at 84% and mottled appearance most suggestive of Septic\n etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high Mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given neg Urine legionalla and Prolonged QTc\n at times avoid FQ.\n Over likely sources include line infection, urine, or sinus (given\n sinusitus on CT head). Drug fever also possible. Fevers to 105 may also\n be a central CNS process.\n - monitor BP for MAP goal > 60\n - CVP goal \n - mixed venous sat goal > 70\n - monitor fever curve\n - Blood, urine, sputum, stool (c diff) cultures.\n - Repeat DFA\n - trend lactate (1.0 currently)\n - replace naficillin for Vanco and Cefepime for HAP\n - Given convincing viral prodrome continue Tamiflu until repeat DFA\n here.\n - f/u final read CXR\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS.\n - ARDS net protocol with TV at 6cc/kg\n - monitor plateau, titrate up PEEP for plateus in low 30s.\n - wean FiO2 as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today.\n # Tachycardia: appears sinus on arrival. Records state Afib, however\n apears sinus on all tracings. OSH EKG with RBBB as recently as .\n This would be an odd presentation of rate related IVCD given the slower\n rate on EKGs with QRS widing. Ddx for sinus tachy includes fever vs\n pain vs agitation vs withdrawl (possible Etoh history).\n - titrate sedation to aggitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL colapse.\n - dialsis per renal\n - maximize minute ventilation\n - trend ABG.\n # mild LFT elevation: likely prolonged hypotension.\n - trend\n - limit tylenol to 2 gm daily\n # DM: BG stable on SS\n - continue Reg SS\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n .\n Prophylaxis: Subcutaneous heparin, PPI\n .\n Access: right IJ and A line. Needs dialysis line.\n .\n Code: Full code confirmed\n .\n Communication: Mother, \n .\n Disposition: pending clinical improvement\n" }, { "category": "Physician ", "chartdate": "2117-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502461, "text": "TITLE:\n Chief Complaint: fevers/sepsis\n 24 Hour Events:\n MULTI LUMEN - START 02:58 PM\n MULTI LUMEN - STOP 04:30 PM\n DIALYSIS CATHETER - STOP 04:30 PM\n EKG - At 12:30 AM\n FEVER - 103.1\nF - 12:00 AM\n Abios: cefipime, vanc, tamiflu\n - Right IJ placed. Left subclavian and dialysis lines sent for\n culture. Dialysis tip touched non-sterile glove.\n - CT scan of head: no acute process. Fluid in mastoid sinuses.\n - CT scan of torso: LLL completely opacified by multifocal pneumonia,\n small amount of free fluid, abdomen otherwise benign.\n - f/u pan cultures -> respiratory culture inadequate.\n - UA w/ epi's, but pt anuric. Will f/u culture.\n - f/u LFT tomorrow to assure trending down\n - repeat ABG: 7.30/38/96, improving acidosis.\n - Started tube feeds with nutren pulmonary to goal 40ml/hour as there\n is no in-house nutrition tonight.\n - flu DFA negative, stopped oseltamivir\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.5\nC (103.1\n Tcurrent: 37.4\nC (99.4\n HR: 77 (77 - 122) bpm\n BP: 118/50(69) {84/46(62) - 123/60(77)} mmHg\n RR: 31 (28 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (12 - 19)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,448 mL\n 526 mL\n PO:\n TF:\n 89 mL\n 220 mL\n IVF:\n 1,499 mL\n 306 mL\n Blood products:\n Total out:\n 108 mL\n 10 mL\n Urine:\n 8 mL\n 10 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,340 mL\n 516 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 35 cmH2O\n Plateau: 29 cmH2O\n SpO2: 96%\n ABG: 7.32/37/116/19/-6\n Ve: 14.8 L/min\n PaO2 / FiO2: 232\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.1 g/dL\n 210 mg/dL\n 7.7 mg/dL\n 19 mEq/L\n 4.7 mEq/L\n 68 mg/dL\n 106 mEq/L\n 143 mEq/L\n 31.2 %\n 12.5 K/uL\n [image002.jpg]\n 11:09 PM\n 11:28 PM\n 04:30 AM\n 11:18 AM\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n WBC\n 12.5\n 10.6\n 12.5\n Hct\n 37.9\n 42\n 31.7\n 31.2\n Plt\n \n Cr\n 5.4\n 7.2\n 7.7\n TropT\n 0.20\n TCO2\n 25\n 19\n 21\n 20\n Glucose\n 147\n 156\n 210\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:6.4 mg/dL\n Imaging: CXR: ET tube high? continued left-sided opacity\n CXR: widespread left mid and lower lobe consolidations as well as\n right basal consolidation. Small amount of bilateral pleural effusion\n is present.\n Micro: Flu DFA negative. Urine and blood cx pending.\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CXRs with L > R\n infiltrates. We broadened antibiotics empirically yesterday with vanc\n and cefepime. CT scan did show fluid in sinuses and multi-focal\n pneumonia but no other clear source.\n Treated for flu although DFA neg x 2 in OSH. Elevated Mixed venous Sat\n elevated at 84% and mottled appearance most suggestive of Septic\n etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high Mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given neg Urine legionalla and Prolonged QTc\n at times avoid FQ.\n Over likely sources include line infection, urine, or sinus (given\n sinusitus on CT head). Drug fever also possible. Fevers to 105 may also\n be a central CNS process.\n - monitor BP for MAP goal > 60\n - CVP goal \n - mixed venous sat goal > 70\n - monitor fever curve\n - Blood, urine, sputum, stool (c diff) cultures.\n - Repeat DFA\n - trend lactate (1.0 currently)\n - Continue Vanco and Cefepime to cover for HAP\n - f/u read of daily CXR\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS.\n - ARDS net protocol with TV at 6cc/kg\n - monitor plateau, titrate up PEEP for plateaus in low 30s.\n - wean FiO2 as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today.\n # Tachycardia: appears sinus on arrival. Records state Afib, however\n apears sinus on all tracings. OSH EKG with RBBB as recently as .\n This would be an odd presentation of rate related IVCD given the slower\n rate on EKGs with QRS widing. Ddx for sinus tachycardia includes fever\n vs pain vs agitation vs withdrawl (possible Etoh history).\n - titrate sedation to agitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG.\n # mild LFT elevation: likely prolonged hypotension.\n - trend\n - limit tylenol to 2 gm daily\n # DM: BG stable on SS\n - continue Reg SS\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n .\n Prophylaxis: Subcutaneous heparin, PPI\n .\n Access: right IJ and A line. Needs dialysis line.\n .\n Code: Full code confirmed\n .\n Communication: Mother, \n .\n Disposition: pending clinical improvement\n" }, { "category": "Physician ", "chartdate": "2117-10-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 502464, "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 39 yo man with MSSA PNA, sepsis, ARDS. Lines changed yesterday.\n Still febrile, but improving\n respiratory status.\n 24 Hour Events:\n MULTI LUMEN - START 02:58 PM\n MULTI LUMEN - STOP 04:30 PM\n DIALYSIS CATHETER - STOP 04:30 PM\n EKG - At 12:30 AM\n FEVER - 103.1\nF - 12:00 AM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 75 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n chlorhex\n cefipime\n SSI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.5\nC (103.1\n Tcurrent: 37.7\nC (99.9\n HR: 79 (77 - 93) bpm\n BP: 121/51(70) {100/46(62) - 123/60(77)} mmHg\n RR: 31 (9 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (12 - 15)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,448 mL\n 737 mL\n PO:\n TF:\n 89 mL\n 371 mL\n IVF:\n 1,499 mL\n 366 mL\n Blood products:\n Total out:\n 108 mL\n 10 mL\n Urine:\n 8 mL\n 10 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,340 mL\n 727 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 96%\n ABG: 7.32/37/116/19/-6\n Ve: 15.9 L/min\n PaO2 / FiO2: 232\n Physical Examination\n General Appearance: No(t) No acute distress\n Eyes / Conjunctiva: No(t) PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present\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 10.1 g/dL\n 226 K/uL\n 210 mg/dL\n 7.7 mg/dL\n 19 mEq/L\n 4.7 mEq/L\n 68 mg/dL\n 106 mEq/L\n 143 mEq/L\n 31.2 %\n 12.5 K/uL\n [image002.jpg]\n 11:09 PM\n 11:28 PM\n 04:30 AM\n 11:18 AM\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n WBC\n 12.5\n 10.6\n 12.5\n Hct\n 37.9\n 42\n 31.7\n 31.2\n Plt\n \n Cr\n 5.4\n 7.2\n 7.7\n TropT\n 0.20\n TCO2\n 25\n 19\n 21\n 20\n Glucose\n 147\n 156\n 210\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:6.4 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Continue weaning PEEP as tolerated.\n Staph PNA/ARDS: Slow improvement. on oxacillin\n Fever curve is lower with antibiotics.\n ATN/ARF: To get new HD catheter for HD.\n DM: Increasing FSBG - going up on SSI.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503813, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,. placement confirmed with x\n ray, but line was unable to flush ,TPA was isnstilled but still unable\n to flush, unable to do the HD.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2117-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502592, "text": "TITLE:\n Chief Complaint: ARDS and ARF\n 24 Hour Events:\n DIALYSIS CATHETER - START 01:13 PM\n catheter with side port.\n Patient went into AFib w/ RVR during dialysis yesterday and it was\n ended early (after 0.5L removed) Given 10 lopressor and 20 of dilt .\n Gave PO load of dilt. Converted back to sinus.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:10 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Metoprolol - 03:30 PM\n Diltiazem - 03:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38.2\nC (100.8\n HR: 89 (72 - 178) bpm\n BP: 128/56(78) {97/42(63) - 161/69(91)} mmHg\n RR: 30 (26 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 20 (9 - 22)mmHg\n Total In:\n 1,501 mL\n 556 mL\n PO:\n TF:\n 921 mL\n 328 mL\n IVF:\n 580 mL\n 228 mL\n Blood products:\n Total out:\n 562 mL\n 505 mL\n Urine:\n 32 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 939 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 23 cmH2O\n SpO2: 96%\n ABG: 7.43/35/78./22/0\n Ve: 16.7 L/min\n PaO2 / FiO2: 158\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 252 K/uL\n 10.1 g/dL\n 227 mg/dL\n 7.4 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 65 mg/dL\n 102 mEq/L\n 141 mEq/L\n 30.3 %\n 10.4 K/uL\n [image002.jpg]\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n WBC\n 10.6\n 12.5\n 10.4\n Hct\n 31.7\n 31.2\n 30.3\n Plt\n 237\n 226\n 252\n Cr\n 7.2\n 7.7\n 6.3\n 7.4\n TCO2\n 21\n 20\n 19\n 24\n 25\n 24\n Glucose\n 156\n 210\n 222\n 227\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.0 mg/dL, Mg++:2.6 mg/dL, PO4:5.6 mg/dL\n Imaging: FINDINGS: As compared to the previous examination, a new\n central venous\n access line has been placed over the left internal jugular vein. The\n tip of\n the line projects over the mid SVC. There is no evidence of\n complications,\n notably no pneumothorax.\n CXR \n The other monitoring and support devices are in unchanged position.\n Also\n unchanged is the size of the cardiac silhouette as well as the right\n suprabasal atelectasis and the relatively extensive left mid lung and\n basal parenchymal opacity with air bronchograms.\n Microbiology: All cultures NTD\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated Mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of Septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high Mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given neg Urine legionalla and\n Prolonged QTc at times avoid FQ.\n - Continue Vanco and Cefepime to cover for HAP. We will continue with\n broad coverage considering improvement, and we will treat for a 15 day\n course from yesterday (today day 3).\n - f/u cultures\n - f/u read of daily CXR\n .\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS.\n Bladder pressures are lower today, suggesting we have room to wean down\n his PEEP.\n - ARDS net protocol with TV at 6cc/kg\n - wean FiO2 and PEEP as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n .\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today with trial of intermittent dialysis.\n .\n # Tachycardia/ AFib: appeared sinus on arrival. Yesterday had a couple\n runs of tachycardia that appeared to be afib with aberrancy that were\n self-limited and well-tolerated. OSH EKG with RBBB as recently as\n , and reports of atrial fibrillation requiring treatment with\n diltiazem. Yesterday went into AFib w/ RVR during dialysis. Treated\n w/ lopressor 10, dilt 20 IV and dilt PO60. Converted back to sinus\n after 1-2 hours.\n - titrate sedation to agitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n .\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG, is improved\n .\n # mild LFT elevation: likely prolonged hypotension. Improving.\n Added on to today's labs because had not been drawn since \n - trend\n - limit tylenol to 2 gm daily\n .\n # DM: Was hyperglycemic yesterday and we are starting tube feeds, so we\n will increase his sliding scale.\n - continue Reg SS\n .\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:44 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 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": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503024, "text": "ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated. . Staph in blood/sputum (OSH), GNR\n in blood, klebsiella in sputum.\n Events: today during H/D he went into VT with a HR of 180\n. He was\n converted with one shock to a narrow complex tachycardia.\n He was given amiodarone 300mg loading dose was ordered the Code. And\n amoidarone 1mg a minute was started after. Ionized calcium 0.99. he\n received 4G calcium gluconate.\n Code status Full code\n Precautions: Contact precautions.\n Cardiac dysrhythmia other\n Assessment:\n This afternoon during H/D he went into VT with a heart rate of 180\n His blood pressure dropped to 100\ns from the 114/60.\n Action:\n Converted with one shock to SVT (narrow complex tachycardia).\n Amiodarone loading dose and than the gtt 1mg a minute.\n Adenosine was given.\n Response:\n Went down to ST heart rate 100\ns. without PVC noted.\n Plan:\n Continue the amiodarone gtt at 1mg a minute.\n Continue to given the dilt via right NG.\n Pneumonia/Respiratory Distress\n Assessment:\n I received the patient on AC 50%X500X24 W12 peep. O2 sat 96%. He is\n positive for a multi-lobar pneumonia. He is MSSA + in sputum form the\n OSH, and now with klebsiella, and gram ndgative rods in sputum, and\n GNR in blood. He had a CXR last night with showed a white out of the\n left lung. Suctioned him for thick yellow/brown sputum in a large\n amount this morning. He continues to have temps of 102.3.\n Action:\n TEE done.\n Gegentamicin was added.\n He will continue with the /nafcillin.\n Cooling blanket/Tylenol\n Pan cultured today.\n Response:\n Awaiting the results from the echo.\n He still continues with temps of 100.5 to 102.6 or4al.\n Ice packs were placed under his arms.\n Plan:\n Follow up cultures from today.\n Continue with the current antibiotic regimen.\n Continue with the Tylenol and cooling blanket.\n f/u echo.\n given the tonight( pharmacy prescribed the time).\n He did have one dose of Genta. He will need Genta level\n tomorrow.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley cath with dark amber urine. 30ml for the 12 hour shift. BUN\n 91/Cr 9.4. H/D line was clogged off\n Action:\n H/D todat.\n Alteplase was given in each port.\n Response:\n 2500 off H/D. During the code 1L given back by H/D RN\n He was able to get through the three hour treatment. But he was\n unable to increase the blood flow grater than 200.\n Plan:\n Question of a new line tonight or tomorrow.\n Also the renal team will discuess having H/D QD.\n Impaired Skin Integrity\n Assessment:\n He has two areas on his buttocks which are stage two. He has a drug\n rash from a question of vanco. He has yeast under his arms.\n Action:\n Please look at the for the creams to use for the yeast.\n I requested a skin care consult.\n Response:\n Mepilex still intact on coccyx.\n Plan:\n Wound care consult tomorrow.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503259, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503260, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,.placement confirmed with x\n ray,but line was unable to flush ,TPA was isnstilled but still unable\n to flush,unable to do the HD.\n Code Status: full code\n Precautions: contact klebsiella\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. Scant amts of\n white sputum suctioned from ETT ABG was 7.44/34/80. SaO2 ,95 -98%.\n Absent gag/impaired cough noted. LS clear/diminished @ bases. O2 sat\n >95% throughout the night. Pt does opens eyes with stimulation,but\n doesn\nt follow commands,no movts noted in the extremity,contd to have\n low grade temp inspite of the cooling blanket was on atc and with\n standing dose of Tylenol,received the pt on triple\n abx(/nafcillin/genta),recent suptum cx with kleb,blood cx from\n osh grews .\n Action:\n No vent changes overnight,abx narrowed to meropenum,contd cooling\n blanket and Atc Tylenol,daily wake up and SBT.\n Response:\n Satting good,no episode of desatuarion,lowest sats noted 93% during\n turning(was not on 100%),.\n Plan:\n .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley catheter notable for icteric/scant UOP. BUN/Creat 84/8.8 (up from\n last evening post HD 69/7.5) Pt tolerated majority of HD treatment\n yesterday. He did have a run of Vtach where he was cardioverted, given\n Adenosine & started on Amiodarone gtt. Pt has remained in SR throughout\n the night. SBP 100-120\ns. MAPS >60.\n Action:\n Plan for HD today. MICU team did discuss being somewhat aggressive with\n fluid removal if pt tolerates.\n Response:\n ? placement of new HD cath today given significant flow/clotting issues\n requiring tPA clearance.\n Plan:\n Plan for HD today & daily given ARF. Cont to follow BUN/Creat. If pt\n does not improve w/ HD or does not tolerate, ? need for CRRT. Renal\n team following.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing.\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Skin care consult today. Cont to assess for s&s of further skin\n breakdown. Pt may benefit from KinAir bed to promote healing of current\n wounds. ? need for nutrition eval to assess caloric intake.\n" }, { "category": "Nursing", "chartdate": "2117-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502284, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp100.6 on admission, BP in 150\ns, MSSA in sputum and blood from OSH,\n OFF pressors since Monday . WBC 10.5, lactate 1.0, was on tamiflu\n for ? H1N1. Cool mottled extremeties.\n Action:\n Temp spike to 105.1, placed on cooling blanket and ice packs in axilla\n and groin, given 650mg PO tylenol, bld cx from a-line and TLC (OSH\n line), urine, sputum, influenza swab, LP attempted, started levophed\n gtt for BP 70\ns, getting PO contrast slowly via NGT for pending CT\n chest/abd, bladder pressure done. Given x1 doses vanco 1gram and\n ciprofloxacin 2grams.\n Response:\n Temp now 101.3, WBC 12.5, bladder pressure (23), Lactate remains 1, LP\n attempt failed, CT pending (check residuals to see if pt can tolerate\n another bottle of contrast), BP 80\ns, MAP >65 on 0.1mcg levophed.\n Plan:\n CT chest/abd, ? reattempt LP, monitor temps, f/u on cx data, still\n needs stool cx, ? KUB for increased bladder pressure if does not get\n CT. Remains on droplet precautions until neg nasal flock swab.\n Cardiac dysrhythmia other\n Assessment:\n Admitted SVT to 150\ns, ? a.fib w/ slower rates in 1teens, occasional\n pvc\ns, trop 0.4 in OSH, ECHO done in OSH, fam hx of heart disease\n Action:\n EKG showing SVT, sent trop and added on cardiac enzymes\n Response:\n ? a.fib @ times, seems to have PAC\ns and change rhythyms but mostly in\n SVT 140\ns to 120\ns. does not correlate w/ temps @ this time.\n Plan:\n ? TEE for ? myocarditis, monitor EKG, f/u on cardiac enzymes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HD started @ OSH for ARF, unclear how pt tolerated or if fluid was\n removed, Last HD prior to admission. BUN/Creat 52/7\n Action:\n Fluid bolus 500cc x1\n Response:\n Anuric, BUN/Creat 39/5.4.\n Plan:\n ? HD vs. CVVH.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2117-10-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 502452, "text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 119 kg\n 122.1 kg ( 06:00 AM)\n up ~3kg d/t fluids.\n 38.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 164% (per adm WT)\n 84.2 kg (per Admit WT)\n -\n -\n Diagnosis: Diabetes, septic shock\n PMHx: NIDDM, HTN\n Food allergies and intolerances: none noted.\n Pertinent medications: RISS, fentanyl, midazolam, protonix, vancomycin.\n Labs:\n Value\n Date\n Glucose\n 210 mg/dL\n 03:17 AM\n Glucose Finger Stick\n 221\n 04:00 AM\n BUN\n 68 mg/dL\n 03:17 AM\n Creatinine\n 7.7 mg/dL\n 03:17 AM\n Sodium\n 143 mEq/L\n 03:17 AM\n Potassium\n 4.7 mEq/L\n 03:17 AM\n Chloride\n 106 mEq/L\n 03:17 AM\n TCO2\n 19 mEq/L\n 03:17 AM\n PO2 (arterial)\n 116 mm Hg\n 03:27 AM\n PCO2 (arterial)\n 37 mm Hg\n 03:27 AM\n pH (arterial)\n 7.32 units\n 03:27 AM\n pH (urine)\n 5.0 units\n 05:53 AM\n CO2 (Calc) arterial\n 20 mEq/L\n 03:27 AM\n Albumin\n 2.1 g/dL\n 03:17 AM\n Calcium non-ionized\n 7.1 mg/dL\n 03:17 AM\n Phosphorus\n 6.4 mg/dL\n 03:17 AM\n Ionized Calcium\n 0.99 mmol/L\n 03:27 AM\n Magnesium\n 2.7 mg/dL\n 03:17 AM\n ALT\n 52 IU/L\n 11:09 PM\n Alkaline Phosphate\n 260 IU/L\n 11:09 PM\n AST\n 104 IU/L\n 11:09 PM\n Total Bilirubin\n 5.2 mg/dL\n 11:09 PM\n WBC\n 12.5 K/uL\n 03:17 AM\n Hgb\n 10.1 g/dL\n 03:17 AM\n Hematocrit\n 31.2 %\n 03:17 AM\n Current diet order / nutrition support: NPO/Tube Feed: Nutren Pulmonary\n at 40mL/hr\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: Low protein stores, sepsis with organ failure.\n Estimated Nutritional Needs\n Calories: 2100-2520 (25-30 cal/kg)\nd/t dialysis\n Protein: 84-126 (1-1.5 g/kg)\n Fluid: per team.\n Calculations based on: Adjusted weight\n Specifics:\n 37 YO male wth hx of NIDDM who initially presented to an OSH with\n septic shock & staph PNA/bacteria c/b ARF & was on dialysis, now with\n fevers & remains intubated. Renal following; will likely continue to\n need dialysis. Started on tube feed & currently tolerating Nutren 2.0\n at 40mL/hr. Recommend change formula to a renal formulary: Novasource\n Renal at goal 45mL/hr, providing 2160kcals & 80g protein. Restricting\n protein at 1g/kg until BUN/Creat start to trend down to acceptable\n ranges, then will increase protein to 1.5g/kg.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Change tube feed to Novasource Renal; start at 30mL/hr;\n advance to goal after 4hrs if tolerates.\n 2. Check residuals Q 4hrs & hold for 1hr if greater than 200mL\n 3. Adjust free water flushes per hydration\n 4. Monitor & replete labs PRN\n 5. Will add Beneprotein to provide 1.5g/kg protein once renal\n function improves with dialysis.\n Will follow plan/progress.\n" }, { "category": "Nursing", "chartdate": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502520, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Events: HD line placed, HD tolerated for 2\n hours then developed SVT\n @ rate 175, converted to SR with lopressor then dilt.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received a dialysis catheter in left IJ by renal fellow, confirmed\n by CXR. Dialysis started at 1330.\n Action:\n Pt tolerated dialysis for 2\n hours, getting 500cc fluid removed. At\n 1500 pt rhythm was 175 SVT, EKG taken but his HR dropped to 120\n Afib. His B/P never dropped below 105/ even when his HR was at it\n fastest.\n Response:\n He was given lopressor 5mg x2 IV with a slight drop in HR. He was then\n given 10mg dilt x2 IV, as well as 60mg dilt PO. He converted back to\n NSR rate 74 at 1720.\n Plan:\n Keep Pt on PO dilt while getting HD, Monitor vital signs closely.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings 50% 500 x 30, Peep 16 FiO2 50%. Suctioned x2 for thick\n dark tan secretions.\n Action:\n Peep was decreased to 10, with little change in O2 sats, 96-97%. When\n his heart rhythm was in afib his O2 sats dropped to 92-94%, ABG drawn\n was 7.46/33/59.\n Response:\n When converted back to NSR O2 sats improved, FiO2 dropped back to 50%,\n ABG pending.\n Plan:\n Check ABG, monitor O2 sats, continue to wean when possible.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502572, "text": "Pt is a 37yo male with a h/o of diabetes and alcohol abuse who\n presented to Hosp on w/ flu-like symptoms,\n including temp 105. In ED had seizure and was intubated. CXR showing\n PNA. Initially was on pressors and was not urinating (new renal\n failure). Thought to be in and out of a.fib w/ RBBB and increasing\n troponin so started on heparin gtt as well. ECHO for ? myocarditis.\n Heparin has been off since, pressors off, tolerating HD w/ goal\n 1-1.5L per treatment. EEG done to f/u w/ seizure activity (? results\n from OSH). MSSA in sputum and blood from OSH. Now has been afebrile,\n WBC 10.5, still w/ ^ vent requirements. Transported to ICU via\n Med flight, arrived unresponsive from bolus sedation and bolus\n paralytic.\n Events: Stable overnight, continues febrile, pt has remained in SR,\n ETT rotated. No family contact overnight.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues with minimal urine output, <15cc\ns for the shift.\n Action:\n Tolerated dialysis for 2\n hours earlier in day.\n Response:\n Requiring no additional meds this shift\n Plan:\n Continue to monitor vital signs closely.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings 50% 500 x 30, Peep 10 FiO2 50%. Suctioned multiple times\n for moderate to large amounts of thick dark tan secretions.\n Action:\n No vent changes made this shift. ABG drawn was 7.43/33/79.\n Response:\n Stable respiratory status overnight\n Plan:\n Check ABG, monitor O2 sats, continue to wean when possible.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T-max of 100.8 po, continues on vanco, post HD, and cefepime.\n Action:\n Pt had been on cooling blanket at 1900. Remained on until ~2100, as\n temp began to fall back to normal.\n Response:\n Awaiting blood culture results, drawn earlier in shift.\n Plan:\n Continue with antibiotics, monitor temp closely, cooling blanket for\n temp >101.0\n" }, { "category": "Physician ", "chartdate": "2117-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 502603, "text": "Chief Complaint: Acute renal failure, afib, hypotension, bacteremia,\n acute respiratory failure, pneumonia, acidosis, 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 Had episode of afib during dialysis. Required lopressor and diltiazem\n to control ventricular rate and then converted to NSR.\n Continues on vent. FIO2 at 0.5.\n Continues on antibiotics. WBC stable at 10.\n 24 Hour Events:\n DIALYSIS CATHETER - START 01:13 PM\n catheter with side port.\n History obtained from Medical records\n Patient unable to provide history: Sedated, Intubated\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:10 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Metoprolol - 03:30 PM\n Diltiazem - 03:50 PM\n Heparin Sodium (Prophylaxis) - 08:23 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 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.5\nC (103.1\n Tcurrent: 39.5\nC (103.1\n HR: 102 (72 - 178) bpm\n BP: 133/61(83) {97/42(63) - 161/69(91)} mmHg\n RR: 25 (25 - 34) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 18 (9 - 22)mmHg\n Total In:\n 1,501 mL\n 707 mL\n PO:\n TF:\n 921 mL\n 394 mL\n IVF:\n 580 mL\n 253 mL\n Blood products:\n Total out:\n 562 mL\n 505 mL\n Urine:\n 32 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 939 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 6\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 23 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 94%\n ABG: 7.43/35/78./22/0\n Ve: 16.2 L/min\n PaO2 / FiO2: 158\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, 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), (Breath\n Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: Coarse\n breath sounds right greater than left)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , Obese\n Extremities: Right lower extremity edema: 1+ edema, Left lower\n extremity edema: 1+, 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: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, No(t) Oriented (to): , Movement: Purposeful,\n Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 10.1 g/dL\n 252 K/uL\n 227 mg/dL\n 7.4 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 65 mg/dL\n 102 mEq/L\n 141 mEq/L\n 30.3 %\n 10.4 K/uL\n [image002.jpg]\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n WBC\n 10.6\n 12.5\n 10.4\n Hct\n 31.7\n 31.2\n 30.3\n Plt\n 237\n 226\n 252\n Cr\n 7.2\n 7.7\n 6.3\n 7.4\n TCO2\n 21\n 20\n 19\n 24\n 25\n 24\n Glucose\n 156\n 210\n 222\n 227\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.0 mg/dL, Mg++:2.6 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n ACIDOSIS\n PNEUMONIA\n ==========================\n Afebrile with high normal WBC on present antibiotics. Continue for now.\n Minute ventilation at 15 L/min with mildly reduced PaCO2 consistent\n with large amount of dead space. Oxygenation adequate. CVP high and\n filling pressure high even corrected for PEEP. Would like to remove\n more fluid with dialysis.\n Afib episode yesterday likely due to fluid shifts. Would check cardiac\n enzymes. Follow ECGs for possible ischemia; check AM ECG. No\n significant change in oxygenation to suggest PE; patient on DVT\n prophylaxis with sc heparin and boots. Would like to avoid contrast\n studies in setting of possible ATN.\n Patient with anion gap acidosis probably from acute renal failure.\n Delta/delta suggests pre-existing metabolic alkalosis before acute\n renal failure.\n Hct 30; no evidence of bleeding. Monitor stool guaiac. Not at\n transfusion threshold.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 11:44 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2117-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502725, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 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 Comments:\n Secretions\n Sputum color / consistency: Brown / 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: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt continues to have temps of 99-102. No weaning tonight. Earlier ABG\n shows acceptable oxygenation and Pco2 WNL , mild metabolic alkalosis.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503087, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: 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: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Tolerating slow peep wean with stable sats.\n" }, { "category": "Nursing", "chartdate": "2117-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503983, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2117-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502833, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 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: Brown / 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:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt\ns RR decreased to 24 today; no other changes made. ABG\ns are good.\n, RRT 17:36\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503197, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n I received the patient on 40%X500X24X10 peep. ABG on these settings\n 7.41/43/120/2/28 O2 sat 97%. Suctioned for scant thin brown\n secretions. During the OTW he was he was lying flat, and dropped his O2\n sat from 96 to 88%. He is positive for GNR in blood, he has Klebsiella\n pneumonia. Temp max 101.5 PO.\n Action:\n ABG obtained.\n Nafcillin IV for the .\n Gentamicin/Meropenem for the Klebsiella/GNR\n Tylenol Q6H.\n Cooling blanket and ICE packs.\n Placed on 100% for the procedure.\n Response:\n 7.42/41/72/1/28/93. after 2 hours we drop the o2 sat to 50%.\n Repeat ABG7.42/40/90/0/27.\n Temp went down to 100.0 oral.\n Plan:\n We dropped PEEP 8. o2 sat remained 95-96%.\n Continue with the IV ABX.\n Attempt to keep his temp down with cooling blanket.\n Pan cultured on . F/U cultures.\n Serial CXR\n Genta level 1.9\n Cardiac dysrhythmia other\n Assessment:\n As stated above he went into Wide complex tachycardia. Amiodarone\n turned off at 1430. He has remained in NSR Heart rate in the 80\ns. No\n PVC or PAC noted. Blood pressure 114 -120\ns with lightening the\n sedation. Also when giving mouth care, or turning his blood pressure\n will increase.\n Action:\n Amiodarone stop at 1430.\n Metoprolol given.\n Response:\n He continue in NSR.\n Plan:\n Titrate up the metoprolol depending on the blood pressure.\n Will reassess the increase in the\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUIN 84/Cr8.8 K4.5/phos 5.9/ionized Ca 1.02. the H/D RN had high\n pressure with the line on . alteplase was placed in the line, and\n although the pressure was high. They preceded with H/D.\n Action:\n Today OTA. The renal fellow had a hard time flushing the line\n after it was placed.\n CXR to confirm placement.\n Obtained order to use the line.\n Response:\n H/D RN had high pressures while using the line. She was unable\n to flush the venous port.\n Obtained order for alteplase.\n Plan:\n Impaired Skin Integrity\n Assessment:\n The patitent came to with stage II on his coccyx. It is actually\n two wounds that are joined. He has yeast under his neck, arms, and\n groin. She has a hemorrhoid (which is purple) at the proximal end of\n his rectum. It is not bleeding. He has a antibiotic rash on his\n trunk, the top of his thigh. And his back. The rash is starting to\n better today. Question of vanc.\n Action:\n Wound care consult was done today.\n Response:\n Continue to use the meilex to coccyx area.\n We will continue to hydrocortisone cream and clotrimazole\n cream to affected areas.\n Plan:\n Continue to with current regime.\n" }, { "category": "Physician ", "chartdate": "2117-11-02 00:00:00.000", "description": "EP Consult Note", "row_id": 503199, "text": "Date of service: \n Initial consultation: Inpatient\n Presenting complaint: Arrhythmia, (Other: SVT, ? VT)\n History of present illness: 37 yo male with DM presents to OSH with flu\n like illness and subsequent developed sepsis with ARF requiring HD.\n Sputum culture grew out Klebsiella, MSSA, G-Rods and has been on\n antibiotics. During dialysis, he would intermittently go into afib\n with RVR. There was a question that his CVP line was inserted too deep\n and was pulled out. Today during HD, he again went into a regular WCT\n 160bpm, hemodynamically tolerated and was cardioverted into a narrow\n complex tach at the same rate which them terminated with adenosine IV.\n He has no previous cardiac history but there were cardiac enzyme\n leaks.\n Past medical history: none\n CAD Risk Factors\n CAD Risk Factors Present\n Diabetes mellitus\n CAD Risk Factors Absent\n Dyslipidemia, Hypertension\n Other: intubated and sedated\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Current medications: Gentamicin\n Meropenam\n Nafcillin\n Diltiazem\n Review of Systems\n ROS Details: None provided. Pt intubated and sedated\n Social History\n Family history: unknown\n Social history details: unknown\n Physical Exam\n Date and time of exam: 15:20\n General appearance: intubated, sedated\n Height: 69 Inch, 175 cm\n T current: 102 C\n HR: 102 bpm\n Vital sign details: 106/55 art line\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: WNL, CTA anterior)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL, +), (Pulsatile mass:\n No), (Other abnormalities: obese)\n Extremities / Musculoskeletal: (Digits and nails: + edema in the\n extremities)\n Skin: (Abnormal, diffuse red rash)\n Labs\n 286\n 9.2\n 191\n 7.5\n 29\n 4.2\n 69\n 98\n 139\n 27.1\n 11.2\n [image002.jpg]\n 03:17 AM\n 03:58 PM\n 02:55 AM\n 01:23 AM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n WBC\n 12.5\n 10.4\n 9.7\n 10.3\n 11.2\n Hgb\n 10.1\n 10.1\n 9.9\n 9.7\n 9.2\n Hct (Serum)\n 31.2\n 30.3\n 29.1\n 30.0\n 27.1\n Plt\n 92\n 286\n INR\n 1.3\n PTT\n 31.0\n Na+\n 143\n 140\n 141\n 142\n 139\n 139\n K + (Serum)\n 4.7\n 3.7\n 3.9\n 3.9\n 4.5\n 4.2\n Cl\n 106\n 103\n 102\n 103\n 102\n 98\n HCO3\n 19\n 22\n 22\n 25\n 21\n 29\n BUN\n 68\n 59\n 65\n 69\n 91\n 69\n Creatinine\n 7.7\n 6.3\n 7.4\n 7.8\n 9.4\n 7.5\n Glucose\n \n CK\n 550\n CK-MB\n 2\n Troponin T\n 0.21\n O2 sat (arterial)\n 92\n 96\n 96\n ABG: 7.46 / 40 / 166 / / 5 Values as of 01:58 PM\n Tests\n ECG: (Date: ), 13:49 Sinus tach HR 106.\n Telemetry: at 13:44 pt with multiple APCs which then went into\n regular WCT which when cardioverted went into a narrow tach at the same\n rate and the QRS marched through the cardioversion.\n Terminated with adenosine with p wave.\n Echocardiogram: (Date: ), Prelim - EF looks normal with normal\n sized atrium\n Ventilator: intubated\n Assessment and Plan\n CARDIAC DYSRHYTHMIA OTHER - pt with history of afib during HD went\n into tachycardia with HR 160's, first wide then narrow after\n cardioversion at exactly the same rate. In addition, the QRS marched\n though at the same time. This points more toward the WCT as being SVT\n with aberrancy instead of having both VT and SVT at exactly the same\n rate and completely marching through. The narrow complex tachycardia\n is a long RP tachy with negative p-wave in lead II and terminates with\n a possible p. Diff includes atypical AVNRT or AVRT and less likely\n atrial tachycardia. Triggers could definitely be from sepsis adn\n fever.\n - Recommendation would be to initiate beta blockers to suppress the\n SVT.\n - Amio load already started. Would finish 24 hour load and then stop\n and titrate up beta blocker. Only if he continues to have incessant\n SVT/afib RVR would we consider more amio.\n Discussed and seen with Dr. .\n ------ Protected Section ------\n I examined the patient and reviewed the chart. I agree with Dr.\n \ns H+P, A+P. WCT and narrow complex tachycardia at same rate (and\n RBBB in SR at slower rate earlier in hospitalization. Most c/w SVT.\n Agree with beta blocker with amio only for recurrent sustained\n arrhythmia.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:43 ------\n" }, { "category": "Physician ", "chartdate": "2117-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502426, "text": "TITLE:\n Chief Complaint: fevers/sepsis\n 24 Hour Events:\n MULTI LUMEN - START 02:58 PM\n MULTI LUMEN - STOP 04:30 PM\n DIALYSIS CATHETER - STOP 04:30 PM\n EKG - At 12:30 AM\n FEVER - 103.1\nF - 12:00 AM\n Abios: cefipime, vanc, tamiflu\n - Right IJ placed. Left subclavian and dialysis lines sent for\n culture. Dialysis tip touched non-sterile glove.\n - CT scan of head: no acute process. Fluid in mastoid sinuses.\n - CT scan of torso: LLL completely opacified by multifocal pneumonia,\n small amount of free fluid, abdomen otherwise benign.\n - f/u pan cultures -> respiratory culture inadequate.\n - UA w/ epi's, but pt anuric. Will f/u culture.\n - f/u LFT tomorrow to assure trending down\n - repeat ABG: 7.30/38/96, improving acidosis.\n - Started tube feeds with nutren pulmonary to goal 40ml/hour as there\n is no in-house nutrition tonight.\n - flu DFA negative, stopped oseltamivir\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.5\nC (103.1\n Tcurrent: 37.4\nC (99.4\n HR: 77 (77 - 122) bpm\n BP: 118/50(69) {84/46(62) - 123/60(77)} mmHg\n RR: 31 (28 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (12 - 19)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,448 mL\n 526 mL\n PO:\n TF:\n 89 mL\n 220 mL\n IVF:\n 1,499 mL\n 306 mL\n Blood products:\n Total out:\n 108 mL\n 10 mL\n Urine:\n 8 mL\n 10 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,340 mL\n 516 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 35 cmH2O\n Plateau: 29 cmH2O\n SpO2: 96%\n ABG: 7.32/37/116/19/-6\n Ve: 14.8 L/min\n PaO2 / FiO2: 232\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.1 g/dL\n 210 mg/dL\n 7.7 mg/dL\n 19 mEq/L\n 4.7 mEq/L\n 68 mg/dL\n 106 mEq/L\n 143 mEq/L\n 31.2 %\n 12.5 K/uL\n [image002.jpg]\n 11:09 PM\n 11:28 PM\n 04:30 AM\n 11:18 AM\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n WBC\n 12.5\n 10.6\n 12.5\n Hct\n 37.9\n 42\n 31.7\n 31.2\n Plt\n \n Cr\n 5.4\n 7.2\n 7.7\n TropT\n 0.20\n TCO2\n 25\n 19\n 21\n 20\n Glucose\n 147\n 156\n 210\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:6.4 mg/dL\n Imaging: CXR: ET tube high? continued left-sided opacity\n CXR: widespread left mid and lower lobe consolidations as well as\n right basal consolidation. Small amount of bilateral pleural effusion\n is present.\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:30 PM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2117-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 504159, "text": "The patient is a 37y/o male with a PMH of DM, ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n On During H/D he went into a wide complex tachycardia with a\n heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine was\n given,converted back to sinus and started on amio gtt.\n : New triple lumen placed L subclavian and HD line rewired over\n prior triple lumen in R IJ. Both confirmed via x-ray.\n Code Status: full code\n Precautions: contact klebsiella (sputum, blood cultures), MSSA(OSH\n blood cultures)\n : Pt placed on SBT this am, developed SVT rate 170-175, remains\n febrile 100-101, no HD.\n Events: VERY HTN, started on hydralazine and clonidine patch, propofol\n up to 40 to help HTN, no weaning, U/O UP!\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n B/P 170-200/88-100, on lopressor 125mg Tid, diltazem 30mg Qid.\n Action:\n Pt sedated with propofol up to 40mcg/kg/hr to help with B/P control as\n well as anxiety control- he was moving his head and legs spontaneously\n before the propofol was increased. He was also started on clopidine\n patch .2 mg/24h and hydralazine 25mg.\n Response:\n B/P better 160-170/60-70,\n Plan:\n Monitor B/P closely and wean propofol as possible.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings PSV 5/ 8 with RR in the low to mid 30\ns. 1500 his RR\n became 40\ns. CXR improved.\n Action:\n He was suctioned for large amount of creamy tan secretions, given\n zyprexa 10mg PO and obtained ABG.\n Response:\n ABG was unchanged but his minute ventilation was 17-18. He was placed\n on A/C 600 X 18 with Peep 10 before his RR dropped to 25.\n Plan:\n No plans for weaning until HTN under control, rest on current vent\n settings, attempt to wean tomorrow.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output continues to improve. U/O 40-80cc/hr.\n Action:\n No HD today\n Response:\n Pt getting very fluid overloaded, may be affecting his resp status.\n However urine output continues to increase every day.\n Plan:\n HD tomorrow, may consider lasix to improve output.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp still 100.0\n 100.8.\n Action:\n Continues on meropenum.\n Response:\n Temp improving but still low grade temp\n Plan:\n Continue as ordered.\n Hyperglycemia\n Assessment:\n Blood sugars 173 and 187.\n Action:\n Covered with regular insulin 3 units at 1000 and 1600.\n Response:\n Improving blood sugars but still alittle high, glargine dose increased\n to 30 units.\n Plan:\n Continue to monitor blood sugars\n" }, { "category": "Nursing", "chartdate": "2117-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502719, "text": "Pt is a 37yo male with a h/o of diabetes and alcohol abuse who\n presented to Hosp on w/ flu-like symptoms,\n including temp 105. In ED had seizure and was intubated. CXR showing\n PNA. Initially was on pressors and was not urinating (new renal\n failure). Thought to be in and out of a.fib w/ RBBB and increasing\n troponin so started on heparin gtt as well. ECHO for ? myocarditis.\n Heparin has been off since, pressors off, tolerating HD w/ goal\n 1-1.5L per treatment. EEG done to f/u w/ seizure activity (? results\n from OSH). MSSA in sputum and blood from OSH. Transported to \n ICU via Med flight, arrived unresponsive from bolus sedation and\n bolus paralytic.\n Events overnight: Tolerated 2hrs hemodialysis with removal of 1L of\n fluid. U/O minimal. Cont\ns to spike, Tylenol, and cooling blanket, IV\n abx. New red blotchy rash noted on trunk. Given benedryl prior to\n infusing vanco at a slower rate, ? of a drug rash. Family friend \n calling for updates.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Con\nts to spike. Received pt at 1900 with low grade temp. Cooling\n blanket removed for several hours. By 12am, temp con\nt to rise to\n 101.5. Cooling blanket on, d/c\nd ~0430 with current temp of Random\n vanco level 9, received 1gm vanco post dialysis\n Action:\n Cooling blanket placed back on, Tylenol 650mg per NGT\n Response:\n Temp improving\n Plan:\n Con\nt to monitor temp and place cooling blanket as appropriate, Tylenol\n PRN. Vanco and cefepime as ordered\n Cardiac dysrhythmia other\n Assessment:\n Without episodes of AFib. One episode of a 5 beat run of VTach\n immediately after dialysis was completed.\n Action:\n Diltiazem 30mg po qid\n Response:\n HR has been in the 80\ns SR with minimal ectopy\n Plan:\n Con\nt to assess, con\nt with po diltiazem\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 69/7.8 con\nt elevated, minimal urine output.\n Action:\n Dialysis\n Response:\n Tolerating removal of 1 liter over 2 hr dialysis treatment\n Plan:\n Con\nt to monitor lab values, assess for improved renal status, urine\n output\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n No vent changes made overnight. Remains on A/C 50%/500/x30 with 10\n peep. Suctioning q2-3 hrs for think brown secretions. latest ABG: PO2\n 85/ PCO2 36/ pH 7.46\n Action:\n Suction prn\n Response:\n Maintaining o2 sats,\n Plan:\n Con\nt to pulmonary toilet, assess resp status, assess ability to wean\n peep when able\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503084, "text": "37 yo M with a h/o of DM & ETOH abuse who presented to on w/ flu-like symptoms, including temp 105 & seizures\n requiring intubation. CXR showing PNA. Tx to for further workup.\n + MSSA (sputum\n from OSH), + Klebsiella (sputum), GNR (blood & sputum)\n Full Code\n R IJ TLC\n L IJ HD Line\n blistered areas noted beneath dsg\n R Radial Aline\n No contact O/N with family\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 12. Scant amts of\n white sputum suctioned from ETT (significantly decreased from )\n ABG this AM 7.43/41/154. SaO2 98%. Absent gag/impaired cough noted. LS\n clear/diminished @ bases. O2 sat >95% throughout the night. Pt opening\n eyes to painful stimuli. Tmax 101.6. CXR showing complete LL\n white out. Febrile - Tmax 101.6 (oral)\n Action:\n Repeat CXR last this AM. TEE . Nafcillin, Meropenem & Gentamicin\n for broadened coverage. Cooling blanket and ice packs throughout the\n night. Ice bath given this AM. Tylenol now ordered Q6hrs via NGT. PEEP\n decreased this AM to 10.\n Response:\n ABG @ 0530: Temps ranging 100-101.6 @ this time.\n Plan:\n Cont to assess lung function & tweak ventilator settings as warranted.\n Trend ABG\ns. F/U culture data & echo results. Cooling blanket. Ice\n Packs. Tylenol ATC.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley catheter notable for icteric/scant UOP. BUN/Creat 84/8.8 (up from\n last evening post HD 69/7.5) Pt tolerated majority of HD treatment\n yesterday. He did have a run of Vtach where he was cardioverted, given\n Adenosine & started on Amiodarone gtt. Pt has remained in SR throughout\n the night. SBP 100-120\ns. MAPS >60.\n Action:\n Plan for HD today. MICU team did discuss being somewhat aggressive with\n fluid removal if pt tolerates.\n Response:\n ? placement of new HD cath today given significant flow/clotting issues\n requiring tPA clearance.\n Plan:\n Plan for HD today & daily given ARF. Cont to follow BUN/Creat. If pt\n does not improve w/ HD or does not tolerate, ? need for CRRT. Renal\n team following.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing.\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Skin care consult today. Cont to assess for s&s of further skin\n breakdown. Pt may benefit from KinAir bed to promote healing of current\n wounds. ? need for nutrition eval to assess caloric intake.\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503185, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n I received the patient on 40%X500X24X10 peep. ABG on these settings\n 7.41/43/120/2/28 O2 sat 97%. Suctioned for scant thin brown\n secretions. During the OTW he was he was lying flat, and dropped his O2\n sat from 96 to 88%. He is positive for GNR in blood, he has Klebsiella\n pneumonia. Temp max 101.5 PO.\n Action:\n ABG obtained.\n Nafcillin IV for the .\n Gentamicin/Meropenem for the Klebsiella/GNR\n Tylenol Q6H.\n Cooling blanket and ICE packs.\n Placed on 100% for the procedure.\n Response:\n 7.42/41/72/1/28/93. after 2 hours we drop the o2 sat to 50%.\n Repeat ABG7.42/40/90/0/27.\n Temp went down to 100.0 oral.\n Plan:\n We dropped PEEP 8. o2 sat remained 95-96%.\n Continue with the IV ABX.\n Attempt to keep his temp down with cooling blanket.\n Pan cultured on . F/U cultures.\n Serial CXR\n Cardiac dysrhythmia other\n Assessment:\n As stated above he went into Wide complex tachycardia. Aamiodarone\n turned off at 1430. he has remained in NSR Heart rate in the 80\ns. No\n PVC or PAC noted. Blood pressure 114 -120\ns with lightening the\n sedation. Also when giving mouth care, or turning his blood pressure\n will increase.\n Action:\n Amiodarone stop at 1430.\n Metoprolol given.\n Response:\n He continue in NSR.\n Plan:\n Titrate up the metoprolol depending on the blood pressure.\n Will reassess the increase in the\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503187, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n I received the patient on 40%X500X24X10 peep. ABG on these settings\n 7.41/43/120/2/28 O2 sat 97%. Suctioned for scant thin brown\n secretions. During the OTW he was he was lying flat, and dropped his O2\n sat from 96 to 88%. He is positive for GNR in blood, he has Klebsiella\n pneumonia. Temp max 101.5 PO.\n Action:\n ABG obtained.\n Nafcillin IV for the .\n Gentamicin/Meropenem for the Klebsiella/GNR\n Tylenol Q6H.\n Cooling blanket and ICE packs.\n Placed on 100% for the procedure.\n Response:\n 7.42/41/72/1/28/93. after 2 hours we drop the o2 sat to 50%.\n Repeat ABG7.42/40/90/0/27.\n Temp went down to 100.0 oral.\n Plan:\n We dropped PEEP 8. o2 sat remained 95-96%.\n Continue with the IV ABX.\n Attempt to keep his temp down with cooling blanket.\n Pan cultured on . F/U cultures.\n Serial CXR\n Genta level 1.9\n Cardiac dysrhythmia other\n Assessment:\n As stated above he went into Wide complex tachycardia. Amiodarone\n turned off at 1430. He has remained in NSR Heart rate in the 80\ns. No\n PVC or PAC noted. Blood pressure 114 -120\ns with lightening the\n sedation. Also when giving mouth care, or turning his blood pressure\n will increase.\n Action:\n Amiodarone stop at 1430.\n Metoprolol given.\n Response:\n He continue in NSR.\n Plan:\n Titrate up the metoprolol depending on the blood pressure.\n Will reassess the increase in the\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502509, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502510, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\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": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502511, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\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": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502513, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Events: Levophed weaned to off, fentanyl turned town to 100mcg/hr,\n versed weaned to 5mg/hr. Central line changed to IJ, dialysis catheter\n removed, afebrile all day except for 1600 when he he was 101.9.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received on levophed .1mcg/kg/min, Fentanyl 250mcg/hr and versed\n 7mg/hr. B/P 105-110/50\ns, HR 80\nHis temp was 98.4. He is on vanco,\n cefepine and taniflu.\n Action:\n He was taken for CT scan of head, chest and abd at 9am. He was given\n bottle of barocat prior to the study on top of the bottle given by\n nights. Following the CT scan the levophed was slowly weaned to off by\n 1630. The fentanyl was weaned to 100 mcg/hr and versed to 5mg/hr.\n Response:\n His B/P has remained 100-110/50\ns and HR in the 80\ns all day. His temp\n started to increase at 1600 with temp to 101.9 PO at 1600.\n Plan:\n Monitor B/P closely and restart levophed if needed. Monitor temp\n closely. Continue antibotics.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings 500 x 30, FiO2 70%, Peep 16.\n Action:\n Suctioned x3 for thick dark tan secretions. ABG 7.30/38/96.\n Response:\n Tolerating current vent settings, no vent changes made. CT of chest\n showed a thick consolidation of the left lower lung.\n Plan:\n No weaning attempts made yet.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt is in oliguric acute renal failure, he has had no urine output since\n admission to MICU.\n Action:\n Renal fellow has no plans to give him dialysis today. But may evaluate\n him for dialysis tomorrow.\n Response:\n Since Pt has been febrile in the past, so the dialysis catheter was\n removed from his groin, site slightly reddened. The plan is for a\n catheter holiday..\n Plan:\n If Pt gets dialysis tomorrow the renal fellow will reinsert the\n catheter tomorrow.\n" }, { "category": "Respiratory ", "chartdate": "2117-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502517, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Blood Tinged / 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 Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved. Pt received on Peep 16 this morning with PaO2 of 116.\n Bladder pressure checked during night and was 8. Peep weaned down from\n 16-14-12-10 today. Pt did well and maintained sats around 95%. Episode\n of v-tach during dialysis. Pt later in a-fib and sats variable. ABG\n drawn 7.41/33/59. FiO2 increased to 60%. Cont current settings, wean\n FiO2 back to 50% as tolerated.\n" }, { "category": "Physician ", "chartdate": "2117-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502790, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 103.1\nF - 08:00 AM\n - started PO dilt 30 qid\n - EKG this am: TWI inferior leads, normalization of TW in lateral leads\n - stool guiac for anemia\n - OSH sensitivities/micro now in chart --> sputum with 4+ Staph, blood\n negative, flu negative\n - Renal recs: get HD today --> Vanc dose after HD. Start Phoslo 667 tid\n for hyperphosphatemia (already ordered for Ca Acetate 1334mg PO tid\n with meals)\n - CE's: Trop flat, MB flat\n - LFT's stable from this am\n - Origin of metabolic alkalosis: thought about it, only thing that made\n sense was post hypercapnia\n - ABG 8p: 7.46/36/85/26\n - Random vanc after HD and before vanc dose: 9.8\n Allergies:\n Last dose of Antibiotics:\n Tamiflu - 08:00 PM\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 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 08:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2 yesterday 11am but still febrile this am\n Tcurrent: 37.2\nC (99\n HR: 75 (75 - 102) bpm\n BP: 135/44(68) {122/39(65) - 167/64(87)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (14 - 19)mmHg\n Total In:\n 1,618 mL\n 854 mL\n PO:\n TF:\n 964 mL\n 334 mL\n IVF:\n 474 mL\n 430 mL\n Blood products:\n Total out:\n 1,540 mL\n 305 mL\n Urine:\n 40 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 78 --> 3.9L positive through LOS mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/36/85/25/1 YESTERDAY PM, CO2 stable, O2 stable through\n yesterday\n Ve: 15.1 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Sedated, intubated. Lungs CTAB, no w/c/r/r but some upper airway\n sounds.\n Labs / Radiology\n 280 K/uL\n 9.9 g/dL\n 215 mg/dL\n 7.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 103 mEq/L\n 142 mEq/L\n 29.1 %\n 9.7 K/uL\n [image002.jpg]\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n WBC\n 12.5\n 10.4\n 9.7 DOWN\n Hct\n 31.2\n 30.3\n 29.1 DOWN\n Plt\n STABLE\n Cr\n 7.7\n 6.3\n 7.4\n 7.8 ELEVATED AND STABLE\n TropT\n 0.21\n TCO2\n 20\n 19\n 24\n 25\n 24\n 26\n Glucose\n 15\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21\n 0.20 , ALT / AST:62/138 SLIGHTLY ELEVATED, Alk\n Phos / T Bili:317/2.7 ALKP RISING AND TBILI STABLE, Amylase /\n Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %,\n Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L YESTERDAY, Albumin:2.1\n g/Dl YESTERDAY , LDH:437 IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.5\n mg/Dl\n Vanc level 9.8 after HD\n Cdiff negative, Bcx negative to date x2, DFA negative for flu,\n catheter tip negative x2\n 2:57 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n RARE GROWTH Commensal Respiratory Flora.\n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.\n YEAST. SPARSE GROWTH.\n GRAM NEGATIVE ROD #2. RARE GROWTH.\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n UCx negative\n CXR worsening of consolidation in lower left lung\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated Mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of Septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high Mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given neg Urine legionalla and\n Prolonged QTc at times avoid FQ.\n - Continue Vanco and Cefepime to cover for HAP. We will continue with\n broad coverage considering improvement, and we will treat for a 15 day\n course from yesterday (today day 4).\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS.\n Bladder pressures are lower today, suggesting we have room to wean down\n his PEEP.\n - ARDS net protocol with TV at 6cc/kg\n - wean down PEEP to 5 today\n - RSBI tomorrow morning\n - Had fluids removed yesterday via HD, 1L\n - fentanyl and versed for sedation.\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - Had HD yesterday and will f/u with renal when to have next HD\n # Tachycardia/ AFib: appeared sinus on arrival. Yesterday had a couple\n runs of tachycardia that appeared to be afib with aberrancy that were\n self-limited and well-tolerated. OSH EKG with RBBB as recently as\n , and reports of atrial fibrillation requiring treatment with\n diltiazem. Yesterday went into AFib w/ RVR during dialysis. Treated\n w/ lopressor 10, dilt 20 IV and dilt PO60. Converted back to sinus\n after 1-2 hours.\n - Was in sinus rhythm through yesterday\n - Diltiazem 30 QID\n - titrate sedation to agitation.\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG, is improved\n # mild LFT elevation: likely prolonged hypotension. Improving.\n Added on to today's labs because had not been drawn since \n - trend\n - limit tylenol to 2 gm daily\n # DM: Blood sugars continue to be elevated, will need to increase his\n ISS\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:37 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2117-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502707, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 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: Brown / 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: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt continues to have temp around a hundred and some hemodynamic\n problems. attempt to wean tonight.\n" }, { "category": "Physician ", "chartdate": "2117-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502804, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 103.1\nF - 08:00 AM\n - started PO dilt 30 qid\n - EKG this am: TWI inferior leads, normalization of TW in lateral leads\n - stool guiac for anemia\n - OSH sensitivities/micro now in chart --> sputum with 4+ Staph, blood\n negative, flu negative\n - Renal recs: get HD today --> Vanc dose after HD. Start Phoslo 667 tid\n for hyperphosphatemia (already ordered for Ca Acetate 1334mg PO tid\n with meals)\n - CE's: Trop flat, MB flat\n - LFT's stable from this am\n - Origin of metabolic alkalosis: thought about it, only thing that made\n sense was post hypercapnia\n - ABG 8p: 7.46/36/85/26\n - Random vanc after HD and before vanc dose: 9.8\n Allergies:\n Last dose of Antibiotics:\n Tamiflu - 08:00 PM\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 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 08:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2 yesterday 11am but still febrile this am\n Tcurrent: 37.2\nC (99\n HR: 75 (75 - 102) bpm\n BP: 135/44(68) {122/39(65) - 167/64(87)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (14 - 19)mmHg\n Total In:\n 1,618 mL\n 854 mL\n PO:\n TF:\n 964 mL\n 334 mL\n IVF:\n 474 mL\n 430 mL\n Blood products:\n Total out:\n 1,540 mL\n 305 mL\n Urine:\n 40 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 78 --> 3.9L positive through LOS mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/36/85/25/1 YESTERDAY PM, CO2 stable, O2 stable through\n yesterday\n Ve: 15.1 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Sedated, intubated. Lungs CTAB, no w/c/r/r but some upper airway\n sounds. RRR, S1 S2 clear, no murmurs. Abdomen obese but soft, NT ND.\n BLE without edema. Has macular erythematous blanching rash on abdomen\n and flanks that is new.\n Labs / Radiology\n 280 K/uL\n 9.9 g/dL\n 215 mg/dL\n 7.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 103 mEq/L\n 142 mEq/L\n 29.1 %\n 9.7 K/uL\n [image002.jpg]\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n WBC\n 12.5\n 10.4\n 9.7 DOWN\n Hct\n 31.2\n 30.3\n 29.1 DOWN\n Plt\n STABLE\n Cr\n 7.7\n 6.3\n 7.4\n 7.8 ELEVATED AND STABLE\n TropT\n 0.21\n TCO2\n 20\n 19\n 24\n 25\n 24\n 26\n Glucose\n 15\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21\n 0.20 , ALT / AST:62/138 SLIGHTLY ELEVATED, Alk\n Phos / T Bili:317/2.7 ALKP RISING AND TBILI STABLE, Amylase /\n Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %,\n Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L YESTERDAY, Albumin:2.1\n g/Dl YESTERDAY , LDH:437 IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.5\n mg/Dl\n Vanc level 9.8 after HD\n Cdiff negative, Bcx negative to date x2, DFA negative for flu,\n catheter tip negative x2\n 2:57 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n RARE GROWTH Commensal Respiratory Flora.\n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.\n YEAST. SPARSE GROWTH.\n GRAM NEGATIVE ROD #2. RARE GROWTH.\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n UCx negative\n CXR worsening of consolidation in lower left lung\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since .\n # Septic shock: BP stable off pressors. Culture data positive only for\n MSSA in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , and radiographic\n evidence of PNA.\n - Would call the lab and ask them to get sensitivities for the Klebs\n culture\n - Pan Cx the pt again today\n - Get surface echo to eval for vegetations\n - Will switch ABx from Vanc/Cefepime to Nafcillin/Merrem. The pt\ns MSSA\n was sensitive to Nafcillin at the OSH and he had been Tx\nd with it in\n the past. The Merrem will cover the GNR (Klebs) in the sputum. Day 1\n for both will be today .\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS. Did\n not have any weaning of his vent setting yesterday.\n - ARDS net protocol with TV at 6cc/kg\n - He is currently a little bit respiratory alkalotic, and with a resp\n rate of 30 implying that we can bring down his resp rate and not have\n him blow off so much CO2 and be alkalotic. We will drop his set resp\n rate to 24 with a calculated CO2 (goal CO2) of 44.\n - F/u ABG\ns later this afternoon.\n - Fentanyl and versed for sedation\n - Had 1L of fluids removed yesterday at HD and is anuric. Would ask\n renal to be more aggressive with HD tomorrow, as HD removed 1L fluids\n but pt was still net even, and approx 4L positive through LOS.\n # New rash on back, abdomen, thighs: appears consistent with a drug\n rash, could be Vanc or Cefepime, but statistically Cefepime would be\n more likely. We could continue this ABx course, given that the rash\n does not seem too bad at this point, or switch Cefepime to Ceftazadime,\n which only has 10% cross reactivity between the two, and the pt is\n critically ill and requires ABx. However, based on above ABx\n discussion, will be switching ABx anyways.\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Renal following\n - Had HD yesterday and will f/u with renal when to have next HD\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours.\n - Was in sinus rhythm through yesterday and currently continues in\n sinus\n - Started Diltiazem 30 QID yesterday, will continue\n - Watch hemodynamics and rhythm\n # DM: Blood sugars continue to be elevated, will need to increase his\n ISS\n OTHER STABLE ISSUES\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend\n - limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2117-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502831, "text": "Pt is a 37yo male with a h/o of diabetes and alcohol abuse who\n presented to Hosp on w/ flu-like symptoms,\n including temp 105. In ED had seizure and was intubated. CXR showing\n PNA. Initially was on pressors and was not urinating (new renal\n failure). Thought to be in and out of a.fib w/ RBBB and increasing\n troponin so started on heparin gtt as well. ECHO for ? myocarditis.\n Heparin has been off since, pressors off, tolerating HD w/ goal\n 1-1.5L per treatment. EEG done to f/u w/ seizure activity (? results\n from OSH). MSSA in sputum and blood from OSH.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 102.2. Hr 70\ns-90\ns, SR. No ectopy. BP 122-170/53-73.\n Action:\n Tylenol given and cooling blanket applied with temp spike. Antibx\n changed for better coverage and ? drug rash. BCx 2 sent and sputum\n sent for culture.\n Response:\n Temp decrease to 100.4.\n Plan:\n Echo tomorrow to r/o vegitatation as source of continual fever. Per\n Pharmacy, please dose meropenum at night as it dializes off with\n treatments. First dose to be given tonight at 10pm\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt remains intubated on ACx24/500/50/10. Thick tan-brown secretions\n noted. LS diminished at bases. Pt remains sedated.\n Action:\n RR decreased from 30-24. Sedation decreased slightly.\n Response:\n ABG:7.41/40/91/26\n Plan:\n No further weaning this shift. Continue to monitor and wean as\n tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal u/o throughout the day. BUN/Creat remain elevated. Pt is net\n positive LOS.\n Action:\n No dialysis today.\n Response:\n Plan:\n Possible HD tomorrow with more aggressive fluid removal goal\n Hyperglycemia\n Assessment:\n Blood sugars >200 throughout shift\n Action:\n RISS as ordered\n Response:\n BS remain elevated.\n Plan:\n Plan to add fixed insulin dose tonight to sliding scale.\n Impaired Skin Integrity\n Assessment:\n Pt came from OSH with fecal incontinent bag in place. Today the bag\n was changed secondary to bag leakage to flexiseal. Once fib was\n removed, pt noted to have 2 stage 2 wounds on coccyx and excoriated\n area on buttock. Also, red rash remains on torso area. Site marked.\n Action:\n Meriplex dressing placed over coccyx area. Antibiotics changed in\n suspection of drug rash.\n Response:\n No change\n Plan:\n ? skin care consult if rash worsens. ? ordering new bed for pt to\n promote better skin integrity.\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502890, "text": "37 yo M with a h/o of DM & ETOH abuse who presented to on w/ flu-like symptoms, including temp 105 & seizures\n requiring intubation. CXR showing PNA. Tx to for further workup.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 101.6. HR 80-160\ns w/ occasional PVC\ns. SBP 130-180\n Action:\n Tylenol 650mg NGT. Cooling blanket PRN. Meropenem X 1 given last\n evening. Nafcillin Q4hrs. ARF (see below) Pt did have issue of aflutter\n in the 160\n and converted back to SR on own. Lopressor 25mg NGT \n ordered (1^st dose last evening) EKG obtained.\n Response:\n 1^st set of BC currently growing gram\n rods. MSSA in sputum & blood\n from OSH.\n Plan:\n Echo today to r/o possible vegitations as source of ongoing fever.\n Tylenol PRN. Cooling blanket PRN. Last sputum & BC\ns sent day\n shift. F/U micro data & trend lab results.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 10. Copious amounts\n of thick tan/brown sputum suctioned via ETT. ABG last evening\n significant for PO2 of 72. Pt is overbreathing vent ~ 6 bpm. Impaired\n cough/gag noted. LS rhoncerous throughout. O2 sat 89-90%. Pt opening\n eyes to painful stimuli.\n Action:\n Repeat CXR last evening significant for left lobe whiteout. RT able to\n recruit some lung function and increased settings (AC 60% x 500 x 24 w/\n PEEP 12) Suctioning Q 1-2 hrs for copious sputum as noted. Lavage PRN.\n Fentanyl & Versed gtts increased for pt comfort.\n Response:\n ABG this AM 7.41/36/116. O2 sat improved 91-95%\n Plan:\n Cont to assess lung function & tweak ventilator settings as warranted.\n Trend ABG\ns. Pt will most likely need bronch today.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Creat significantly elevated 69/7.8. Pt has tolerated HD\n previously. (HD line in place) Minimal UOP.\n Action:\n Plan for HD today. AM BUN/Creat 91/9.4 (MD aware) Goal fluid removal\n originally 1-1.5L (MICU team did discuss potentially being more\n aggressive with fluid removal if pt tolerates)\n Response:\n Ongoing\n Plan:\n Plan for HD today. Cont to follow BUN/Creat. If pt does not improve w/\n HD or does not tolerate, ? need for CRRT.\n Hyperglycemia\n Assessment:\n Blood sugars remain elevated. > 200 throughout the night.\n Action:\n RISS as ordered. Glargine 5 units given last evening.\n Response:\n BS remain elevated.\n Plan:\n Titrate sliding scale. ? need for Glargine increase.\n Impaired Skin Integrity\n Assessment:\n HD dsg changed last evening, 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Mepilex dsg remains intact. 2 stage II wounds noted beneath dsg.\n Pt cont to have drug rash\n notable on torso and abd. Axilla areas\n excoriated. Groin also reddened. (MD into see various sites)\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Miconazole powder\n applied to groin & axilla regions. Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Pt will most likely need skin care consult. Cont to assess for s&s of\n further skin breakdown. Pt may benefit from KinAir bed to promote\n healing of current wounds. ? need for nutrition eval to assess caloric\n intake.\n * Full Code\n * R IJ TLC\n pulled back last evening and re-sutured. Line is\n properly placed according to MICU team.\n * L IJ HD Line\n blistered areas noted beneath dsg\n * R Radial Aline\n * No contact O/N with family\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503180, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n I received the patient on 40%X500X24X10 peep. ABG on these settings O2\n sat 97%. Suctioned for scant thin brown secretions. During the OTW he\n was he was lying flat, and dropped his O2 sat from 96 to 88%.\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502363, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Events: Levophed weaned to off, fentanyl turned town to 100mcg/hr,\n versed weaned to 5mg/hr. Central line changed to IJ, dialysis catheter\n removed, afebrile all day except for 1600 when he he was 101.9.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received on levophed .1mcg/kg/min, Fentanyl 250mcg/hr and versed\n 7mg/hr. B/P 105-110/50\ns, HR 80\nHis temp was 98.4. He is on vanco,\n cefepine and taniflu.\n Action:\n He was taken for CT scan of head, chest and abd at 9am. He was given\n bottle of barocat prior to the study on top of the bottle given by\n nights. Following the CT scan the levophed was slowly weaned to off by\n 1630. The fentanyl was weaned to 100 mcg/hr and versed to 5mg/hr.\n Response:\n His B/P has remained 100-110/50\ns and HR in the 80\ns all day. His temp\n started to increase at 1600 with temp to 101.9 PO at 1600.\n Plan:\n Monitor B/P closely and restart levophed if needed. Monitor temp\n closely. Continue antibotics.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings 500 x 30, FiO2 70%, Peep 16.\n Action:\n Suctioned x3 for thick dark tan secretions. ABG 7.30/38/96.\n Response:\n Tolerating current vent settings, no vent changes made. CT of chest\n showed a thick consolidation of the left lower lung.\n Plan:\n No weaning attempts made yet.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt is in oliguric acute renal failure, he has had no urine output since\n admission to MICU.\n Action:\n Renal fellow has no plans to give him dialysis today. But may evaluate\n him for dialysis tomorrow.\n Response:\n Since Pt has been febrile in the past, so the dialysis catheter was\n removed from his groin, site slightly reddened. The plan is for a\n catheter holiday..\n Plan:\n If Pt gets dialysis tomorrow the renal fellow will reinsert the\n catheter tomorrow.\n" }, { "category": "Respiratory ", "chartdate": "2117-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502647, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: 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 No changes on this patient today\n, RRT 16:54\n" }, { "category": "Physician ", "chartdate": "2117-10-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 502798, "text": "Chief Complaint: Acute respiratory failure, staph bacteremia,\n pneumonia, afib, acute renal failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Fever continues. WBC improved\n Tachycardia improved with oral diltiazem.\n Fluids even yesterday.\n 24 Hour Events:\n FEVER - 103.1\nF - 08:00 AM\n History obtained from Medical records\n Patient unable to provide history: Intubated\n Allergies:\n Last dose of Antibiotics:\n Tamiflu - 08:00 PM\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 04:00 AM\n Midazolam (Versed) - 08:25 AM\n Heparin Sodium (Prophylaxis) - 08:26 AM\n Fentanyl - 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 12:36 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 39\nC (102.2\n HR: 95 (75 - 95) bpm\n BP: 138/61(84) {122/39(65) - 170/75(93)} mmHg\n RR: 28 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 3 (3 - 19)mmHg\n Total In:\n 1,618 mL\n 1,066 mL\n PO:\n TF:\n 964 mL\n 487 mL\n IVF:\n 474 mL\n 489 mL\n Blood products:\n Total out:\n 1,540 mL\n 315 mL\n Urine:\n 40 mL\n 15 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 78 mL\n 751 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/36/85./25/1\n Ve: 15.5 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube,\n 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: Systolic, No(t)\n Diastolic), I-II/VI systolic murmur at base\n Peripheral 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 : Anterior and lateral, No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: 1+ edema, Left lower\n extremity edema: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, Rash: Erythematous rash on trunk extending to legs, No(t)\n Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, No(t) Oriented (to): , Movement: No spontaneous\n movement, Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 280 K/uL\n 215 mg/dL\n 7.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 103 mEq/L\n 142 mEq/L\n 29.1 %\n 9.7 K/uL\n [image002.jpg]\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n WBC\n 12.5\n 10.4\n 9.7\n Hct\n 31.2\n 30.3\n 29.1\n Plt\n \n Cr\n 7.7\n 6.3\n 7.4\n 7.8\n TropT\n 0.21\n TCO2\n 20\n 19\n 24\n 25\n 24\n 26\n Glucose\n 15\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:62/138, Alk Phos / T Bili:317/2.7,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.1 g/dL,\n LDH:437 IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.5 mg/dL\n Imaging: CXR: improved alveolar infiltrates on the right; worse on the\n left.\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n AFIB\n ANEMIA\n =============================\n Patient's respiratory status stable. Acceptable oxygenation on 50% FIO2\n and PEEP 10. Minute ventilation 15L/min but patient not overbreathing\n the vent. Will reduce rate to 24 and lighten sedatoin to see if he\n overbreathes the vent. Consider trying to reduce PEEP. CXR with\n somewhat worse infiltrate on the left. Fluid balance was even yesterday\n and is positive today, thus far. When dialysis next done, need to take\n off more fluid.\n Patient with drug rash; concern for cephalosporin allergy. Wil replace\n cephalosporin with meropenem and vanco with nafcillin. Echo to assess\n for valve vegetations.\n Heart rate better controlled on calcium blocker.\n Hct stable. No evidence of bleeding. Not at transfusion threshold.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:37 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503045, "text": "ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated. . Staph in blood/sputum (OSH), GNR\n in blood, klebsiella in sputum.\n Events: today during H/D he went into VT with a HR of 180\n. He was\n converted with one shock to a narrow complex tachycardia.\n He was given amiodarone 300mg loading dose was ordered the Code. And\n amoidarone 1mg a minute was started after. Ionized calcium 0.99. he\n received 4G calcium gluconate.\n Code status Full code\n Precautions: Contact precautions.\n Cardiac dysrhythmia other\n Assessment:\n This afternoon during H/D he went into VT with a heart rate of 180\n His blood pressure dropped to 100\ns from the 114/60.\n Action:\n Converted with one shock to SVT (narrow complex tachycardia).\n Amiodarone loading dose and than the gtt 1mg a minute.\n Adenosine was given.\n Response:\n Went down to ST heart rate 100\ns. without PVC noted.\n Plan:\n Continue the amiodarone gtt at 1mg a minute.\n Continue to given the dilt via right NG.\n Pneumonia/Respiratory Distress\n Assessment:\n I received the patient on AC 50%X500X24 W12 peep. O2 sat 96%. He is\n positive for a multi-lobar pneumonia. He is MSSA + in sputum form the\n OSH, and now with klebsiella, and gram ndgative rods in sputum, and\n GNR in blood. He had a CXR last night with showed a white out of the\n left lung. Suctioned him for thick yellow/brown sputum in a large\n amount this morning. He continues to have temps of 102.3.\n Action:\n TEE done.\n Gegentamicin was added.\n He will continue with the /nafcillin.\n Cooling blanket/Tylenol\n Pan cultured today.\n Response:\n Awaiting the results from the echo.\n He still continues with temps of 100.5 to 102.6 or4al.\n Ice packs were placed under his arms.\n Plan:\n Follow up cultures from today.\n Continue with the current antibiotic regimen.\n Continue with the Tylenol and cooling blanket.\n f/u echo.\n given the tonight( pharmacy prescribed the time).\n He did have one dose of Genta. He will need Genta level\n tomorrow.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley cath with dark amber urine. 30ml for the 12 hour shift. BUN\n 91/Cr 9.4. H/D line was clogged off\n Action:\n H/D todat.\n Alteplase was given in each port.\n Response:\n 2500 off H/D. During the code 1L given back by H/D RN\n He was able to get through the three hour treatment. But he was\n unable to increase the blood flow grater than 200.\n Plan:\n Question of a new line tonight or tomorrow.\n Also the renal team will discuess having H/D QD.\n Impaired Skin Integrity\n Assessment:\n He has two areas on his buttocks which are stage two. He has a drug\n rash from a question of vanco. He has yeast under his arms.\n Action:\n Please look at the for the creams to use for the yeast.\n I requested a skin care consult.\n Response:\n Mepilex still intact on coccyx.\n Plan:\n Wound care consult tomorrow.\n 19:17\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502880, "text": "37 yo M with a h/o of DM & ETOH abuse who presented to on w/ flu-like symptoms, including temp 105 & seizures\n requiring intubation. CXR showing PNA. Tx to for further workup.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 101.6. HR 80-160\ns w/ occasional PVC\ns. SBP 130-180\n Action:\n Tylenol 650mg NGT. Cooling blanket PRN. Meropenem X 1 given last\n evening. Nafcillin Q4hrs. ARF (see below) Pt did have issue of aflutter\n in the 160\ns. Lopressor 25mg NGT ordered (1^st dose last evening)\n EKG obtained.\n Response:\n 1^st set of BC currently growing gram\n rods. MSSA in sputum & blood\n from OSH.\n Plan:\n Echo today to r/o possible vegitations as source of ongoing fever.\n Tylenol PRN. Cooling blanket PRN. Last sputum & BC\ns sent day\n shift. F/U micro data & trend lab results.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 10. Copious amounts\n of thick tan/brown sputum suctioned via ETT. ABG last evening\n significant for PO2 of 72. Pt is overbreathing vent ~ 6 bpm. Impaired\n cough/gag noted. LS rhoncerous throughout. O2 sat 89-90%. Pt opening\n eyes to painful stimuli.\n Action:\n Repeat CXR last evening significant for left lobe whiteout. RT able to\n recruit some lung function and increased settings (AC 60% x 500 x 24 w/\n PEEP 12) Suctioning Q 1-2 hrs for copious sputum as noted. Lavage PRN.\n Fentanyl & Versed gtts increased for pt comfort.\n Response:\n ABG this AM. O2 sat improved 91-95%\n Plan:\n Cont to assess lung function & tweak ventilator settings as warranted.\n Trend ABG\ns. ? need for bronch today.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Creat significantly elevated Pt has tolerated HD previously. (HD\n line in place) Minimal UOP.\n Action:\n Plan for HD today. Goal fluid removal originally 1-1.5L (MICU team did\n discuss potentially being more aggressive with fluid removal if pt\n tolerates)\n Response:\n Ongoing\n Plan:\n Plan for HD today. Cont to follow BUN/Creat. If pt does not improve w/\n HD or does not tolerate, ? need for CRRT.\n Hyperglycemia\n Assessment:\n Blood sugars remain elevated. > 200 throughout the night.\n Action:\n RISS as ordered. Glargine 5 units given last evening.\n Response:\n BS remain elevated.\n Plan:\n Titrate sliding scale. ? need for Glargine increase.\n Impaired Skin Integrity\n Assessment:\n HD dsg changed last evening, 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Mepilex dsg remains intact. 2 stage II wounds noted beneath dsg.\n Pt cont to have drug rash\n notable on torso and abd. Axilla areas\n excoriated. Groin also reddened. (MD into see various sites)\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Miconazole powder\n applied to groin & axilla regions. Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Pt will most likely need skin care consult. Cont to assess for s&s of\n further skin breakdown. Pt may benefit from KinAir bed to promote\n healing of current wounds. ? need for nutrition eval to assess caloric\n intake.\n * Full Code\n * R IJ TLC\n pulled back last evening and resutured. Line is\n properly placed according to MICU team.\n * L IJ HD Line\n * R Radial Aline\n * No contact O/N with family\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503004, "text": "ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated. . Staph in blood/sputum (OSH), GNR\n in blood, klebsiella in sputum.\n Events: today during H/D he went into VT with a HR of 180\n. He was\n converted with one shock to a narrow complex tachycardia.\n He was given amiodarone 300mg loading dose was ordered the Code. And\n amoidarone 1mg a minute was started after. Ionized calcium 0.99. he\n received 4G calcium gluconate.\n Code status Full code\n Precautions: Contact precautions.\n Cardiac dysrhythmia other\n Assessment:\n This afternoon during H/D he went into VT with a heart rate of 180\n His blood pressure dropped to 100\ns from the 114/60.\n Action:\n Converted with one shock to SVT (narrow complex tachycardia).\n Amiodarone loading dose and than the gtt 1mg a minute.\n Adenosine was given.\n Response:\n Went down to ST heart rate 100\ns. without PVC noted.\n Plan:\n Continue the amiodarone gtt at 1mg a minute.\n Continue to given the dilt via right NG.\n Pneumonia/Respiratory Distress\n Assessment:\n I received the patient on AC 50%X500X24 W12 peep. O2 sat 96%. He is\n positive for a multi-lobar pneumonia. He is MSSA + in sputum form the\n OSH, and now with klebsiella, and gram ndgative rods in sputum, and\n GNR in blood. He had a CXR last night with showed a white out of the\n left lung. Suctioned him for thick yellow/brown sputum in a large\n amount this morning. He continues to have temps of 102.3.\n Action:\n TEE done.\n Gegentamicin was added.\n He will continue with the /nafcillin.\n Cooling blanket/Tylenol\n Pan cultured today.\n Response:\n Awaiting the results from the echo.\n He still continues with temps of 100.5 to 102.6 or4al.\n Ice packs were placed under his arms.\n Plan:\n Follow up cultures from today.\n Continue with the current antibiotic regimen.\n Continue with the Tylenol and cooling blanket.\n f/u echo.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley cath with dark amber urine. 30ml for the 12 hour shift. BUN\n 91/Cr 9.4. H/D line was clogged off\n Action:\n H/D todat.\n Alteplase was given in each port.\n Response:\n 2500 off H/D. During the code 1L given back by H/D RN\n He was able to get through the three hour treatment. But he was\n unable to increase the blood flow grater than 200.\n Plan:\n Question of a new line tonight or tomorrow.\n Also the renal team will discuess having H/D QD.\n Impaired Skin Integrity\n Assessment:\n He has two areas on his buttocks which are stage two. He has a drug\n rash from a question of vanco. He has yeast under his arms.\n Action:\n Please look at the for the creams to use for the yeast.\n I requested a skin care consult.\n Response:\n Mepilex still intact on coccyx.\n Plan:\n Wound care consult tomorrow.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504316, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: 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: 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 Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved\n Comments: PT switched over to PSV with Vt ranging from 400-500ml and\n stable MV. Will obtain ABG and make changes accordingly.\n" }, { "category": "Physician ", "chartdate": "2117-11-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504324, "text": "TITLE:\n Chief Complaint: septic , ARDS\n 24 Hour Events:\n - surveillance cultures on not drawn for some reason- rechecked\n that order was in. Cultures from and negative. Make sure\n cultures get drawn \n - started on clonidine patch and hydral bridge\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 PM\n Famotidine (Pepcid) - 04:16 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 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: 37.9\nC (100.3\n HR: 86 (76 - 94) bpm\n BP: 167/65(89) {142/54(76) - 192/99(122)} mmHg\n RR: 24 (19 - 40) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 2,262 mL\n 617 mL\n PO:\n TF:\n 1,086 mL\n 295 mL\n IVF:\n 806 mL\n 292 mL\n Blood products:\n Total out:\n 1,105 mL\n 375 mL\n Urine:\n 1,105 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,157 mL\n 242 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 0 (0 - 388) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/35/86/22/0\n Ve: 12 L/min\n PaO2 / FiO2: 215\n Physical Examination\n GEN: Sedated, does not open eyes to command, spontaneously moving legs\n (and arms a bit).\n CV: Tachycardic, regular rate, no m/r/g\n PULM: Mild rales b/l anteriorly\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema\n Labs / Radiology\n 277 K/uL\n 7.8 g/dL\n 193 mg/dL\n 6.4 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 23.8 %\n 7.7 K/uL\n [image002.jpg]\n 02:49 PM\n 01:22 AM\n 02:14 AM\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n WBC\n 7.9\n 8.2\n 8.2\n 7.7\n Hct\n 23.6\n 25.1\n 25.2\n 23.8\n Plt\n 77\n Cr\n 7.0\n 5.5\n 6.5\n 6.4\n TCO2\n 29\n 29\n 28\n 29\n 24\n 25\n Glucose\n 93\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.6 mg/dL, Mg++:1.7 mg/dL, PO4:8.4 mg/dL\n Imaging:\n CXR done\n CXR : In comparison with the study of , there is probably\n little\n overall change. Monitoring and support devices remain in place.\n Extensive\n opacification in the lower half of the left lung is again seen. Again\n this is\n probably consistent with pneumonia and pleural effusion. Small amount\n of\n opacification at the right base most likely represents atelectasis.\n Microbiology: B Cxrs from , , pending\n 10:47 am BLOOD CULTURE Source: Line- CVP. Blood Culture,\n Routine (Final ): KLEBSIELLA PNEUMONIAE. ESBL.\n 10:48 am SPUTUM Source: Endotracheal. KLEBSIELLA\n PNEUMONIAE. ESBL. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get culture today from HD line and triple lumen (cultured the prior\n two days too), and culture tomorrow (until cultures negative x48 hours,\n per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Too altered for SBT at this\n time despite adequate RSBI\n - Increasing propofol to help with hypertension/tachycardia (see\n below); so will postpone doing an SBT today as feel that increased\n sedation will result in an SBT failure\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs\n - No HD today, next planned for Monday\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Watch hemodynamics and rhythm; on telemetry\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too\n - d/c labetalol gtt\n .\n # Hypertension\n - Apply clonidine patch 0.2 (know that there will be a delay before it\n starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Start Amlodipine 5mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - Increase glargine from 28 to 30, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503179, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n I received the patient on 40%X500X24X10 peep. O2 sat 97%. Suctioned\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502419, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Received pt w/ temp 102.2, was on cooling blanket. Pt on vanco,\n cefepime and tamiflu.\n Action:\n Vanco level done w/ AM labs, Tamiflu dc\nd since pt is many days out\n from initial symptoms. Pt temp continued to elevate despite cooling\n blanket and PO Tylenol. Later noted blanket was clamped but machine was\n running anyway. Unclamped cooling blanket, temp down to 99.4\n eventually, took pt off blanket.\n Response:\n BP remains stable off Levophed, T.max 103.1 but now down to 99.4. cx\n results pending. WBC 12.5 from 10.6.\n Plan:\n Monitor B/P closely and restart levophed if needed. Monitor temp\n closely, place back on cooling blanket if needed, Tylenol PO if needed,\n ? resend cx\ns if spikes again. ? change vanco to Q24 since level 18\n this AM.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings 500 x 30, FiO2 70%, Peep 16.\n Action:\n Weaned vent to 50%, AM CXR done, Monitoring abg\ns, sxn for thick brown\n secretions x1.\n Response:\n O2sat >95% on 50%, CXR results pending.\n Plan:\n be able to start weaning PEEP and/or rate today. Sxn prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains in acute renal failure, BUN/Creat 60/7.2.\n Action:\n Bladder pressure (8).\n Response:\n 18cc urine total overnight, Ca 6.6 early evening, given 2grams Ca\n Gluconate, now 7.1. BUN/Creat cont to go up 68/7.2.\n Plan:\n Pt had been on dialysis, ? if BP will tolerate. require CRRT.\n Either decision would require another HD line to be placed (previous\n was remove and tip sent for cx).\n Cardiac dysrhythmia other\n Assessment:\n Pt w/ episodes of a.fib @ OSH. Was admitted in SVT w/ rate to 140\n Overnight had a few episodes of frequent PVC\ns w/ a.fib for several\n beats and then pvc and back to NSR.\n Action:\n EKG done, able to catch dysrhythmia.\n Response:\n Resolved on own, had several short periods 10-30seconds w/ rate as high\n as 180\ns. MD\ns notified. No episodes since around 0200AM.\n Plan:\n Cont to monitor telemetry for changes.\n TF @ goal 40cc/hr, residual <10cc Q4H, +BS.\n" }, { "category": "Physician ", "chartdate": "2117-11-01 00:00:00.000", "description": "EP Consult Note", "row_id": 502996, "text": "Date of service: \n Initial consultation: Inpatient\n Presenting complaint: Arrhythmia, (Other: SVT, ? VT)\n History of present illness: 37 yo male with DM presents to OSH with flu\n like illness and subsequent developed sepsis with ARF requiring HD.\n Sputum culture grew out Klebsiella, MSSA, G-Rods and has been on\n antibiotics. During dialysis, he would intermittently go into afib\n with RVR. There was a question that his CVP line was inserted too deep\n and was pulled out. Today during HD, he again went into a regular WCT\n 160bpm, hemodynamically tolerated and was cardioverted into a narrow\n complex tach at the same rate which them terminated with adenosine IV.\n He has no previous cardiac history but there were cardiac enzyme\n leaks.\n Past medical history: none\n CAD Risk Factors\n CAD Risk Factors Present\n Diabetes mellitus\n CAD Risk Factors Absent\n Dyslipidemia, Hypertension\n Other: intubated and sedated\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Current medications: Gentamicin\n Meropenam\n Nafcillin\n Diltiazem\n Review of Systems\n ROS Details: None provided. Pt intubated and sedated\n Social History\n Family history: unknown\n Social history details: unknown\n Physical Exam\n Date and time of exam: 15:20\n General appearance: intubated, sedated\n Height: 69 Inch, 175 cm\n T current: 102 C\n HR: 102 bpm\n Vital sign details: 106/55 art line\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible)\n Respiratory: (Effort: WNL), (Auscultation: WNL, CTA anterior)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL, +), (Pulsatile mass:\n No), (Other abnormalities: obese)\n Extremities / Musculoskeletal: (Digits and nails: + edema in the\n extremities)\n Skin: (Abnormal, diffuse red rash)\n Labs\n 286\n 9.2\n 191\n 7.5\n 29\n 4.2\n 69\n 98\n 139\n 27.1\n 11.2\n [image002.jpg]\n 03:17 AM\n 03:58 PM\n 02:55 AM\n 01:23 AM\n 09:46 PM\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n WBC\n 12.5\n 10.4\n 9.7\n 10.3\n 11.2\n Hgb\n 10.1\n 10.1\n 9.9\n 9.7\n 9.2\n Hct (Serum)\n 31.2\n 30.3\n 29.1\n 30.0\n 27.1\n Plt\n 92\n 286\n INR\n 1.3\n PTT\n 31.0\n Na+\n 143\n 140\n 141\n 142\n 139\n 139\n K + (Serum)\n 4.7\n 3.7\n 3.9\n 3.9\n 4.5\n 4.2\n Cl\n 106\n 103\n 102\n 103\n 102\n 98\n HCO3\n 19\n 22\n 22\n 25\n 21\n 29\n BUN\n 68\n 59\n 65\n 69\n 91\n 69\n Creatinine\n 7.7\n 6.3\n 7.4\n 7.8\n 9.4\n 7.5\n Glucose\n \n CK\n 550\n CK-MB\n 2\n Troponin T\n 0.21\n O2 sat (arterial)\n 92\n 96\n 96\n ABG: 7.46 / 40 / 166 / / 5 Values as of 01:58 PM\n Tests\n ECG: (Date: ), 13:49 Sinus tach HR 106.\n Telemetry: at 13:44 pt with multiple APCs which then went into\n regular WCT which when cardioverted went into a narrow tach at the same\n rate and the QRS marched through the cardioversion.\n Terminated with adenosine with p wave.\n Echocardiogram: (Date: ), Prelim - EF looks normal with normal\n sized atrium\n Ventilator: intubated\n Assessment and Plan\n CARDIAC DYSRHYTHMIA OTHER - pt with history of afib during HD went\n into tachycardia with HR 160's, first wide then narrow after\n cardioversion at exactly the same rate. In addition, the QRS marched\n though at the same time. This points more toward the WCT as being SVT\n with aberrancy instead of having both VT and SVT at exactly the same\n rate and completely marching through. The narrow complex tachycardia\n is a long RP tachy with negative p-wave in lead II and terminates with\n a possible p. Diff includes atypical AVNRT or AVRT and less likely\n atrial tachycardia. Triggers could definitely be from sepsis adn\n fever.\n - Recommendation would be to initiate beta blockers to suppress the\n SVT.\n - Amio load already started. Would finish 24 hour load and then stop\n and titrate up beta blocker. Only if he continues to have incessant\n SVT/afib RVR would we consider more amio.\n Discussed and seen with Dr. .\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503058, "text": "37 yo M with a h/o of DM & ETOH abuse who presented to on w/ flu-like symptoms, including temp 105 & seizures\n requiring intubation. CXR showing PNA. Tx to for further workup.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 101.6. HR 80-160\ns w/ occasional PVC\ns. SBP 130-180\n Action:\n Tylenol 650mg NGT. Cooling blanket PRN. Meropenem X 1 given last\n evening. Nafcillin Q4hrs. ARF (see below) Pt did have issue of aflutter\n in the 160\n and converted back to SR on own. Lopressor 25mg NGT \n ordered (1^st dose last evening) EKG obtained.\n Response:\n 1^st set of BC currently growing gram\n rods. MSSA in sputum & blood\n from OSH.\n Plan:\n Echo today to r/o possible vegitations as source of ongoing fever.\n Tylenol PRN. Cooling blanket PRN. Last sputum & BC\ns sent day\n shift. F/U micro data & trend lab results.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 10. Copious amounts\n of thick tan/brown sputum suctioned via ETT. ABG last evening\n significant for PO2 of 72. Pt is overbreathing vent ~ 6 bpm. Impaired\n cough/gag noted. LS rhoncerous throughout. O2 sat 89-90%. Pt opening\n eyes to painful stimuli.\n Action:\n Repeat CXR last evening significant for left lobe whiteout. RT able to\n recruit some lung function and increased settings (AC 60% x 500 x 24 w/\n PEEP 12) Suctioning Q 1-2 hrs for copious sputum as noted. Lavage PRN.\n Fentanyl & Versed gtts increased for pt comfort.\n Response:\n ABG this AM 7.41/36/116. O2 sat improved 91-95%\n Plan:\n Cont to assess lung function & tweak ventilator settings as warranted.\n Trend ABG\ns. Pt will most likely need bronch today.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Creat significantly elevated 69/7.8. Pt has tolerated HD\n previously. (HD line in place) Minimal UOP.\n Action:\n Plan for HD today. AM BUN/Creat 91/9.4 (MD aware) Goal fluid removal\n originally 1-1.5L (MICU team did discuss potentially being more\n aggressive with fluid removal if pt tolerates)\n Response:\n Ongoing\n Plan:\n Plan for HD today. Cont to follow BUN/Creat. If pt does not improve w/\n HD or does not tolerate, ? need for CRRT.\n Hyperglycemia\n Assessment:\n Blood sugars remain elevated. > 200 throughout the night.\n Action:\n RISS as ordered. Glargine 5 units given last evening.\n Response:\n BS remain elevated.\n Plan:\n Titrate sliding scale. ? need for Glargine increase.\n Impaired Skin Integrity\n Assessment:\n HD dsg changed last evening, 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Mepilex dsg remains intact. 2 stage II wounds noted beneath dsg.\n Pt cont to have drug rash\n notable on torso and abd. Axilla areas\n excoriated. Groin also reddened. (MD into see various sites)\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Miconazole powder\n applied to groin & axilla regions. Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Pt will most likely need skin care consult. Cont to assess for s&s of\n further skin breakdown. Pt may benefit from KinAir bed to promote\n healing of current wounds. ? need for nutrition eval to assess caloric\n intake.\n * Full Code\n * R IJ TLC\n pulled back last evening and re-sutured. Line is\n properly placed according to MICU team.\n * L IJ HD Line\n blistered areas noted beneath dsg\n * R Radial Aline\n * No contact O/N with family\n" }, { "category": "Nutrition", "chartdate": "2117-11-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 504460, "text": "Subjective\n Patient intubated/sedated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 186 mg/dL\n 03:43 AM\n Glucose Finger Stick\n 216\n 10:00 AM\n BUN\n 51 mg/dL\n 03:43 AM\n Creatinine\n 4.0 mg/dL\n 03:43 AM\n Sodium\n 139 mEq/L\n 03:43 AM\n Potassium\n 4.1 mEq/L\n 03:43 AM\n Chloride\n 100 mEq/L\n 03:43 AM\n TCO2\n 26 mEq/L\n 03:43 AM\n PO2 (arterial)\n 120 mm Hg\n 12:42 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:42 AM\n pH (arterial)\n 7.48 units\n 04:57 AM\n CO2 (Calc) arterial\n 29 mEq/L\n 12:42 AM\n Calcium non-ionized\n 7.9 mg/dL\n 03:43 AM\n Phosphorus\n 5.6 mg/dL\n 03:43 AM\n Ionized Calcium\n 1.01 mmol/L\n 04:57 AM\n Magnesium\n 1.6 mg/dL\n 03:43 AM\n WBC\n 6.8 K/uL\n 03:43 AM\n Hgb\n 7.5 g/dL\n 03:43 AM\n Hematocrit\n 23.4 %\n 03:43 AM\n Current diet order / nutrition support: Novasource Renal @45mL/hr (2160\n kcals/80 gr protein)\n GI: Abd: soft/distended/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Patient remains intubated/sedated and continues on tube feeds @ goal c/\n good tolerance. Patient receiving propofol for sedation which is\n providing 1.1 kcals/mL. Tube feeds and propofol meeting 100% estimated\n nutrition needs. Noted plan to hold HD for now as patient c/ improving\n renal function and urine output. Low Ca noted- patient on SS CaGluc\n for repletion. Blood sugars elevated. Glargine increased form 30 to\n 40 units today.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue tube feeds @ goal\n Lyte management as you are\n Continue to adjust insulin regimen prn\n Following #\n" }, { "category": "Physician ", "chartdate": "2117-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504464, "text": "TITLE:\n Chief Complaint: pneumonia, speptic \n 24 Hour Events:\n - Started Amlodipine 5mg to improve HTN control. Now on Propofol drip,\n Dilt, Metoprolol, Clonidine patch, Hydralazine and Amlodipine.\n - dialyzed yesterday\n - On pressure support ventilation\n - pt has had increasing urine output, which began to drop off so\n received 500cc NS (30-40/hour)\n - per respiratory, RSBI-38, however when pt was placed on RSBI he\n became very hypertensive. MAPS rose from 90's to 120's within 5 minutes\n so SBT was stopped. Pt also had pronounced active exhalation. Pt was\n also weaned from 8 to 5 of peep which was not tolerated again by HTN so\n peep was increased back to 8.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n ISS 20U insulin given in 24 hrs\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.9\n HR: 83 (77 - 90) bpm\n BP: 153/69(90) {123/43(65) - 185/89(113)} mmHg\n RR: 28 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,891 mL\n 1,068 mL\n PO:\n TF:\n 1,087 mL\n 319 mL\n IVF:\n 775 mL\n 600 mL\n Blood products:\n Total out:\n 1,090 mL + 1L taken off by HD\n 275 mL\n Urine:\n 1,090 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 616 (410 - 674) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 17 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.48/37/120/26/5\n Ve: 12 L/min\n PaO2 / FiO2: 300\n Physical Examination\n GEN: Sedated, tracking, PERRL 2->1mm\n CV: regular rate, no m/r/g\n PULM: fairly clear, few crackles bilat bases w. few scattered wheezes,\n mod amt of white/yello purulent sputum suctioned by resp\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema, puffy hands/face\n Labs / Radiology\n 277 K/uL\n 7.5 g/dL\n 186 mg/dL\n 4.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 51 mg/dL\n 100 mEq/L\n 139 mEq/L\n 23.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n WBC\n 8.2\n 8.2\n 7.7\n 6.8\n Hct\n 25.1\n 25.2\n 23.8\n 23.4\n Plt\n 244\n 248\n 277\n 277\n Cr\n 5.5\n 6.5\n 6.4\n 4.0\n TCO2\n 28\n 29\n 24\n 25\n 28\n 29\n Glucose\n 193\n 172\n 193\n 163\n 186\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR No significant change of the left lower lobe\n opacification or right basilar\n atalectasis.\n Microbiology: B cxrs , , , pending\n B cxr KLEBSIELLA PNEUMONIAE.\n Legionella urine negative\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8.\n - Increasing propofol to help with hypertension/tachycardia (see\n below).\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n - Will decrease fentanyl, propofol and start precedex x 24 hours to\n attempt to extubate\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD yesterday.\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 500 mL.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increase amlodipine to 10mg daily.\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increase Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 40 QD, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503293, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,.placement confirmed with x\n ray,but line was unable to flush ,TPA was isnstilled but still unable\n to flush,unable to do the HD.\n Code Status: full code\n Precautions: contact klebsiella\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. small to mod\n amts of thick yellow sputum suctioned from ETT ABG was 7.44/34/80.\n SaO2 ,95 -98%. Absent gag/impaired cough noted. LS clear/diminished @\n bases. O2 sat >95% throughout the night. Pt does opens eyes with\n stimulation,but doesn\nt follow commands,no movts noted in the\n extremity,contd to have low grade temp inspite of the cooling blanket\n was on atc and with standing dose of Tylenol,received the pt on triple\n abx(/nafcillin/genta),recent suptum cx with kleb,blood cx from\n osh grews MSSA.\n Action:\n No vent changes overnight,abx narrowed to meropenum,contd cooling\n blanket and Atc Tylenol,daily wake up and SBT.\n Response:\n Satting good,no episode of desatuarion,lowest sats noted 93% during\n turning(was not on 100%).rpt abg in am was 7.41/,42/112. wbc\n 8.8,\n..?drug fever. with am sbt pt was\n tachypnic,tachycardic,hypertensive and desated to 89%.sedation\n restarted at lower dose(cut down 40%)\n Plan:\n .will cont the current abx,follow fever curve off cooling\n blanket,follow cx and sensitivities,daily wake up and SBT.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt essentially anuric,(16cc in this shift),HD line was changed over the\n wire last day high access pressure,confirmed the line placement but\n unable to flush the new line,so didn\nt have HD yesterday,bun/s.cr\n trending up,Ionised ca running on the low side,CVP was 13.\n Action:\n Plan for new HD line today(possibly in the IR),and HD\n afterwards,received 6gm of calcium gluconate in this shift,\n Response:\n Pending. I ca was 1.08 after the 4gm of ca.received a total of 6gm in\n this shift,bun/s.cr worsening.\n Plan:\n New HD line placement and HD.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing. One of the port of the HD cath was found coiled under the\n dsg,\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n novasource renal at goal(held since 0400am for possible IR HD line\n placement,\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition as needed,contd\n enteral nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503297, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,.placement confirmed with x\n ray,but line was unable to flush ,TPA was isnstilled but still unable\n to flush,unable to do the HD.\n Code Status: full code\n Precautions: contact klebsiella\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. small to mod\n amts of thick yellow sputum suctioned from ETT ABG was 7.44/34/80.\n SaO2 ,95 -98%. impaired cough/gag noted. LS clear/diminished @ bases.\n O2 sat 94-98%. Pt does opens eyes with stimulation,but doesn\nt follow\n commands,no movts noted in the extremity,contd to have low grade temp\n inspite of the cooling blanket was on atc and with standing dose of\n Tylenol,received the pt on triple abx(/nafcillin/genta),recent\n suptum cx with kleb,blood cx from osh grews MSSA.\n Action:\n No vent changes overnight,abx narrowed to meropenum,contd cooling\n blanket and Atc Tylenol,daily wake up and SBT.\n Response:\n Satting good,no episode of desatuarion,lowest sats noted 93% during\n turning(was not on 100%).rpt abg in am was 7.41/,42/112. wbc\n 8.8,\n..?drug fever. with am sbt pt was\n tachypnic,tachycardic,hypertensive and desated to 89%.sedation\n restarted at lower dose(fent 50+midaz 2)\n Plan:\n .will cont the current abx,follow fever curve off cooling\n blanket,follow cx and sensitivities,daily wake up and SBT.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt essentially anuric,(16cc in this shift),HD line was changed over the\n wire last day high access pressure,confirmed the line placement but\n unable to flush the new line,so didn\nt have HD yesterday,bun/s.cr\n trending up,Ionised ca running on the low side,CVP was 13.\n Action:\n Plan for new HD line today(possibly in the IR),and HD\n afterwards,received 6gm of calcium gluconate in this shift,\n Response:\n Pending. I ca was 1.08 after the 4gm of ca.received a total of 6gm in\n this shift,bun/s.cr worsening.\n Plan:\n New HD line placement and HD.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing. One of the port of the HD cath was found coiled under the\n dsg,\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n novasource renal at goal(held since 0400am for possible IR HD line\n placement,\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition as needed,contd\n enteral nutrition.\n Others:\n sinus rythum in 80\ns, sbp mostly 120-140;s up to 170\ns with sbt this\n am.\n FS <200,on lantus and sliding scale.\n Family was here in the beginning of the shift,updated by this RN.\n" }, { "category": "Physician ", "chartdate": "2117-10-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502784, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 103.1\nF - 08:00 AM\n - started PO dilt 30 qid\n - EKG this am: TWI inferior leads, normalization of TW in lateral leads\n - stool guiac for anemia\n - OSH sensitivities/micro now in chart --> sputum with 4+ Staph, blood\n negative, flu negative\n - Renal recs: get HD today --> Vanc dose after HD. Start Phoslo 667 tid\n for hyperphosphatemia (already ordered for Ca Acetate 1334mg PO tid\n with meals)\n - CE's: Trop flat, MB flat\n - LFT's stable from this am\n - Origin of metabolic alkalosis: thought about it, only thing that made\n sense was post hypercapnia\n - ABG 8p: 7.46/36/85/26\n - Random vanc after HD and before vanc dose: 9.8\n Allergies:\n Last dose of Antibiotics:\n Tamiflu - 08:00 PM\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Infusions:\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 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 08:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2 yesterday 11am but still febrile this am\n Tcurrent: 37.2\nC (99\n HR: 75 (75 - 102) bpm\n BP: 135/44(68) {122/39(65) - 167/64(87)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (14 - 19)mmHg\n Total In:\n 1,618 mL\n 854 mL\n PO:\n TF:\n 964 mL\n 334 mL\n IVF:\n 474 mL\n 430 mL\n Blood products:\n Total out:\n 1,540 mL\n 305 mL\n Urine:\n 40 mL\n 5 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 78 --> 3.9L positive through LOS mL\n 549 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 27 cmH2O\n Plateau: 22 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.46/36/85/25/1 YESTERDAY PM, CO2 stable, O2 stable through\n yesterday\n Ve: 15.1 L/min\n PaO2 / FiO2: 170\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 280 K/uL\n 9.9 g/dL\n 215 mg/dL\n 7.8 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 103 mEq/L\n 142 mEq/L\n 29.1 %\n 9.7 K/uL\n [image002.jpg]\n 03:17 AM\n 03:27 AM\n 10:31 AM\n 03:58 PM\n 04:08 PM\n 06:29 PM\n 02:55 AM\n 03:00 AM\n 07:50 PM\n 01:23 AM\n WBC\n 12.5\n 10.4\n 9.7 DOWN\n Hct\n 31.2\n 30.3\n 29.1 DOWN\n Plt\n STABLE\n Cr\n 7.7\n 6.3\n 7.4\n 7.8 ELEVATED AND STABLE\n TropT\n 0.21\n TCO2\n 20\n 19\n 24\n 25\n 24\n 26\n Glucose\n 15\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:550/2/0.21\n 0.20 , ALT / AST:62/138 SLIGHTLY ELEVATED, Alk\n Phos / T Bili:317/2.7 ALKP RISING AND TBILI STABLE, Amylase /\n Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %,\n Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L YESTERDAY, Albumin:2.1\n g/Dl YESTERDAY , LDH:437 IU/L, Ca++:7.4 mg/dL, Mg++:2.6 mg/dL, PO4:4.5\n mg/Dl\n Vanc level 9.8 after HD\n Cdiff negative, Bcx negative to date x2, DFA negative for flu,\n catheter tip negative x2\n 2:57 am SPUTUM Site: ENDOTRACHEAL\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n RARE GROWTH Commensal Respiratory Flora.\n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.\n YEAST. SPARSE GROWTH.\n GRAM NEGATIVE ROD #2. RARE GROWTH.\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n UCx negative\n CXR worsening of consolidation in lower left lung\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu.\n Elevated Mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of Septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high Mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given neg Urine legionalla and\n Prolonged QTc at times avoid FQ.\n - Continue Vanco and Cefepime to cover for HAP. We will continue with\n broad coverage considering improvement, and we will treat for a 15 day\n course from yesterday (today day 3).\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS.\n Bladder pressures are lower today, suggesting we have room to wean down\n his PEEP.\n - ARDS net protocol with TV at 6cc/kg\n - wean FiO2 and PEEP as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today with trial of intermittent dialysis.\n # Tachycardia/ AFib: appeared sinus on arrival. Yesterday had a couple\n runs of tachycardia that appeared to be afib with aberrancy that were\n self-limited and well-tolerated. OSH EKG with RBBB as recently as\n , and reports of atrial fibrillation requiring treatment with\n diltiazem. Yesterday went into AFib w/ RVR during dialysis. Treated\n w/ lopressor 10, dilt 20 IV and dilt PO60. Converted back to sinus\n after 1-2 hours.\n - repeat EKG today to make sure that he does not have any acute\n ischemic changes in the setting of his Afib\n - Diltiazem 30 QID\n - titrate sedation to agitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG, is improved\n # mild LFT elevation: likely prolonged hypotension. Improving.\n Added on to today's labs because had not been drawn since \n - trend\n - limit tylenol to 2 gm daily\n # DM: Was hyperglycemic yesterday and we are starting tube feeds, so we\n will increase his sliding scale.\n - continue Reg SS\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 12:37 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 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": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503115, "text": "37 yo M with a h/o of DM & ETOH abuse who presented to on w/ flu-like symptoms, including temp 105 & seizures\n requiring intubation. CXR showing PNA. Tx to for further workup.\n + MSSA (sputum\n from OSH), + Klebsiella (sputum), GNR (blood & sputum)\n Full Code\n R IJ TLC\n L IJ HD Line\n blistered areas noted beneath dsg\n R Radial Aline\n No contact O/N with family\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 12. Scant amts of\n white sputum suctioned from ETT (significantly decreased from )\n ABG this AM 7.43/41/154. SaO2 98%. Absent gag/impaired cough noted. LS\n clear/diminished @ bases. O2 sat >95% throughout the night. Pt opening\n eyes to painful stimuli. Tmax 101.6. CXR showing complete LL\n white out. Febrile - Tmax 101.6 (oral)\n Action:\n Repeat CXR last this AM. TEE . Nafcillin, Meropenem & Gentamicin\n for broadened coverage. Cooling blanket and ice packs throughout the\n night. Ice bath given this AM. Tylenol now ordered Q6hrs via NGT. PEEP\n decreased this AM to 10.\n Response:\n Current vent settings: AC 40% x 500 x 24 w/ PEEP 10 (ABG 7.41/43/120)\n Temps ranging 100-101.6 @ this time. CXR significantly improved this\n AM.\n Plan:\n Cont to assess lung function & tweak ventilator settings as warranted.\n Trend ABG\ns. F/U culture data & echo results. Cooling blanket. Ice\n Packs. Tylenol ATC.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley catheter notable for icteric/scant UOP. BUN/Creat 84/8.8 (up from\n last evening post HD 69/7.5) Pt tolerated majority of HD treatment\n yesterday. He did have a run of Vtach where he was cardioverted, given\n Adenosine & started on Amiodarone gtt. Pt has remained in SR throughout\n the night. SBP 100-120\ns. MAPS >60.\n Action:\n Plan for HD today. MICU team did discuss being somewhat aggressive with\n fluid removal if pt tolerates.\n Response:\n ? placement of new HD cath today given significant flow/clotting issues\n requiring tPA clearance.\n Plan:\n Plan for HD today & daily given ARF. Cont to follow BUN/Creat. If pt\n does not improve w/ HD or does not tolerate, ? need for CRRT. Renal\n team following.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing.\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n Nutren pulmonary @ 40cc/hr (goal)\n Response:\n Unchanged\n Plan:\n Skin care consult today. Cont to assess for s&s of further skin\n breakdown. Pt may benefit from KinAir bed to promote healing of current\n wounds. ? need for nutrition eval to assess caloric intake.\n" }, { "category": "Physician ", "chartdate": "2117-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504423, "text": "TITLE:\n Chief Complaint: pneumonia, speptic \n 24 Hour Events:\n - Started Amlodipine 5mg to improve HTN control. Now on Propofol drip,\n Dilt, Metoprolol, Clonidine patch, and Amlodipine.\n - dialyzed yesterday\n - On pressure support ventilation\n - bcx daily\n - pt has had increasing urine output, which began to drop off so\n received 500cc NS (30-40/hour)\n - per respiratory, RSBI-38, however when pt was placed on RSBI he\n became very hypertensive. MAPS rose from 90's to 120's within 5 minutes\n so SBT was stopped. Pt also had pronounced active exhalation. Pt was\n also weaned from 8 to 5 of peep which was not tolerated again by HTN so\n peep was increased back to 8.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.9\n HR: 83 (77 - 90) bpm\n BP: 153/69(90) {123/43(65) - 185/89(113)} mmHg\n RR: 28 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,891 mL\n 1,068 mL\n PO:\n TF:\n 1,087 mL\n 319 mL\n IVF:\n 775 mL\n 600 mL\n Blood products:\n Total out:\n 1,090 mL\n 275 mL\n Urine:\n 1,090 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 801 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 616 (410 - 674) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 17 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.48/37/120/26/5\n Ve: 12 L/min\n PaO2 / FiO2: 300\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 277 K/uL\n 7.5 g/dL\n 186 mg/dL\n 4.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 51 mg/dL\n 100 mEq/L\n 139 mEq/L\n 23.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n WBC\n 8.2\n 8.2\n 7.7\n 6.8\n Hct\n 25.1\n 25.2\n 23.8\n 23.4\n Plt\n 244\n 248\n 277\n 277\n Cr\n 5.5\n 6.5\n 6.4\n 4.0\n TCO2\n 28\n 29\n 24\n 25\n 28\n 29\n Glucose\n 193\n 172\n 193\n 163\n 186\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR No significant change of the left lower lobe\n opacification or right basilar\n atalectasis.\n Microbiology: B cxrs , , , pending\n B cxr KLEBSIELLA PNEUMONIAE.\n Legionella negative\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n - Consider bronchoscopy.\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8.\n - Increasing propofol to help with hypertension/tachycardia (see\n below).\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD yesterday.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increase amlodipine to 10mg daily.\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increase Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 30, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Physician ", "chartdate": "2117-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504424, "text": "TITLE:\n Chief Complaint: pneumonia, speptic \n 24 Hour Events:\n - Started Amlodipine 5mg to improve HTN control. Now on Propofol drip,\n Dilt, Metoprolol, Clonidine patch, and Amlodipine.\n - dialyzed yesterday\n - On pressure support ventilation\n - bcx daily\n - pt has had increasing urine output, which began to drop off so\n received 500cc NS (30-40/hour)\n - per respiratory, RSBI-38, however when pt was placed on RSBI he\n became very hypertensive. MAPS rose from 90's to 120's within 5 minutes\n so SBT was stopped. Pt also had pronounced active exhalation. Pt was\n also weaned from 8 to 5 of peep which was not tolerated again by HTN so\n peep was increased back to 8.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.9\n HR: 83 (77 - 90) bpm\n BP: 153/69(90) {123/43(65) - 185/89(113)} mmHg\n RR: 28 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,891 mL\n 1,068 mL\n PO:\n TF:\n 1,087 mL\n 319 mL\n IVF:\n 775 mL\n 600 mL\n Blood products:\n Total out:\n 1,090 mL\n 275 mL\n Urine:\n 1,090 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 801 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 616 (410 - 674) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 17 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.48/37/120/26/5\n Ve: 12 L/min\n PaO2 / FiO2: 300\n Physical Examination\n GEN: Sedated, does not open eyes to command\n CV: Tachycardic, regular rate, no m/r/g\n PULM: rhonchi bilaterally\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema\n Labs / Radiology\n 277 K/uL\n 7.5 g/dL\n 186 mg/dL\n 4.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 51 mg/dL\n 100 mEq/L\n 139 mEq/L\n 23.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n WBC\n 8.2\n 8.2\n 7.7\n 6.8\n Hct\n 25.1\n 25.2\n 23.8\n 23.4\n Plt\n 244\n 248\n 277\n 277\n Cr\n 5.5\n 6.5\n 6.4\n 4.0\n TCO2\n 28\n 29\n 24\n 25\n 28\n 29\n Glucose\n 193\n 172\n 193\n 163\n 186\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR No significant change of the left lower lobe\n opacification or right basilar\n atalectasis.\n Microbiology: B cxrs , , , pending\n B cxr KLEBSIELLA PNEUMONIAE.\n Legionella negative\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n - Consider bronchoscopy.\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8.\n - Increasing propofol to help with hypertension/tachycardia (see\n below).\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD yesterday.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increase amlodipine to 10mg daily.\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increase Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 30, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Physician ", "chartdate": "2117-11-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 504451, "text": "Chief Complaint: Respiratory Failure, ESBL Klebsiella pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Had RSBI of 38, but then became very agitated with SBT and holding\n sedation\n 24 Hour Events:\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\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: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Tachycardia\n Respiratory: mechanical ventilation\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:47 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: 37.9\nC (100.2\n HR: 88 (77 - 93) bpm\n BP: 175/89(115) {123/43(65) - 185/89(115)} mmHg\n RR: 19 (19 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,891 mL\n 1,375 mL\n PO:\n TF:\n 1,087 mL\n 478 mL\n IVF:\n 775 mL\n 657 mL\n Blood products:\n Total out:\n 1,090 mL\n 460 mL\n Urine:\n 1,090 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 801 mL\n 915 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 595 (410 - 674) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 24\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 17 cmH2O\n Plateau: 22 cmH2O\n SpO2: 98%\n ABG: 7.48/37/120/26/5\n Ve: 15.1 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.5 g/dL\n 277 K/uL\n 186 mg/dL\n 4.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 51 mg/dL\n 100 mEq/L\n 139 mEq/L\n 23.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n WBC\n 8.2\n 8.2\n 7.7\n 6.8\n Hct\n 25.1\n 25.2\n 23.8\n 23.4\n Plt\n 244\n 248\n 277\n 277\n Cr\n 5.5\n 6.5\n 6.4\n 4.0\n TCO2\n 28\n 29\n 24\n 25\n 28\n 29\n Glucose\n 193\n 172\n 193\n 163\n 186\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 yo man with DM, here respiratory failure from ESBL Klebsiella\n Septic shock with ESBL klebs bacteremia: Cont meropenem\n Acute respiratory failure: Agitated today with SBT. RSBI quite good -\n will try 24 hr trial of Precidex to facilitate extubation\n Hypertension: c/w dilt and metoprolol, clonidine\n Tachcardia/SVT: dilt and metoprolol\n ARF - HD per renal. Is having some modest urine output.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:36 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 504459, "text": "TITLE:\n Chief Complaint: pneumonia, speptic \n 24 Hour Events:\n - Started Amlodipine 5mg to improve HTN control. Now on Propofol drip,\n Dilt, Metoprolol, Clonidine patch, Hydralazine and Amlodipine.\n - dialyzed yesterday\n - On pressure support ventilation\n - pt has had increasing urine output, which began to drop off so\n received 500cc NS (30-40/hour)\n - per respiratory, RSBI-38, however when pt was placed on RSBI he\n became very hypertensive. MAPS rose from 90's to 120's within 5 minutes\n so SBT was stopped. Pt also had pronounced active exhalation. Pt was\n also weaned from 8 to 5 of peep which was not tolerated again by HTN so\n peep was increased back to 8.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 08:01 PM\n Infusions:\n Fentanyl - 25 mcg/hour\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n ISS 20U insulin given in 24 hrs\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.7\nC (99.9\n HR: 83 (77 - 90) bpm\n BP: 153/69(90) {123/43(65) - 185/89(113)} mmHg\n RR: 28 (19 - 31) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,891 mL\n 1,068 mL\n PO:\n TF:\n 1,087 mL\n 319 mL\n IVF:\n 775 mL\n 600 mL\n Blood products:\n Total out:\n 1,090 mL + 1L taken off by HD\n 275 mL\n Urine:\n 1,090 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 616 (410 - 674) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 17 cmH2O\n Plateau: 22 cmH2O\n SpO2: 96%\n ABG: 7.48/37/120/26/5\n Ve: 12 L/min\n PaO2 / FiO2: 300\n Physical Examination\n GEN: Sedated, tracking, PERRL 2->1mm\n CV: regular rate, no m/r/g\n PULM: fairly clear, few crackles bilat bases w. few scattered wheezes,\n mod amt of white/yello purulent sputum suctioned by resp\n ABD: obese, +BS, soft, nt, nd\n EXTR; 1+ b/l pedal edema, puffy hands/face\n Labs / Radiology\n 277 K/uL\n 7.5 g/dL\n 186 mg/dL\n 4.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 51 mg/dL\n 100 mEq/L\n 139 mEq/L\n 23.4 %\n 6.8 K/uL\n [image002.jpg]\n 05:01 PM\n 02:05 AM\n 02:37 AM\n 04:16 AM\n 05:04 AM\n 03:01 PM\n 03:38 AM\n 03:04 PM\n 12:42 AM\n 03:43 AM\n WBC\n 8.2\n 8.2\n 7.7\n 6.8\n Hct\n 25.1\n 25.2\n 23.8\n 23.4\n Plt\n 244\n 248\n 277\n 277\n Cr\n 5.5\n 6.5\n 6.4\n 4.0\n TCO2\n 28\n 29\n 24\n 25\n 28\n 29\n Glucose\n 193\n 172\n 193\n 163\n 186\n Other labs: PT / PTT / INR:13.6/31.2/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:23/42, Alk Phos / T Bili:132/0.9,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.5 mmol/L, Albumin:1.9 g/dL,\n LDH:215 IU/L, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:5.6 mg/dL\n Imaging: CXR No significant change of the left lower lobe\n opacification or right basilar\n atalectasis.\n Microbiology: B cxrs , , , pending\n B cxr KLEBSIELLA PNEUMONIAE.\n Legionella urine negative\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic : BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic . Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from .\n - Per ID consult, patient changed from nafcillin/meropenem/gent to:\n solely Meropenem (day 1 was ). Now on day 9. Length of\n hospital course?\n f/u with ID (likely pending presence of negative\n blood cultures first)\n - get cultures daily from HD line and triple lumen (until cultures\n negative x48 hours, per ID)\n - f/u daily CXR\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8.\n - Increasing propofol to help with hypertension/tachycardia (see\n below).\n - Continue pressure support for today, attempt to decr PEEP to 7 and\n re-eval.\n -Meropenem as above\n - Daily CXR\n - If anxious d/t intubation, try zyprexa\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick. Urine output increasing\n considerably over past few days.\n - F/u renal recs, HD per renal.\n - HD yesterday.\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension yesterday & today.\n - Adenosine if SVT tonight to see if sinus; if need to , so in\n synced mode; adenosine is at bedside; alternatively could also try\n diltiazem is another SVT occurs as that broke it previously too.\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increase amlodipine to 10mg daily.\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Hypertension\n - Continue clonidine patch 0.2 (know that there will be a delay before\n it starts affecting BP)\n - Increase propofol until the clonidine patch\ns effectiveness increases\n - Cont Dilt and Metop.\n - Increase Amlodipine to 10 mg PO daily.\n .\n # DM: Blood sugars were elevated, now much better controlled.\n - glargine increased to 30, and continue ISS\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD schedule\n per renal\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line.\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room. Family was updated yesterday morning at\n bedside ().\n Disposition: pending extubation and clinical improvement.\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503171, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503241, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for , and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,\n And adenosine was given. He converted back to a NSR. He was started on\n a amiodarone gtt.\n Also during H/D his temporary line was alarming for high pressure.\n Today he had a OTW of the left H/D line. He has a VIP port on that\n line. CXR confirmed placement.\n Code Status: full code\n Precautions: contact /\n Pneumonia, other\n Assessment:\n I received the patient on 40%X500X24X10 peep. ABG on these settings\n 7.41/43/120/2/28 O2 sat 97%. Suctioned for scant thin brown\n secretions. During the OTW he was he was lying flat, and dropped his O2\n sat from 96 to 88%. He is positive for GNR in blood, he has Klebsiella\n pneumonia. Temp max 101.5 PO. I also noted with turning he dropped his\n o2 sat.\n Action:\n ABG obtained.\n Nafcillin IV for the .\n Gentamicin/Meropenem for the Klebsiella/GNR\n Tylenol Q6H.\n Cooling blanket and ICE packs.\n Placed on 100% for the procedure.\n Placed on 100% o2 for turning.\n Response:\n 7.42/41/72/1/28/93. after 2 hours we drop the o2 sat to 50%.\n Repeat ABG7.42/40/90/0/27.\n Temp went down to 100.0 oral.\n Plan:\n We dropped PEEP 8. o2 sat remained 95-96%.\n Continue with the IV ABX.\n Attempt to keep his temp down with cooling blanket.\n Pan cultured on . F/U cultures.\n Serial CXR\n Genta level 1.9\n Cardiac dysrhythmia other\n Assessment:\n As stated above he went into Wide complex tachycardia. Amiodarone\n turned off at 1430. He has remained in NSR Heart rate in the 80\ns. No\n PVC or PAC noted. Blood pressure 114 -120\ns with lightening the\n sedation. Also when giving mouth care, or turning his blood pressure\n will increase.\n Action:\n Amiodarone stop at 1430.\n Metoprolol given.\n Response:\n He continue in NSR.\n Plan:\n Titrate up the metoprolol depending on the blood pressure.\n Will reassess the increase in the\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUIN 84/Cr8.8 K4.5/phos 5.9/ionized Ca 1.02. the H/D RN had high\n pressure with the line on . alteplase was placed in the line, and\n although the pressure was high. They preceded with H/D.\n Action:\n Today OTW. The renal fellow had a hard time flushing the line\n after it was placed.\n CXR to confirm placement.\n Obtained order to use the line.\n The plan was to replace the calcium with H/D.\n To give the gentamicin with H/D\n Response:\n H/D started at 1400. their was high pressure alarm, and unable\n to flush the new line venous port.\n Obtained order for alteplase.\n Calcium gluconate 2Grams upat 1820.\n Plan:\n After the alteplase dwelled in the line for 45minutes. The\n line still would not flush.\n If he has no temps tomorrow . He will go to IR.\n Unable to give gentamicin today.\n Please give tomorrow with H/D. he will need a peak after the\n dose.\n If he has temps. The Renal team will re-site the line.\n Impaired Skin Integrity\n Assessment:\n The patitent came to with stage II on his coccyx. It is actually\n two wounds that are joined. He has yeast under his neck, arms, and\n groin. She has a hemorrhoid (which is purple) at the proximal end of\n his rectum. It is not bleeding. He has a antibiotic rash on his\n trunk, the top of his thigh. And his back. The rash is starting to\n better today. Question of vanc.\n Action:\n Wound care consult was done today.\n Response:\n Continue to use the meilex to coccyx area.\n We will continue to hydrocortisone cream and clotrimazole\n cream to affected areas.\n Plan:\n Continue to with current regime.\n Mental Status\n Assessment:\n I received the patient on fent 100mcg and versed 3mg. No cough, NO gag,\n no movement of his extremities noted. His pupils are 3mm and brisk. No\n localization of withdraw to noxious stimulation.\n Action:\n Fent decreased to 80mcg.\n Response:\n Now with turning he will cough.\n He will open his eyes. But no tracking noted.\n Corneal reflex slow but intact.\n Plan:\n 18:42\n" }, { "category": "Respiratory ", "chartdate": "2117-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502265, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, Gasping\n efforts, High flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Pt transported from outside hospital. Large cuff leak noted on\n admission. Required inc peep/fio2/rate to correct abg. Recruitmentt\n done x2 with improved sat.\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502865, "text": "Pt is a 37yo male with a h/o of diabetes and alcohol abuse who\n presented to Hosp on w/ flu-like symptoms,\n including temp 105. In ED had seizure and was intubated. CXR showing\n PNA. Initially was on pressors and was not urinating (new renal\n failure). Thought to be in and out of a.fib w/ RBBB and increasing\n troponin so started on heparin gtt as well. ECHO for ? myocarditis.\n Heparin has been off since, pressors off, tolerating HD w/ goal\n 1-1.5L per treatment. EEG done to f/u w/ seizure activity (? results\n from OSH). MSSA in sputum and blood from OSH.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 102.2. Hr 70\ns-90\ns, SR. No ectopy. BP 122-170/53-73.\n Action:\n Tylenol given and cooling blanket applied with temp spike. Antibx\n changed for better coverage and ? drug rash. BCx 2 sent and sputum\n sent for culture.\n Response:\n Temp decrease to 100.4.\n Plan:\n Echo tomorrow to r/o vegitatation as source of continual fever. Per\n Pharmacy, please dose meropenum at night as it dializes off with\n treatments. First dose to be given tonight at 10pm\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt remains intubated on ACx24/500/50/10. Thick tan-brown secretions\n noted. LS diminished at bases. Pt remains sedated.\n Action:\n RR decreased from 30-24. Sedation decreased slightly.\n Response:\n ABG:7.41/40/91/26\n Plan:\n No further weaning this shift. Continue to monitor and wean as\n tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal u/o throughout the day. BUN/Creat remain elevated. Pt is net\n positive LOS.\n Action:\n No dialysis today.\n Response:\n Plan:\n Possible HD tomorrow with more aggressive fluid removal goal\n Hyperglycemia\n Assessment:\n Blood sugars >200 throughout shift\n Action:\n RISS as ordered\n Response:\n BS remain elevated.\n Plan:\n Plan to add fixed insulin dose tonight to sliding scale.\n Impaired Skin Integrity\n Assessment:\n Pt came from OSH with fecal incontinent bag in place. Today the bag\n was changed secondary to bag leakage to flexiseal. Once fib was\n removed, pt noted to have 2 stage 2 wounds on coccyx and excoriated\n area on buttock. Also, red rash remains on torso area. Site marked.\n Action:\n Meriplex dressing placed over coccyx area. Antibiotics changed in\n suspection of drug rash.\n Response:\n No change\n Plan:\n ? skin care consult if rash worsens. ? ordering new bed for pt to\n promote better skin integrity.\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502982, "text": "ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated. . Staph in blood/sputum (OSH), GNR\n in blood, klebsiella in sputum.\n Events: today during H/D he went into VT with a HR of 180\n. He was\n converted with one shock to a narrow complex tachycardia.\n He was given amiodarone 300mg loading dose was ordered the Code. And\n amoidarone 1mg a minute was started\n" }, { "category": "Physician ", "chartdate": "2117-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503128, "text": "TITLE:\n Chief Complaint: sepsis and ARF requiring dialysis\n 24 Hour Events:\n - wide complex tachycardia, with pulse, synch cardioversion, amiodarone\n and adenosine and back in sinus\n - EP consult: finish 24 hour amiodarone drip and give BBlocker.\n - repleted Ca2+\n - were able to wean PEEP to 10\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 38.2\nC (100.7\n HR: 78 (78 - 185) bpm\n BP: 103/40(57) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 3 (3 - 359)mmHg\n Total In:\n 3,784 mL\n 843 mL\n PO:\n TF:\n 961 mL\n 280 mL\n IVF:\n 2,522 mL\n 443 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 433 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 95%\n ABG: 7.41/43/120/24/2\n Ve: 13.4 L/min\n PaO2 / FiO2: 300\n Physical Examination\n Gen: intubated and sedated.\n Heart: NRRR; no murmurs\n Chest: CTAB\n Abdomen: obese, soft, bowel sounds present\n Ext: warm and well perfused\n Skin: morbilliform rash over abdomen improving. Warm to touch. t\n Labs / Radiology\n 261 K/uL\n 8.8 g/dL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Imaging: CXR\n IMPRESSION: AP chest compared to chest radiographs since \n including a torso CT:\n Confluent pneumonia in the left lung has worsened since .\n Small\n nodular areas of infection in the right lung documented on the torso CT\n are\n more evident today. Mediastinal widening of the thoracic inlet to the\n level\n of the carina is slightly more pronounced today than it was on .\n This area should be monitored carefully because of the possibility of\n progressive adenopathy, mediastinitis or septic thrombophlebitis.\n Bilateral internal jugular lines end in the upper SVC, ET tube is in\n standard\n placement, and nasogastric tube passes below the diaphragm and out of\n view.\n Microbiology: 10:48 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2:19 pm BLOOD CULTURE Source: Line-cvl.\n Blood Culture, Routine (Preliminary):\n GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - Continue Nafcillin/Meropenem. The pt\ns MSSA was sensitive to\n Nafcillin at the OSH. The GNR (Klebsiella) in the sputum are sensitive\n to Meropenem. Day 1 for both was .\n - Add gentamycin (day #1 = ) to double-cover for GNR\ns (in sputum\n and blood).\n - f/u cultures\n - f/u daily CXR\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n - Weaned FiO2 to 40% and now with PEEP of 10. Continue to attempt to\n wean PEEP\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning.\n - HD today\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on\n gent/meropenem/nafcillin.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today; renal will attempt to rewire.\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Yesterday, atrial irritation\n (believed due to IJ that was too deep, now pulled back)\n - Dilt stopped and lopressor started again according to cardiology recs\n - 24 hour amiodarone will be done at 1430\n - Watch hemodynamics and rhythm\n .\n # DM: Blood sugars continue to be elevated\n - Increased glargine; continue ISS\n - readjust this afternoon depending on sugars\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend daily LFTs\n - Limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Respiratory ", "chartdate": "2117-11-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 504523, "text": "Demographics\n Day of intubation: 14\n Day of mechanical ventilation: 14\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP 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 Big move today peep down to 6 from 8.. RR waxes and wanes, Sx\nd for\n small amounts of yellow secretions. ABG OK.\n Not extubating today.\n, RRT 17:55\n" }, { "category": "Nursing", "chartdate": "2117-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502355, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502356, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Events:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502981, "text": "ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated. . Staph in blood/sputum (OSH), GNR\n in blood, klebsiella in sputum.\n Events: today during H/D he went into VT with a HR of 180\n. He was\n converted with one shock to a narrow complex tachycardia.\n He was given amiodarone\n" }, { "category": "Nursing", "chartdate": "2117-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502985, "text": "ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated. . Staph in blood/sputum (OSH), GNR\n in blood, klebsiella in sputum.\n Events: today during H/D he went into VT with a HR of 180\n. He was\n converted with one shock to a narrow complex tachycardia.\n He was given amiodarone 300mg loading dose was ordered the Code. And\n amoidarone 1mg a minute was started after. Ionized calcium 0.99. he\n received 4G calcium gluconate.\n" }, { "category": "Physician ", "chartdate": "2117-10-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 502303, "text": "Chief Complaint: respiratory failure, sepsis.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 37 yo man with h/o DM II presents at OSH with 7 days of myalgias,\n weakness, fever, had seizure on presentation to ED. Had MSSA grow from\n blood and sputum. Required intubation, developed ARF, placed on\n dialiysis. Course also c/b tachycardia, ?Afib, Had troponin leak,\n and treated with heparin, plavix, asa. Medflighted yesterday, was\n paralyzed for trip. In MICU T 100.6, sat 92% with PEEP 12 and 0.70\n FiO2. Examine notable for being very mottled. Had temp spike to 105\n and arrival. BP trended down with MAP down to 60. By report, echo at\n OSH with nl EF, no clear vegetations.\n 24 Hour Events:\n EKG - At 11:00 PM\n NASAL SWAB - At 11:00 PM\n INVASIVE VENTILATION - START 11:00 PM\n DIALYSIS CATHETER - START 11:01 PM\n MULTI LUMEN - START 11:02 PM\n ARTERIAL LINE - START 02:14 AM\n BLOOD CULTURED - At 02:30 AM\n from TLC.\n NASAL SWAB - At 02:45 AM\n Flock swab for influenza cx's.\n URINE CULTURE - At 06:00 AM\n LUMBAR PUNCTURE - At 06:00 AM\n failed attempt.\n FEVER - 105.1\nF - 03:30 AM\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 02:45 AM\n Vancomycin - 03:15 AM\n Infusions:\n Fentanyl - 250 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 04:00 AM\n Other medications:\n SSI\n hep s/q\n chlorhexidine\n Changes to medical and family history:\n FHx: CAD in father and brother\n . Chef, heavy ETOH use, no drugs or tobacco\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 09:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 40.6\nC (105.1\n Tcurrent: 36.9\nC (98.4\n HR: 122 (116 - 149) bpm\n BP: 104/56(70) {78/46(61) - 109/58(73)} mmHg\n RR: 30 (17 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n CVP: 19 (13 - 19)mmHg\n Bladder pressure: 23 (23 - 23) mmHg\n Mixed Venous O2% Sat: 84 - 84\n Total In:\n 12 mL\n 1,812 mL\n PO:\n TF:\n IVF:\n 12 mL\n 1,062 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 1,812 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (450 - 500) mL\n Vt (Spontaneous): 109 (109 - 109) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 30 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.18/63/125/25/-5\n Ve: 15.2 L/min\n PaO2 / FiO2: 179\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, pinpoint pupils\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: Bronchial: right base,\n Rhonchorous: righ tbase)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Cool, Rash: mottled skin rash\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.8 g/dL\n 214 K/uL\n 147 mg/dL\n 5.4 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 39 mg/dL\n 104 mEq/L\n 144 mEq/L\n 42\n 12.5 K/uL\n [image002.jpg]\n 11:09 PM\n 11:28 PM\n 04:30 AM\n WBC\n 12.5\n Hct\n 37.9\n 42\n Plt\n 214\n Cr\n 5.4\n TropT\n 0.20\n TCO2\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.2 g/dL, LDH:437 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:6.0 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Respiratory failure: MSSA bacteremia/PNA. have had influenza\n originally. Can try and drop FiO2 and increase PEEP as needed.\n Fevers: have new infection given fever spike, but no clear\n source. Now on vanco/cefepime. Getting CT torso to check for\n occult sources of infection. Consider changing lines. Also continue\n tamiflu for now.\n DM: will need better control\n Will change subclavian line given fever. Will consider removing HD\n line and place another before his next HD.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 11:01 PM\n Multi Lumen - 11:02 PM\n Arterial Line - 02:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 503730, "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 37 yo man with MSSA sepsis, ARDS, renal failure. Blood cx from \n with GNRs.\n 24 Hour Events:\n FEVER - 101.6\nF - 06:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Nafcillin - 10:13 PM\n Meropenem - 08:26 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 05:00 PM\n Fentanyl - 10:45 PM\n Propofol - 11:14 PM\n Famotidine (Pepcid) - 03:14 AM\n Insulin - Regular - 05:07 AM\n Other medications:\n heparin\n pepcid\n SSI\n lopressor\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 11:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.6\n Tcurrent: 38.2\nC (100.8\n HR: 94 (81 - 100) bpm\n BP: 172/80(102) {126/47(70) - 187/89(113)} mmHg\n RR: 31 (23 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 1,895 mL\n 973 mL\n PO:\n TF:\n 1,083 mL\n 490 mL\n IVF:\n 572 mL\n 483 mL\n Blood products:\n Total out:\n 2,227 mL\n 110 mL\n Urine:\n 227 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n -332 mL\n 863 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 490 (455 - 490) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 76\n PIP: 21 cmH2O\n Plateau: 21 cmH2O\n SpO2: 96%\n ABG: 7.42/43/139/23/3\n Ve: 11.3 L/min\n PaO2 / FiO2: 348\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: L>R)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 239 K/uL\n 228 mg/dL\n 7.0 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 63 mg/dL\n 100 mEq/L\n 138 mEq/L\n 23.6 %\n 7.9 K/uL\n [image002.jpg]\n 02:55 AM\n 03:24 AM\n 05:01 PM\n 08:53 PM\n 10:40 PM\n 03:00 AM\n 03:37 AM\n 02:49 PM\n 01:22 AM\n 02:14 AM\n WBC\n 8.8\n 8.9\n 7.9\n Hct\n 26.8\n 25.1\n 23.6\n Plt\n 255\n 282\n 239\n Cr\n 9.4\n 8.4\n 7.0\n TCO2\n 28\n 32\n 31\n 31\n 32\n 29\n 29\n Glucose\n 137\n 187\n 228\n Other labs: PT / PTT / INR:13.6/31.4/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/47, Alk Phos / T Bili:166/1.1,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.1 mmol/L, Albumin:1.9 g/dL,\n LDH:239 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Klebsiella bacteremia: has another positive blood cx from . It\n was from the same line, which has now been changed to the HD cath.\n Will get a culture form it.\n respiratory failure: wean his peep.\n mental status us likely main barrier to extubation. Hold all sedation\n and try to wake him up using bolus sedation.\n tachcardia: doing well on lopressor\n DM: glargine 25.\n increased LFTs: are all decreasing. Likely from shock liver.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 12:07 AM 45 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Dialysis Catheter - 02:00 PM\n Multi Lumen - 02:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2117-11-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503312, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 08:00 AM\n -Altepase given for HD catheter placed today which was not flushing\n (per renal), but HD catheter still not flush so could not receive HD\n today\n - EP recs: uptitrate metoprolol as necessary. d/c amiodarone after\n initial lg. signing off.\n - Gent and Nafcillin d/c'ed per ID, initiated Meropenem for ESBL\n Klebsiella\n - febrile (ie: 100.2 to 100.7) through most of the night, and\n 99.5-100 this morning\n - LFT\ns downtrending\n -\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 03:18 PM\n Meropenem - 08:01 PM\n Nafcillin - 10:13 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:27 AM\n Famotidine (Pepcid) - 04:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 37.8\nC (100\n HR: 93 (77 - 93) bpm\n BP: 153/64(87) {109/42(62) - 169/81(101)} mmHg\n RR: 28 (21 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 12 (5 - 19)mmHg\n Total In:\n 2,563 mL\n 733 mL\n PO:\n 240 mL\n TF:\n 955 mL\n 173 mL\n IVF:\n 1,188 mL\n 440 mL\n Blood products:\n Total out:\n 427 mL\n 409 mL\n Urine:\n 27 mL\n 9 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,136 mL\n 324 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 3\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 68\n PIP: 22 cmH2O\n Plateau: 21 cmH2O\n Compliance: 40 cmH2O/mL\n SpO2: 92%\n ABG: 7.41/42/112/24/1\n Ve: 14.3 L/min\n PaO2 / FiO2: 224\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 255 K/uL\n 8.5 g/dL\n 137 mg/dL\n 9.4 mg/dL\n 24 mEq/L\n 5.0 mEq/L\n 96 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n 09:15 AM\n 02:25 PM\n 09:21 PM\n 09:39 PM\n 02:55 AM\n 03:24 AM\n WBC\n 9.5\n 8.8\n Hct\n 26.5\n 26.8\n Plt\n 261\n 255\n Cr\n 8.8\n 9.1\n 9.4\n TCO2\n 28\n 29\n 28\n 28\n 27\n 26\n 28\n Glucose\n 172\n 146\n 137\n Other labs: PT / PTT / INR:13.9/34.0/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:39/60, Alk Phos / T Bili:197/1.6,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:265 IU/L, Ca++:8.2 mg/dL, Mg++:2.4 mg/dL, PO4:7.6 mg/dL\n CXR: increased effusion (decreased visualization of right\n hemidiaphragm) on the right.\n Sputum :\nKLEBSIELLA PNEUMONIAE. MODERATE GROWTH.\n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 286-2926K\n .\n GRAM NEGATIVE ROD #2. SPARSE GROWTH. SUGGESTING PSEUDOMONAS.\n Blood culture:\nBlood Culture, Routine (Preliminary):\n KLEBSIELLA PNEUMONIAE.\n WARNING! This isolate is an extended-spectrum beta-lactamase\n (ESBL) producer and should be considered resistant to all\n penicillins, cephalosporins, and aztreonam. Consider Infectious\n Disease consultation for serious infections caused by\n ESBL-producing species.\n Anaerobic Bottle Gram Stain (Final ):\n REPORTED BY PHONE TO @ 0340 ON - CC6D.\n GRAM NEGATIVE ROD(S).\n Aerobic Bottle Gram Stain (Final ): GRAM NEGATIVE ROD(S).\n Assessment and Plan\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - ID consult re: double coverage for gram negative flora. Will get a\n gent level for this morning and adjust at HD\n - Continue Nafcillin/Meropenem/Gent. The pt\ns MSSA was sensitive to\n Nafcillin at the OSH. The GNR (Klebsiella) in the sputum are sensitive\n to Meropenem. Day 1 for both was . Day 1 for gent was \n - f/u cultures\n - f/u daily CXR\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n - Weaned FiO2 to 40% and now with PEEP of 10. Continue to attempt to\n wean PEEP\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning.\n - HD today\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on\n gent/meropenem/nafcillin.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today; renal will attempt to rewire.\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear.\n - Dilt stopped and lopressor started again according to cardiology recs\n - Dose of lopressor 12.5 TID, will increase tomorrow if needed.\n - 24 hour amiodarone will be done at 1430\n - Watch hemodynamics and rhythm\n .\n # DM: Blood sugars continue to be elevated\n - Increased glargine; continue ISS\n - readjust this afternoon depending on sugars\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend daily LFTs\n - Limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 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": "2117-11-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 506224, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - 4L deficit per renal; getting D5W\n - per renal, if still with large urine output for another 2 days plus\n hyperNa, check lytes to consider diabetes insipidus as potentially\n causative\n - on 35% shovel mask - SpO2 100%\n - question to talk about on rounds: long-term feeding solution\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:58 PM\n Meropenem - 12:21 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 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 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.1\nC (97\n HR: 81 (71 - 91) bpm\n BP: 122/67(81) {111/54(72) - 155/81(97)} mmHg\n RR: 17 (17 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.8 kg (admission): 119 kg\n Height: 69 Inch\n Total In:\n 6,625 mL\n 1,351 mL\n PO:\n TF:\n 1,085 mL\n 339 mL\n IVF:\n 3,710 mL\n 353 mL\n Blood products:\n Total out:\n 2,910 mL\n 1,250 mL\n Urine:\n 2,910 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,715 mL\n 101 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: GEN\n NAD, alert, tracks, does not speak, shakes\n head to\nno pain\n CV\n RRR, no murmurs\n PULM\n CTAB, equal BS\n ABD\n obese, soft, nt\n EXTR\n no edema\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 305 K/uL\n 7.9 g/dL\n 159 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 31 mg/dL\n 110 mEq/L\n 143 mEq/L\n 24.7 %\n 8.9 K/uL\n [image002.jpg]\n 05:12 AM\n 09:36 PM\n 03:06 AM\n 03:00 PM\n 07:49 PM\n 03:59 AM\n 05:40 PM\n 05:38 AM\n 04:59 PM\n 03:20 AM\n WBC\n 8.0\n 8.1\n 8.8\n 7.6\n 8.9\n Hct\n 27.3\n 26.4\n 24.7\n 24.9\n 24.7\n Plt\n 39\n 305\n Cr\n 2.7\n 2.0\n 1.7\n 1.6\n 1.4\n 1.1\n 1.0\n 1.0\n TCO2\n 29\n 29\n Glucose\n \n Other labs: PT / PTT / INR:14.0/32.3/1.2, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:29/28, Alk Phos / T Bili:83/0.7,\n Amylase / Lipase:57/, Differential-Neuts:78.3 %, Band:1.0 %, Lymph:15.4\n %, Mono:4.5 %, Eos:1.4 %, Lactic Acid:1.8 mmol/L, Albumin:2.7 g/dL,\n LDH:194 IU/L, Ca++:8.0 mg/dL, Mg++:1.5 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR - improved aeration b/l with decreased haziness and\n improved left lung base opacity\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n DYSPNEA (SHORTNESS OF BREATH)\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella and pseudomonas in\n sputum. Has gone into SVT (wide complex) in the past, resolved with\n adenosine.\n .\n # Septic shock/Pneumonia: BP stable off pressors. Culture data positive\n for MSSA in the sputum and blood early in OSH course. CT scan with L >\n R infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae and pseudomonas in the sputum from , GNR in\n blood and radiographic evidence of PNA. TTE normal, no signs of\n vegetations. Gram negative rods in blood culture from , growing\n Pseudomonas and Klebsiella. s/p removal of aline, HD line, TLC\n - Per ID consult: should treat with 14 total days Meropenem since first\n negative blood culture = course should be from to (coag neg\n staph on and likely staph epi and a contaminant).\n - Meropenem re-dosed for pt\ns improved renal function\n - Continue vancomycin, started on for GPC\n - F/u ID recs\n - hold on daily CXR given continued improvement\n - d/c daily cultures given negative x48 hours, per ID\n - f/u sputum cxr, sensitivities, speciation\n - prn Tylenol for fevers\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n Weaned FiO2 to 40% and now with PEEP of 8. Extubated on (s/p\n precedex, benzo use to help with anxiety while intubated).\n Significantly resolving. Continues to have episodes of respiratory\n disress and requires frequent suctioning, nebs and respiratory toilet.\n -Meropenem, vancomycin as above\n - Wean O2 as tolerated\n - NAC nebs x1 day to help prevent mucus plugging\n - Frequent suctioning and CPT as tolerated\n .\n #Altered mental status: Given patient\ns prolonged intubation and\n sedation (>3 weeks) as well as ongoing infection, think pt\ns MS is\n likely due to toxic-metabolic encephalopathy. If no improvement can\n consider head CT, EEG monitoring and AMS w/u.\n - Monitor for now.\n .\n # ARF: Cr initially elevated at 7.8 and pt was oliguric, while patient\n was in septic shock. Urine output increasing considerably over past few\n days and pt\ns GFR is likely normal at this point. Resolved Cr, HD line\n removed.\n - F/u renal recs\n - Per renal recs, will give PRN Lasix to keep total daily UOP > 2L\n .\n # Volume Status: Hypernatremia improved with 1/2D5 at 240 ml/hr\n overnight but then worsened after lasix given for resp distress.\n Resolved, now becoming hyponatremic.\n - Hold IVF today as pt hyponatremic; no D5W\n - Decrease free H20 flushes from 300cc q4h PM of to 200cc q4h\n - Consider U lytes if hyponatremia worsens, though likely volume\n overload\n - Assess I/O and use Lasix for diuresis if necessary in PM\n - Re check electrolytes this pm\n .\n # Hypertension\n - Increase Lisinopril from 10mg to 20mg daily\n - Decrease Hydralazine from 50mg Q6 hrs to 25mg q6h\n - Continue Amlodipine 10 mg PO daily.\n - Continue clonidine patch 0.3\n - Cont Dilt and Metoprolol\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam (started on )\n - Consider initiating Celexa 20mg daily for anxiety with goal of\n d/c\ning Clonazepam once SSRI becomes effective\n .\n # DM: Blood sugars poorly controlled but pt on D5 for hypernatremia\n yesterday.\n - Glargine 50 QD and continue ISS, increase SSI for sugars in 200\n .\n OTHER STABLE ISSUES\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear. 24 hour amiodarone has completed. Patient with persistent\n tachycardia and hypertension for 2 days. Tachycardia resolved x 5\n 7 days as of .\n - Adenosine at bedside in case of SVT\n - Continue diltiazem 30mg qid\n - Continue metoprolol at 125mg tid\n - Increased amlodipine to 10mg daily.\n - anxiety component of tachy/HTN seems apparent, start 1mg \n clonazepam\n - Watch hemodynamics and rhythm; on telemetry\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on meropenem. Improved\n clinically, less erythematous.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n Improved/stable.\n - Continue to trend LFTs\n - Limit tylenol to 2 gm daily; changed standing Tylenol to PRN\n .\n FEN; Lytes prn, tube feeds, speech & swallow and PT consults, HD per\n renal\n holding for now given improved renal fxn. Calculate free water\n deficit given hypernatremia\n give D5W at 120cc/hr x1L, check pm lytes\n and urine lytes (hyperna could be contributing to AMS).\n Prophylaxis: Subcutaneous heparin, PPI\n Access: PICC line, peripheral\n Code: Full code confirmed\n Communication: Mother, . HCP name/number\n (ICU RN) on whiteboard in room.\n Disposition: ICU given tenuous respiratory status\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:59 AM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Echo", "chartdate": "2117-11-01 00:00:00.000", "description": "Report", "row_id": 88005, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 69\nWeight (lb): 220\nBSA (m2): 2.15 m2\nBP (mm Hg): 111/58\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 15:49\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal 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: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. No TS. Indeterminate PA systolic pressure.\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: Resting tachycardia (HR>100bpm).\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. The right ventricular cavity is mildly dilated with\nborderline normal free wall function. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nNo masses or vegetations are seen on the aortic valve. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. No mass or vegetation is seen on the mitral valve. The\npulmonary artery systolic pressure could not be determined. No vegetation/mass\nis seen on the pulmonic valve. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2117-11-04 00:00:00.000", "description": "Report", "row_id": 235074, "text": "Supraventricular tachycardia most likely representing atrio-ventricular nodal\nreentrant tachycardia but cannot exclude orthodromic atrio-ventricular\nreciprocating tachycardia. Compared to the previous tracing of \nsupraventricular tachycardia is now present.\n\n" }, { "category": "ECG", "chartdate": "2117-11-01 00:00:00.000", "description": "Report", "row_id": 235075, "text": "Sinus tachycardia. ST-T wave abnormalities are non-specific. Since the\nprevious tracing of sinus tachycardia and further ST-T wave changes\nare now present.\n\n" }, { "category": "ECG", "chartdate": "2117-10-31 00:00:00.000", "description": "Report", "row_id": 235076, "text": "Sinus rhythm. Right axis deviation. Non-specific ST segment changes.\nCompared to the previous tracing of the axis has moved rightward.\n\n" }, { "category": "ECG", "chartdate": "2117-10-30 00:00:00.000", "description": "Report", "row_id": 235302, "text": "Sinus rhythm. Compared to the previous tracing of the rate and rhythm\nhave changed.\n\n" }, { "category": "ECG", "chartdate": "2117-10-29 00:00:00.000", "description": "Report", "row_id": 235303, "text": "Sinus tachycardia. Non-sustained ventricular tachycardia. Atrial ectopy.\nRight axis deviation. Non-specific ST-T wave changes. Compared to the\nprevious tracing incomplete right bundle-branch block is no longer present and\nthe rate in sinus rhythm is slower. Non-sustained ventricular tachycardia is\nnew.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2117-10-27 00:00:00.000", "description": "Report", "row_id": 235304, "text": "Sinus tachycardia. Incomplete right bundle-branch block. Non-specific\nST-T wave changes. The P-R interval is 160 milliseconds. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503287, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,.placement confirmed with x\n ray,but line was unable to flush ,TPA was isnstilled but still unable\n to flush,unable to do the HD.\n Code Status: full code\n Precautions: contact klebsiella\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. small to mod\n amts of thick yellow sputum suctioned from ETT ABG was 7.44/34/80.\n SaO2 ,95 -98%. Absent gag/impaired cough noted. LS clear/diminished @\n bases. O2 sat >95% throughout the night. Pt does opens eyes with\n stimulation,but doesn\nt follow commands,no movts noted in the\n extremity,contd to have low grade temp inspite of the cooling blanket\n was on atc and with standing dose of Tylenol,received the pt on triple\n abx(/nafcillin/genta),recent suptum cx with kleb,blood cx from\n osh grews MSSA.\n Action:\n No vent changes overnight,abx narrowed to meropenum,contd cooling\n blanket and Atc Tylenol,daily wake up and SBT.\n Response:\n Satting good,no episode of desatuarion,lowest sats noted 93% during\n turning(was not on 100%).rpt abg in am was 7.41/,42/112.\n Plan:\n .will cont the current abx,follow fever curve off cooling\n blanket,follow cx and sensitivities,daily wake up and SBT.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt essentially anuric,(16cc in this shift),HD line was changed over the\n wire last day high access pressure,confirmed the line placement but\n unable to flush the new line,so didn\nt have HD yesterday,bun/s.cr\n trending up,Ionised ca running on the low side,CVP was 13.\n Action:\n Plan for new HD line today(possibly in the IR),and HD\n afterwards,received 6gm of calcium gluconate in this shift,\n Response:\n Pending. I ca was 1.08 after the 4gm of ca.received a total of 6gm in\n this shift,bun/s.cr worsening.\n Plan:\n New HD line placement and HD.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing. One of the port of the HD cath was found coiled under the\n dsg,\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n novasource renal at goal(held since 0400am for possible IR HD line\n placement,\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition as needed,contd\n enteral nutrition.\n" }, { "category": "Nursing", "chartdate": "2117-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 503289, "text": "The patient is a 37y/o male with a PMH of DM,ETOH. He admitted to\n on after syncopal episode. There was a question\n of him having a seizure. Per his family, he had sneezing, and coughing\n for 10 days with a decrease in his PO intake. On admission he was\n shocked and intubated. Started on vasopresson, levophed and\n tamiflu,levaquin and vanco. Flu swab were negative. Blood cultures and\n sputum were positive for MSSA, and also has GNR from blood. He was\n started on naficillin. His hospital course was than completed by ARF,\n and was started on H/D hyperkalemia. When the H/D line was placed\n he had intermittent episode of A-fib which was treated with cardize.\n He was transferred to MICU 6 on .\n Now he has klebsiella from sputum culture at .\n Events: on During H/D he went into a wide complex tachycardia\n with a heart rate of 180\ns.Cardioversion X1,amiodarone ,and adenosine\n was given,converted back to sinus and started on amio gtt.\n 12/01The HD line was changed over the wire,.placement confirmed with x\n ray,but line was unable to flush ,TPA was isnstilled but still unable\n to flush,unable to do the HD.\n Code Status: full code\n Precautions: contact klebsiella\n Pneumonia/Respiratory Distress\n Assessment:\n Received pt intubated on AC 50% x 500 x 24 w/ PEEP 8. small to mod\n amts of thick yellow sputum suctioned from ETT ABG was 7.44/34/80.\n SaO2 ,95 -98%. Absent gag/impaired cough noted. LS clear/diminished @\n bases. O2 sat >95% throughout the night. Pt does opens eyes with\n stimulation,but doesn\nt follow commands,no movts noted in the\n extremity,contd to have low grade temp inspite of the cooling blanket\n was on atc and with standing dose of Tylenol,received the pt on triple\n abx(/nafcillin/genta),recent suptum cx with kleb,blood cx from\n osh grews MSSA.\n Action:\n No vent changes overnight,abx narrowed to meropenum,contd cooling\n blanket and Atc Tylenol,daily wake up and SBT.\n Response:\n Satting good,no episode of desatuarion,lowest sats noted 93% during\n turning(was not on 100%).rpt abg in am was 7.41/,42/112. wbc\n 8.8,\n..?drug fever.\n Plan:\n .will cont the current abx,follow fever curve off cooling\n blanket,follow cx and sensitivities,daily wake up and SBT.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt essentially anuric,(16cc in this shift),HD line was changed over the\n wire last day high access pressure,confirmed the line placement but\n unable to flush the new line,so didn\nt have HD yesterday,bun/s.cr\n trending up,Ionised ca running on the low side,CVP was 13.\n Action:\n Plan for new HD line today(possibly in the IR),and HD\n afterwards,received 6gm of calcium gluconate in this shift,\n Response:\n Pending. I ca was 1.08 after the 4gm of ca.received a total of 6gm in\n this shift,bun/s.cr worsening.\n Plan:\n New HD line placement and HD.\n Impaired Skin Integrity\n Assessment:\n HD dsg reinforced at outer edges. 2 small blisters noted (cleansed and\n covered with DSD) Flexiseal in place draining loose brownish/\n stool. Skin appearing pink\n repositioning of Flexiseal importants !\n this time. Mepilex dsg remains intact. 2 stage II wounds noted beneath\n dsg. Pt cont to have drug rash\n notable on torso, abd & part of\n extremities. Groin, axilla & neck folds are excoriated and yeast\n appearing. One of the port of the HD cath was found coiled under the\n dsg,\n Action:\n Mepilex dsg remains on coccyx area. CDI @ this time. Multiple topical\n creams/ointments ordered improve healing (please see for details)\n novasource renal at goal(held since 0400am for possible IR HD line\n placement,\n Response:\n Ongoing.\n Plan:\n Will cont the current management,turn and reposition as needed,contd\n enteral nutrition.\n" }, { "category": "Physician ", "chartdate": "2117-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 503144, "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 37 yo man with MSSA PNA, septic shock, ARF. C/b VAP with ESBL\n klebsiella. Pt. with wide complex\n tachycardia yesterday - EP feels more consistent with SVT with\n aberrancy.\n 24 Hour Events:\n FEVER - 102.6\nF - 03:00 PM\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 80 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n calcium acetate\n nafcillin\n SSI\n meropenem\n lopressor\n tylenol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:00 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: 38.8\nC (101.8\n HR: 81 (78 - 185) bpm\n BP: 111/43(63) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (0 - 359)mmHg\n Total In:\n 3,784 mL\n 1,018 mL\n PO:\n 60 mL\n TF:\n 961 mL\n 348 mL\n IVF:\n 2,522 mL\n 490 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 608 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/43/120/24/2\n Ve: 13.4 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : left baes)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, Rash: improved now\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 261 K/uL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n HYPERGLYCEMIA\n IMPAIRED SKIN INTEGRITY\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Septic shock: overall improvement. Now on nafcillin, meropenem,\n gentamicin. Will consult ID re: need for double coverage.\n acute renal failure: getting HD again today after rewire of line\n SVT: likely AVNRT or AVRT.\n respiratory failure: continue to try and wean Peep, and if able to\n wean peep, can consider PSV.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:22 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 02:14 AM\n Multi Lumen - 02:58 PM\n Dialysis Catheter - 01:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Critically ill\n" }, { "category": "Consult", "chartdate": "2117-11-02 00:00:00.000", "description": "Electrophysiology Consult Progress Note", "row_id": 503146, "text": "Consult requested by: MICU \n Chief Complaint: 27M with DM admitted with MSSA PNA c/b klebsiella VAP.\n Found to have WCT then narrow complex tachcyardia yesterday during HD\n that resolved with adenosine, likely SVT with aberrancy.\n 24 Hour Events:\n FEVER - 102.6\nF - 03:00 PM\n -no further episodes of tachycardia since yesterday afternoon\n -started on metoprolol 12.5 \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 80 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n Metoprolol 12.5mg \n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:11 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: 38.8\nC (101.8\n HR: 81 (78 - 185) bpm\n BP: 111/43(63) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 97%\n Heart rhythm:: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (0 - 359)mmHg\n Total In:\n 3,784 mL\n 1,048 mL\n PO:\n 60 mL\n TF:\n 961 mL\n 366 mL\n IVF:\n 2,522 mL\n 502 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 638 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/43/120/24/2\n Ve: 12.5 L/min\n PaO2 / FiO2: 300\n Physical Examination:\n Labs / Radiology\n 261 K/uL\n 8.8 g/dL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 37M with DM in MICU with MSSA and Klebsiella PNA, who had WCT and\n narrow-complex tachycardia during HD yesterday that appears most\n consistent with SVT with aberrancy (AVRNT vs AVRT). No further episodes\n of tachycardia since yesterday and has tolerated metoprolol.\n -continue metoprolol, would uptitrate as tolerated by blood pressure\n -no need for further amiodarone once 24hr drip has been completed\n" }, { "category": "Consult", "chartdate": "2117-11-02 00:00:00.000", "description": "Electrophysiology Consult Progress Note", "row_id": 503147, "text": "Consult requested by: MICU \n Chief Complaint: 27M with DM admitted with MSSA PNA c/b klebsiella VAP.\n Found to have WCT then narrow complex tachcyardia yesterday during HD\n that resolved with adenosine, likely SVT with aberrancy.\n 24 Hour Events:\n FEVER - 102.6\nF - 03:00 PM\n -no further episodes of tachycardia since yesterday afternoon\n -started on metoprolol 12.5 \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 80 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n Metoprolol 12.5mg \n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:11 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: 38.8\nC (101.8\n HR: 81 (78 - 185) bpm\n BP: 111/43(63) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 97%\n Heart rhythm:: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (0 - 359)mmHg\n Total In:\n 3,784 mL\n 1,048 mL\n PO:\n 60 mL\n TF:\n 961 mL\n 366 mL\n IVF:\n 2,522 mL\n 502 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 638 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/43/120/24/2\n Ve: 12.5 L/min\n PaO2 / FiO2: 300\n Physical Examination:\n Labs / Radiology\n 261 K/uL\n 8.8 g/dL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 37M with DM in MICU with MSSA and Klebsiella PNA, who had WCT and\n narrow-complex tachycardia during HD yesterday that appears most\n consistent with SVT with aberrancy (AVRNT vs AVRT). No further episodes\n of tachycardia since yesterday and has tolerated metoprolol.\n -continue metoprolol, would uptitrate as tolerated by blood pressure\n -no need for further amiodarone once 24hr drip has been completed\n" }, { "category": "Consult", "chartdate": "2117-11-02 00:00:00.000", "description": "Electrophysiology Consult Progress Note", "row_id": 503148, "text": "Consult requested by: MICU \n Chief Complaint: 27M with DM admitted with MSSA PNA c/b klebsiella VAP,\n ARF requiring HD, septic shock. Found to have WCT then narrow complex\n tachcyardia yesterday during HD that resolved with adenosine, likely\n SVT with aberrancy.\n 24 Hour Events:\n FEVER - 102.6\nF - 03:00 PM\n -no further episodes of tachycardia since yesterday afternoon\n -started on metoprolol 12.5 \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 80 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n Metoprolol 12.5mg \n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:11 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: 38.8\nC (101.8\n HR: 81 (78 - 185) bpm\n BP: 111/43(63) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 97%\n Heart rhythm:: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (0 - 359)mmHg\n Total In:\n 3,784 mL\n 1,048 mL\n PO:\n 60 mL\n TF:\n 961 mL\n 366 mL\n IVF:\n 2,522 mL\n 502 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 638 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/43/120/24/2\n Ve: 12.5 L/min\n PaO2 / FiO2: 300\n Physical Examination:\n Gen: intubated, sedated\n CV: s1/s2, rrr, no mrg\n Chest: CTA anteriorly\n Abd: soft, nt/nd +bs\n Ext: no c/c/e\n Labs / Radiology\n 261 K/uL\n 8.8 g/dL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 37M with DM in MICU with MSSA and Klebsiella PNA, who had WCT and\n narrow-complex tachycardia during HD yesterday that appears most\n consistent with SVT with aberrancy (AVRNT vs AVRT). No further episodes\n of tachycardia since yesterday and has tolerated metoprolol.\n -continue metoprolol, would uptitrate as tolerated by blood pressure\n -no need for further amiodarone once 24hr drip has been completed\n" }, { "category": "Physician ", "chartdate": "2117-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 503149, "text": "TITLE:\n Chief Complaint: sepsis and ARF requiring dialysis\n 24 Hour Events:\n - wide complex tachycardia, with pulse, synch cardioversion, amiodarone\n and adenosine and back in sinus\n - EP consult: finish 24 hour amiodarone drip and give BBlocker.\n - repleted Ca2+\n - were able to wean PEEP to 10\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 100 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 38.2\nC (100.7\n HR: 78 (78 - 185) bpm\n BP: 103/40(57) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 3 (3 - 359)mmHg\n Total In:\n 3,784 mL\n 843 mL\n PO:\n TF:\n 961 mL\n 280 mL\n IVF:\n 2,522 mL\n 443 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 433 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 19 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 95%\n ABG: 7.41/43/120/24/2\n Ve: 13.4 L/min\n PaO2 / FiO2: 300\n Physical Examination\n Gen: intubated and sedated.\n Heart: NRRR; no murmurs\n Chest: CTAB\n Abdomen: obese, soft, bowel sounds present\n Ext: warm and well perfused\n Skin: morbilliform rash over abdomen improving. Warm to touch. t\n Labs / Radiology\n 261 K/uL\n 8.8 g/dL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Imaging: CXR\n IMPRESSION: AP chest compared to chest radiographs since \n including a torso CT:\n Confluent pneumonia in the left lung has worsened since .\n Small\n nodular areas of infection in the right lung documented on the torso CT\n are\n more evident today. Mediastinal widening of the thoracic inlet to the\n level\n of the carina is slightly more pronounced today than it was on .\n This area should be monitored carefully because of the possibility of\n progressive adenopathy, mediastinitis or septic thrombophlebitis.\n Bilateral internal jugular lines end in the upper SVC, ET tube is in\n standard\n placement, and nasogastric tube passes below the diaphragm and out of\n view.\n Microbiology: 10:48 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2:19 pm BLOOD CULTURE Source: Line-cvl.\n Blood Culture, Routine (Preliminary):\n GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia,\n currently remains intubated but off pressors since . Staph in\n blood/sputum (OSH), GNR in blood, klebsiella in sputum.\n .\n # Septic shock: BP stable off pressors. Culture data positive for MSSA\n in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically with vanc and cefepime with improvement in the patient\n status. CT scan did show fluid in sinuses and multi-focal pneumonia\n but no other clear source. Treated for flu although DFA neg x 2 in\n OSH, with another negative DFA here we stopped Tamiflu. Elevated mixed\n venous Sat elevated at 84% and mottled appearance most suggestive of\n septic etiology. CVP at 15, hypovolemia unlikely. Robust BP despite\n tachycardia, high mixed venous, and preserved EF on OSH ECHO suggests\n against cardiogenic shock. Given negative urine legionalla and\n prolonged QTc at times, we have avoided using a fluoroquinolone.\n Currently, we are treating for the MSSA found on blood/sputum from OSH,\n Klebsiella pneumoniae in the sputum from , GNR in blood and\n radiographic evidence of PNA. TTE normal, no signs of vegetations.\n - ID consult re: double coverage for gram negative flora. Will get a\n gent level for this morning and adjust at HD\n - Continue Nafcillin/Meropenem/Gent. The pt\ns MSSA was sensitive to\n Nafcillin at the OSH. The GNR (Klebsiella) in the sputum are sensitive\n to Meropenem. Day 1 for both was . Day 1 for gent was \n - f/u cultures\n - f/u daily CXR\n .\n # Hypoxic Resp failure: Bilateral infiltrates on CXR and high oxygen\n requirement suggestive of ARDS. Did not have any weaning of his vent\n setting yesterday, other than decreased RR to counteract alkalosis.\n - Weaned FiO2 to 40% and now with PEEP of 10. Continue to attempt to\n wean PEEP\n - Check PM ABG\n - Fentanyl and versed for sedation\n wean down as patient was minimally\n responsive this morning.\n - HD today\n .\n # Rash on back, abdomen, thighs: appears consistent with a drug rash,\n could be Vanc or Cefepime, but statistically Cefepime would be more\n likely. Discontinued vanc/cefepime on ; now on\n gent/meropenem/nafcillin.\n - Monitor\n - Clobetasol 0.05% for abdomen\n - Clotrimazole/hydro groin cream for rash\n .\n # ARF: Cr currently elevated at 7.8, currently oliguric, which will\n likely continue while he is so sick.\n - Needs new HD line today; renal will attempt to rewire.\n - Renal following\n - HD today\n .\n # Tachycardia/ AFib: appeared sinus on arrival, then through his course\n had couple runs of tachycardia that appeared to be Afib with aberrancy\n that were self-limited and well-tolerated. OSH EKG with RBBB as\n recently as , and reports of atrial fibrillation requiring\n treatment with diltiazem. Several days ago, went into AFib w/ RVR\n during dialysis. Treated w/ lopressor 10, dilt 20 IV and dilt PO60.\n Converted back to sinus after 1-2 hours. Atrial irritation believed due\n to IJ that was too deep, now pulled back. Cause of aberrant SVT during\n second HD session likely due to intracellular shifts, although cause\n not clear.\n - Dilt stopped and lopressor started again according to cardiology recs\n - Dose of lopressor 12.5 TID, will increase tomorrow if needed.\n - 24 hour amiodarone will be done at 1430\n - Watch hemodynamics and rhythm\n .\n # DM: Blood sugars continue to be elevated\n - Increased glargine; continue ISS\n - readjust this afternoon depending on sugars\n .\n OTHER STABLE ISSUES\n .\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix. No longer trending cardiac enzymes.\n .\n # Mild LFT elevation: likely prolonged hypotension.\n - Continue to trend daily LFTs\n - Limit tylenol to 2 gm daily\n #: FEN; no IVF, lytes prn, on tube feeds nutren at 40cc/hr, HD today\n Prophylaxis: Subcutaneous heparin, PPI\n Access: right IJ and A line, and HD line\n Code: Full code confirmed\n Communication: Mother, \n Disposition: pending clinical improvement\n" }, { "category": "Respiratory ", "chartdate": "2117-11-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503230, "text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 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: 26 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: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Peep weaned to 8cms, he was dialyzed with some amount of fluid removed\n ?? No other changes.\n, RRT 18:06\n" }, { "category": "Physician ", "chartdate": "2117-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 502470, "text": "TITLE:\n Chief Complaint: fevers/sepsis\n 24 Hour Events:\n MULTI LUMEN - START 02:58 PM\n MULTI LUMEN - STOP 04:30 PM\n DIALYSIS CATHETER - STOP 04:30 PM\n EKG - At 12:30 AM\n FEVER - 103.1\nF - 12:00 AM\n Abios: cefipime, vanc, tamiflu\n - Right IJ placed. Left subclavian and dialysis lines sent for\n culture. Dialysis tip touched non-sterile glove.\n - CT scan of head: no acute process. Fluid in mastoid sinuses.\n - CT scan of torso: LLL completely opacified by multifocal pneumonia,\n small amount of free fluid, abdomen otherwise benign.\n - f/u pan cultures -> respiratory culture inadequate.\n - UA w/ epi's, but pt anuric. Will f/u culture.\n - f/u LFT tomorrow to assure trending down\n - repeat ABG: 7.30/38/96, improving acidosis.\n - Started tube feeds with nutren pulmonary to goal 40ml/hour as there\n is no in-house nutrition tonight.\n - flu DFA negative, stopped oseltamivir\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 03:15 AM\n Tamiflu - 08:00 PM\n Cefipime - 04:00 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.5\nC (103.1\n Tcurrent: 37.4\nC (99.4\n HR: 77 (77 - 122) bpm\n BP: 118/50(69) {84/46(62) - 123/60(77)} mmHg\n RR: 31 (28 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 14 (12 - 19)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,448 mL\n 526 mL\n PO:\n TF:\n 89 mL\n 220 mL\n IVF:\n 1,499 mL\n 306 mL\n Blood products:\n Total out:\n 108 mL\n 10 mL\n Urine:\n 8 mL\n 10 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 2,340 mL\n 516 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 35 cmH2O\n Plateau: 29 cmH2O\n SpO2: 96%\n ABG: 7.32/37/116/19/-6\n Ve: 14.8 L/min\n PaO2 / FiO2: 232\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.1 g/dL\n 210 mg/dL\n 7.7 mg/dL\n 19 mEq/L\n 4.7 mEq/L\n 68 mg/dL\n 106 mEq/L\n 143 mEq/L\n 31.2 %\n 12.5 K/uL\n [image002.jpg]\n 11:09 PM\n 11:28 PM\n 04:30 AM\n 11:18 AM\n 06:06 PM\n 11:17 PM\n 03:17 AM\n 03:27 AM\n WBC\n 12.5\n 10.6\n 12.5\n Hct\n 37.9\n 42\n 31.7\n 31.2\n Plt\n \n Cr\n 5.4\n 7.2\n 7.7\n TropT\n 0.20\n TCO2\n 25\n 19\n 21\n 20\n Glucose\n 147\n 156\n 210\n Other labs: PT / PTT / INR:14.4/42.1/1.2, CK / CKMB /\n Troponin-T:238/2/0.20, ALT / AST:52/104, Alk Phos / T Bili:260/5.2,\n Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0 %, Mono:6.0 %,\n Eos:1.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.1 g/dL, LDH:437 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.7 mg/dL, PO4:6.4 mg/dL\n Imaging: CXR: ET tube high? continued left-sided opacity\n CXR: widespread left mid and lower lobe consolidations as well as\n right basal consolidation. Small amount of bilateral pleural effusion\n is present.\n Micro: Flu DFA negative. Urine and blood cx pending.\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n CARDIAC DYSRHYTHMIA OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n 37 y/o with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia\n .\n # Septic shock: BP stable off pressors. Culture data positive only for\n staph in the sputum and blood early in OSH course. CT scan with L > R\n infiltrates, but no sign of empyema. We broadened antibiotics\n empirically yesterday with vanc and cefepime with improvement in the\n patient\ns status. CT scan did show fluid in sinuses and multi-focal\n pneumonia but no other clear source. Treated for flu although DFA neg\n x 2 in OSH, with another negative DFA here we stopped Tamiflu.\n Elevated Mixed venous Sat elevated at 84% and mottled appearance most\n suggestive of Septic etiology. CVP at 15, hypovolemia unlikely. Robust\n BP despite tachycardia, high Mixed venous, and preserved EF on OSH ECHO\n suggests against cardiogenic shock. Given neg Urine legionalla and\n Prolonged QTc at times avoid FQ.\n - Continue Vanco and Cefepime to cover for HAP. We will continue with\n broad coverage considering improvement, and we will treat for a 15 day\n course from yesterday (today day 2).\n - f/u cultures\n - f/u read of daily CXR\n # Hypoxic Resp failure: O2 saturations have improved. Bilateral\n infiltrates on CXR and high oxygen requirement suggestive of ARDS.\n Bladder pressures are lower today, suggesting we have room to wean down\n his PEEP.\n - ARDS net protocol with TV at 6cc/kg\n - wean FiO2 and PEEP as tolerated\n - fluid removal via dialysis\n - RSBI in am\n - fentanyl and versed for sedation.\n # ARF: Cr peak at 7.5 on HD at OSH. Likely ATN. Currently oliguric,\n which will likely continue while he is so sick.\n - Renal following\n - dialysis catheter today with trial of intermittent dialysis.\n # Tachycardia: appeared sinus on arrival. Yesterday had a couple runs\n of tachycardia that appeared to be afib with aberrancy that were\n self-limited and well-tolerated. OSH EKG with RBBB as recently as\n , and reports of atrial fibrillation requiring treatment with\n diltiazem. He is currently in normal sinus rhthym.\n - titrate sedation to agitation.\n - tylenol prn\n - optimize respiratory status\n - abx as above, infectious w/u\n - monitor BP\n # Elevated Troponin: CK elevated, CKMB flat. most likely demand\n ischemia in setting of shock and persistent tachycardia vs elevated \n renal failure. ACS given age unlikely, d/c ACS treatment including ASA,\n heparin gtt, plavix\n # Acidemia: Anion gap metabolic acidosis with normal Lactic acid .\n Likely renal failure. Combined with Resp acidosis, likely poor\n ventilation in setting of LLL collapse.\n - dialysis per renal\n - maximize minute ventilation\n - trend ABG.\n # mild LFT elevation: likely prolonged hypotension. Improving.\n - trend\n - limit tylenol to 2 gm daily\n # DM: Was hyperglycemic yesterday and we are starting tube feeds, so we\n will increase his sliding scale.\n - continue Reg SS\n #: FEN; no IVF, lytes prn, on tube feeds but needs nutrition consult\n .\n Prophylaxis: Subcutaneous heparin, PPI\n .\n Access: right IJ and A line. Needs dialysis line.\n .\n Code: Full code confirmed\n .\n Communication: Mother, \n .\n Disposition: pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2117-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502532, "text": "37yo M w/ hx of diabetes and alcohol abuse who presented to Hosp on w/ flu-like symptoms including temp 105. In ED\n had seizure and was intubated. CXR showing PNA but ? H1N1. Initially\n was on pressors and was not urinating (new renal failure). Thought to\n be in and out of a.fib w/ RBBB and increasing troponin so started on\n heparin gtt as well. ECHO for ? myocarditis. Heparing off since,\n pressors OFF, tolerating HD w/ goal 1-1.5L per treatment. EEG\n done to f/u w/ seizure activity (? results from OSH). MSSA in sputum\n and blood from OSH. Now has been afebrile, WBC 10.5, still w/ ^ vent\n requirements. Transported to ICU via Med flight, arrived\n unresponsive from bolus sedation and bolus paralytic.\n Events: HD line placed, HD tolerated for 2\n hours then developed SVT\n @ rate 175, converted to SR with lopressor then dilt.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received a dialysis catheter in left IJ by renal fellow, confirmed\n by CXR. Dialysis started at 1330.\n Action:\n Pt tolerated dialysis for 2\n hours, getting 500cc fluid removed. At\n 1500 pt rhythm was 175 SVT, EKG taken but his HR dropped to 120\n Afib. His B/P never dropped below 105/ even when his HR was at it\n fastest.\n Response:\n He was given lopressor 5mg x2 IV with a slight drop in HR. He was then\n given 10mg dilt x2 IV, as well as 60mg dilt PO. He converted back to\n NSR rate 74 at 1720.\n Plan:\n Keep Pt on PO dilt while getting HD, Monitor vital signs closely.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent settings 50% 500 x 30, Peep 16 FiO2 50%. Suctioned x2 for thick\n dark tan secretions.\n Action:\n Peep was decreased to 10, with little change in O2 sats, 96-97%. When\n his heart rhythm was in afib his O2 sats dropped to 92-94%, ABG drawn\n was 7.46/33/59.\n Response:\n When converted back to NSR O2 sats improved, FiO2 dropped back to 50%,\n ABG pending.\n Plan:\n Check ABG, monitor O2 sats, continue to wean when possible.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp has been up and down today with temp max of 101.0, continues on\n vanco, received 500mg post HD, and cefepime.\n Action:\n Pt placed on cooling blanket with each temp spike, each time on cooling\n blanket for 1/2h to get his temp down.\n Response:\n Blood cultures drawn at 1800 when he spiked his temp to 101.0. He\n tends to spike his fevers at night.\n Plan:\n Continue with antibiotics, monitor temp closely, cooling blanket for\n temp >101.0\n" }, { "category": "Nursing", "chartdate": "2117-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 502665, "text": "Pt is a 37yo male with a h/o of diabetes and alcohol abuse who\n presented to Hosp on w/ flu-like symptoms,\n including temp 105. In ED had seizure and was intubated. CXR showing\n PNA. Initially was on pressors and was not urinating (new renal\n failure). Thought to be in and out of a.fib w/ RBBB and increasing\n troponin so started on heparin gtt as well. ECHO for ? myocarditis.\n Heparin has been off since, pressors off, tolerating HD w/ goal\n 1-1.5L per treatment. EEG done to f/u w/ seizure activity (? results\n from OSH). MSSA in sputum and blood from OSH. Now has been afebrile,\n WBC 10.5, still w/ ^ vent requirements. Transported to ICU via\n Med flight, arrived unresponsive from bolus sedation and bolus\n paralytic.\n Pt started on PO diltizem today for h/o afib/svt.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Hemodynamically stable. Remains off pressers today. Tmax 103.3.\n Action:\n Cooling blanket on all day. Tylenol given this am.\n Response:\n Temp down to 99.5\n Plan:\n Continue to monitor. Antibx. As ordered\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains on ACx 30/500/50/10. LS Rhonchorus. Sxned for thick tan\n secretions\n Action:\n No vent changes or weaning attempted today.\n Response:\n No change in vent status\n Plan:\n Continue to monitor\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal u./o today.\n Action:\n HD started this evening. Goal 1 liter removal with 2 hour HD\n Response:\n Plan:\n Continue to monitor.\n" }, { "category": "Respiratory ", "chartdate": "2117-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502576, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 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 Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / 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: triggers irregularly, little dysynchronous on\n inspiration. Total RR sometimes > 35\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n ABG with 10 peep and 50% on vent = 7.43,35,79.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 502885, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: OSH\n Reason: emergent\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: 29 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:\n Secretions\n Sputum color / consistency: Green / Tenacious\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:\n Reason for continuing current ventilatory support: cannot protect\n airway, Pneumonia, white out left lung, pending procedure\n ( BAL )\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Today CXR showing L lung white out, ETT appears ~ 4.7 cm ^ carina.\n Recruitment maneuvers ordered. Done x 2 @ 2330.\n Peep ^ to 12 cm from 10. After breaths, pt coughed and was sx for\n copious tk green secretions. Spec sent during daytime today. Suggested\n bronchoscopy may be needed.\n" }, { "category": "Respiratory ", "chartdate": "2117-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 503009, "text": "Demographics\n Day of intubation: 6\n Day of mechanical ventilation: 6\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: 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:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt changes today; Fio2 to 50%, In the PM he had a sustained V-Tach\n that was Rx\nd with a Amioderone drip to control.\n Presently stable.\n, RRT 16:48\n" }, { "category": "Consult", "chartdate": "2117-11-02 00:00:00.000", "description": "Electrophysiology Consult Progress Note", "row_id": 503162, "text": "Consult requested by: MICU \n Chief Complaint: 27M with DM admitted with MSSA PNA c/b klebsiella VAP,\n ARF requiring HD, septic shock. Found to have WCT then narrow complex\n tachcyardia yesterday during HD that resolved with adenosine, likely\n SVT with aberrancy.\n 24 Hour Events:\n FEVER - 102.6\nF - 03:00 PM\n -no further episodes of tachycardia since yesterday afternoon\n -started on metoprolol 12.5 \n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Cefipime - 04:00 AM\n Gentamicin - 03:18 PM\n Meropenem - 08:00 PM\n Nafcillin - 06:12 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 80 mcg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Famotidine (Pepcid) - 04:06 AM\n Other medications:\n Metoprolol 12.5mg \n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:11 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: 38.8\nC (101.8\n HR: 81 (78 - 185) bpm\n BP: 111/43(63) {102/40(57) - 122/59(76)} mmHg\n RR: 25 (23 - 31) insp/min\n SpO2: 97%\n Heart rhythm:: SR (Sinus Rhythm)\n Wgt (current): 122.1 kg (admission): 119 kg\n Height: 69 Inch\n CVP: 5 (0 - 359)mmHg\n Total In:\n 3,784 mL\n 1,048 mL\n PO:\n 60 mL\n TF:\n 961 mL\n 366 mL\n IVF:\n 2,522 mL\n 502 mL\n Blood products:\n Total out:\n 2,853 mL\n 410 mL\n Urine:\n 53 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 931 mL\n 638 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 4\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/43/120/24/2\n Ve: 12.5 L/min\n PaO2 / FiO2: 300\n Physical Examination:\n Gen: intubated, sedated\n CV: s1/s2, rrr, no mrg\n Chest: CTA anteriorly\n Abd: soft, nt/nd +bs\n Ext: no c/c/e\n Labs / Radiology\n 261 K/uL\n 8.8 g/dL\n 172 mg/dL\n 8.8 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 84 mg/dL\n 97 mEq/L\n 137 mEq/L\n 26.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:49 AM\n 03:58 AM\n 11:13 AM\n 01:50 PM\n 01:55 PM\n 01:58 PM\n 02:16 AM\n 02:33 AM\n 05:09 AM\n 06:15 AM\n WBC\n 10.3\n 11.2\n 9.5\n Hct\n 30.0\n 27.1\n 26.5\n Plt\n 292\n 286\n 261\n Cr\n 9.4\n 7.5\n 8.8\n TCO2\n 26\n 25\n 29\n 28\n 29\n 28\n Glucose\n 199\n 191\n 172\n Other labs: PT / PTT / INR:15.0/33.5/1.3, CK / CKMB /\n Troponin-T:550/2/0.21, ALT / AST:50/85, Alk Phos / T Bili:246/2.4,\n Amylase / Lipase:57/, Differential-Neuts:82.0 %, Band:1.0 %, Lymph:10.0\n %, Mono:6.0 %, Eos:1.0 %, Lactic Acid:1.4 mmol/L, Albumin:1.9 g/dL,\n LDH:321 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 37M with DM in MICU with MSSA and Klebsiella PNA and ARF requiring HD,\n who had WCT and narrow-complex tachycardia during HD yesterday that\n appears most consistent with SVT with aberrancy (AVRNT vs AVRT). No\n further episodes of tachycardia since yesterday and has tolerated\n metoprolol.\n -Continue metoprolol, would uptitrate as tolerated by blood pressure\n -No need for further amiodarone once 24hr drip has been completed\n -We will sign off for now but please call with any questions. Thank you\n for this consult.\n" }, { "category": "Radiology", "chartdate": "2117-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110044, "text": " 2:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for ETT placement & lung fields\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with ARDS, ARF, Febrile\n REASON FOR THIS EXAMINATION:\n please evaluate for ETT placement & lung fields\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Acute renal failure, fever, ARDS. Endotracheal tube\n placement.\n\n COMPARISON: Multiple chest radiograph and chest CT, with the most recent from\n .\n\n SINGLE FRONTAL VIEW OF THE CHEST: The right lateral pleural sulcus is not\n included in the image. An endotracheal tube with the tip approximately 4.5 cm\n above the carina. An NG tube with the tip below the diaphragm but not\n included on the image are again seen. Bilateral internal jugular intravenous\n catheter with the tip at the junction of SVC-brachiocephalic vein are noted.\n Left sided areas of pulmonary consolidations have improved. Right lung\n pulmonary nodular opacities are less visible. There is no radiological\n evidence of ARDS. Heart is not enlarged. Right paratracheal fullness is\n stable and secondary to fat and lymph nodes as suggested by prior CT.\n\n IMPRESSION:\n 1. Right lung pulmonary nodular opacities are less visible. This may be\n secondary to resolution of these infiltrates or new underlying pulmonary edema\n making the nodules indistinct.\n 2. Improved left pneumonia.\n 3. Lines and tubes as above.\n 4. No radiological evidence of ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1110321, "text": " 2:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? pneumo\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man s/p L subclavian TLC and right HD cath\n REASON FOR THIS EXAMINATION:\n ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest, port line placement.\n\n REASON FOR EXAM: Assess for pneumothorax.\n\n FINDINGS: The ET tube and right internal jugular catheter are unchanged. The\n NG tube passes into the stomach and out of view. A new left subclavian\n catheter tip is at the brachiocephalic/SVC junction. Widening of the superior\n mediastinum is due to a combination of enlargement of the azygos vein and\n right paratracheal lymph node enlargement on recent CT, .\n\n Increased lung volumes account for resolution of bibasilar atelectasis,\n although dense left perihilar and infrahilar consolidation, probably\n pneumonia, is unchanged. Heart size is top normal.\n\n IMPRESSION: Persistent dense left consolidation is probably pneumonia. New\n left hemodialysis catheter. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2117-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1109399, "text": " 9:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for CNS process, infection. Please scan CT head, chest,\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 y.o with DM with sepsis, multilobar PNA with new fever to 105.\n REASON FOR THIS EXAMINATION:\n eval for CNS process, infection. Please scan CT head, chest, abd, pelvis\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: 10:51 AM\n No acute intracranial process. Evaluation for incracranial infection limited\n on ct. sinus disease. fluid in the mastoid air cells bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old man with diabetes mellitus and sepsis, multilobar\n pneumonia with new fever to 105 degrees. Evaluate for CNS process.\n\n COMPARISON: None.\n\n TECHNIQUE: Axially acquired images were obtained through the head without\n contrast.\n\n FINDINGS: There is no acute hemorrhage, large areas of edema, large masses,\n or mass effect. There is preservation of normal -white matter\n differentiation. The visualized paranasal sinuses demonstrate mucosal\n thickening of the ethmoid air cells and opacification of some of the\n left-sided ethmoid air cells and the left sphenoid sinus. The mastoid air\n cells demonstrate fluid bilaterally.\n\n IMPRESSION: No acute intracranial process. Evaluation for infection is\n limited on CT. Sinus disease. Fluid within the mastoid air cells\n bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-10-28 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1109400, "text": " 9:08 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious sources. Please Scan CT head, chest, abd\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n Field of view: 46\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 y.o with DM with sepsis, multilobar PNA with new fever to 105.\n REASON FOR THIS EXAMINATION:\n eval for infectious sources. Please Scan CT head, chest, abd/pelvis.\n non-contrast given ARF\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old man with diabetes mellitus and sepsis, multilobar\n pneumonia with new fever to 105 degrees Fahrenheit. Evaluate for infectious\n sources.\n\n COMPARISON: Chest radiograph of the same day.\n\n TECHNIQUE: Axially acquired images were obtained through the torso after the\n administration of oral contrast only. Coronal and sagittal reformatted images\n were also displayed.\n\n FINDINGS:\n\n CT OF THE CHEST WITHOUT CONTRAST: There is almost complete consolidation of\n the left lower lobe. Patchy opacities throughout the left upper lobe and\n right lung are also seen. These findings are consistent with multifocal\n pneumonia as seen on recent chest x-ray. Mediastinal lymphadenopathy is\n present, which may be reactive in nature. There is no axillary\n lymphadenopathy. The patient is intubated with the endotracheal tube ending\n 5.1 cm above the carina. An NG tube is noted ending within the stomach. There\n is a left-sided central line, which terminates at the upper SVC.\n\n CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Evaluation is slightly limited due\n to streak artifact from overlying arms. The non-contrast appearance of the\n spleen, adrenal glands, kidneys, gallbladder, pancreas and intra-abdominal\n loops of bowel are within normal limits. There is diffuse fatty infiltration\n of the liver. There is no free air. There is a trace amount of free fluid\n within the abdomen. There is no mesenteric or retroperitoneal\n lymphadenopathy.\n\n CT OF THE PELVIS WITH ORAL CONTRAST ONLY: The rectum, prostate and\n intrapelvic loops of bowel are within normal limits. A Foley catheter is\n noted within a decompressed bladder. Air within the bladder is likely from\n instrumentation. A right-sided femoral line is noted. A small amount of free\n fluid is noted within the pelvis. There is no pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: No suspicious osseous lesions are identified. A small\n sclerotic focus in the left femoral neck is consistent with a bone island.\n (Over)\n\n 9:08 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious sources. Please Scan CT head, chest, abd\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n Field of view: 46\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Evaluation limited due to lack of IV contrast and streak artifact from\n overlying arms. Multifocal pneumonia as seen on recent chest x-ray.\n 2. Fatty liver. Otherwise, non-contrast appearance of the abdomen and pelvis\n is unremarkable except for small amount of free fluid.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110088, "text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval post HD change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with diabetes, staph sepsis, atrial arrhythmia, on HD.\n REASON FOR THIS EXAMINATION:\n Please eval post HD change.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, .\n\n HISTORY: 37-year-old diabetic male with staph sepsis and atrial arrhythmia,\n on hemodialysis.\n\n FINDINGS: Single bedside AP examination \"supine at 9:50 a.m.\" is compared\n with similar examination obtained some 7 hours earlier. The ET tube and\n endogastric tube, extending below the diaphragm and beyond the inferior margin\n of the study, are unchanged. The large-bore left (likely HD) and\n standard-caliber right IJ central venous catheters reaching the\n SVC-brachiocephalic venous confluence are unchanged, with no supine evidence\n of pneumothorax. There are persistent ill-defined opacities involving the\n left more than right lung base, likely corresponding to known pneumonic\n consolidation. In addition, there is now pulmonary vascular congestion and\n blurring with mediastinal prominence, likely reflecting volume overload/CHF.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110415, "text": " 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT and PNA?\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with PNA and intubated\n REASON FOR THIS EXAMINATION:\n ETT and PNA?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Pneumonia and intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube is in the standard position. Right IJ and NG tube remain in place.\n There is opacity in the left perihilar region and left lower lobe have\n minimally improved. There are low lung volumes. Cardiac size is top normal.\n Widened mediastinum is unchanged. There is no pneumothorax or enlarging\n pleural effusion.\n\n Left subclavian catheter tip is in unchanged position in the left\n brachiocephalic vein/in the junction of the brachiocephalic veins.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110624, "text": " 2:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA status\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with spiking fevers and PNA\n REASON FOR THIS EXAMINATION:\n PNA status\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest, portable AP.\n\n REASON FOR EXAM: Evaluate for pneumonia.\n\n FINDINGS: In comparison to the previous chest radiograph, the consolidation\n in the left perihilar region and lower lobe has increased and is more dense,\n right paratracheal lymphadenopathy unchanged. The NG tube and left\n subclavian catheter are unchanged in position.\n\n IMPRESSION:\n\n Increasing left lung consolidation, most likely pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2117-10-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1109533, "text": " 12:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? line placement\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with new L IJ HD cath placed\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New line placed.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, a new central venous\n access line has been placed over the left internal jugular vein. The tip of\n the line projects over the mid SVC. There is no evidence of complications,\n notably no pneumothorax.\n\n The other monitoring and support devices are in unchanged position. Also\n unchanged is the size of the cardiac silhouette as well as the right\n suprabasal atelectasis and the relatively extensive left mid lung and basal\n parenchymal opacity with air bronchograms.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-10-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1109447, "text": " 3:04 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Confirm line placement.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with new RIJ CVL\n REASON FOR THIS EXAMINATION:\n Confirm line placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of new right internal jugular line\n placement.\n\n Portable AP chest radiograph was compared to the prior study obtained earlier\n at midnight.\n\n The right internal jugular line has been inserted in the interim with its tip\n being located at the low SVC level. The left subclavian line tip is at the\n low SVC as well. The ET tube tip is approximately 6.7 cm above the carina.\n The NG tube passes below the diaphragm with its tip below the inferior field\n of view most likely in the stomach. There is no significant interval change\n in widespread left mid and lower lobe consolidations as well as in the right\n basal consolidation. Small amount of bilateral pleural effusion is present\n and most likely unchanged since the prior imaging. No pneumothorax is\n demonstrated after insertion of the right internal jugular line.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109870, "text": " 3:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with DM, staph sepsis, hypoxic respiratory failure.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:27 A.M. :\n\n HISTORY: Diabetes, staph sepsis and hypoxic respiratory failure.\n\n IMPRESSION: AP chest compared to chest radiographs since \n including a torso CT:\n\n Confluent pneumonia in the left lung has worsened since . Small\n nodular areas of infection in the right lung documented on the torso CT are\n more evident today. Mediastinal widening of the thoracic inlet to the level\n of the carina is slightly more pronounced today than it was on .\n This area should be monitored carefully because of the possibility of\n progressive adenopathy, mediastinitis or septic thrombophlebitis.\n\n Bilateral internal jugular lines end in the upper SVC, ET tube is in standard\n placement, and nasogastric tube passes below the diaphragm and out of view.\n\n Dr. was paged to report these findings.\n\n" }, { "category": "Radiology", "chartdate": "2117-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109742, "text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with DM, sseptic shock and a course complicated by ARF and\n tachycardia, and AMS.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Shock, ARF, tachycardia.\n\n One portable view. Comparison with . Lung volumes are low, as\n before. Bilateral parenchymal radiopacities most pronounced in the lower left\n lung are again demonstrated. The heart and mediastinal structures are\n unchanged. An endotracheal tube, nasogastric tube and right internal jugular\n catheter remain in place. Compared with the previous study, density at the\n right base appears somewhat worse.\n\n IMPRESSION: Persistent parenchymal radiopacities with interval worsening of\n consolidation in the lower left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109867, "text": " 10:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? IJ placement\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with IJ into atrium and ectopy, IJ pulled back.\n REASON FOR THIS EXAMINATION:\n ? IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:41 P.M., \n\n HISTORY: IJ line in the atrium, pulled back.\n\n IMPRESSION: AP chest compared to 4:33 a.m.:\n\n Greater opacification in the left lung accompanied by leftward shift of the\n lower mediastinum indicates large part of the change is due to atelectasis,\n not surprising given the obstructive secretions in the left bronchial tree\n seen on the recent torso CT. Respiratory motion obscures detail in the right\n lung where there may be several small nodules, presumably infectious.\n Apparent increase in the caliber of the mediastinal widening, particularly to\n the left could be a function of atelectasis. On subsequent chest radiograph\n (3:30 a.m. on ) extent of progressive mediastinal widening is much\n less severe, but nevertheless warrants close surveillance for complications of\n severe infection, including progressive adenopathy or even mediastinitis,\n septic phlebitis. Bilateral central venous catheters end in the upper SVC.\n ET tube is in standard placement. Nasogastric tube passes into the stomach\n and out of view.\n\n" }, { "category": "Radiology", "chartdate": "2117-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109612, "text": " 3:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with DM presents from OSH after presenting in septic shock with\n Staph PNA / bacteria with a course complicated by ARF and tachycardia.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Tachycardia, shock.\n\n One portable view at 4 a.m. Comparison with the previous study done .\n Bilateral parenchymal opacities, with relative sparing of the apices and\n greater involvement of the left lung, are again demonstrated. The\n retrocardiac area is not well penetrated. The heart and mediastinal\n structures are stable. Endotracheal tube and bilateral internal jugular\n catheters remain in place. There is no acute change.\n\n IMPRESSION: No significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2117-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109364, "text": " 12:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF, PTX\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with PNA, intubated\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF, PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with pneumonia.\n\n No prior studies are available for comparison.\n\n Portable AP chest radiograph was reviewed. The ET tube tip is 6.3 cm above\n the carina. The NG tube tip is not clearly seen and can be followed to the\n level of low esophagus and should be evaluated on the dedicated abdominal view\n for its precise localization.\n\n There is widening of the right upper mediastinum at the level of the azygos\n vein and above. It might represent either dilated pulmonary vessels or\n lymphadenopathy. There is extensive consolidation involving most of the mid\n and low left lung zone and might be consistent with known pneumonia. Right\n basal consolidation is present, less in extent and density. There is also\n left lower lobe atelectasis giving the abrupt termination of left lower lobe\n bronchus and slight left mediastinal shift. The exact amount of pleural\n effusion is difficult to estimate, but it is most likely present, bilaterally.\n The left subclavian line tip is at the level of mid SVC.\n\n Comparison with prior radiographs is highly recommended if possible. Further\n evaluation with chest CT might be considered in particular for the evaluation\n of the mediastinum to exclude the possibility of lymphadenopathy.\n\n Within the limitations of the study, no evidence of pulmonary edema is\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110230, "text": " 2:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with diabetes, staph sputum and blood, atrial arrhythmia.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n WET READ: AEBc WED 10:36 AM\n 1. Stable mediastinal widening and convexity, attributable, at least mostly,\n to mediastinal lymphadenopathy.\n 2. Patchy consolidations throughout the left lung.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bacteremia and infected sputum. History of atrial arrhythmia.\n\n COMPARISONS: Prior day.\n\n CHEST, AP SUPINE: The patient remains intubated. A nasogastric tube courses\n into the stomach, as before. A right internal jugular venous catheter is\n unchanged. An introducer catheter terminates in the left brachiocephalic\n vein.\n\n A convex widened contour of the right upper mediastinal contour, as well as\n overall widening, likely reflects mediastinal lymphadenopathy seen on a prior\n CT. To some extent, the widening could also reflect edema. Although the\n right lung appears better aerated, noting only mild prominence of the\n pulmonary vascularity and right basilar atelectasis with low lung volumes,\n there are persistent patchy consolidations in the left lung. The latter\n appear more conspicuous. Whether this is due to considerably smaller lung\n volumes or true progression is uncertain. Small pleural effusions cannot be\n excluded.\n\n IMPRESSION:\n\n 1. Stable mediastinal widening, at least in part reflecting mediastinal\n lymphadenopathy.\n\n 2. Persistent consolidative opacities throughout much of the left lung,\n worrisome for pneumonia.\n\n 3. Better aeration of the right lung, which may be due to improvement in\n pulmonary vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2117-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1109469, "text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with ?PNA\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with pneumonia.\n\n Portable AP chest radiograph was compared to and , CT torso.\n\n There is minimal improvement of the left mid lung opacity that might be\n consistent with gradual resolution of consolidation. There is also slight\n improvement in the right basal opacity. Cardiomediastinal silhouette is\n unchanged and there is no change in the position of tubes and lines.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111973, "text": " 7:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: cxr\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pna\n REASON FOR THIS EXAMINATION:\n cxr\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Pneumonia.\n\n REFERENCE EXAM: at 0400.\n\n FINDINGS: Again seen are patchy consolidations in the left mid and lower lung\n and in the right lower lung. There is slightly increased compared to prior.\n NG tube tip is in the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111555, "text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pneumonia\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, the patient has been\n extubated. The other monitoring and support devices are in unchanged\n position. The size of the cardiac silhouette as well as the predominantly\n left basal and left mid lung parenchymal opacities are unchanged. No evidence\n of newly occurred parenchymal opacities. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-11 00:00:00.000", "description": "REPOSITION CATHETER", "row_id": 1111654, "text": " 2:39 PM\n PIC CHECK/REPO Clip # \n Reason: l dl picc 51cm, up in ij, need ir to repo\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER REPOSITION CATHETER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with l picc, r ij dialysis, l subclaivein cl\n REASON FOR THIS EXAMINATION:\n l dl picc 51cm, up in ij, need ir to repo\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 35-year-old man with left-sided PICC placement by venous\n access team on the floor. The PICC is malpositioned with catheter going up\n into the neck. A request was placed for IR-guided PICC repositioning.\n\n CLINICIANS: Dr. performed the procedure.\n\n PROCEDURE AND FINDINGS: Patient was brought to angiography suite and placed\n supine on the imaging table. The left upper arm including the existing PICC\n line was prepped and draped in the usual sterile fashion. A preprocedure\n timeout was performed. Using sterile technique, under fluoroscopic guidance,\n the indwelling left arm PICC line gradually withdrawn into the subclavian\n vein. Under fluoroscopic guidance, the PICC was advanced into SVC. The\n indicator wire which was already present in the catheter was removed. About\n 1.5 cc of contrast was injected into each port to highlight the catheter.\n Total contrast used was about 3 mL. Fluoroscopic chest image showed the\n catheter tip to be positioned in the SVC and the image was digitally saved.\n Following the repositioning, both ports were easily aspirated and flushed with\n saline. Catheter was secured to the skin with StatLock device, and sterile\n dressings were applied. The patient tolerated the procedure well with no\n immediate complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line repositioning\n with final tip position in the SVC. The line is ready to use.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1112102, "text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change of infiltrate\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with respiratory distress, pneumonia\n REASON FOR THIS EXAMINATION:\n interval change of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory distress and pneumonia.\n\n Portable AP chest radiograph was compared to .\n\n The NG tube tip is in the stomach. The cardiomediastinal silhouette is\n unchanged including right paratracheal thickening and left lung consolidations\n that when compared to several prior radiographs dating back to appears to be slightly more dense which might represent a combination of\n the consolidation with developing lung fibrosis or progression of the\n consolidation. The right basilar opacity is gradually developing and clearly\n seen on the current radiograph and might represent a progression of the right\n basal infectious process as well. There is otherwise no significant interval\n change.\n\n Findings were discussed with Dr. over the phone by Dr. \n at 9:30 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2117-11-22 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1113063, "text": ", E. MED CC7A 1:50 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: infarct, anoxic brain injury, bleed\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pneumonia and bacteremia, extubated on , now has\n word-finding difficulties\n REASON FOR THIS EXAMINATION:\n infarct, anoxic brain injury, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Extensive confluent T2 hyperintensities throughout the centrum semiovale\n and peritrigonal regions without restricted diffusion. Primary differential\n considerations would include HIV-related processes such as PML or viral\n encephalopathy versus evolving watershed infarcts with pseudonormalization of\n the ADC map. Correlation with the patient's history and followup examination\n with gadolinium administration is recommended in further evaluation.\n 2. Bilateral mastoid air cell effusions as well as maxillary and sphenoid\n sinus disease, which may in part be related to recent intubation.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1112262, "text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS, to evaluate for change.\n\n FINDINGS: In comparison with study of , there is little overall change\n in the appearance of the cardiomediastinal silhouette with extensive right\n paratracheal thickening. Extensive left lung consolidation has somewhat\n decreased since the previous study. Also, the area of opacification in the\n right lung has improved.\n\n Nasogastric tube remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1111591, "text": " 9:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 51 cm Picc placed in basilic vein, need Picc tip placement\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 51 cm Picc placed in basilic vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old male status post PICC placement.\n\n COMPARISON: Chest radiographs available from .\n\n UPRIGHT AP VIEW OF THE CHEST: The patient is status post placement of a\n left-sided PICC, which deviates up the left internal jugular vein, with\n termination point beyond the scope of this examination. The right internal\n jugular and left subclavian central venous catheters are unchanged in position\n from prior exam. A nasogastric tube terminates within the stomach. Cardiac\n and mediastinal silhouette is unchanged from prior exam. Bilateral pulmonary\n opacities, worse on the left, is unchanged. There is no pneumothorax.\n\n IMPRESSION: Status post PICC placement via left approach with the catheter\n deviated superiorly into the left internal jugular vein, with unknown\n termination point.\n\n Findings discussed by Dr. with the venous access team at 10AM .\n\n" }, { "category": "Radiology", "chartdate": "2117-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110806, "text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for source of fever, or interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with DM, febrile, on HD.\n REASON FOR THIS EXAMINATION:\n Please eval for source of fever, or interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Source of fever in a patient with diabetes mellitus\n and febrile.\n\n Portable AP chest radiograph was compared to and multiple\n prior chest radiographs.\n\n There is left lower lobe consolidation that appears to be unchanged compared\n to the prior study. This might be consistent with left lower lobe pneumonia.\n The NG tube tip passes below the diaphragm, most likely in the stomach. The\n ET tube tip is 4.3 cm above the carina. The left subclavian line tip is at\n the junction of the left brachiocephalic vein and SVC. The right internal\n jugular line tip is at the level of low SVC. The persistent right upper\n mediastinal widening is related to the presence of known lymph nodes as\n demonstrated on the CT from .\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1111614, "text": " 11:18 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Picc line reposition needs Picc tip placement\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with repositioned Picc\n REASON FOR THIS EXAMINATION:\n Picc line reposition needs Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line evaluation.\n\n Newly inserted PICC line over the left upper extremity. The line is still\n positioned in the left internal jugular vein. There is no evidence of\n changes. Unchanged distribution and density of the pre-existing parenchymal\n bilateral opacities.\n\n Venous access team was notified by the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111381, "text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Unchanged position of the monitoring and support devices. The\n pre-existing parenchymal opacities are also unchanged. Unchanged size of the\n cardiac silhouette. The left sinus is missing on today's image. No larger\n pleural effusion on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111046, "text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA status\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with PNA\n REASON FOR THIS EXAMINATION:\n PNA status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 37-year-old male with pneumonia.\n\n COMPARISON: Chest radiographs available from .\n\n SUPINE AP VIEW OF THE CHEST:\n The patient is status post intubation, with endotracheal tube terminating 4.2\n cm above the level of the carina. There is a right internal jugular central\n venous line terminating within the mid SVC. There is also a left subclavian\n central venous catheter terminating within the distal SVC. In comparison with\n prior chest radiograph from , there has been no significant change of\n the lower left lung opacification or right basilar atalectasis.\n\n IMPRESSION:\n No significant change of the left lower lobe opacification or right basilar\n atalectasis.\n\n" }, { "category": "Radiology", "chartdate": "2117-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110933, "text": " 3:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with diabetes, febrile, staph bacteremia,\n klebsiella/pseudomonas in sputum.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetes with fever.\n\n FINDINGS: In comparison with the study of , there is probably little\n overall change. Monitoring and support devices remain in place. Extensive\n opacification in the lower half of the left lung is again seen. Again this is\n probably consistent with pneumonia and pleural effusion. Small amount of\n opacification at the right base most likely represents atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111725, "text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with fevers, evaluate for infiltrate\n REASON FOR THIS EXAMINATION:\n ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the left and right central\n venous access lines have been removed. A left-sided PICC line has been\n re-positioned. The pre-existing left pneumonia shows signs of decrease in\n extent and density. No evidence of newly appeared focal parenchymal\n opacities, unchanged size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111878, "text": " 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pna\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Pneumonia, evaluate for change.\n\n One view. Comparison with the previous study done earlier the same day.\n There is motion artifact. Patchy consolidation in the left mid and lower lung\n and ill-defined increased density at the right base persist. The heart and\n mediastinal structures are unchanged. A nasogastric tube remains in place.\n\n IMPRESSION: Limited study demonstrating no definite change.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1112054, "text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with whiteout of left lung\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON AT 1248\n\n HISTORY: Whiteout of left lung, interval change.\n\n FINDINGS: Compared to the film from earlier the same day there is improved\n aeration in the left lung however there continues to be a left mid lung and\n lower lobe patchy alveolar infiltrate more confluent in the lower lung _____\n volume loss is evident. There is improved aeration of the left upper lung.\n There is increased alveolar infiltrate in the right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111328, "text": " 2:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Patient with pneumonia, evaluate for interval change.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position and analysis is performed in direct comparison\n with the next preceding study of . The patient's position was\n slightly changed from supine to slightly elevated. The patient remains\n intubated, the ETT terminating in the trachea. Previously described right\n internal jugular approach central venous line remains unchanged. The same\n holds for a previously described NG tube reaching far below diaphragm. No\n pneumothorax has developed. Previously described density in left lower lung\n field obliterating he diaphragmatic contour persists. No new pulmonary\n abnormalities are seen, however, more crowded appearance of pulmonary\n vasculature is suggestive of poor inspirational level at the time of image\n exposure.\n\n IMPRESSION: Persistent pneumonic infiltrate mostly in left lower lung field.\n No pneumothorax or other abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-23 00:00:00.000", "description": "LUMBAR SPINAL PUNCTURE", "row_id": 1113262, "text": " 9:42 AM\n LUMBAR PUNCTURE Clip # \n Reason: infection\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ********************************* CPT Codes ********************************\n * LUMBAR SPINAL PUNCTURE FLUORO GUID FOR SPINE DIAG/THE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with mental status changes, MRI finding of possible\n encephalitis, HIV status pending. Failed bedside attemps.\n REASON FOR THIS EXAMINATION:\n infection\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR PUNCTURE:\n\n HISTORY: Multiple attempts for lumbar puncture on the floor by the referring\n clinician were unsuccessful. Patient is referred for fluoroscopic guided\n lumbar puncture.\n\n Patient is a 37 y/o male with a history of pneumonia and change in mental\n status.\n\n Informed consent was obtained after explaining the risks, indications, and\n alternative management. Patient was brought to the fluoroscopic suite and\n placed on the fluoroscopic table in prone position. Access to the lumbar\n subarachnoid space was obtained with a 22 gauge spinal needle under local\n anesthesia using 1% Lidocaine with aseptic precautions. Approximately 23 cc of\n CSF collected. The patient tolerated the procedure well without any\n complications. The patient was sent to the floor with post-procedure orders.\n\n Access was obtained at the level of L2/3.\n\n IMPRESSION: Successful fluoro guided lumbar puncture with samples sent for\n routine laboratory analysis as requested by the referring physician.\n\n Dr. the attending interventionalist was present and supervising\n throughout the entire procedure.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-22 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1113062, "text": " 1:50 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: infarct, anoxic brain injury, bleed\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pneumonia and bacteremia, extubated on , now has\n word-finding difficulties\n REASON FOR THIS EXAMINATION:\n infarct, anoxic brain injury, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BLjb MON 10:00 AM\n PFI:\n 1. Extensive confluent T2 hyperintensities throughout the centrum semiovale\n and peritrigonal regions without restricted diffusion. Primary differential\n considerations would include HIV-related processes such as PML or viral\n encephalopathy versus evolving watershed infarcts with pseudonormalization of\n the ADC map. Correlation with the patient's history and followup examination\n with gadolinium administration is recommended in further evaluation.\n 2. Bilateral mastoid air cell effusions as well as maxillary and sphenoid\n sinus disease, which may in part be related to recent intubation.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Brain MRI.\n\n HISTORY: 37-year-old male with pneumonia and bacteremia, now with word\n finding difficulties.\n\n COMPARISON: None.\n\n TECHNIQUE: Sagittal T1, axial T2 FSE, T2 GRE, FLAIR, diffusion-weighted\n sequences of the brain were obtained.\n\n FINDINGS: There are striking confluent T2 and FLIR hyperintensities\n throughout the centrum semiovale, extending into the peritrigonal regions.\n There is subtle abnormal T2 hyperintense signal within the pons and a tiny\n cystic- appearing abnormality in the right centrum semiovale. There is no\n restricted diffusion or hydrocephalus. There are bilateral mastoid air cell\n effusions with a mucus retention cyst within the left maxiallry sinus with\n mucosal disease in the sphenoid sinus. The flow voids are normal.\n\n IMPRESSION:\n 1. Extensive confluent T2 and FLAIR hyperintensities throughout the centrum\n semiovale and peritrigonal regions without restricted diffusion. The findings\n most likely represent sequelae of a systemic metabolic/hypoxic insult with\n additional considerations to include infectious or HIV-related processes such\n as PML or viral encephalopathy. Given the marked hypotension 3 weeks prior,\n the findings could represent evolving watershed infarcts with\n pseudonormalization of the ADC map or even osmotic demyelination in the\n appropriate context. Correlation with the patient's history and followup\n examination with gadolinium administration is recommended in further\n evaluation.\n (Over)\n\n 1:50 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: infarct, anoxic brain injury, bleed\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Bilateral mastoid air cell effusions as well as maxillary and sphenoid\n sinus disease, which may in part be related to recent intubation.\n\n The findings were discussed with Dr. by Dr. at 09:00 hours on\n .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110841, "text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval NG tube placement\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n please eval NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of NG tube placement.\n\n Portable AP chest radiograph was compared to .\n\n The NG tube tip passes below the diaphragm with its tip below the inferior\n margin of the field of view most likely in the distal stomach. The ET tube\n tip is 5 cm above the carina. Right internal jugular line and left subclavian\n line are in unchanged position. The left lower lobe consolidation is\n redemonstrated, as well as right basal linear opacities most likely consistent\n with atelectasis. No pulmonary edema has been demonstrated as well as no\n appreciable pneumothorax or pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111876, "text": " 1:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with pneumonia, with decreased breath sounds on right.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Decreased breath sounds on right.\n\n One view. Comparison with the previous study of . Patchy\n consolidation in the left lung. Minimally increased streaky density at the\n right base persists. The heart and mediastinal structures are unchanged. The\n nasogastric tube remains in place.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-22 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1113102, "text": " 9:44 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: infection, anoxic brain injury. Please get MRI with contra\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with bacteremia and pneumonia, recovering nicely but has word\n finding difficulties. MRI without contrast showed possible encephalitis.\n Please get MRI with contrast\n REASON FOR THIS EXAMINATION:\n infection, anoxic brain injury. Please get MRI with contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Brain MRI with gadolinium.\n\n HISTORY: A 37-year-old male with complicated medical course initiated with\n bacteremia and pneumonia, followed by extended intubation. The patient now\n shows signs of possible encephalitis.\n\n COMPARISON: Brain MRI on this date.\n\n TECHNIQUE: Axial pre- and post-gadolinium fast spin echo T1, sagittal post-\n gadolinium MP-RAGE with axial and coronal reformatted sequences of the brain\n were obtained.\n\n FINDINGS: There are patchy linear regions of enhancement embedded essentially\n within the signal abnormality within the centrum semiovale. The majority of\n lesions demonstrate reticular nodular patterns of enhancement, with only a\n single lesion demonstrating subtle rim enhancement, though measuring just\n under 5 mm. There is no appreciable enhancement within the pons.\n\n IMPRESSION: Patchy foci of enhancement throughout the signal abnormality\n within the centrum semiovale with primary differential considerations again\n including metabolic/hypoxic processes. The findings could relate to subacute\n infarcts relating to prior watershed event or osmotic demyelination.\n Correlation with CSF sampling is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1112005, "text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: DIABETES MELLITUS;SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with PNA\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Pneumonia, question interval change.\n\n REFERENCE EXAM: .\n\n FINDINGS: Compared to the prior study there is new complete opacification of\n a left hemithorax with mediastinal shift to the left. This is consistent with\n volume loss and probable associated effusion. There is some patchy infiltrate\n in the right lower lung. The NG tube tip is in the stomach. These findings\n were called to the MICU at the time of dictating this report at 8:30 a.m. on\n .\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2111-10-12 00:00:00.000", "description": "Report", "row_id": 79334, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 158\nBSA (m2): 1.83 m2\nBP (mm Hg): 105/55\nHR (bpm): 86\nStatus: Outpatient\nDate/Time: at 15:12\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severe\nglobal LV hypokinesis. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\n\nAORTA: Mildly dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe\n[3+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is mildly dilated. There\nis severe global left ventricular hypokinesis. No masses or thrombi are seen\nin the left ventricle. The right ventricular cavity is dilated. Right\nventricular systolic function appears depressed. The aortic root is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate to severe (3+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate to severe [3+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-19 00:00:00.000", "description": "PICC W/O PORT", "row_id": 882741, "text": " 8:51 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: need PICC line placed by interventional rads\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ********************************* CPT Codes ********************************\n * PICC W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION *\n * FLUOR GUID PLCT/REPLCT/REMOVE FEE ADJUSTED IN SPECIFIC SITUATION *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with L humeral fracture and AMS\n REASON FOR THIS EXAMINATION:\n need PICC line placed by interventional rads\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left humeral fracture and AMS. Requires TPN and antibiotics. Unable\n to place PICC at bedside.\n\n PROCEDURE: Procedure was performed by Dr. . No attending radiologist\n was present for the procedure. As no suitable superficial veins were present,\n the deep venous system of the right upper extremity was examined with\n ultrasound and the right basilic vein was found to be patent and compressible.\n Standard sterile prep and drape of the right arm. Using realtime ultrasound\n guidance, a 21-gauge needle was used to puncture the right basilic vein. A\n 0.018-inch guide wire was advanced through the needle into the superior vena\n cava using fluoroscopic guidance. Needle was exchanged for the micropuncture\n sheath and then a 5- French double- lumen PICC was cut to a length of 40 cm\n based on the markers on the guide wire. The PICC was then placed over the\n wire through the sheath and the wire and sheath were removed. Both lumens of\n the catheter flushed and aspirated well, were capped and heplocked. The\n catheter was fixed in place with a StatLock device and a sterile transparent\n dressing was applied. Final limited chest radiograph confirmed the catheter\n tip position at the superior vena- right atrial junction. No immediate\n complications.\n The study was reviewed by Dr. .\n\n IMPRESSION: Successful placement of a 5-French double lumen 40 cm PICC by way\n of the right basilic vein with tip at the superior vena cava-right atrial\n junction. The catheter may be used immediately.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-28 00:00:00.000", "description": "PICC W/O PORT", "row_id": 883822, "text": " 11:47 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: unable to place PICC at bedside recently, last IR guided PIC\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man w/ vent-associated PNA, poor iv access, needs picc for abx\n REASON FOR THIS EXAMINATION:\n unable to place PICC at bedside recently, last IR guided PICC falling out\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia, left humeral fracture, IV team unable to place bedside\n PICC.\n\n PROCEDURE: The procedure was performed by Drs. and with Dr.\n , the attending radiologist, supervising during the entire procedure.\n\n As no suitable superficial veins were present, the deep venous system of the\n right upper extremity was examined with ultrasound. The right brachial vein\n was found to be patent and compressible. Standard sterile prep and drape of\n the right arm. Local anesthesia with 7 cc of 1% lidocaine subcutaneously.\n Using realtime ultrasound guidance, the right brachial vein was punctured\n using a 21-gauge needle. A 0.018-inch guidewire was advanced through the\n needle into the superior vena cava using fluoroscopic guidance. The needle\n was exchanged for the introducer sheath and then a 4 French single-lumen PICC\n was cut to the length of 37 cm based on the markers on the guidewire. The\n PICC was then placed over the wire through the sheath. The wire and sheath\n were removed. The catheter flushed and aspirated well, was capped and\n heplocked. The catheter was sutured in place with a single 2-0 Prolene suture\n and also fixated in position with a StatLock device. Final limited chest\n radiograph confirmed the catheter tip position at the superior vena cava-right\n atrial junction. A sterile transparent dressing was applied.\n\n No immediate complications.\n\n IMPRESSION: Successful placement of a 37-cm 4 French single-lumen PICC by way\n of the right brachial vein with tip at the superior vena cava-right atrial\n junction. The catheter may be used immediately.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-24 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 883420, "text": " 4:54 PM\n PORTABLE ABDOMEN Clip # \n Reason: Check for OG tube placement.\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with respiratory distress.\n REASON FOR THIS EXAMINATION:\n Check for OG tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: Tube insertion.\n\n An NGT is present terminating in the mid stomach. There is no bowel\n distension. A femoral vascular catheter is present on the left side of the\n pelvis. The visualized left base of the lung is opacified.\n\n IMPRESSION: The NGT terminates in the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883138, "text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening pulmonary edema\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF and AMS, now with episode of labored breathing.\n\n REASON FOR THIS EXAMINATION:\n ? worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF and dyspnea. Worsening pulmonary edema.\n\n IMPRESSION: AP chest compared to and :\n\n Low lung volumes have worsened; there is more consolidation at both lung\n bases, worrisome for pneumonia. Moderate cardiomegaly is stable. Upper lungs\n show pulmonary vascular congestion but no edema. Tip of the right PIC\n catheter is in the SVC. Right atrial and left ventricular pacers and right\n ventricular pacer defibrillator leads are unchanged in their respective\n positions. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883217, "text": " 3:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ETT placement; infiltrates\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF and AMS, now s/p intubation\n REASON FOR THIS EXAMINATION:\n ? ETT placement; infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n INDICATION: Patient with failure, recently intubated.\n\n Since an earlier chest x-ray this morning at 9 a.m., the patient has been\n intubated, and the ETT terminates 1 cm above the carina. Otherwise, the\n appearance of the chest remains the same as eight hours previously. The\n comminuted fracture of proximal left humerus is again noted.\n\n IMPRESSION: ETT insertion as noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883460, "text": " 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o new infiltrate\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF and AMS, intubated.\n REASON FOR THIS EXAMINATION:\n r/o new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n CLINICAL DETAILS: Congestive cardiac failure, evaluate for consolidation.\n\n Comparison made with previous x-ray.\n\n FINDINGS:\n Even allowing for AP projection the heart size is enlarged. Biventricular\n pacemaker in situ. Patient is post sternotomy and CABG.\n\n The endotracheal tube tip lies at least 2 cm above the level of the carina.\n\n The right lung is clear. There is increased at the lung base with indistinct\n lateral left hemidiaphragm outline likely due to some left basal pleural\n effusion.\n\n No pulmonary edema or consolidation.\n\n Only the very medial edge of the known comminuted proximal left humeral\n fracture is included on the film.\n\n CONCLUSION: Small left pleural effusion and adjacent atelectasis.\n\n" }, { "category": "ECG", "chartdate": "2111-10-24 00:00:00.000", "description": "Report", "row_id": 209633, "text": "Ventricular paced rhythm\nVentricular premature complexes\nAtrial mechanism uncertain\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-10-21 00:00:00.000", "description": "Report", "row_id": 209634, "text": "Baseline artifact\nVentricular paced rhythm\nVentricular premature complexes\nAtrial mechanism is probable atrial fibrillation\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-10-13 00:00:00.000", "description": "Report", "row_id": 209874, "text": "Probable atrial fibrillation with rapid ventricular response intermittent\nventricular premature complex\nVentricular premature complex\nRight ventricular conduction delay pattern/ Incomplete right bundle branch\nblock pattern\nConsider left anterior fascicular block and possible inferior infarct, age\nindeterminate\nAnteroseptal myocardial infarct, age indeterminate\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-10-11 00:00:00.000", "description": "Report", "row_id": 209875, "text": "Baseline artifact\nProbable atrial fibrillation with rapid ventricular response intermittent\nventricular paced beats\nRight ventricular conduction delay pattern/incomplete right bundle branch\nblock pattern\nConsider left anterior fascicular block and possible inferior infarct, age\nindeterminate\nAnteroseptal myocardial infarct, age indeterminate\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of the same date, tachy arrhythmia with intrinsic\nconduction now present\n\n" }, { "category": "ECG", "chartdate": "2111-10-11 00:00:00.000", "description": "Report", "row_id": 209876, "text": "Ventricular paced rhythm\nVentricular premature complexes\nAtrial mechanism is atrial fibrillation\nSince previous tracing of , ventricular rate increased\n\n" }, { "category": "ECG", "chartdate": "2111-10-10 00:00:00.000", "description": "Report", "row_id": 209877, "text": "Ventricular paced rhythm\nVentricular premature complexes\nAtrial mechanism is atrial fibrillation\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-10-09 00:00:00.000", "description": "Report", "row_id": 209878, "text": "Ventricular paced rhythm\nVentricular premature complexes\nAtrial mechanism is atrial fibrillation\nNo previous tracing for comparison\n\n" }, { "category": "Radiology", "chartdate": "2111-10-28 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 883835, "text": " 1:00 PM\n N-G TUBE PLACEMENT Clip # \n Reason: Please place post-pyloric tube\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ********************************* CPT Codes ********************************\n * -INTESTINAL TUBE PLACEMENT (W/FL *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p displace humerous fracture now with pain and decreased\n mental status now s/p extubation.\n REASON FOR THIS EXAMINATION:\n Please place post-pyloric tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia, left humeral fracture, decreased level of consciousness,\n needs enteric access for feeds and medications.\n\n PROCEDURE: The procedure was performed by Drs. and with Dr.\n , the attending radiologist, supervised the procedure.\n\n Hurricaine spray and Surgilube jelly were applied to the right nostril. With\n the aid of a Glidewire, the nasoenteric tube was passed through the right\n nostril into the stomach using fluoroscopic guidance. The Glidewire was\n exchanged for an Amplatz wire and the feeding tube was exchanged for \n catheter and the guidewire was positioned beyond the pylorus in the proximal\n jejunum. The catheter was then exchanged for the feeding tube and\n feeding tube was positioned with its tip at the level of the ligament of\n Treitz (duodenal-jejunal junction) in a post-pyloric location. This was done\n using fluoroscopic guidance. Injection of air through the catheter under\n fluoroscopic control confirmed catheter tip placement as outlined above. A\n final limited abdominal radiograph confirmed catheter tip position as outlined\n above. The catheter was fixed in position with tape on the nose. No\n immediate complications. The catheter may be used immediately.\n\n IMPRESSION: Successful placement of a 12 French nasoenteric feeding tube with\n tip in a post-pyloric location at the level of the ligament of Treitz\n (duodenal-jejunal junction). The catheter may be used immediately.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 883590, "text": " 12:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PICC line location\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF and AMS, intubated. Please eval for placement of PICC\n and evaluate progression of pneumonia.\n REASON FOR THIS EXAMINATION:\n PICC line location\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST WITH PRIOR COMPARISON .\n\n INDICATION: PICC line placement.\n\n A chest radiograph centered to the left of midline including the left shoulder\n is submitted for interpretation. The periphery of the right lung and the\n right axillary region are not included on this radiograph. With this\n limitation in mind, no definite PICC line is visualized. An endotracheal\n tube, ICD with biventricular pacing lead, and nasogastric tube remain in\n place. There is stable cardiomegaly and retrocardiac opacification as well as\n persistent bilateral pleural effusions. An impacted displaced fracture of the\n left humeral neck is also noted.\n\n IMPRESSION: No PICC line is identified on this limited study. Previously\n present right PICC line is not visualized, as discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2111-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881783, "text": " 12:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hypoxia.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:06 A.M. ON \n\n HISTORY: Hypoxia, rule out pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Mild pulmonary edema has developed accompanied by numerous small right pleural\n effusion. Severe cardiomegaly is stable. Atrial biventricular pacer leads\n are in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882974, "text": " 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna, chf, pneumothorax.\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF and AMS, now with episode of acute desaturation.\n REASON FOR THIS EXAMINATION:\n r/o pna, chf, pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, acute desaturation.\n\n Single portable AP semi-upright chest radiograph is reviewed and compared to\n the prior study of . Again seen is an atrio-biventricular\n pacer and ICD with leads in standard position. The patient is status post\n median sternotomy and CABG. There is a right-sided PICC line with its tip in\n the mid SVC. There is no evidence of pneumothorax. There has been interval\n removal of the nasogastric tube. There is severe cardiomegaly with aortic\n tortuosity. Perihilar haziness suggests mild congestive heart failure. There\n is increasing consolidation in the left lower lobe which represents\n atelectasis or pneumonia.\n\n IMPRESSION:\n 1. Mild congestive heart failure.\n 2. Increasing atelectasis or pneumonia in the left lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-14 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 882165, "text": " 2:36 PM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n Reason: evaluation of humeral fracture\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with L humeral fracture\n REASON FOR THIS EXAMINATION:\n evaluation of humeral fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left humeral fracture.\n\n TECHNIQUE: Multidetector CT images of the left shoulder were obtained without\n intravenous contrast material.\n\n Sagittal and coronal reformations were created.\n\n CT OF THE LEFT SHOULDER WITHOUT CONTRAST: A reference is made to a prior\n radiograph dated . There is a complex, comminuted fracture\n through the surgical neck of the left humerus with anteromedial angulation of\n the humeral shaft. A small fracture involving the distalmost aspect of the\n clavicle is likely also present. The acromioclavicular joint is preserved.\n The humeral head is normally seated within the glenoid, without evidence of\n dislocation. An unusual dense ovoid bony \"nodule\" is present adjacent to the\n fracture site and is of unclear etiology. ? sclerotic focus within the\n bone (e.g. bone island which was \"released\" by the fracture or possibly a\n dense loose body in the joint space. There is surrounding soft tissue hematoma\n and effusion. Incidental note is made of a 3.3 x 1.7 cm lipoma along the\n lateral aspect of the proximal humeral shaft.\n\n IMPRESSION: Comminuted, displaced fracture through the surgical neck of the\n left humerus as above. Small distal clavicular fracture. Unusual ovoid\n density, as described.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 881512, "text": " 11:19 AM\n CHEST (PA & LAT) Clip # \n Reason: R/O PNA\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with L humeral fracture and basilar crackles\n REASON FOR THIS EXAMINATION:\n R/O PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:32 A.M:\n\n HISTORY: Basal crackles.\n\n IMPRESSION: PA and lateral view. Consolidation at the base of the left lung\n may represent pneumonia. Lungs are otherwise clear. Small left pleural\n effusion is probably present. Heart is severely enlarged. Transvenous right\n atrial and left ventricular pacer and right ventricular pacer defibrillator\n leads are in standard placements, continuous from the left axillary pacemaker.\n\n Fracture of the proximal left humerus is noted.\n\n Dr. and I discussed these findings.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882418, "text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess progression of pulmonary effusions/edema\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF with AMS\n REASON FOR THIS EXAMINATION:\n please assess progression of pulmonary effusions/edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old. Assess for primary effusions and edema.\n\n CHEST X-RAY AP PORTABLE VIEW.\n\n COMPARISON: .\n\n FINDINGS: The biventricular pacer device is in good position with the leads\n in the floor of the right ventricle and the anterior intraventricular vein.\n There is normal alignment of the median sternotomy sutures. The heart and\n mediastinal contours are stable. Perihilar haziness with pulmonary venous\n congestion is again noted consistent with pulmonary edema.\n\n IMPRESSION: Persistent pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-08 00:00:00.000", "description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT", "row_id": 881413, "text": " 6:02 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: pt s/p fall ? dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with ? dislocation s/p fall\n REASON FOR THIS EXAMINATION:\n pt s/p fall ? dislocation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question dislocation status post fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Left shoulder, 2 views.\n\n 2 VIEWS OF LEFT SHOULDER: There is a comminuted fracture of the left proximal\n humerus, with medial displacement of the distal fracture fragment with respect\n to the proximal fracture fragment. Comminuted fracture fragments are seen\n posteriorly and medially. The humeral head fracture fragment appears to\n overlie the glenoid, although the relationship of the articular surfaces is\n poorly delineated. A left-sided pacemaker is seen in the left chest wall.\n There is irregularity of the distal aspect of the left clavicle possibly\n related to prior trauma, although no definite displaced fracture fragment is\n identified.\n\n IMPRESSION: Comminuted, displaced fracture of the left proximal humerus.\n\n 2. Irregularity of distal left clavicle may relate to old trauma. Additional\n radiographs of this area could be obtained for further evaluation.\n Alternatively, a CT of the shoulder could be obtained for further\n characterization of the humeral fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882616, "text": " 10:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O pneumothorax\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF with AMS s/p failed Left IJ placement\n\n REASON FOR THIS EXAMINATION:\n R/O pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM\n\n History of failed left jugular CV line placement.\n\n No pneumothorax. Status post CABG. There is a left-sided ICD with\n atrioventricular and coronary sinus leads in situ. NG tube is in a right\n lower zone bronchus. No pneumothorax. Ill-defined opacities are present at\n both lung bases.\n\n IMPRESSION: NG tube in right bronchus. Findings called by telephone to\n resident covering for Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2111-10-17 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 882599, "text": " 5:36 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please evaluate for cirrhosis/clot etc (with doppler)\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with acute rise in lft's\n REASON FOR THIS EXAMINATION:\n please evaluate for cirrhosis/clot etc (with doppler)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rise in LFTs.\n\n RIGHT UPPER QUADRANT ULTRASOUND: This examination was extremely limited due\n to altered mental status. No ascites is seen. This study should be repeated\n when the patient is more able to cooperate with the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-19 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 882808, "text": " 3:05 PM\n DUPLEX DOPP ABD/PEL; ABDOMEN U.S. (COMPLETE STUDY) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: R/O portal venous thrombosis\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with acute rise in lft's/INR and ARF on CRF\n\n REASON FOR THIS EXAMINATION:\n R/O portal venous thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with acute rise in liver function tests and INR\n and, with acute on chronic renal failure.\n\n COMPARISON: Abdominal ultrasound dated .\n\n ABDOMINAL ULTRASOUND WITH LIVER DOPPLER EXAMINATION: The gallbladder is not\n visualized. The common bile duct is not dilated at 3 mm. The liver\n parenchyma is normal in echo texture without focal nodules or masses. There\n is a moderate right-sided pleural effusion. The right kidney measures 11.4\n cm. There is an exophytic 2.9 x 2.8 x 2.5 cm simple cyst off the lateral\n aspect of the right kidney. The left kidney measures 12.4 cm, with a 7.5 x\n 6.2 x 6.9 cm cyst, which a thin septation and mild calcifications. The spleen\n is not enlarged. The pancreas is poorly visualized secondary to overlying\n bowel gas.\n\n Doppler examination reveals normal flow and phasicity within the main and\n right portal veins, demonstrating hepatopetal flow. Normal flow and phasicity\n is seen within the main hepatic artery. All hepatic veins are patent, with\n appropriate flow. Increased phasicity is consistent with underlying right\n heart failure.\n\n IMPRESSION:\n 1. All hepatic vessels are patent with normal directional flow. Increased\n phasicity within the hepatic veins is consistent with underlying right heart\n failure.\n\n 2. Normal appearing liver parenchyma without focal nodules or masses\n identified.\n\n 3. No evidence of hydronephrosis bilaterally. Simple cyst in right kidney.\n Cyst with internal calcification and thin septation within left kidney.\n\n 4. Moderate right-sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882257, "text": " 8:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hypoxia likely aspiration pneumonia now with\n pulmonary/vascular congestion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with likely aspiration pneumonia. Now congested.\n\n A single portable AP upright chest radiograph is reviewed and compared to the\n prior study of . Again seen is an atrial biventricular\n pacer, with leads in standard position. The patient is status post median\n sternotomy. The heart and mediastinal contours are stable. There has been\n interval improvement in right lower lobe opacity, which could represent\n improved mild pulmonary edema versus an improving pneumonia.\n\n IMPRESSION: Improving mild pulmonary edema or resolving pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882621, "text": " 11:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval NG placement\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CHF with AMS s/p failed Left IJ placement\n REASON FOR THIS EXAMINATION:\n eval NG placement\n ______________________________________________________________________________\n FINAL REPORT\n Chest, single AP film.\n\n History of AMS and NG tube placement.\n\n The NG tube is in the body of the stomach. No other change since prior film\n of same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-16 00:00:00.000", "description": "RENAL U.S.", "row_id": 882449, "text": " 11:53 AM\n RENAL U.S. Clip # \n Reason: RENAL FAILURE\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with acute renal failure\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with acute renal failure, rule out obstruction.\n\n RENAL ULTRASOUND: The right and left kidneys measure 10.8 and 10.5 cm\n respectively. There is a 2.8 cm simple cyst in the lower pole of the right\n kidney. A 6.3 x 6.9 x 7 cm cyst is visualized in the left kidney. A thick\n septation is also visualized with some calcifications. There is minimal\n thinning of the cortex with minimal increase in the echogenicity compared to\n the liver.\n\n A vague area of decreased echogenicity is visualized at the tip of the liver.\n Similar areas are seen more superiorly and likely are artifactual.\n\n IMPRESSION: Large left renal cyst with a thick septation with calcification\n falling in the Bosniak II F category. A four to six month followup is\n recommended. There is no evidence of hydronephrosis or renal stones.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 881724, "text": " 10:58 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVALUATE FOR SDH; CHANGE IN MENTAL STATUS\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with recent fall and change in mental status.\n REASON FOR THIS EXAMINATION:\n R/O subdurals\n CONTRAINDICATIONS for IV CONTRAST:\n Creat 2.0\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent fall and change in mental status.\n\n TECHNIQUE: Non-contrast head CT: There are no comparison studies. There is\n no intraaxial hemorrhage. There is no shift of normally midline structures,\n acute fractures, loss of the -white matter differentiation, or major\n vascular territorial infarct. The ventricles and sulci are prominent\n consistent with mild brain atrophy. There is low attenuation of the\n centrum semi-ovale consistent with chronic microvascular ischemia. There is a\n low attenuation in the left basal ganglia consistent with an old lacunar\n infarct. This study is degraded secondary to patient motion and streak\n artifact. There are prominent low density extra-axial spaces over the right\n convexity and in the left parafalcine region, most likely representing\n subdural hygromas or chronic subdural collections. There is no evidence of an\n acute subdural hematoma. There is no mass effect.\n\n The sinuses are normal.\n\n IMPRESSION: Study degraded by motion artifact. No definite acute\n intracranial hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2111-10-12 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 881890, "text": " 4:02 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: HYPOXIA ,DYSPNEA SUSPICIOUS FOR DVT\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with h/o CAD and PE, with acute onset dyspnea, hypoxia,\n suspicious for PE. (CXR with pulm edema and LLL opacity, and renal\n insufficiency)\n REASON FOR THIS EXAMINATION:\n ?DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with history of coronary artery disease and\n pulmonary embolism, now with acute onset of shortness of breath, hypoxia, and\n suspicion for pulmonary embolism.\n\n COMPARISON: None.\n\n BILATERAL LOWER EXTREMITY DOPPLER EXAMINATION: Grayscale, color flow, and\n Doppler ultrasound of bilateral common femoral, superficial femoral, and\n popliteal veins were performed. Normal flow, augmentation, compressibility,\n and waveforms were demonstrated. No intraluminal thrombus was seen.\n\n IMPRESSION: Negative bilateral lower extremity Doppler examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-10-16 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 882508, "text": " 5:35 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: PAIN AND SWELLING ASSESS UPPER EXTREMITY FOR VENOUS THROMBOSIS\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p humeral fracture with RUE swelling\n REASON FOR THIS EXAMINATION:\n R/O upper extremity venous thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post humeral fracture with right upper extremity swelling.\n Evaluate for right upper extremity deep venous thrombosis.\n\n COMPARISON: None.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler son of\n the right internal jugular, right subclavian, right axillary, right brachial,\n right basilic, and right cephalic veins were performed. The most superiorly\n located brachial vein is noncompressible and does not demonstrate any wall to\n wall color or venous waveforms. These findings are suggestive of thrombosis\n involving the superior brachial vein. The remaining veins otherwise appeared\n normal with wall-to-wall color flow, normal waveforms, and normal\n compressibility.\n\n IMPRESSION: Noncompressibility of the superior right brachial vein, with lack\n of color flow and absent venous waveforms, findings consistent with venous\n thrombosis. These findings were relayed to Dr. at 6:15 p.m., .\n\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2111-10-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 881788, "text": " 2:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: re-assess subdural\n Admitting Diagnosis: LEFT HUMERUS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with worsening mental status ?subdural on head CT read today.\n need repeat stat. thank you\n REASON FOR THIS EXAMINATION:\n re-assess subdural\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening mental status.\n\n COMPARISONS: .\n\n TECHNIQUE: Axial non-contrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: There is no evidence of intracranial hemorrhage,\n hydrocephalus, shift of normally midline structures or edema. There is\n prominence of the sulci and ventricles consistent with cerebral atrophy. There\n is prominence of the right-sided subdural extra-axial space, which may\n represent atrophy or a subdural hygroma. The -white matter\n differentiation appears intact. The paranasal sinuses are well aerated. There\n are dense calcifications within the left globe, which is small, consistent\n with old trauma and resulting phthisis bulbi.\n\n IMPRESSION:\n 1. No evidence of intracranial hemorrhage or edema.\n 2. Cerebral atrophy.\n 3. Widening of the right extra-axial space likely secondary to atrophy and/or\n a subdural hygroma.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-12 00:00:00.000", "description": "Report", "row_id": 1466574, "text": "S/MICU Acceptance Note\n Pt is a 83y/o gentleman admitted to 12R on 9/16after falling at a hotel fracturing left humerus, ?dislocating left shoudler. Had entered the EW A&Ox3 with some periods of confusion. received 4mg Morphine and 2 tabs of percocet and pt increasely became confused.on 12R pain management still and issue.. recieving RTC tyenol and motrin with sm doses of morphine and ativan. worsening MS, did have an episode of CP showing some ischemic changes... ST down in I,II and V5-6. tonight pt less responsive,hypoxic to sat of 86%,tachycardic to 140 received lopressor 5mg.transferred to S/MICU for closer monitoring R/O PE, R/O MI and pneumonia.\n Allergies: PCN\n System Review:\n Neuro: speech grabbled,tongue very dry, MAE(though left arm is in sling),spont moving legs,and right arm. picking at sheets and cloths, calling out at times. states he is at the hotel(pt is visiting from and was staying at hotel when accident occured) right pupil 2mm and rxn to light. surgical pupil on the left. CT of head done tonight to r/o bleed,CT scan neg, started on heparin, bolused with 4,000units and started on 1,000units/hr. started on 3:30 am (will need PTT at 9:30 am).sitter with pt as he tries to climb out of bed. is safety risk.\n Cardiac: HR 120-130's afib with frequent paced beats, on lopressor 5mg q6hr BP stable 120-130/70's pt does have extensive cardiac Hx, ?low EF. not anticoagulated. on r/o MI protocol\n Respiratory: on 2liters NC with O2 sat of 92-96%. BS clear with fine crackles at the bases bilaterally. ? on pneumonia or CHF on xray.. ABG from the floor 64/27/7.44 RR 24-32.\n ID: temp 101 ax, pan cultured, blood cultures x2, urine sent no sputum to send. on levoquin q48hr.\n GU: foley in place, inserted tonight. I&O's over the past three days are +1300cc but not completely accurate as pt had a number of incon episodes. baseline creat 0.8 now up to 2.4\n GI: NPO, no stool abd soft distended.\n IV access: #20 angio in the right hand.\n Social: married, lives with wife in 6months of the year and 6months he lives in . has daughter.\n : anticoagulate, frequent neuro checks, avoid narcotics for pain control ?avoid motrin as may be contributing to rise in creat.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-12 00:00:00.000", "description": "Report", "row_id": 1466575, "text": "NPN 0700-1900\nNeuro: Pt remains confused, agitated with respositioning or when touched, MS appears improved from this am as pt able to state his name, ask for H2O, and c/o pain, speech remains garbled. Pt given Tylenol PR for pain, avoiding narcotics d/t MS changes, zyprexa prn ordered for agitation, sitter in room, SR up x 4 for safety, wrist restraints intact bilat., R ankle restraint intact.\n\nResp: Lungs CTA bilat, (+)cough reflex, O2 at 2L NC, RR 20-31, SPo2 92-98%, Resp. even and unlabored. No MRI as pt has pacemaker.\n\nCV: HR 83-122 Atrial Paced, V-sensed, BP's 98-115/50-60's, Metoprolol 5mg IV given at 1000 d/t HR 130's with good effect, metoprolol 5mg IV held at 1200 per HO, then given Metoprol 5mg IV at 1600 resulting in SBP in 80's, current BP 107/38, 1800 Metoprolol IV held. Leni's (-). Heparin at 750u/hr, PTT drawn at 1840 please follow. Echo results pending. NS at 50cc/hr.\n\nOrtho: Pt to go for CT for L arm for fixation when MS returns to baseline per Ortho team.\n\nGI: BS (+), no bm. Remains NPO\n\nGU: Foley cath intact draining dark yellow urine 15-30cc/hr, HO aware. Urine sent for lytes at 1830.\n\nSKin: Bruising to L shoulder, L arm, dark puple and yellow in color.\n\nSocial: Daughter in, spoke with team, aware of current plan of care.\n\nPlan: Monitor VS, monitor UO, adm IV flds as order, follow PTT and titrate Heparin according to Protocol, adm Tylenol as needed for pain.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-13 00:00:00.000", "description": "Report", "row_id": 1466576, "text": "NPN 1900-0700:\nNEURO: PT IS ALERT, WITH GARBLED SPEECH, VERY AGITATED MOST OF THE TIME, MOVING ALL EXTREMITIES PURPOSEFULLY, CONFUSED, DISORIENTED, OPENING EYES SPONTANEOUSLY, FOLLOWING COMMANDS, BUT VERY RESTLESS, GIVEN OLANZEPINE, HAS ONE TO ONE SITTER, NOT C/O ANY PAIN.\n\nRESP: ON O2 NASAL CANULA, BREATHING REGULARLY, RR 20-27, SPO2 96-100, LUNG SOUNDS ARE CLEAR.\n\nCV: ON A-PACED RYTHM WITH FREQUENT PVCS, HR 89-126, BP 102-133/59-99, MAP 67-110, WITH ONE RT PERIPHERAL IV RECEIVING 75 CC/HR NS, D/C HEPARIN, PERIPHERAL PULSES EASILY PALPABLE.\n\nGI/GU: NPO FOR RISK OF ASPIRATION, ABDOMEN IS SOFT DISTENDED, BOWEL SOUNDS PRESENT, PASSED ONE SMALL BOWEL MOVEMENT.\n\nINT: SKIN IS INTACT EXCEPT FOR HEMATOMA OVER LEFT SHOULDER.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-13 00:00:00.000", "description": "Report", "row_id": 1466577, "text": "NPN\n\nNeuro: Pt was confused early this morning, oriented to name and occationally a hospital, cooperative with his care, admitted to a painful L shoulder. By noon time he was very aggitated, hitting, trying to get out of bed, yelling at the staff as well as his daughter, refusing to take any meds. He was given a supp of Tylenol and fell asleep for a few hours. When he woke this afternoon he was still confused but had very little aggitation, let me shave him, put him on a bed pan and brush his teeth. The team feels that the confusiong and delerium could well be from pain as well as sleep deprivation and being in an unfamiliar place. He was started on traMADOL but he refused to take it, he is to start quetiapine tonight to try to help him sleep.\n\nCV: Conts on IV lopressor Q6 hrs, he initially drops his BP to this (80s) but quickly recovers, his HR has been 80s-110s.\n\nResp: LS coarse but he has a lot of upper airway noise. 02 SAT in the mid to upper 90s on 2 L NC. RR in the 20s.\n\nGI: He remains NPO due to confusion, he had a small BM today.\n\nGU: Conts to have a low u/o, creat 2.6 with a creat of 68, Na 148, he is now on D5W to corect his free water loss.\n\nSoc: His daughter was in today while he was confused and aggitated, she was upset by this, told that this is not out of the norm for his age and what has happened to him.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-14 00:00:00.000", "description": "Report", "row_id": 1466578, "text": "neuro: Continues to be confused. Awakes and calls out occasionally but then falls back asleep. Pt. has slept very well all night. Medications were orally administered with small amt. ice cream. Tylenol atc given rectally for pain. continues with 1:1 sitter.\ncv/resp paced/ many pvcs. bp stable. resp stable good o2 sat. lungs fairly clear.\ngi/gu npo except meds. foley w marginal/low uop. no stools.\ninteg: left shoulder remains bruised. and supported in a sling.\nplan: continue to monitor mental status. pain management.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-22 00:00:00.000", "description": "Report", "row_id": 1466579, "text": "Respiratory Care Note:\n Patient admitted s/p respiratory arrest on 11. Intubated with a #7.5 ET tube on first attempt.23cm at lip. Positive color change on capnometer.BS coarse with rhonchi bilat, suctioned for moderate amount of thick tan sputum. Transferred to MICU and placed on assist control of 600 by 16, 100% and 5 PEEP. ABGs with good results. See Carevue flowsheet for details. Plan to wean FIO2 as tolerated and provide aggressive pulmonary hygiene.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-22 00:00:00.000", "description": "Report", "row_id": 1466580, "text": "MICU ADMIT NOTE\nSEE FHP FOR UP TO DATE INFORMATION.\nPT RESP. ARRESTED ON 11R, THIS AFTERNOON, CODE WAS CALLED, AND PT. WAS INTUBATED, AND BROUGHT TO MICU, BP WAS HARD TO GET MANUALLY, DUE TO PICC LINE IN RIGHT ARM AND LEFT ARM IS BROKEN, SO BP WAS TAKEN ON RIGHT THIGH WHICH WAS NOT ACCURATE, PT. WAS VERY HYPOTENSIVE, STARTED ON NEO AND VASOPRESSIN SEE CAREVUE FOR NUMBERS. RIGHT FEMORAL A-LINE WAS PLACED AND LEFT TRIPLE LUMEN CENTRAL LINE WAS PLACED IN LEFT GROIN.\n\nNEURO: WILL NEED TO BE SEDATED, VERSED AND FENTANYL ORDERED BUT NOT UP FROM PHARMACY.\n\nCV: HAS A PACEMAKER, EP CONSULTED LOOKS LIKE PT. IS IN A VENTRICULAR RYTHM. ON VASOPRESSIN AND NEO, BP IS STABLE NOW, NEO HAS BEEN WEAN TO HALF OF WHAT IS WAS AND BP IS STABLE. RECEIVED TOTAL OF 2.5 LITERS FOR HYPOTENSION.\n\nRESP: SEE CAREVUE FOR VENT SETTINGS, AND LAST ABG RESULTS.\n\nGI/GU: NEEDS OGT PLACED FOR PO MEDS. FOLEY IN PLACE DRAINING DK. AMBER\n URINE.\n\nSOCIAL: DAUGHTER AND SON IN LAW VERY SUPPORTIVE.\n\nPLAN: CONTINUE PRESENT CARE.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-23 00:00:00.000", "description": "Report", "row_id": 1466581, "text": "Resp: pt on a/c 18/600/+5/50%. ETT retaped and secured. Bs reveal bilateral aeration. Suctioned for small amounts of thick yellow secretions. Sputum sample sent. AM ABG 7.39/25/124/16. No changes noc. Will continue full vent support\n" }, { "category": "Nursing/other", "chartdate": "2111-10-23 00:00:00.000", "description": "Report", "row_id": 1466582, "text": "M/SICU NPN 7P-7A\nNEURO: RECEIVED ON 50MCG FENTANYL AND 2MG VERSED. PATIENT UNRESPONSIVE TO ALL STIMULI. LATER DECREASED FENT TO 25MCG. THIS AM WAS GRIMACING TO SXTING AND MOVEMENT OF LEFT ARM. NO SPONTANEOUS MOVEMENTS. IMPAIRED GAG AND COUGH.\n\nCARDIAC: HR 83-100 VPACED WITH FREQUENT ECTOPY/RUNS VTACH. RECEIVED ON VASO @2.4U/HR AND NEO @.15MCG. ABLE TO ONLY WEAN NEO TO .10MCG WHILE MAINTAINING MAPS >65. BP 94-105/54-65. HCT 31.8 DOWN FROM 33.3. CK WAS FLAT WITH TROP .12 WHICH WAS UNCHANGED FROM YESTERDAY. PPP. DOPPERABLE RADIAL PULSE ON LEFT.\n\nRESP: ON A/C 600X18 50% +5PEEP. NOT OVERBREATHING VENT. SATS 99-100%. AM ABG 7.39/25/124/16. LS COARSE AND SXTED FOR THICK TAN/YELLOW SPUTUM. OLD BLOODY ORAL SECRETIONS. ATTEMPTED RSBI BUT PATIENT DID NOT BREATH.\n\nGI/GU: ABD SOFT WITH +BS. BROWN SOFT STOOL X2. NO OGT PER TEAM AS THEY WERE HOPING TO EXTUBATE HIM TODAY. UOP 25-100CC/HR AMBER AND CLEAR. CREAT 2.1 THIS AM.\n\nFEN: IVF @KVO. CVP 15-21. + EDEMA TO UE'S. LYTES PER CAREVUE. NPO.\n\nID: TMAX 103.6 RECTALLY, MD AWARE AND PATIENT PANCXED. 1GM TYLENOL GIVEN @MIDNOC WITH TEMP DOWN TO 102.6 AND GIVEN ANOTHER GM TYLENOL PR @0600. WBC 13 UNCHANGED. RESTARTED ON VANCO AND ZOSYN.\n\nSKIN: WEEPING FROM HANDS/FOREARMS. ECCHYMOSIS TO LEFT ARM, LEFT DISCOLORED, MD AWARE. COCCYX RED AND BARRIER CREAM APPLIED.\n\nACCESS: LEFT FEM CVL, RIGHT FEM ART LINE, RIGHT BRACHIAL PICC.\n\nSOCIAL/DISPO: FULL CODE. DAUGHTER REVISITED BRIEFLY LAST NOC. QUESTIONS ANSWERED. NO FURTHER CONTACT DURING THE NIGHT. PLAN IS TO TRANSITION PATIENT TO PROPOFOL AND PLACE HIM ON PSV IF HE AWAKENS.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-23 00:00:00.000", "description": "Report", "row_id": 1466583, "text": "Respiratory Care Note:\n Patient on PSV. He tolerated spontaneous breathing trial well. However, he is not waking up. He has been suctioned for tenacious, brown sputum. BS with occassional rhonchi that clear with suctioning. Bases are diminished. Plan to maintain until patient more able to protect his own airway. He does have a gag and cough.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-23 00:00:00.000", "description": "Report", "row_id": 1466584, "text": "MICU NPN\nNEURO: OFF ALL SEDATION WITH HOPES TO EXTUBATE TODAY, FOLLOWING VERY SIMPLE COMMANDS INCONSISITANTY, NOT AWAKE ENOUGH TO EXTUBATE, ONCE MORE AWAKE HE CAN BE EXTUBATED.\n\nRESP: VENT SETTINGS CAHNGE OVER TO P/S 10 FIO2 40% AND NO PEEP, BLOOD GAS ON THESE SETTINGS 7.35/29/113/17, ONCE IT WAS DECIDED NOT TO EXTUBATE 5 OF PEEP WAS ADDED. MOD. OF AMT. OF THICK YELLOW/WHITE/BLOOD TINGED SECREATIONS NOTED.\n\nCV: CONTINUES TO BE V-PACED WITH RUNS OF V-TACH, TEAM IS AWARE, OFF NEO AND VASOPRESSIN, BP STABLE VIA RIGHT FEMORAL ARTERY SEE CAREVUE FOR NUMBERS. HR 100-130'S AT TIMES.\n\nGI: NPO, NO NGT OR OGT, IF NOT INTUBATED TOMORROW WANT TO CONDIDER TUBE FEEDS, PT. WAS TPN ON THE FLOOR DUE TO PULLING OUT NGT. INC. OF SMALL AMT. OF LOOSE STOOL X2. 500CC D5W FREE WATER BOLUS WAS GIVEN X1.\n\nGU: FOLEY IN PLACE DRAINING DK. AMBER URINE, U/O POOR. 30-50CC/HR TEAM IS AWARE INCREASED IV RATE TO 125CC/HR.\n\nID: TEMP SPIKE LAST NIGHT, T-MAX TODAY 101.4 R 100MG OF TYLENOL WAS GIVEN, TEMP NOW 99.8 R. CONTINUES ON IN ABX.\n\nSKIN: ANASARCA ON RIGHT HAND AND WRIST, GAUZE DSG. APPLIED ALONG WITH SOFTSORB DSG.\n\nACCESS: PICC LINE RIGHT ANTE. RIGHT FEMORAL A-LINE, LEFT GROIN CENTRAL LINE.\n\nPLAN: TO EXTUBATE WHEN MORE AWAKE, MONITOR BLOOD PRESSURE, HR. CONTINUE WITH SEDATION OFF.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-24 00:00:00.000", "description": "Report", "row_id": 1466585, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes throughout the night. No morning abg results at this time.\n\nRSBI = 55.3 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-24 00:00:00.000", "description": "Report", "row_id": 1466586, "text": "NPN 1900-0700\nNeuro: Continues to be off sedation, continues to sleep, inconsistently follows commands to open eyes, to be extubated when awake, did not give 2200 Zyprexa as pt continued to be sleeping and difficult to arouse.\n\nResp: Lungs coarse to auscultation, sx'd moderate tan thick secretions, currently on CPAP with 10PS, FIo2 40%, TV 610, PEEP 5. O2 sats 100%.\n\nCV: HR 103-118 Atrial Sensed V-Paced, BP 91-135/60-70's, pedal pulse palpable, A-line to R groin, 3-lumen line to L Groin, continues on D51/2NS at 100cc/hr, PICC to RAC.\n\nID: T 100.1, cont. on Piperacillin IV.\n\nGI:BS (+), abd soft, x1 formed bm, if not extubated today will need to put down OGT and start TF.\n\nGU: Foley cath intact draining adequate amts of amb. clear urine.\n\nSkin: .5cm/.5cm purplish/red abrasion stage II found to coccyx, duoderm applied, skin care nurse consult ordered by HO. Anasarca to R FA with weeping, gauze and softsorb drsg. applied.\n\nPlan: COntinue to monitor BP, continue to assess Mental Status and possibly extubate today if awake.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-24 00:00:00.000", "description": "Report", "row_id": 1466587, "text": "altered loc\nd: pt has not received any sedation for 24 hrs now. difficult to arouse and does not follow simple commands. with elevated bun and creat as well as elevated lft's pt may not have exvreted sedative drugs yet. pt received 3 dosses of .4 mg ivp narcan and when ogt was being placed pt reaching for ogt and opening eyes. will cotninue to assess pt's loc.\n\nresp: remains orally intubated with intial vent settings of 40% cpap with 5 peep and ips of 10 with o2 sats > 97%. abg's on these settings=7.46/23/138/17/-4. coarse bs bil on auscultation. suctioned ett for mod amts of thick tan sputum. this afternoon ips dropped to 5 cm but by 16oo pt's resp effort appears labored so ips increased back to 10 cm. will continue to wean vent as pt tolerates but the quality of the sputum is concerning for extubation.\n\ncv: hr 109-120 a sensed and v paced with occasional pvc's. sbp by r femoral aline 109-146. cardiology fellow at bedsdie to evaluate pacer and feels that pt is demanding this hr b/cause of fever/sepsis/pain and feels that pace is functioning without problems. will cont to foolw hemodynamics and check electrolytes as ordered repleting as needed.\n\ngi: ogt placed and in good position by auscultation and by cxr. tube fdgs of probalance fs initiated at 10cc's /hr and will increase as tolerated to a goal rate of 60cc's/hr. abd soft and nontender with pos bowel sounds on auscultation. no stool output this shift.\n\ngu: foley cath in palce with adequate hourly uo. bun=78 and creat=2.0. pos 1.6 liters for this shift and for los pos 5 liters. pt with serous drainage from r hand and from r groin. l fmeoral tlc in tact.\n\nid: max temp=101 and medicated with tylenol 650 mg via ogt. vancomysin d/c'd and pt continues to receive zosyn as ordered.\n\nsocial: pt is a full code. his family was in to visit and have been updated by nursing and medical staff. will contiue with present medical management and will keep family well informed on a daily basis.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-25 00:00:00.000", "description": "Report", "row_id": 1466588, "text": "Nursing note (1900-0700) 04:40\n\n\nNeuro.\nPt with gradually improving neuro exam as night progressed, pt now opening eyes to speach, moving limbs with some intent, not following commands as yet. Pt still biting down when attempting to do mouthcare.\n\nResp.\nNo vent changes overnight, SpO2 96-100%, LS coarse to all fields, Sx'd for thick tan secretions Q4hrs, sample sent for C+S.\n\nCVS.\nHR 100's AV Paced with no real ectopy seen.\nBP 120's/60's stable, tracing from arterial line positional. Pt on 125cc/hr of D5W 1/2NS.\n\nGI/GU.\nTF's now at 30cc/hr (goal 40cc) with no residuals noted. +BS with no BM passd this shift.\nUOP adequate at 30-50cc/hr amber/cloudy urine via foley.\n\nSkin.\nPt with generalised edema, invasive line sites oozing serous fluid.\n\nSocial.\nContact by daughter for update.\n\nPlan.\nMonitor MS.\n?? work up for extubation.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-26 00:00:00.000", "description": "Report", "row_id": 1466593, "text": "Nursing note (1900-0700) 04:35.\n\n\nNeuro.\nPt with improved MS since last shift, pt opening eyes spontaneously, moving limbs on bed with some purpose, not following commands as yet.\n\n\nResp.\nNo vent changes overnight, SpO2 97-100%, LS coarse to diminished, Sx'd for copious amounts of thick yellow secretions Q2-4hrs.\n\n\nCVS.\nHR 100's , pt with occasional own beats noted.\nBP 130's/70's stable, 1x unit PRBC tx'd overnight with adequate rise in Hct in anticipation of SBT and ?? extubation.\n\nGI/GU.\nTF's at goal of 40cc/hr with no residuals, +BS with no BM as yet this shift.\nAdequate amounts of amber urine with sediment passed via foley. Pt with known CRI with some ARF this admit.\n\nID temp 98's via Ax, on Vanco and Zosyn, Vanco Q48hrs, next due dependant on level.\n\nSkin.\nPt continues to ooze serous fluid from all access points.\n\nSocial.\nCalled by daughter for update, no other contact.\n\nPlan.\nMonitor MS, Possible CT head.\nSBT with ?? extubation.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-26 00:00:00.000", "description": "Report", "row_id": 1466594, "text": "Respiratory Care:\nPatient having occurences of panea earlier in the shift. Decreased PSV from 10 cm to 5 cm with improved consistent rr. No morning abg results.\n\nRSBI = 47.2 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-26 00:00:00.000", "description": "Report", "row_id": 1466595, "text": "Respiratory Care\nPt remains on CPAP/PSV throughout the shift. Suction moderate to large amounts of light tan colored secreations. Bilateral breath sounds diminished throughout with scattered rhonchi. Clearing with suctioning.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-26 00:00:00.000", "description": "Report", "row_id": 1466596, "text": "RESP: BS'S CLEAR THIS AFTERNOON. SUCTIONED FREQUENTLY FOR THICK YELLOW CREAMY SECRETIONS. NO VENT CHANGES.\nGI; CONT. ON TF'INGS WITH NO RESIDUALS. TF'INGS AT GOAL. INCONT. 2X OF SMALL AMT OF BROWN FORMED STOOL.\nRENAL: LASIX 20MG IVP GIVEN WITH POOR RESPONSE. PLAN WAS FOR 40MG, BUT BP LOW AND PLAN IS TO GIVE LATER THIS EVENING. BUN/CREAT ARE IMRPROVING.\nCV: A-LINE REMOVED FROM GROIN. NBP HAVE BEEN SIGNIFICANTLY LOWER, BUT MEANS ARE FROM 64-80. ISORDIL HELD AT 18PM D/T BP. EF IS ONLY 15-20%. RIGHT FOOT EDEMATOUS. ALSO OOZING FROM VARIOUS SITES ON HIS ARMS. CONT. IN PACED RYTHYM WITH ? OF PVC'S. DIFFICULT TO ASSESS.\nNEURO; MORE AWAKE THIS AM. NODDING APPROPRIATELY TO VARIOUS QUESTIONS. REFUSING EYE GTTS. MOVING RIGHT ARM AND FEET. AT TIMES PT. REFUSING TO HAVE ME SUCTION HIS MOUTH ETC.\nENDOC: LYTES REPLETED. NO SSI REQUIRED.\nID: AFEBRILE TODAY AFTER VANCO RESTARTED. CONT. ON ANTIBIOTICS.\nSKIN INTEGRITY: SKIN NURSE IN AND CHANGED DUODERM ON BUTTUCKS. WILL NEED TO ASSESS FOR SPECIAL BED TOMORROW.\nSOCIAL: WIFE AND FAMILY INTO VISIT.\nORTHO: SLING REMOVED AND ARM ELEVATED ON PILLOW. REMAINS SWOLLEN. GIVEN TYLENOL FOR PAIN AND ATC.\nACCESS: R FEM A-LINE REMOVED. PICC LINE OUT. TRIPLE LUMEN REMAINS. PLAN IS FOR PICC LINE TOMORROW AFTER DISCUSSION WITH FAMILY WHICH IS HAPPENING TOMORROW AT 3PM.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-27 00:00:00.000", "description": "Report", "row_id": 1466597, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms function. Patients ps increased this eve as his tidal volumes fell to 200cc and respiratory rate increased to high 30's low 40's. Breathsounds are coarse. Suctioned for copious amounts of thick yellow. ETT rotated and retaped. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-27 00:00:00.000", "description": "Report", "row_id": 1466598, "text": "micu/sicu nsg note: 19:00-7:00\nthis is an 83 y.o. man adm s/p fall breaking is l shoulder and arm with arm placed in sling. not a surgical candidate at this time. pt s/p resp arrest on 11 several days ago and was transferred to for medical/resp management. pt initially hypotensive tx'd with vasopressin and levophed. pt currently off pressors with borderline low bp.\n\nneuro: pt more alert at the beginning of the shift but was appearing very uncomfortable with rr in the 40s with copious amts creamy white sputum sx'd out. pt nodding when asked if he had l shoulder pain. md notifed and was up to see pt. pt was able to follow simple commands at this time but inconsistently. mae in bed but very limited in l arm-replaced in sling. pt was given 1 gm tylenol q6hrs without effect. md, pt was gived .5mg iv ativan and 25mg trazadone via ogt with good effect within 1 hour. pt has been more lethargic found sleeping at rest but shuts eyes tight when eye gtts given and attemtpting to assess pupils. mae with min l arm movement noted. r wrist restraint maintained for safety.\n\ncv: hr ranging 60-61 apaced with frequent pvcs in beginning of shift slowing down to occas pvcs. pt was given 40mg iv lasix in beginning of shift with brisk diuresis followed by 40meq kcl via ogt. repeat k was 4.7 off the abg taken during tacypnea: 7.38/26/107. + pedal and hand edema. hands weeping serous fluid. + weak pp.\n\nresp: remains intubated on cpap +ps with ps adjusted by resp therapist during episode of tacypneia and low minute ventilation after given ativan and trazadone for discomfort. pt currently on fi02 40%, peep 5 ps 5. sp02 ranging 98-100%. sx'd for copious to now small to moderate amts thick creamy white sputum.\n\ngi/gu: abd soft,nt, +bs, small brown formed bm. tolerating tube feedings probalance at goal rate of 60cc/hr with only 5cc resiudal. foley patent draining yellow urine with sediment >60cc/hr. approx even over 24 hours. approx 7liters + los.\n\nskin: coccyx with new dsg placed by skin care specialist still intact. weeping areas on l arm wrapped in softsorb and changed freqently.\n\nendo: stable fs with no ssri required.\n\nid: t max 98.6 ax, continues on iv vanco ordered q48 hours next due today.\n\nplan: continue to monitor vent and adjust as tolerated, ? can reattempt rsbi later today. per resp, didn't tolerate attempt to try rsbi. monitor level of comfort. continue rtc tylenol, iv abx, monitor temp, replete lytes prn. ? family meeting later today.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-28 00:00:00.000", "description": "Report", "row_id": 1466604, "text": "NURISNG NOTE 0700HRS-1600HRS\n\n\nEVENTS...PAICC PLACED, CENTRAL LINE REMOVED, DOPOFF PLACED...\n\n\n\nNEURO...SEEMS ALITTLE MORE ALERT /RESPONSIVE TODAY, TURNING HEAD WHEN NAME CALLED FOLLOW SIMPLE COMMANDS, DENIES PAIN, ATTEMPTING TO COMMUNICATE WITH FAMILY...CONTINUES WITH PR TYLENOL\n\n\nRESP...SATS REMAIN 98% ON 4L N/C SOUNDS LESS COURSE OVER THE COURSE OF THE DAY, MOVING SECRETIONS...STRONG COUGH, ABLE TO BRING TO BACK OF THE THROAT SUCTIONING WHEN PATIENT ALLOWS THICK TAN SECRETIONS...\n\n\nCVS...B/P NOW TAKEN FROM LEFT LEG [ AS PICC IN RT ARM] LOWER THAN ARM BY POSSIBLY ...B/P STABLE FOR PATIENT\nBBLOCKER COMMENCED FOR VARIABLE RATE 100-120 AV PACED WITH OCCASSIONAL PVC...OTHER CARDIAC MEDS CONTINUE NOW N/G IN PLACE\nAFEBRILE AB'S STOP THIS AM\nB/S STABLE\n\n\nGI...DOPLOFF PLACED IN IR..FEED RE-COMMENCED AT GOAL WITH MEDS RECOMMENCED..X2 BOWEL MOTION TODAY\n\n\nGU...URINE OUTPUT TAILING OF THIS AM..REVIWED BY TEAM AND IN VIEW OF POS BALANCE FURTHER LASIX GIVEN OF 80MGS...TO OBSERVE\n\n\nSKIN...DUODERM INTACT ON SACRUM...THRUSH EVIDENT IN BOTH GROINS AND RT ARM [ JUST BELOW PICC] AREAS TO BE CLAENED AND MEDS APPLIED [ AWAIT FROM PHARMACY]\n\n\nLINES...CENTRAL LINE PULLED AND SINGLE LUMEN PICC PLACED RT ARM\n\n\nSOCIAL..ALL FAMILY VISISTED PM\n\n\nPLAN...TO STAY IN MICU FOR TONIGHT AS ? CLAERING SECREATIONS EFFECTIVELY...OBSERVE VITALS SUCTION ? CALL OUT TOMORROW\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-25 00:00:00.000", "description": "Report", "row_id": 1466589, "text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support iwth no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 47 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-25 00:00:00.000", "description": "Report", "row_id": 1466590, "text": "Resp Care\n\nPt remains intubated and on CPAP/PSV. Tv's have been in th3 500-700 range with mv's in the 7-13L range. Pt with thick brown sputum and coarse BS. Plan for ct of chest in am\n" }, { "category": "Nursing/other", "chartdate": "2111-10-25 00:00:00.000", "description": "Report", "row_id": 1466591, "text": "Resp Care\n\nPt remains intubated and on CPAP/PSV. Pressure support at 10 with TV's 600-700's with resp rate in low teen's. Suctioning thick brown sputum. Plan for ct of chest and head followed by possible bronch on \n" }, { "category": "Nursing/other", "chartdate": "2111-10-25 00:00:00.000", "description": "Report", "row_id": 1466592, "text": "altered resp status\nd: pt has not received any sedation for 48 hrs now. pt much more awke than previous 24 hrs. pt awake and mae's but not following simple commands. when pt's daughter was at the bedside she asked him if he wanted a chesseburger and he nodded no. olanzepine and lidocaine patch have been d/c'd so that we can r/o any other explanation for his lethargy. plan is to do head ct in the am if pt's ms does not improve further overnoc. now that pt is more awake pt appear more uncomfortable with turning ad nursing care. pt medicated with 1 gm tylenol via ogt and will avoid all narcotics.\n\nresp: remains orally intubated with vent settings of 40% cpap with 5 peep and ips of 10 with o2 sats> 96%. coarse bs bil on auscultation. suctioned ett for lg amts of thick tan to yellow sputum. because of increased quantity of seretions and his decreased ms decision made to not extubate pt today. may have chest ct and bronchoscopy in the am. will need to consult with medical staff if tube fdgs should be stooped after midnoc.\n\ncv: hr av paced hr 96-117 and sbp by r femoral aline 100-130's. k+ this am repleted with a total of 80 meq kcl and will follow electrolytes as ordered and replete as needed. pt restarted on his outpt meds of captopril and isordil and will need to follow hmeodynamics closely. hct30.9 and becasue of his cad and possibility of extubating soon decision made to transfuse pt with 1 u prbc.\n\ngi: ogt in place by asucutlation and pt receiving probalance at 40cc's/hr with goal rate of 60cc's/hr. abd soft nad nontender with pso bowel sounds on auscultation\n\n\ngu: pt with markedly decreased hourly uo. attemoted to irrigate foley without success. new 16 fr 5 cc foley cath inserted with improved uo. hypernatremic with na=152 and pt now receiving d5w at 100cc's/hr. bun=68 and creat-1.9. i&o pos 2.3 liters for this shift and for los 8 liters.pt oozing serous fluid from r hand and r femoral aline site.\n\nid: pt restarted on vancomycin 1 gm being renally dosed b/casue of increased secretions. no cahnge in antibiotic regime.\n\nsocial: pt is a full code and plan is for family meeting in the next 24-48 hrs to decide on plan of care. continue with present medical management and keep family well informed on a daily basis.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-27 00:00:00.000", "description": "Report", "row_id": 1466599, "text": "micu/sicu nsg note: 19:00-7:00 addendum\nclarification: sbp ranging 80s-90s with maps 60 or greater (not sbp in the 140s-150s). ? sbp readings accurate. md, when taken, sbps weren't correlating with the aline when the aline was in place. when the bp reads low, the pt had been sleeping and was woken up with an improved sbp with a map 60 or greater.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-27 00:00:00.000", "description": "Report", "row_id": 1466600, "text": "RESP: BS'S CLEAR. SUCTIONED FOR THICK CREAMY SECRETIONS THIS AM, BUT SECRETIONS HAVE DECREASED THROUGHOUT THE DAY. O2 SATS REMAIN STABLE.\nGI: TF'INGS CONT. AT 60CC/HR. INCONT. OF SMALL AMT OF STOOL THIS AM.\nRENAL; GIVEN 40MG LASIX IVP WITH GOOD RESPONSE.\nENDOC; NO SSI REQUIRED.\nID: CONT. ON ANTIBIOTICS. AFEBRILE, BUT RECEIVING TYLENOL ATC.\nNEURO; LESS RESPONSIVE THIS AM, D/T ATIVAN AT NIGHT. PT. CONT. TO REFUSE EYE GTTS AND REFUSES TO OPEN HIS MOUTH. PRESENTLY LESS RESPONSIVE. MAE EXCEPT LEFT ARM.\nCV: UNABLE TO GIVEN CARDIAC MEDS D/T LOW BP. HO'S AWARE.\nSOCIAL: DAUGHTER AND REST OF FAMILY INTO VISIT PT NOW. PLAN IS FOR A 3PM MEETING, AND THEN EXTUBATE. ? OF NEED FOR A MORPHINE GTT. HO WANTS TO HOLD OFF AND JUST GIVE HIM PRN MS. FAMILY IS PREPARED FOR WHATEVER HAPPENS WHEN HE'S EXTUBATED. ? OF NEED FOR FURTHER INTERVENTION.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-27 00:00:00.000", "description": "Report", "row_id": 1466601, "text": "Respiratory Care\nPt remains on CPAP/PSV. No vent changes this shift. Suction for small to moderate amounts of thick pale yellow/tan secreations. Breath sounds diminished, coarse throughout. Pt is responsive to questioning. Family meeting pending.\n" }, { "category": "Nursing/other", "chartdate": "2111-10-27 00:00:00.000", "description": "Report", "row_id": 1466602, "text": "NURSING UPDATE @ 1700HRS\n\n\nMEETING WITH FAMILY AND TEAM @ 1500HRS DECESION TO EXTUBATE DNR/ DNI THEN TO ASSESS PATIENT COMFORT FROM THERE...\nEXTUBATED @ 1600HRS WITH FAMILY PRESENT ...RESP RATE 20-30 SHALLOW BREATHS SATS 98% ON 70 COOL MASK...OPENS EYES SPONTAEOUSLY DEINIES PAIN [ ALTHOUGH DOES APPEAR UNCMORTABLE WHEN RE-POSTIONING PATIENT]ATTEMPTING TO COMMUNICATE WITH FAMILY.... TO CONTINUE TO MONITOR COMFORT LEVEL\n\n" }, { "category": "Nursing/other", "chartdate": "2111-10-28 00:00:00.000", "description": "Report", "row_id": 1466603, "text": "S/MICU Nursing Progress Note\n Respiratory: pt cont on face mask FIO@ 100% but frequently pulls it off. BS coarse throughout. coughing at times, productive but not able to suction with yankuer. discussed with family expectations of suctioning and all felt that pt has suffered enough and if pt will clamp down on yankuer then NT suction would not be comfortable.\n Cardiac: HR 100-120 paced, BP 100-120/70's not able to take po's so captopril not given.\n Neuro\" pt opens eyes spont but not really following commands only understandable words are \"I want to go home\" then only able to understand one or two words at a time.\n GI: abd soft, groin distention. foley in place but leaking a fair amount NS instill. sm stools,\n Plan: pt is now a DNR/DNI family (daughter) speaks about comfort care but at the same sentence talk about not giving too much Morphine as it has been know to decrease his RR. family supportive.\n cont supportive care,antibx,hydrations.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2152-05-04 00:00:00.000", "description": "Report", "row_id": 100560, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease. Right ventricular function. Valvular heart disease.\nHeight: (in) 61\nWeight (lb): 105\nBSA (m2): 1.44 m2\nBP (mm Hg): 100/60\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 12:11\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: Markedly dilated RA.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size. Overall normal LVEF (>55%).\nNo resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. RV function depressed. Abnormal\nseptal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\nNormal aortic arch diameter. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: \"Ball-and-cage\" type mitral valve prosthesis (MVR).. Mild (1+)\nMR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe\n[3+] TR. Moderate PA systolic hypertension. Given severity of TR, PASP may be\nunderestimated due to elevated RA pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Mild PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is markedly dilated. Left\nventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is normal (LVEF>55%). There is no ventricular\nseptal defect. The right ventricular cavity is markedly dilated with depressed\nfree wall contractility. There is abnormal septal motion/position consistent\nwith right ventricular pressure/volume overload. The aortic valve leaflets (3)\nare mildly thickened. Mild (1+) aortic regurgitation is seen. A\n\"ball-and-cage\" type mitral valve prosthesis is present. Mild (1+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. [In the\nsetting of at least moderate to severe tricuspid regurgitation, the estimated\npulmonary artery systolic pressure may be underestimated due to a very high\nright atrial pressure.] There is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular function. Ball and cage mitral prosthesis\nwith normal gradient and at least mild mitral regurgitation. Dilated and\nhypokinetic right ventricle with severe tricuspid regurgitation and moderate\npulmonary hypertension. Mild aortic regurgitation. Biatrial dilatation with\nthe right atrium being markedly dilated.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar. There was mild mitral regurgitation present on the prior study (seen\nin the parasternal views). Estimated pulmonary pressures are higher. Evidence\nof pressure-volume overload is more obvious on the current study.\n\n\n" }, { "category": "ECG", "chartdate": "2152-05-19 00:00:00.000", "description": "Report", "row_id": 293980, "text": "Atrial fibrillation with a rapid ventricular response. A single ventricular\npremature beat. Non-specific ST-T wave changes. Compared to the previous\ntracing of no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2152-05-12 00:00:00.000", "description": "Report", "row_id": 293981, "text": "Tachycardia of uncertain mechanism but may be atrial tachycardia. Left anterior\nfascicular block. Consider left ventricular hypertrophy. Lateral lead ST-T wave\nabnormalities are non-specific. Since the previous tracing of \ntachycardia with periods of irregularity are now present.\n\n" }, { "category": "ECG", "chartdate": "2152-05-07 00:00:00.000", "description": "Report", "row_id": 293982, "text": "Atrial fibrillation. Leftward axis. Non-specific ST-T wave changes. Compared to\nthe previous tracing of no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2152-05-04 00:00:00.000", "description": "Report", "row_id": 294220, "text": "Atrial fibrillation with a mean ventricular rate of 72. Non-specific\nQRS widening. Borderline left axis deviation. Non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of multiple\nabnormalities persist without major change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2179-08-01 00:00:00.000", "description": "Report", "row_id": 1719960, "text": "Nursing Progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions. 4 brady's to time of report, 3\nwith apnea and required mild stim. A: Slight increase in\nspells today. P:Continue to monitor.\n#2 O: Total fluids 140cc/kg/day. Feeds of SC given\nevery 4 hours over 1 hour and 15 min. No spit at 1200\nfeeding. Abdomen soft, bowel sounds active, no loop,s girth\nstable, voiding well, stool soaked into diaper with a small\namount of seedy stool. Bottom excoriated, changed to\ncriticaid this morning, bottom bleeding at 1200 feeding.\nKUB done at 1200 do up. Bottle offered once with Dr \nbottle provided by . 20cc taken before tiring out.\nA: Beginging to PO feed, mostly gavage fed for now. P:\nContinue bottle feeding about twice a day.\n#3 O:Temp stable in isolette on air mode. Baby is double\nswaddled today after initial temp of 97.5. NAS scores of 14\nand 12. Baby started on Neonatal opium solution at noon.\nA: REquired treatment for NAS scores today. P:Continue NAS\nscores and treatment as needed. Continue to support\ndevelopment.\n#5 O: Mother in to visit and feed baby this afternoon. Baby\nthen held for feeding. Mother tearful visit about\ntreatment for withdrawal. A: Involved mother. P: Continue\nto keep informed.\n#6 O: Bili improved today. P: Problem resolved.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-01 00:00:00.000", "description": "Report", "row_id": 1719961, "text": "NNP Note\nMet with mother at the bedside today. Discussed withdrawal and treatment with neonatal opium solution. Also discussed apnea or prematurity, possible need for Caffeine Citrate. Discussed criteria for discharge home. Mother most of the time.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-05 00:00:00.000", "description": "Report", "row_id": 1719978, "text": "Neonatology Attending\nDOL 9 / PMA 35-2/7 weeks\n\n remains in room air with no distress. Five bradycardias in 24 hours (not yet on caffeine).\n\nNo murmur. BP 77/39 (48).\n\nWt 1650 (unchanged) on TFI 140 cc/kg/day SC26 by gavage over one hour for history of reflux. Bottled twice over 24 hours for partial volumes only. Abd benign. Voiding and stooling appropriately.\n\nDiaper dermatitis being treated topically.\n\nNAS 3,4. Remains on weaning DTO.\n\nA&P\n34 week GA infant with NWS\n-Continue to wean DTO by 10% daily as indicated based on NAS \n-Monitor for apnea of prematurity\n-Continue to await maturation of oral feeding skills\n-Advance caloric density tomorrow if no significant weight gain today\\\n- remain involved; SW involved\n" }, { "category": "Nursing/other", "chartdate": "2179-08-05 00:00:00.000", "description": "Report", "row_id": 1719979, "text": "Rehab/OT\n\nMet mom at the bedside during infant cares. Will continues to be active yet calms well with developmental interventions. Full, active ROM and tone is WNL. No tremors or clonus observed. + excoriation on buttocks. OT to monitor closely during NICU stay.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-05 00:00:00.000", "description": "Report", "row_id": 1719980, "text": "Neonatology - NNP Progress Note\n\nInfant is active with good tone. AFOF. He is pale pink, well perfused, no murmur auscultated. He is comfortable in room air, breath sounds clear and equal. He is tolerating full volume po/pg feeds, abd soft, active bowel sounds, voiding and stooling. Excoriated diaper area. NAS scores . Weaning neonatal opium sol'n. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-05 00:00:00.000", "description": "Report", "row_id": 1719981, "text": "Nursing PRogress Notes\n\n\n#1 O: BAby remains in room air. Breath sounds clear and\nequal, mild retractions, 4 spells to time of report. A:\nIncreased spells today. P: Continue to monitor.\n#2 O: Total fluids 140cc/kg/day. Feeds of SC26 given\nevery 4 hours over 1 hour. 1 small spit, abdomen soft,\nbowel sounds active, no loops, girth stable, voiding and\nstooling. Bottle offered by mother, 35cc taken with Dr \nbottle. A: Tolerating feeds well by gavage, learning to PO\nfeed. P: continue with current feeds.\n#3 O; Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares, swaddled and in\ncovered isolette. Baby woke for first cares only.\nPacifier taken when offered. NAS scores 5 and 3, Neonatal\nopium solution weaned. A: Appriopriate for age. P:\nContinue to support development.\n#5 O: Mother and grandmother in to visit. Mother changed\nand fed baby. Mother asking appropriate questions about car\nseat tests, feeding at home, when to call the pediatrician\netc. A: involved mother. P: continue to keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-18 00:00:00.000", "description": "Report", "row_id": 1720040, "text": "Rehab Services/ OT\n\nWill seen today for follow up. Mass discovered on right sternocleidomastoid. Mass changing in size since discovery. Diagnosed as a muscle \"knot\" located in the muscle belly.\n\nOT asked to assess infant. Mass noted to be larger then pea size on right sternocleidomastoid. Firm to the touch, round in shape. Infant observed to have full, active next ROM. No active or passive restrictions noted. Educated mom on what to look for and to make sure she is monitoring changes in neck/ head movement as well as size/ shape of the mass.\n\nSpoke with team. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-06 00:00:00.000", "description": "Report", "row_id": 1719982, "text": "NPN Nights 7pm-7am\n\n\n#1 O: infant remains in roomair with O2 sats 97-100%. LUng\nsounds are clear and equal with resp rates 40s-60s, mils\nsubcostal retractions at times. A: maintaing adeq sats in\nroomair. P: Continue to moniter.\n#2 O: Wgt ^50g to 1700g. Remains on TF of 140cc/k/day of\nSSC 26 cals/oz. INfant bottled X 1 and took 10cc - sucked\nwell but did not sustain sucking very long. TOlerating\ngavage feeds well with min apirates, small spit X 1 thus far\nthis shift. Abd remains soft, +bs, no loops, Ag stable.\nCritcaid ointment applied to buttocks - excoriated area with\nminimal redness and appears to be healing well. A:\ntolerating feeds well, doing some bottling. P: Continue to\nencouage po intake as tolerated.\n#3 O: Infant is and active with cares. Infant is\nswaddled with stable temp in off isolette. Took 10cc using\nthe DR. nipple/bottle. Continues to have occasional\n\"quick\" bradys - has had 2 thus far this shift. Remains on\nNeonatal Opium solution with scores of 1 and 1 thus far this\nshift (see flwo sheet). A: AGA, working on po feeding\nskills, remains on NOS. P: Continue to moniter for\nmilestones.\n#5 Infant's mom called X 1 - updates given.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-06 00:00:00.000", "description": "Report", "row_id": 1719983, "text": "Neonatology Attending\nDOL 10 / PMA 35-3/7 weeks\n\nIn room air with no distress. Nine bradycardias in 24 hours.\n\nNo murmur. BP 68/42 (50).\n\nWt 1700 (+50) on TFI 140 cc/kg/day SC26, tolerating well. PO/PG (bottling partial volumes only). Voiding and stooling normally. Abd benign. On iron.\n\nNAS 3 and 1 on DTO 0.28 ml/kg/day.\n\nA&P\n34 week GA infant with NWS, feeding immaturity\n-Continue to monitor frequency and severity of bradycardias; start caffeine if any increase\n-Will wean DTO to then discontinue later today if NAS remains low\n-No changes in nutritional support\n-Will discuss status of DSS filing with SW today\n" }, { "category": "Nursing/other", "chartdate": "2179-08-06 00:00:00.000", "description": "Report", "row_id": 1719984, "text": "Neonatology NP Note\nPE\nswaddled in isolette\nAFOF, sagital, coronal and lamboidal sutures very slightly split\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 appropriate tone, bringing hands to mouth, no tremors\nbuttocks with very mild excoriation, much improved since my last exam 3 days ago\n" }, { "category": "Nursing/other", "chartdate": "2179-08-06 00:00:00.000", "description": "Report", "row_id": 1719985, "text": "SOCIAL WORK\nDSS has met with both and will be opening case to monitor. DSS investigator was , /. Case will be assigned to ongoing worker next week. Mother is aware and appears wanting to do whatever necessary to get her infant discharged to her care. Father is visiting separately but are communicating about baby's condition. Mother to remain with her thru baby's discharge. Please cont to document all visits and any concerns.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-02 00:00:00.000", "description": "Report", "row_id": 1719962, "text": "NPn Nights 7pm-7am\n\n\n#1 O: Infant remains in roomair with O2 sats 94-99%. Has had\nfew desats associated with bradys - see below. Lung sounds\nremain clear and equal with resp rates 20-40s. Mild\nretractions noted at times. A: occasional desat with bradys,\notherwise maintaining sats and breathing comfortably in\nroomair. P: Continue to moniter.\n#2 O: Wgt tonight 1555g, ^30g. Remains on TF of 140cc/k/day\nof SSC 2o cals/oz. Tolerating gavage feeds well with\nminimal aspirates and no spits thus far this shift. Abd\nremain soft, +bs, no loops, Ag satble. Infant bottlled X 1\nthus far this shift - took 5cc and then was sleepy. Voiding\nadeq amts. Stool slighttly loose intially then formed.\nCritcaid applied to skin breakdown over buttocks, with small\namount of bleeding noted. A: tolerating feeds weel, wgt^.\nMinimal po intkae, excoriated skin as noted. P: Continue to\nmoniter tolerance of feeds, offer po s as tolerated, apply\nCritcaid PRN.\n#3 O: Infant awake, with eyes open at 8pm cares -at 12am\ncares infant noted to be more \"drowsey\" with eyes \"half way\"\nopen. NAS at 8pm was 5, decresed to 2 at 12am cares -\ndecision then made to decrease Neonatal Opium dose by 10%.\nTemp remains stable in heated isolette, infant is swaddled.\nInfant has had 4 episodes of bradys thus far this shift -\nwith HR to the 50s-70s and sats as low as the 70s - needing\nstim to resolve X 2. Minimal sucking on his pacifer and\nbottled only 5cc during the evening. A: activity as noted,\nneonatal opium dose decreased as noted. Having occasional\nbradys. P: Continue to moniter activity closely and moniter\noccurence and character of spells. Offer bottles as\ntolerated.\n#5 O: Infant's in to visit at the 8pm cares.\n updated on plan of care re: NAS and use of\nneonatal opium and reexplained s/s of drug withdrawal. Dad\nchecked infant's temp and changed diaper with minimal asst.\nMom attempted to bottle infant and then dad held \nwhile mom pumped. continued...\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-02 00:00:00.000", "description": "Report", "row_id": 1719963, "text": "NPN nights continued\n\n\ncontinued - Mom states that she has been \"pumping and\ndumping\" in hopes that she might be able to breastfeed in\nthe future - she said that she has a doctors in\n3 weeks and hopes that by then \"the drug\" will be out of her\nsystem and she could then breastfeed. A: in to\nvisit, asking questions and participating in infant's cares.\nP: Continue to support and keep updated with plan of\ncare.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-02 00:00:00.000", "description": "Report", "row_id": 1719964, "text": "Neonatology Attending\nDOL 6 / PMA 34-6/7 weeks\n\n remains in room air with improving tachypnea and no significant distress. Nine bradycardias in 24 hours, mild stim only, improved with lower DTO dose.\n\nNo murmur. BP 67/49 (53).\n\nWt 1555 (+30) on TFI 140 cc/kg/day SC20. Feeding small volumes only orally. Abd benign. Voiding normally, stools more formed. KUB normal last night.\n\nTemp stable in air isolette.\n\nNAS 5, 2, 2 ( from yesterday). On NMS 0.16 ml q4h (=0.064 mg/kg/dose).\n\nA&P\n34 week GA infant with NAS, respiratory and feeding immaturity\n-Continue to monitor frequency and severity of apneas and bradycardias\n-Advance caloric density to 22 kcal/oz\n-Continue with current neonatal morphine solution dosing; consider wean tomorrow\n-SW involved; 51A filed last week\n" }, { "category": "Nursing/other", "chartdate": "2179-08-02 00:00:00.000", "description": "Report", "row_id": 1719965, "text": "NPN 7a-7p\n\n\n#1: remains in RA, easily maintaining sats >/= 94%.\nRR stable. BBS cl/=. Breathing comfortably with mild\nretractions. Brady x1, no apnea- QSR. A: stable in RA\nP:Cont to monitor and provide support as needed.\n\n#2: TF: 140cc/k/d. Conts on SC20, tol'ing 41cc q4hrs\ngavaged over 75mins. No spits noted. Min benign asp. Abd\nsoft, +, no loops. AG stable. Voiding qs. Stooled x2,\nfirst was soft formed stool heme negative. The 2nd stool was\nboth soft formed and watery absorbed into diaper. Bottom\nremains excoriated. At last care did bleed at one tiny spot\nwhen cleaning gently with mineral oil on a cottonball.\nApplied new skin care plan: stomahesive powder on skin once\nclean and dry, followed by ointment(criticaid/desitin mix),\nand then covered again with stomahesive powder to seal\nointment on. CNS assessed skin and advised the above plan.\nWhen were in at noon care infant did wake and\nrespond to stimuli, but was sleepy, not showing any interest\nin bottling. will be in at 20care to offer bottle.\nA: tol'ing feeds P:Cont to follow wt and exam. Monitor tol\nto feeds.\n\n#3: Temps stable while swaddled in an air isolette. Infant\nis calm and has been sleeping well in btw cares. He does\nwake during cares and opens his eyes. He moves his\nextremities and responds appropriately to stim. Tol'ed being\nheld by Mom. NAS scores 5, 2, 6 respectively. See flowsheet\nfor details. Conts on Tincture of Opium q4hrs PO/PG as\nordered. Infant has been comfortable today, but not overly\nsedated. A: stable P:Cont to support dev needs. Cont with\nNAS . Monitor tol to meds.\n\n#5: and maternal grandparents in today for noon\ncare. updated and did state that it was acceptable\nto talk about the withdrawal in front of her .\n also spoke with Dr. at bedside for update.\nMom conts to pump/dump at home. Mom did ask Rn and MD if she\nshould cont to pump, as she would like to give infant\nbreastmilk when the \"meds clear out of her system\".\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-15 00:00:00.000", "description": "Report", "row_id": 1720025, "text": "Neonatology Attending\nDOL 19 / PMA 36-5/7 weeks\n\n remains in room air. One bradycardia at rest last night.\n\nNo murmur. BP 79/47 (57). Well-perfused.\n\nWt (+45) on TFI 150 cc/kg/day SC26, tolerating well PO with intake 172 cc/kg/day in the past 24 hours. Abd benign. Voiding and stooling normally.\n\nTemp stable in open crib. NAS \n\nA&P\n34 week GA infant with resolving NWS, respiratory immaturity\n-Continue to await maturation of respiratory drive\n-Continue to monitor NAS\n" }, { "category": "Nursing/other", "chartdate": "2179-08-15 00:00:00.000", "description": "Report", "row_id": 1720026, "text": "Neonatology Attending\nAddendum - Physical Examination\n\nHEENT AFSF\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\nCNS active, resp to stim; tone slightly increased in generalized distribution; MAE symmetricall; suck/root/gag intact; grasp symm\nINTEG normal\nMSK normal insp/palp/ROM all ext\n" }, { "category": "Nursing/other", "chartdate": "2179-08-15 00:00:00.000", "description": "Report", "row_id": 1720027, "text": "NPNOte\n\n\n#1. Remains in Ra ir, BBS clear, equal, mild subcostal/\nintercostal retractions present, no spell thus far this\nshift.A; stable in Ra ir. P; cont to monitor for spells.\n\n#2. Tf=150cc/kg/day,SC26 po fed tolerated, BS+, no loops,\nvoided, no stool thus far this shift.no spit, A; feeds\ntolerated. P; cont current feeding plan.\n\n#3. ,active with care, temp stable in a open crib,\nswaddled with blanket, mae. excoraited butt care given\nhealing ,A; AGA P; cont dev support.\n\n#5. visited, with paternal grand , asking app\nquestions. A; loving P; cont update and support.\n\n#6. Neuro: NAS score 3 today, team aware.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-18 00:00:00.000", "description": "Report", "row_id": 1720041, "text": "Nursing Progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, no spells to time of report. A:\nLast spell on and 2100. P: continue spell count down.\n#2 O: Baby continues to feed ad lib demand with SimSC26.\nBaby woke every 3 to 4 hours and took 60 yo 70cc with a\nsoothie bottle, #2 nipple. No spits or large aspirates,\nabodmen soft, bowel sounds active, no loops, voiding well,\nno stool today. A: All PO feeding well today. P: Continue\nto encourage PO feeds ad lib.\n#3 O: Temp stable in open crib. BAby is and active\nwith cares and sleeps well between cares. Fibromatosis coli\non right side of neck is about dime sized today. Baby has\nfull range of motion and does not seem to favour turning his\nhead either direction. Circ planned for 1000 tomorrow. A:\nenlarging lump on neck is fibromatosis coli. P: Continue to\nsupport development.\n#5 O; Mother in to visit and feed baby this afternoon. She\nwas updated by NNP. Discharge teaching continued. A:\nInvolved mother. P: Continue to keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-18 00:00:00.000", "description": "Report", "row_id": 1720042, "text": "NP NOTE\nPE: small growming premature infant swaddled in open crib. PInk well perfused in RA. Quiet, drowsy state. AFOF sutures approximated, eyes clear, nares patent, MMMP\nNeck with 2 cm nodule on right side, appears to have good ROM.\nChest is clear, equal bs, cmfortabel breathing pattern\nCV; RRR, no murmurm.,pulses+2=\nAbd: soft, active bs\nGU: testes in scrotum\nEXT: , \nneuro: active with symmetric tone and reflexes\n\nMother updated on nodule on neck. Discussed wiuth Radiology, felt it to be a fibromatosis , and will be followed by clinical exam and possible repeat US at a later date. Dr , PMD visited and was shown findings.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-19 00:00:00.000", "description": "Report", "row_id": 1720043, "text": "Nursing Progress Note\n\n\n#1. O: Infant remains in RA with O2 sats>98%. RR 30's-40's.\nBreath sounds are clear and equal. Mild SC retractions\nnoted. No spells thus far. A: Stable in RA. P: Continue to\nmonitor.\n\n#2. O: Infant remains on TF's of min 130cc/k/d of SC26. All\npo adlib. Infant recieved 200cc/k/d yesterday. No spits. Abd\nsoft and round with active bowel sounds. No loops. Voiding\nqs. Med green stools, neg guiac. Wgt is up 75gms to 2175gms.\nA: Tolerating feeds. P: Continue to monitor feeding\ntolerance.\n\n#3. O: Infant remains in open crib with stable temp. He is\n and active with cares. MAEW. Waking for feeds. A: AGA.\nP: Continue to assess and support developmental needs.\n\n#5. O: in this evening. independently gave\nson . Asking appropriate questions. A: Involved .\nP: Continue to inform and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-16 00:00:00.000", "description": "Report", "row_id": 1720028, "text": "Nursing Progress Note\n\n\n1. In room air with sats in high 90's, no spells or desats.\nRR 30-60's, lungs clear and equal with mild retractions.\nDay of spell countdown. Continue to monitor.\n2. Feeds SC26cals at 150ml/kg/d, all bottles with yellow\nnipple. Took 65, 40, 50 with fairly good suck/swallow\ncoordination. No spits. Abdomen benign. Voiding qs,\nstools x3, pasty green. Bottom healing, criticaid/\nstomahesive applied. Weight up 40gms tonight to 2.035kgs.\nFeeding and growing appropriately. Continue ad lib feeds.\n3. In open crib with stable temps. and active, wakes\nfor some feeds. NAS scores 3. Slightly increased tone.\nDoing well, ? d/c NAS scores.\n5. Mom called tonight, given update. Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-16 00:00:00.000", "description": "Report", "row_id": 1720029, "text": "Attending Note\nDay of life 20 PM 36 \nin room air RR 30-60 sat 97-100%\nmild retractions no spells yesterday but had some this am HR to 60's one needing stimulation\nHR 130-150 BP 79/47 mean 57\nweight 2035 up 40 grams on 150 cc/kg/day took in 155 cc/kg/day of SSC 26 cal/oz\nvoiding and stooling\ngetting criticaid\nstable temp in open crib\nNAS scores 3 for past 24 hours\n\nImp-infant in stable condition\nwill plan to d/c NAS scores\nad lib po min 130 cc/kg/day\nwill restart spell count\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-16 00:00:00.000", "description": "Report", "row_id": 1720030, "text": "NNP Physical Exam\nAwake and . AFOF with good tone and mild jitteriness. Mottled with exam. Small neck ?cyst/mass palpable on right side (possible cyst vs enlarged lymph node), no errythema. Breath sounds clear and equal on room air with no retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with active BS, no HSM or masses. Normal GU. Pink buttox.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-01 00:00:00.000", "description": "Report", "row_id": 1719957, "text": "NPN Noc\n\n\n#1 Resp: RA, 50-80's, c/=, mild IC/SC retrac. No spells so\nfar this shift. P: Cont to monitor resp status.\n#2 FEN: CW1525g(-5), TF=140cc/kg/day SSC20, gavaged over 75\nmins. Infant with one medium spits, min asp. PO fed 20cc x1.\nAbd benign, AG 21, V/S, stooling heme neg. Stools appear sl\nwatery. Infant's bottom is excoriated, Desitin applied. P:\nCont to monitor FEN status, encourage po feeds.\n#3 G&D: Temp stable in air isolette, swaddled. ,\nactive, and irritable with care. Infant wakes frequently,\nexcessively sucks on his pacifier, AFSF, MAE, has increased\ntone. Triple abx applied to excoriated axillae. P: Cont to\nmonitor and support G&D.\n#5 Social: in for eve caretimes, held infant after\ncares, during gavage feed. Mom asking appropriate questions,\nverbalized being very \"worried\" and upset to have to leave\ninfant to go to the hotel. Mom called later in the eve,\nupdated by this RN. P: Cont to encourage parental calls and\nvisits.\n#6 Bili: Infant appears jaundiced, rebound bili drawn this\nAM (see labs). P: Cont to monitor for hyperbili,\nphototherapy as needed.\nSee flowsheet/NAS for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-01 00:00:00.000", "description": "Report", "row_id": 1719958, "text": "Neonatology NP Note\nswaddled in isolette\nAFOF, sutures approximated\nmild subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\n2 eschars on left arm without drainage or erythema\noverall increased tone, sucking voraciaously on pacifier, buttocks excoriated\n" }, { "category": "Nursing/other", "chartdate": "2179-08-01 00:00:00.000", "description": "Report", "row_id": 1719959, "text": "Neonatology\nDOL #5, CGA 34 wks.\n\nCVR: Remains in RA, RR 60s-70s, mild retractions, O2sats > 95%. One spell in 24 hrs, not on caffeine. Hemodynamically stable, no murmur.\n\nFEN: Wt 1525, down 5 grams. TF 140 cc/kg/day, on SSC 20, PG over 75 mins for hx of spits. Continues with frequent small spits. Minimal aspirates. Stools more liquid.\n\nGI: Jaundiced. Bili 6.0/0.3, rebound from 7.2/0.2.\n\nNEURO/DEV: Described as irritable, difficult to console. NAS scores 7, 10, 8, 13, 14, 15.\n\nIMP: Former 34 wk infant with in-utero exposure to buprenorphine, positive cocaine tox screen. Overall stable, mild respiratory insufficiency. Minimal apnea. Increasing NAS scores. Full-volume feeds with mild issues of dysmotility and loose stools; this may be due to neonatal abstinence syndrome, but given prematurity, also need to consider feeding intolerance, although exam benign. Resolving hyperbilirubinemia.\n\nPLANS:\n- Continue monitoring in RA.\n- Continue 140, 20 cals for today.\n- KUB (precautionary).\n- Begin neonatal opium solution, monitor NAS scores.\n- Monitor jaundice clinically.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-14 00:00:00.000", "description": "Report", "row_id": 1720020, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 98-100%.RR 30-60's.LS\nremain clear and equal with sc retractions.Infant with no\nA's and B's or desats thus far.Day#.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day.Rec.Special Care 26\n49cc's q 4 hrs.Infant bottling 50-55cc's with a yellow\nnipple.Appears coordinated.Weight=1.950 up 40 grams.Abd.\nsoft with pos bs,no loops or spits,minimal aspirates.Girth\n23-24.Voiding and stooling heme negative.\n\nG/D:AF soft and flat. and active with cares.Noted to be\nhypertonic.MAE.Bringing hands to face and mouth.Infant less\nirritable.Swaddled and intermitently sucking on\npacifier.NAS=4.Temp. remains stable.\n\nSocial:Mom called x 2.Updated by this RN.Asking appropriate\nquestions.Appears invested.A/P:Cont. to update,support,and\neducate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-14 00:00:00.000", "description": "Report", "row_id": 1720021, "text": "Addendum:Infant with a HR 72 and a saturation 91%.QSR.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-14 00:00:00.000", "description": "Report", "row_id": 1720022, "text": "Neonatology\nDOL # 18, CGA 36 wks.\n\nCVR: Remains in RA, O2sat > 97%. Clear and equal, mild retractions. One spell, quick and self-resolving. Hemodynamically stable, no murmur.\n\nFEN: Wt , up 40 grams. TF 150 cc/kg/day, SC 26, PO/PG, all PO overnight! Voiding/stooling.\n\nDEV: In open crib. NAS scores in 5 range.\n\nIMP: Former 34 wk infant, doing well. Stable in RA. Minimal apnea, immaturity of resp control. Improving PO intake.\n\nPLANS:\n- Continue as at present.\n- Monitor spells.\n- Monitor PO intake.\n- Monitor NAS scores.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-14 00:00:00.000", "description": "Report", "row_id": 1720023, "text": "NPN DAYS\n\n\n1. In RA. LS clear. O2 sat>96%. No spells. Stable.\n\n2. TF at 150cc/kg of SC26. All bottles. Bottling well with\ngood coordination. Abd benign. Voiding and stooling. No\nspits. On Fe. Good po intake.\n\n3. Temp stable in open crib. Active and with cares.\nWaking on own for cares. Continues with NAS . Today\nhas scored 5's. Continue to monitor.\n\n5. Mother called x2 updated. Asking appropriate questions.\nWill be in tonight to give a bath. Loving parent.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-15 00:00:00.000", "description": "Report", "row_id": 1720024, "text": "Nursing Progress Note\n\n\n1. In room air with sats in high 90's, RR 30-50's, lungs\nclear and equal. Had one quick brady to 63, no desat, QSR\nduring sleep after feeding. Day 0 of countdown.\n2. Feedings SC26 at 150ml/kg/d. Weight up 45gms to 1.995\ntonight. Taking all feedings by bottle, 52-65ml q4hrs. Not\nwaking for feedings tonight. Abdomen benign. Voiding and\nstooling qs. Bottom slightly broken down on R buttock,\nstomahesive pdr and criticaid applied. Continue with\ncurrent plan.\n3. and active with cares, bottles with good\ncoordination. Slept well between feeds, NAS scores 3 each\ntime. Temp borderline in open crib, hat and extra blanket\napplied. Continue to support development.\n5. Both in for 8pm feeding. Wanted to do bath but\ntime would not allow. cared for infant lovingly and\nindependently. Asking appropriate questions, anxious for\ndischarge. DSS involved. Support, discharge teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-19 00:00:00.000", "description": "Report", "row_id": 1720044, "text": "Attending Note\nDay of life 23 PMA 37 \nin room air sat 98 and higher RR 30-40 mild retractions\nday no spells\nHR 130-150 BP 51/35 mean 40\nweight 2175 up 75 grams on min of 130 cc/kg/day of SSC 26 cal/oz took in 200 cc/kg/day all po\none small spit\nvoiding and stooling heme negative\ngetting criticaid to buttocks\nstable temp in open crib\nneck mass consistent fibromatosis coli\n\nImp=stable making progress\nwill change to neosure 24 cal/oz in anticipation of discharge on Monday\nwill continue discharge teaching\nwill have a hearing screen\nwill have a circ today\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-19 00:00:00.000", "description": "Report", "row_id": 1720045, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin: warm and dry; color pink\nHEENT: elongated occiput, fontanels open, level; sutures moveable, opposed; large fixed oval mass right neck identified as ; full range of motion in neck\nChest: breath sounds clear/=\nCV: RRR without murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; cord off umbilicus healing\nGU: normal male; testes descended\nExt: moves all\nNeuro: alerat; + suck; + grasps; symmetric tone\n" }, { "category": "Nursing/other", "chartdate": "2179-08-19 00:00:00.000", "description": "Report", "row_id": 1720046, "text": "Nursing Progress Note\n\n7 Circumcision care\n\n#1 O: in room air, lungs clear/equal, color pale pink. RR\n30's-50's, no retractions. no apnea/bradycardia episodes\nnoted this shift, last episode 9pm. P: monitor\n#2 O: ad lib demand w/min 130cc/k/d now Neosure 24. taking\n50-70cc w/soothie #2 bottle. abd benign, vdg after\ncircumcision this morning, gassy and attempting to stool.\nFerisol given by mom. P: present care\n#3 O: w/cares, temp stable swaddled in open crib.\nTylenol and/or sucrose for pain d/t circ. P: cont to assess\nand support.\n#5 O: mom here this morning w/mgm, concerned about baby,\npain s/p circ. very loving w/baby but not really his\nclues well around trying to settle him when fussing this\naftrnoon- bouncing him around, pacifier immediately\nw/crying, needing support w/position changes to burb.\nsupport given as well as reassurance that baby fine despite\nfussiness and all related to circ.\n#7 O: circ this morning, site clean w/sl. bruising at base\nof penis, sl. bleeding underside of glans when gauze fell\noff. reapplied vaseline/gauze and bleeding stopped. has\nvoided already. P: present care.\n\n\nREVISIONS TO PATHWAY:\n\n 7 Circumcision care; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-19 00:00:00.000", "description": "Report", "row_id": 1720047, "text": "SOCIAL WORK\nSpoke with DSS worker today re d/c plans tenetatively planned for Monday. DSS worker is at . She would like to speak with Mother and will inform this provider of authorization of d/c plan before the end of Friday. Did not have chance to speak with mother today. Please page on Friday if she is visiting.#.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-04 00:00:00.000", "description": "Report", "row_id": 1719973, "text": "NPN Nights 7pm-7am\n\n\n#1 O: Infant remains in roomair with O2 sats 94-98%. Lung\nsounds remain clear and equal with resp rates 50-60s,\ncontinued mild retractions. A: stable in roomair. P:\nContinue to moniter.\n#2 O: Wgt ^65g to 1650g. Remains on SSC 24 cals/oz at TF of\n140cc/k/day. Infant bottled X 1 and took 10cc - has a few\ncoordinated sucks but does not sustain interest in\nbottling/sucking. Tolerating gavage feeds well with minimal\naspirates and moderate spit X 1. Abd remains soft, +bs, no\nloops. Voiding adeq amts, passing formed yellow stool.\nSkin over buttocks remains excoriated, looks a little less\nreddened - using water and mineral oil to cleanse area and\nhave re-applied stomahesive powder and criticaid ointment.\nA: wgt ^. Spit X 1, minimal interest in po feeds.\nExcoriated skin as noted. P: Continue to moniter tolerance\nof feeds. Continue with skin care regime to buttocks.\n#3 O: Infant is and active with cares, waking self for\nsome feeds. Temp okay in off isolette, swaddled. Remains on\nNeonatal Opium Solution with dose weaned tonight. NAS\nscores tonight have been 1 and 4 (see flow sheet). Bottled\nX 1 with minimal interest. A: AGA, continuing to wean NOS.\nP: Continue to moniter.\n#5 Infant's mom called x 1 - updates given. She plan to\nvisit this morning (Wednesday).\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-04 00:00:00.000", "description": "Report", "row_id": 1719974, "text": "Neonatology Attending\nDOL 8 / PMA 35-1/7 weeks\n\n remains in room air with no distress. Two bradycardias overnight (eight in 24 hours). Not on caffeine.\n\nNo murmur. BP 71/33 (47).\n\nWt 1650 (+65) on TFI 140 cc/kg/day SC24 PO/PG. Abd benign. Voiding and stooling. Tolerating feeds well with infrequent reflux. Bottling small volumes only.\n\nTemp stable in isolette.\n\nNAS on DTO 0.11 ml/dose.\n\nA&P\n34 week GA infant with NWS, respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive. We will defer caffeine therapy unless frequency of apnea increases to > \n-Wean DTO by 10% again this evening for NAS < 8\n-Advance caloric density to 26 kcal/oz and add iron supplementation\n" }, { "category": "Nursing/other", "chartdate": "2179-08-04 00:00:00.000", "description": "Report", "row_id": 1719975, "text": "NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with comfortable WoB, no murmlur, abd soft, soft bowel sounds, diaper rash covered with criticaid, calm, mild increased tone of extremities.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-04 00:00:00.000", "description": "Report", "row_id": 1719976, "text": "NPN 7a-7p\n\n\n#1: in RA, sating >/= 94%. RR stable. BBS\ncl/=. Breathing comfortably with mild retractions. 2 brady\nspells thus far with apnea. Mild stim needed to recover. A:\nstable in RA P:Cont to monitor and provide support as\nneeded.\n\n#2: TF: 140cc/k/d. Adv'ed to SC26 today. Conts receiving\n41cc q4hrs gavaged over 1hr. Med spit x1 after bottling\nattempt. Mom offered infant bottle at 1230care. Infant took\n15cc with poor coordination. Still trying to learn how to\ncoordinate suck/swallow/breathe pattern and form mouth\naround nipple correctly. Min benign asps. Abd soft, +,\nno loops. AG stable. Voiding qs. Stooled x2. Bottom\nexcoriation much improved. Skin is pink on left, slightly\nredder on right, but intact and healing. No bleeding noted.\nSkin care regimen of stomahesive powder/criticaid/stoma\npowder applied as needed. A: adv'ing cals P:Follow wt and\nexam. Monitor tol to feeds. Offer bottle as tol'ed.\n\n#3: Temps stable while swaddled in an off isolette. Will\nhas been /active with cares. MAE. Sleeps well in btw\ncares. Fonts soft/flat. Brings hands to face. Will suck on\npacifier intermittently. Tol'ed being held. NAS scores\n2-2-2. Conts on neonatal opium as ordered. A: AGA P:Cont\nto support dev needs.\n\n#5: Mom in for few mins this am alone. Rn asked Mom if she\nfelt safe with FOB . Mom stated that she did fell\nsafe with him. Also that she knows sometimes he can seem\n\"rough\". Encouraged Mom to let Team know at any time if\nthis changes and she feels unsafe, assistance can be given.\nLater in the day Mom was alone again and , SW\nwent in and spoke with her. See her note for details. Mom\nparticipated in cares and offered infant bottle this\nafternoon. Mom very appropriate with infant, loving and\naffectionate. . grandmother in this am as well. Dad did\ncome in for 16care. He participated in care and then held\ninfant. both updated. interactions\npleasant. A: Involved, loving family P:Cont to support and\neduc\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-05 00:00:00.000", "description": "Report", "row_id": 1719977, "text": "2300-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS >95%. BS CLEAR. RESP RATE 34-46\nWIHT MILD SC RETRACTIONS. NO SPELLS OVERNIGHT\nA:STABLE\nP:CONTINUE TO MONITOR RESP STATUS AND SPELLS\n\n#2F/E/N\nO:TF AT 140CC/KG SCF26 41CC Q4HR PO/PG. BABY BOTTLED 26CC X1\nOVERNIGHT, REMAINDER GAVAGE. ABDOMEN SOFT, FULL WITH GOOD\nBS. AG 23.5-24CM. NO SPITS AND <1CC ASPIRATES. VOIDING WELL;\nSMALL YELLOW STOOL X1. WT UNCHANGED\nA:TOLERATING FEEDS WELL; LEARNING TO PO\nP:CONTINUE TO ENCOURAGE PO'S AS ABLE, MONITOR TOLERANCE TO\nFEEDS\n\n#3G&D\nO:IN OFF ISOLETTE WITH STABLE TEMPERATURE. ACTIVE/MAE WITH\nCARES; SLEEPING WELL BETWEEN. DOESN'T WAKE TO EAT ON OWN BUT\nIS AND ACTIVE WITH CARES. FONTANEL SOFT AND FLAT;\nSUTURES SMOOTH. NAS 3 AND 4 OVERNIGHT--REMAINS ON DTO AS\nORDERED. BOTTLED SLOW BUT WITH GOOD COORDINATION X1 USING\nYELLOW NIPPLE\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5SOCIAL\nO:NO CONTACT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-17 00:00:00.000", "description": "Report", "row_id": 1720036, "text": "NPN Days 7am-7pm\n\n\n#1 O: Infant remains in roomair with O2 sats 98-100%. Lung\nsound remain clear and equal, with mild subcostal\nretractions at times. No episodes of desast noted. A:\nmaintaining adeq sats in roomair. P: Continue to moniter.\n#2 O: Remains on adlib feeds of SSC 26 cals/oz. Infant\nwaking ~ q 4 hours and has taken 55-60cc each feeding. Mom\nbrought in a new \"Soothie\" nipple and infant did okay with\nthat/flow may be a little too slow for him. Abd is soft,\n+bs, no loops. Voiding adeq amts, stool heme neg. Criticaid\napplied to small area of previous skin breakdown on right\nbuttock. A: bottling well. P: Continue to encourage po\nintake. Plan made to check nutrition labs tomorrow morning.\n#3 O: Infant is and active with cares, waking self for\nfeeds. Temp is stable in open crib. Ultrasound done to\nright side of neck where \"nodule\" is located - per team site\nhas been described as torticollis and OT has been called to\ngive intput for positioning, etc. Lower extrmities remain\nsomewhat hypertonic. No episodes of bradys this shift. A:\nAGA, with neck \"issue\" as noted above. P: COntinue to\nmoniter for milestones.\n#5 O: Infant's mom was in to visit this afternoon. She was\nupdated at the bedside by this RN and over the phone by MD\n. She also psoke with DR. about consenting for\ninfant's circumcision and that has been planned for Thursday\nat 10am. Mom is with cares, needing some verbal\ncues for bottling. She asked appr questions and was shown\nhow to give infant his iron. A: involved and invested mom .\n P: COntinue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-18 00:00:00.000", "description": "Report", "row_id": 1720037, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WIHT SATS >97%. BS CLEAR. RESP 30-72\nWITH MILD SC RETRACTIONS. HAS HAD NO SPELLS OVERNIGHT\nA:STABLE\nP:CONTINUE TO MONITOR FOR SPELLS\n\n#2F/E/N\nO:ON MINIMUM, 130CC/KG SCF26. BABY BOTTLING 80CC Q4HR\nOVERNIGHT. ABDOMEN SOFT, FULL WITH GOOD BS. NO SPITS.\nVOIDING WELL; NO STOOL THUS FAR. WT UP 25GM. TOOK IN\n173CC/KG PAST 24HR.\nA:STABLE\nP:CONTINUE TO ENCOURAGE PO'S, MONITOR WT GAIN\n\n#3G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. HEP B GIVEN AS ORDERED WITH DOSE OF\nTYLENOL X1. FONTANEL SOFT AND FLAT; SUTURES SMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5SOCIAL\nO:MOM X2 FOR UPDATE.\nA:INVOLVED, INVESTED MOM\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-18 00:00:00.000", "description": "Report", "row_id": 1720038, "text": "ADDENDUM TO ABOVE\nNECK \"MASS\" VISIBLE RIGHT SIDE OF NECK. OT TO SEE BABY TODAY RE:DX OF TORTICOLLIS. ROLL BETWEEN LEGS AS ORDERED. BOTTLING WELL COORDINATED WITHOUT CHOKING\n" }, { "category": "Nursing/other", "chartdate": "2179-08-18 00:00:00.000", "description": "Report", "row_id": 1720039, "text": "Attending Note\nDay of life 22 PMA 37 \nin room air RR 30-70 no spells in 24 hours\nHR 120-170 no murmur BP 82/37 mean 47\nweight 2100 up 25 grams on 130 cc/kg/day min took in 173 cc/kg/day of SSC 26 cal/oz\nvoiding and heme negative\ngetting criticaid to buttock\nCa 10.4 Phos 7.4 Alk Phos 238 D stick 75\ns/p Hep B\n\nImp-making progress\nwill monitor for spells\nwill have OT evaluate the tortocollis\ncirc planned for tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2179-08-03 00:00:00.000", "description": "Report", "row_id": 1719970, "text": "Neonatology Attending\nDOL 7 / PMA 35 weeks\n\nRemains in room air with no distress. Five bradycardias in 24 hours, with ongoing very brief events, associated with periodic breathing but not caffeine.\n\nNo murmur. Well-perfused. BP 55/37 (42).\n\nWt 1585 (+30) on tFI 140 cc/kg/day, tolerating by gavage over 1 hour for history of reflux. Bottling minimal volumes only. Abd benign. Voiding and stooling (stools now formed)\n\nDiaper dermatitis with excoriation. Temp stable in off isolette.\n\nNAS .\n\nA&P\n34 week GA infant with NWS, respiratory and feeding immaturity\n-Continue to monitor frequency and severity of bradycardia. If significant\n(Continued)\n-Weaned neonatal morphine solution by 10% overnight; continue to monitor NAS scores\n" }, { "category": "Nursing/other", "chartdate": "2179-08-03 00:00:00.000", "description": "Report", "row_id": 1719971, "text": "Nursing PRogress Note\n\n\n#1 O: room air w/sats 100%, lungs clear/equal, color pink.\nRR 30's-60's, baseline mild sc/ic retractions. averaging one\nbradycardia/hour this shift so far, HR 50's-70's but no\ndesats, all QSR and associated w/shallow breathing /no\napnea. not on caffeine as yet. A: premie breathing vs.\nnarcotic effect on weaning NOS. P: ? start caffeine if cont.\nmonitor and document episodes.\n#2 O: TF 140cc/k/d now SSS24; alt po attempts w/pg for rest\nof feeds, taking 10-15cc slowly w/encouragement. min. asp.\nand no spits this shift w/pg feeds over 1hour. abd benign,\nvdg and stooling formed yellow stools. butt excoriated,\ncriticaid/stomadhesive as per plan. A: adv feeds tol well so\nfar. P: present care.\n#3 O: weaned Neonatal opium suspension as ordered, NAS\nscores 2. behaviour appropriate for gestational age, no\novert s/s withdrawal today other than skin excoriation and\ntone. slow bottling effort, fairly good coordination w/suck\nbut unable to sustain for longer than a couple of cc's. P:\ncont to wean NOS as tol, NAS scores, offer bottle qofeed as\ntol.\n#5 O: in this morning before leaving for home. mom\ncalled several times since and will be back later today.\nasking about bradys, stooling, feeds. P: cont to support,\ndocument interactions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-03 00:00:00.000", "description": "Report", "row_id": 1719972, "text": "NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with mild retracting, no murmur, abd soft, non distended, + bowel sounds, diaper rash improving, active, increased tone, calmer on neonatal opium solution\n" }, { "category": "Nursing/other", "chartdate": "2179-08-17 00:00:00.000", "description": "Report", "row_id": 1720033, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 98-100%.RR 30-60's.LS\nremain clear and equal with sc retractions.Infant with 1\nspell HR 72 with a saturation of 98%.QSR.\n\nF/N:TF Ad lib demand with a Min.130cc's/kg/day.Infant taking\n148cc's/kg/day.Bottling 50-52cc's of Special Care 26.Appears\nwell coordinated.Weight=2.075 up 40 grams.Abd.soft with pos\nbs,no loops or spits.Voiding no stool.Buttocks healing\nwell.Cont.to apply Criticaid with good effectiveness.\n\nG/D:AF soft and flat.R side of neck with palpable\nlump.Question cyst.Remains unchanged.No increased redness or\nswelling.Temp. stable.MAE. and active with\ncares.Sleeping well b/t.Waking prior to feeds.Infant remains\nin open crib and swaddled.Temp.stable.\n\nSocial:Mom called x 1.Asking appropriate questions.Plans to\ncall prior to visit d/t ad lib demand schedule.Appears\ninvested and loving toward infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-02 00:00:00.000", "description": "Report", "row_id": 1719966, "text": "NPN 7a-7pcont'ed\n\n\n#5cont'ed: Rn encouraged Mom to cont pumping/dumping for now\nto keep her Bm supply up if that is what she wants as it\nwill dry up is she stops. As for if and when it would be\ndetermined that her BM could be given to infant, Dr.\n addressed that issue. Family supportive of one\nanother and appropriate with infant. Mom held infant for\n~1hr. Mom called later in the day for update. A: Involved\nfamily P:Cont to support and educate. planning to\nvisit at 20care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-02 00:00:00.000", "description": "Report", "row_id": 1719967, "text": "NP NOTE\nPE: small preterm infant nestled in isolette. Pink, mildly jaundiced in RA.\nAFOF sutures approximated, prominent occiput. NG in place, MMMP\nChest is clear, equal bs, comfortable\nCV: RRR, no murmur, pulses+2=\nAbd: soft,a ctive bs cord dry\nGU: testes descended, excoriated perianla area.\nEXT: acrocyanosis\nNeuro: increased tone UE>LE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-03 00:00:00.000", "description": "Report", "row_id": 1719968, "text": "NPN Nights 7pm-7am\n\n\n#1 O: Infant remains in roomair with O2 sats 95-99%. Lung\nsounds remain clear and equal. Resp rates 20s-60 with\noccasional mild retractions. A: maintaining sats well in\nroomair, breathing comfortably. P: Continue to moniter.\n#2 O: Wgt ^30g to 1585g. Remains on SSC 22 cals/oz at\n140cc/k/day. Infant bottled Xat 8pm cares and took 5cc -\nwas awake but had minimal interest in bottleing. Tolerating\ngavage feeds well with min aspirates and no spits. Abd\nremains softly round, +bs, no loops. Voifing adeq amts,\nstool soft and formed. Skin breakdown still present over\nbottom with occasional min bleeding noted - skin care regime\nconts to are with use of stomahesive powder and cirticaid\ncombo, cleansed with water and mineral oil. A: tolerating\ngavage feeds well, minimal interest in po feeding. P:\nContinue to encouarge po intake as tolerated. COntinue to\nassess skin integrity issues.\n#3 O: Infant needing to be awakened for cares and then has\nbeen calm with eyes open. Temp stable/warm in heated\nisolette while swaddled, temp setting weaned tonight.\nRemains on Neonatal OPium, dose weaned, with NAS scores of\n2 and 2 (scored for excoriation and mottling). Sucking\noccasionally on his pacfier, minimal interest in po feeds.\nA: AGA, weaning opium, minimal interest in po feeds. P:\nContinue to moniter for milestones.\n#5 O: Infant's and paternal grandparents were in to\nvisit this evening. asking appr questions about\ninfant's status and dad asked specific questions concerning\nthe weaning of infant's opium dose. Dad needing some\nverbal cues about bottling infant and RN reviewed skin care\nwith them. Infant's mom called later in shift for updates.\nA: invested , asking appr. questions. P: Continue to\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-03 00:00:00.000", "description": "Report", "row_id": 1719969, "text": "Neonatology Attending\nAddendum\n-If increased frequency of bradycardia, will consider caffeine therapy\n-Advance caloric density to 24 kcal/oz\n-SW involved\n" }, { "category": "Nursing/other", "chartdate": "2179-08-17 00:00:00.000", "description": "Report", "row_id": 1720034, "text": "Attending Note\nDay of life 21 PMA 37 0/7\nin room air sat 95-100% RR 30-60 mild retractions one spell overnight and 3 during the day (one needing stimulation)\nHR 120-150's 77/43 mean 55\nmottles with cares pale BP\nweight 2075 up 40 grams on ad lib demand feeds min 130 took in 148 cc/kg/day of SSC 26 cal/oz all po\none small spit overnight\nbuttock excoriation improved\nneck mass present had ultrasound c/w tortocollis\n\nImp-infant making some slow progress still showing signs of immaturity\nCV-will monitor for spells\nFEN-will check nutrition labs on tomorrow. Will continue current calories.\nOT/PT-will have an OT evaluation because of the tortocollis\n" }, { "category": "Nursing/other", "chartdate": "2179-08-17 00:00:00.000", "description": "Report", "row_id": 1720035, "text": "Neonatology - NNP Progress Note\n\nInfant is active with good tone. AFOF. Mass noted just inferior to right ear. Ultrasound of mass today shows that mass is intramuscular, may be torticollis. He is comfortable in room air, breath sounds clear and equal. He is tolerating enteral feeds, abd soft, active bowel sounds, voiding and stooling. Stable temp in opencrib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719938, "text": "Clinical Nutrition:\nO:\n34 0/7 week gestational age BB, AGA, now on DOL 1.\nBWT: 1745g(10-25th %ile)\nHC @ Birth: 30cm(~25th %ile)\nLN @ Birth: 42cm(10-25th %ile)\nNutrition: TF @ 60cc/kg/day. NPO. D10W ivf's infusing via PIV. Plan to start feeds today.\nGI: Abd benign.\n\nA/Goals:\nNPO with ivf's as above & plan to start EN feeds today. When able to start feeds, initial goal is 150cc/kg/day SSC 24, providing ~120kcals/kg/day & ~3.3g pro/kg/day. Further advances as per growth & tolerance. Appropriate to start Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15-20g/kg/day for WT gain, ~0.5-1cm/wk for HC gain & ~1cm/wk for LN gain. Will follow w/ team & participate in nutriton plans.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719939, "text": "SOCIAL WORK\nMet with both , and , with Dr today. Regarding finding of positive cocaine, mother reports that she had novocaine last Friday for repair of tooth cavities and was told by her dentist that a drug screen would be positive for cocaine. Dr will clarify this possibility. Mother relates use of pain medication following an autoplasty and has been going to a clinic in every 2 weeks for tx of this addiction. She reported that she had hoped to be off all medication by the time the baby was in . Mother was , asking questions and expressing concern for the baby's welfare. Will follow along. Gave father info on .\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719940, "text": "NPN 7a-7p\n\n\n#1: had some drifting this am, followed by desat to\n81%-slow to recover and then hovering in sats 85%. Placed in\nNC 100%, initially 50cc flow, and quickly weaned to 25cc\nflow. RR stable. Breathing comfortably with mild SC\nretractions. BBS cl/=. 3 brady spells thus far. One with\napnea. See flowsheet for details. A: min O2 req P:Cont to\nmonitor and provide support as needed.\n\n#2: TF: 60cc/k/d. Currently on D10W with 2meqNaCl & 1meq\nKCl at 30cc/k/d, infusing via patent peripheral IV. D/S\nstable. Enteral feeds started this afternoon. At noon\n offered infant a bottle, but he did not feed well.\nDid not form mouth around nipple well and most of the\nformula dripped out sides of his mouth. After feed infant\nhad a med spit. At 16care NG tube placed and enteral feeds\nstarted at 30cc/k/d. Infant tol'ed 9cc SC 20 PG. No further\nspits noted. Abd soft, +, no loops. AG stable. Voiding\nqs. Lg mec stool x1. Since feeds were started Team decided\nnot to draw 24hr lytes. Plan to check bili in am. A: began\nenteral feeds P:Cont to monitor tol to feeds. Offer bottle\nas tol'ed. Follow wt and exam. I&O.\n\n#3: Temps stable in servo isolette. Infant is nested on\nsheepskin within boundaries. Fonts soft/flat. Brings hands\nto face. MAE. Highest score on NAS= 3. Infant has been\nsleeping comfortably in btw cares. Tol'ed being held by\n this afternoon. A: AGA P:Cont to support dev needs.\n\n#4: Blood culture remains negative to date. CBC benign.\nConts on antibiotics as ordered. Temps stable. A: stable\nP:Cont to follow labs. Cont with antibx as ordered. Monitor\nfor s&s of infection.\n\n#5: Dad in numerous times today to see infant and show him\noff to his visitors. did come in together for\n12care and both participated in feeding and held infant.\nBoth updated and asking appropriate questions. Aware of\nneed for NC and NG tube. Team did speak with Mom today\nregarding tox screen results of infant. See SW note for\ndetails. P:Cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 1719941, "text": "NPN Nights 7pm-7am\n\n\n#1 O: Infant remains in NC O2, in 100% and needing ~25cc of\nflow to maintain adeq sats. Lung sounds remain clear and\nequal with resp rates 30s-50s. A: needing min flow O2. P:\nContinue to moniter.\n#2 O: Wgt 1645g, down 100g. TF remain at 60cc/k/day. IVF\nare D10W with added lytes, infusing peripherally. Feeds\nincreased to 50cc/k/day- tolerating gavage feeds well with\nmin aspirates and no spits. Abd remains softly round, good\nBS, no loops. Voiding adeq amts, passing m,ec stool.\nD-stick was 59. Bilirubin this Am was 7.0/.2/6.8. A:\ntolerating advnacing of feeds well. P: Continue to moniter.\n#3 O: Infant's temp remains stable in servo controlled\nisolette. Infant is alert and active with cares, is\nirritable at times but does settle with containment and with\nsucking on his pacfier. NAS scores were over night.\nInfant had 3 episodes of bradys this shift - needing to stim\nto resolve X2. A: AGA, having some bradys. P: Continue to\nmoniter for milestones.\n#4 O: Infant remains on Ampi and Gent as per plan, blood\ncultures remain negative to date. Temp remains stable in\nservo controlled isolette and infant has been tolerating\ngavage feeds well. A: r/o sepsis. P: Continue to moniter.\n#5 O: Infant's mom and dad and were in to visit\nduring the evening portion of the shift. asked appr\nquestions and were updated at the bedside. Dad assisted\nwith infant's care and mom held infant. A: invested\n. P: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-23 00:00:00.000", "description": "Report", "row_id": 1720065, "text": "Neonatology Attending\nDOL 27 / PMA 37-6/7 weeks\n\nIn room air with no distress. No cardiorespiratory events in 3 days.\n\nIntermittent murmur noted overnight. BP 72/40 (52).\n\nWt 2330 (+120) on TFI 130 cc/kg/day min Neo24, with ad lib intake 233 cc/kg/day yesterday. Tolerating feeds well. Voiding and stooling normally.\n\nTemp stable in open crib.\n\nA&P\n34 week GA infant with resolving respriatory immaturity, fibromatosis coli\n-Continue to monitor until free of apneas/bradycardias for at least 5 days prior to discharge home\n-Follow intermittent murmur clinically\n-Discharge planning in progress including EIP for physical therapy\n" }, { "category": "Nursing/other", "chartdate": "2179-08-23 00:00:00.000", "description": "Report", "row_id": 1720066, "text": "Rehab/OT\n\nWill seen today for neck ROM. Fibrous mass on right sternocleidomastoid may restrict neck ROM in the future, risk for torticolis. Full, passive ROM observed to cervical spine. This will need to be CLOSELY monitored by EI after d/c. Page 3 completed.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719934, "text": "NPN 2300-0700\n\n\n1. RESP: Infant remains in RA with RR 30-60's and sats\n>92%. Lung sounds are clear. Mild retractions noted. One\nspell so far this shift of HR58 which required mild stim to\nresolve. No grunting noted. Will monitor.\n\n2. F&N: TF remain at 60cc/k/d of D10W infusing well via\nPIV. D/S 71. NPO. Abd soft. BS+. A/G stable. U/O\n1cc/k/h but has been increasing throughout this shift. Mild\ngeneralized edema noted. No stool noted. BW 1745. 24 hour\nlytes to be drawn at 1400 today.\n\n3. DEV: is active and irritable during his cares\nbut he settles easily when left alone with boundaries. He\nwas moved into a servo-controlled isolette and temp has been\nstable. He puts his hands to his face and sucks on his\npacifier at times.\n\n4. : Infant remains on Ampi and Gent as ordered. Med\ndosages reviewed by this RN and NNP ST. and no\nchanges were made. Meds given as ordered.\n\n5. PAR: No contact from so far this shift. Infant\nurine was sent for tox screen yesterday and is positive for\ncocaine. Will make team aware. Will monitor closely for and\nsupport infant if he develops drug withdrawal symptoms.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719935, "text": "NNP Physical Exam\nPE: pin, AFOF, breath sounds clear/equal with mild tachypnea, mild subcostal retracting, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719936, "text": "Neonatology Attending\nDOL 1\n\nTransitioned off CPAP last night to room air, currently in NC 25 cc/min of 100% FiO2 for desaturation. No significant distress other than mild intermittent tachypnea. One bradycardia overnight.\n\nNo murmur. Well-perfused. BP 62/30 (41).\n\nOn amp/gent. WBC benign.\n\nWt 1745 on TFI 60 cc/kg/day, NPO on D10W. D-stick 71. Abd benign. Voiding 1 cc/kg/hr and stooled appropriately.\n\nTemp stable in isolette.\n\nNo current signs of withdrawal and neuro-irritability. Urine tox screen positive for cocaine but otherwise negative.\n\nA&P\n34 week GA infant with resolved TTN, antenatal opioid and naloxone exposure\n-Continue to monitor for respiratory matuarity and wean oxygen as tolerated\n-Will start enteral feeds cautiously as tolerated today\n-Bilirubin in am\n-Continue with antibiotic coverage for anticipated duration of 48 hours pending culture results and continued clinical stability\n-Will meet with mother today regarding result of urine tox screen\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719937, "text": "Case Management Note\nChart has been reviewed and events noted. I will place EIP & VNA options in record. I will be providing clinical updates to and will assist w/any d'c planning needs along with team & family\n" }, { "category": "Nursing/other", "chartdate": "2179-08-09 00:00:00.000", "description": "Report", "row_id": 1719997, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-100%.RR 40-60's.LS\nremain clear and equal with sc retractions.Infant with no\nA's and B's or desats thus far.\n\nF/N:Infant cont's on TF 140cc's/kg/day.Rec.Special Care 26\n42cc's q 4 hrs gavaged over 1 hr.Infant waking prior to\nfeeds and bottled x 2 taking the full amount.Appears well\ncoordinated.Weight=1.785 up 35.Abd. soft and round with pos\nbs,minimal aspirates,girth=23.Infant voiding and stooling\nwith q diaper change.Buttocks appears excoriated.Mineral\nOil,Criticaid,and Stomahesive applied.\n\nG/D:AF soft and flat. and active with cares.Mild\nhypertonia noted.NAS (See Flow Sheet).MAE.Bringing hands\nto face and mouth.Sucking on pacifier.Noted\nirritability,calms with containment and pacifier.\n\nSocial: in tonight asking appropriate\nquestions.Handling infant well.Appear loving and\ninvested.Cont. to update,support,and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-09 00:00:00.000", "description": "Report", "row_id": 1719998, "text": "Neonatology Attending Progress Note\n\nNow day of life 13, CA 6/7 weeks.\nIn RA with RR 40-60s.\n3 episodes of apnea/bradycardia today.\nHR - 130-150s BP 63/32 42\n\nWt. 1785 up 35gm on SSC26 140ml/kg/d - took all of feedings po overnight but did require gavage this morning.\nNormal urine and stool output.\n\nNAS scores \n\nSocial - awaiting word from DSS regarding 51A status\n\nPE - breathing comfortably in RA.\nAF soft and flat.\nResp - breath sounds clear and equal.\nCVS - S1 S2 normal no murmur, perfusion good\nAbd - soft with no distension\nDiaper region - perianal excoriation\nNeuro - tone symmetrical, wnl, calm during my exam.\n\nAssessment/plan:\nBaby still demonstrating immaturity of feeding skills.\nWill advance to 150ml/kg/d.\nNAS continues.\nWill continue to await word from DSS on their investigation.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-09 00:00:00.000", "description": "Report", "row_id": 1719999, "text": "Nursing PRogress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions. 3 spells, 1 required mild stim.\nA: Occasional spells. P: continue to support development.\n#2 O; Total fluids increased to 150cc/kg/day of SC 26\ncal/oz. Feeds offered by bottle, taken at first 2 feeds\nand the 8cc at third feeding before falling asleep. Abdomen\nbenign, voiding and stooling, 1 small spit, criticaid\napplied to excoriated bottom. A: tiring out on bottle\nfeeds. P:Continue to offer bottles after a gavge feed break\nthis evening.\n#3 O: Baby hot in off isolette, moved to open crib this\nmorning. Baby is and active with feeds and quickly\nfalls asleep. Baby did not sleep well today and between 1\nset of cares slept less than 1 hour. NAS scores 7,8 and 3.\nPacifier taken very eagerly whenever offered. A: Baby\nhaving trouble sleeping today P: Continue to support\ndevelopment and continue NAS scores.\n#5 O: Mother and grandmother in to visit this afternoon.\nMother fed baby and is asking appropriate questions about\ngetting ready to go home. I suggested that they might want\nto sign up for CPR now before it was too late. They will\ndiscuss it. WIC was declined unless they get back to us.\nMom would like baby circumcised when he is ready. Bulb\nsyringe use discussed. A: Involved mother preparing for\nbaby to go home. DSS involved. P: continue to keep\ninformed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-08 00:00:00.000", "description": "Report", "row_id": 1719993, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 95-100%.RR 40-70's.LS\nremain clear and equal b/l.No A's and B's or desats thus\nfar.A:Stable P:Cont.to assess resp.status.\n\nF/N:Infant cont's on TF 140cc's/kg/day.Rec.Special Care 26\n41 cc's q 4 hrs.Infant bottled x 2 and took 17-25cc's,the\nremainder gavaged.Weight=1.750 up 15 grams.Abd. soft with\npos bs,no loops or spits,minimal\naspirates.Girth=21.5-23.Infant voiding and stooling heme\nnegative stool.Buttocks cont's excoriated applied Mineral\nOil,Criticaid,and Stomahesive.A:Adequate Weight\nGain;tolerating feeds well P:Cont.to assess tolerance of\nfeeds and monitor weight gain.\n\nG/D:AF soft and flat. and active does appear irritable\nwith cares.Settles with containment and pacifier.Noted to be\nintermitently jittery.Cont's to mottle with cares.Presently\nswaddled in off isolette with nested\nboundaries.Temp.maintained.NAS A:Stable P:Cont. to\nassess growth and dev.and NAS.\n\nSocial:Mom called x 2.Updated by this RN.Asking appropriate\nquestions.Concerned regarding restart of DTO.Informed mom\nthat we will cont. to assess infant's status.A/P:Cont. to\nupdate,support,and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-08 00:00:00.000", "description": "Report", "row_id": 1719994, "text": "Neonatology Attending Note\nDay 12, PMA 35 5\n\nRA. Cl and = BS. RR40-60s. Mild sc rtxns. No murmur. HR 140-150s. BP 68/42, 51.\n\nWt 1750, up 15. TF 140 SC26. PO/PG. Tol well. Nl voiding and stooling. Nl voiding and stooling.\n+ diaper dermatitis\nFe.\n\nNAS scores \n\nIn open crib.\n\nA/P:\nGrowing preterm infant learning how to po feed. Resolving NAS. No changes to current management.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-08 00:00:00.000", "description": "Report", "row_id": 1719995, "text": "NNP Physical Exam\nAwake and . AFOF with mild hypertonia and jitters with exam. Breath sounds clear and equal on room air with slight retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with activw BS, no HSM or masses. Buttox excorriated and open to air.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-08 00:00:00.000", "description": "Report", "row_id": 1719996, "text": "NPN 0700-\n\n\n1. In RA with sats 96-100%. Lungs clear. RR 40-70's with\nmild SC retractions. No A&B/desats. Stable in RA.\n\n2. TF 140cc/k/d SC26=41cc Q4hr. Able to take 41cc and then\n26cc thus far with Dr. nipple. Infant well\ncoordinated with bottles. Abdomen benign. Voiding and\nstooling with every diaper. Buttocks remain excoriated and\nbleeding this morning. Left open to air for 2hrs, applying\nstomahesive powder and criticaid with diaper changes.\nButtocks remains excoriated, although not bleeding this\nafternoon. Tolerating PO/PG without aspirates and one spit.\nContinue to encourage PO's as tolerated.\n\n3. Temp stable loosely swaddled in off isolette. ,\nirritable, mottles with cares. Upper extremities are more\nhypertonic than lower extremities. NAS scores have been 6\nand 5 thus far; see flowsheet for details. AFSF. Brings\nhands to face and mouth. Able to rest well with pacifier\nand containment. Continue to promote development.\n\n5. Mom called and updated on plan of care. Mom is planning\nto visit sometime today. Continue to support, update, and\neducate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-22 00:00:00.000", "description": "Report", "row_id": 1720059, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS >97%. RESP RATE38-72 WIHT MILD SC\nRETRACTIONS. BS CLEAR. NO SPELLS\nA:STABLE\nP:COTINUE TO MONITOR, LAST SPELL AT 0215\n\n#2F/E/N\nO: ON MINIMUM 130CC/KG 24. BABY BOTTLING 95-100CC\nQ3.5-4HR OVERNIGHT. TOOK IN 278CC/KG LAST 24HR. ABDOMEN\nSOFT, FULL WITH GOOD BS. VOIDING WELL; NO STOOL. WT UP 85GM.\nA:STABLE\nP:CONTINUE TO MONITOR WT AND PO INTAKE\n\n#3G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. WAKING Q3.5-4HR TO EAT. FONTANEL SOFT\nAND FLAT; SUTURES SMOOTH. BABY BOTTLING WELL WITHOUT SPELLS\nOR CHOKING. ROLL BETWEEN LEGS. RIGHT NECK MASS UNCHANGED\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5SOCIAL\nO:MOM X1\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-22 00:00:00.000", "description": "Report", "row_id": 1720060, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOf, sutures approximated\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused,mottling of lower extremities with exam\nabdomen soft, nontender and nondistended, active bowel sounds\nhealed circumsion\n1.5 firm mass on right neck no erythema, full range of motion of neck\nactive with good tone\n" }, { "category": "Nursing/other", "chartdate": "2179-08-22 00:00:00.000", "description": "Report", "row_id": 1720061, "text": "NICU Attending Note\n\nDOL # 26 = 37 6/7 weeks PMA with resolving A/B, day 2-> of \"spell countdown,\" no new concerns. I agree with above . I have examined patient and discussed plan of care with team.\n\nCVR/RESP: RRR without murmur, skin pale pink, mottled, no retractions, BS clear/=, RA, no caffeine, last spell at 2 am. Will continue to monitor.\n\nFEN: Abd , diaper dermatitis healing well, weight today 2210, up 85 gm on minimum of 130 mL/kg/day, took 278 mL/kg in last 24 hours ! 24. voiding/stooling. Will continue current diet.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-22 00:00:00.000", "description": "Report", "row_id": 1720062, "text": "Nursing Progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, no spells to time of report. A:\nLast spell on . P: Continue to monitor.\n#2 &7 O: Total fluid min 130cc/kg/day. Baby easily\nexceeding min intake. Baby wakes every 2 to 4 hours and\nfeeds well with soothie bottle. Abdomen benign, voiding\nwell, no stool yet today. Circ is healing well. A: Feeding\nwell on ad lib demand schedule. P: Continue ad lib feeds.\n#3 O; Temp stable in open crib. Baby wakes for feeds and\nfeeds well and sleeps well on his back in a flat crib with a\nblanket swaddle between cares. Right fibromatosis \nappears unchanged from yesterday. Baby continues to have\nfull range of motion. A: Appropriate for age. P: Continue\nto support development. Call in early intervention referal\ntomorrow for PT.\n#5 O: Both have called today but have not been able\nto visit today. Mother will be in tomorrow even if unable\nto visit this evening. A: involved family with DSS\ninvolved. P: Continue to keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-21 00:00:00.000", "description": "Report", "row_id": 1720055, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS >98%. BS CLEAR. RESP RATE 30-56\nWIHT MILD SC RETRACTIONS. NO SPELLS THUS FAR.\nA:STABLE\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#2F/E/N\nO:ON MINIMUM 130CC/KG. BABY BOTTLING 75-93CC 24\nEVERY 3-4HR. ABDOMEN SOFT, FULL WITH GOOD BS. NO SPITS.\nVOIDING WELL; SMALL GREEN HEME NEG STOOL X1. WT DOWN 105GM\n(CHECKED X2). TOOK I N 193CC/KG PAST 24HR.\nA:FEEDING WELL\nP:CONTINUE TO MONITOR PO'S, FOLLOW WT GAIN\n\n#3G&D\nO:IN OAC WIHT STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. WAKING EVERY 3-4HR TO EAT. BOTTLING\nWELL WITHOUT SPELLS/CHOKING. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH. TYLENOL X1 FOR COMFORT\nA:AGA\nP:CONTINUE TO MONITOR AND SUPPORT\n\n#5SOCIAL\nO:MOM X1 FOR UPDATE.\nA:INVOLVED, INVESTED PARENT\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#7CIRCUMCISION CARE\nO:CIRC SITE HEALING WELL; NO DRAINAGE.\nP:MONITOR\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-21 00:00:00.000", "description": "Report", "row_id": 1720056, "text": "Neo Attend\nDay 25 now 37.5 wk\nra, rr 30-50s, clear =bs, last brady .\nCV: no murmur, 120-160s, pale/mottled, 71/38, mean 52\nwt 2125, down 105 gm. Has been gaining.\nmin 130 cc/kg/day, 192 cc/kg/day. 24.\npo every 3 hr up to 3 oz/feed.\nuop and stools wnl.\nbottom resolving.\nCirc healing.\nTemp stable.\nTorticollis with increasing size of fibromatosis . Full range of motion of neck. Dx made by ultrasound. Will continue to monitor.\n\nWill speak with mother.\nDSS involved due to substance abuse (cocaine). are known to DSS. Mother is also on methadone.\n\nInfant is stable.\nPt evaluated and discussed with staff.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-21 00:00:00.000", "description": "Report", "row_id": 1720057, "text": "NEonatology-NNP Progress Note\n\nPE: Will remains in his open crib, swaddled, in room air, bbs cl=, right neck mass, pea size,(see attending note above) mobile with good rom, rrr s1s2 no murmur, abd soft, nontender, circumsized penis healing nicely, stable hips, afso, , well perfused\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2179-08-21 00:00:00.000", "description": "Report", "row_id": 1720058, "text": "Nursing Progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, no spells today. A: Last spell on\nThursday night. P: Continue to monitor and continue spell\ncountdown.\n#2 &7 O: Total fluid min 130cc/kg/day which baby is easily\nexceeding. Feeds of neosure24 offered on demand. Baby woke\nevery 3 hours and took 80 to 105cc. No spits, abdomen\nbenign, voiding well, stool guiac negative. Circ healing\nwell. Vaseline guaze applied to circ. A: Feeding well with\nsoothie bottle. P: Continue ad lib feeds.\n#5 O: and paternal grandparents in to visit this\nafternoon. Mother had called for an update this morning and\nexpressed concern about the baby's mass on his neck in view\nof a paternal family history of cancer in several people, 1\nas young as 1 month old. I encourage mom to talk with the\nattending and to express her concerns. Both were\nupdated by Dr . The possiblity of a CT or MRI will\nbe revisited on Monday. Baby continues to have full range\nof motion in his neck but was noted to be always sleeping\nwith his head turned away from the mass. A: Involved\nfamily. P: Continue to keep informed. Discuss concerns\nwith attending on Monday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 1719930, "text": "Neonatology Attending Admission\n(Continued)\naditional therapies such as methadone. There is limited information on the effects of the medication in pregnancy or lactation (pregnancy Class C, lactation 'infant risk has been demonstrated,' related to CNS depression and decreased feeding). Of note, the antagonist component may reduce the efficacy of opiate analgesics in the neonatal period.\n\nPLAN\n-Infant has been placed on CPAP. Blood gas and chest radiograph are pending. Target SaO2 87-94%\n-Cardiac examination is normal. Monitor for signs of PDA and target mean BP > 36 mmHg\n-Enteral feeds will be deferred until cardiorespiratory stability is established. In the interim, will provide maintenance IV D10W with usual attention to fluid and glucose status\n-CBC and blood culture have been sent. We will start empirical broad-spectrum antibiotic therapy for anticipated duration of 48 hours pending culture and WBC results and clinical course\n-Observe neurological status closely for evidence of withdrawal.\n-In the event that narcotic analgesic is required for treatment of neonatal pain, assess adequacy of response carefully given antenatal exposure to opiate antagonist.\n-We will send urine tox screen in light of antenatal exposure and current acute cardiorespiratory instability\n\nDelivering OB; Dr. \n: Hospital\nPediatrician: Not yet charted\n" }, { "category": "Nursing/other", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 1719931, "text": "Nsg Admit note\n\n\n34 week infant admitted from L&D for prematurity- see MD\nnote for maternal history. Initial O2 sats 93-95% in RA,\nyet infant grunting and retracting. LSC and equal. Infant\nplaced on NC at 1600, yet continued to grunt, so placed on\nprong CPAP 5 at 1630, 21%. RR 30-60's. No further grunting\non CPAP. CXR done at 1730. No murmur, HR 120-140's.\nInfant pink, warm with + pulses. CBC and blood culture\ndrawn and sent to lab- see carevue for details. Amp and\ngent started for 48 hour rule out. Initial D stick 42- IV\nplaced by NNP after multiple attempts by RNs, D10 now\nrunning at 60/kg. Repeat D stick 79. BW 1745gms. Infant\nnested in sheepskin on open warmer. Alert and active,\nsettles well, no s/s of withdrawal. Dad visiting with\nvarious family members, mom here on way to floor. Parents\nupdated by RN, NNP, and MD, parents oriented to unit.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 1719932, "text": "1 Resp\n2 F/N\n3 G/D\n4 ID\n5 Social\n\nREVISIONS TO PATHWAY:\n\n 1 Resp; added\n Start date: \n 2 F/N; added\n Start date: \n 3 G/D; added\n Start date: \n 4 ID; added\n Start date: \n 5 Social; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-28 00:00:00.000", "description": "Report", "row_id": 1719933, "text": "Respiratory Care Note\nPt. received on 5cmH2O of nasal prong CPAP and 21%. Pt. had been placed on CPAP on previous shift for grunting. Pt.comfortable, no longer grunting, d/c'd to room air.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-31 00:00:00.000", "description": "Report", "row_id": 1719953, "text": "NPN Nights continued\n\n\n#2 O: Infant remains on SSC 20 cals/oz, with TF/full volume\nfeeding goal of 150cc/k/day. Feeds increased from\n100>120>140cc/k/day over 8 hour period r/t to low ac D-stick\nof 49, with f/u d-stick of 57. Abd remains soft, +bs, no\nloops, minimal aspirates, small spit x 1 and stable girth.\nInfant bottled X 2 - took ~ 6cc for dad and 10cc at 4am -\nsome increased WOB noted with bottling. Voiding adeq amts,\nstool hem neg. A: infant seems to be tolerating advancement\nof feeds with small spit X 1, borderline ac d-stick imporved\nwith increased feeding volume. P: Continue to moniter.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-31 00:00:00.000", "description": "Report", "row_id": 1719954, "text": "Neonatology NP Note\nPE\nnested in isolette under phototherapy\nAFOF, sutures approximated\nmild subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive, no jitteryness, age appropriate tone and reflexes\nface jaundiced\n2 small areas on left arm with healing excars, no erythema\n" }, { "category": "Nursing/other", "chartdate": "2179-08-07 00:00:00.000", "description": "Report", "row_id": 1719988, "text": "Progress Note 7p-7a\n\n\nRESP: RA, c/=, mild SCR, RR and O2 sats WNL. No spells noted\nsince 11pm. Will continue to monitor resp status.\n\nFEN:Wt 1735 up 10grams. TF=140cc/K SSC 26 PO/PG (41cc q.\n4hrs over 1 hr). Abdomen soft and benign. No spits or large\naspirates noted. Fe q. day. Will continue to monitor feeding\ntolerance and progression.\n\nG&D: Temps stable swaddled in off warmer. Active and\nirritable with cares. Continues to score for tone and\nirritability on neonatal abstinece sheet. Sucks vigorously\non pacifier. Will continue to support developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-07 00:00:00.000", "description": "Report", "row_id": 1719989, "text": "Progress Note 7p-7a\nUpdated at add: Mother called and updated by this RN on infants status and plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-07 00:00:00.000", "description": "Report", "row_id": 1719990, "text": "Neonatology Attending Progress Note:\nDOL #11\nPMA 35 4/7 weeks\nremains in RA, sats 90's. lungs clear, RR=40-60's\n3 bradys in 24 hours, no caffeine\nno murmur, HR=140-160's\n85/47 (mean=61), 71/46 mean=56)\n1735g (up 35g), TF=140cc/kg/d SC 26 po (taking 10-20cc) and pg.\nvoiding, stooling heme negative\nexcoriated buttocks\n1 small spit, no aspirates\noff isolette\njittery, now off DTO, MAS=5 this am.\nImp/Plan: premie infant with apnea of prematurity, neonatal abstincenc syndrome--now off DTO, learning to po feed\n--monitor weight, encourage po feedings\n--monitor for spells\n--continue to monitor NAS\n--continue rest of present management\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2179-08-07 00:00:00.000", "description": "Report", "row_id": 1719991, "text": "NPN 0700-\n\n\n1. IN RA with sats 97-100%. Lungs clear. RR 30-60's with\nmild SC retractions. No A&B/desats thus far. Stable in RA.\nContinue to monitor for A&B/desats.\n\n2. TF 140cc/k/d SC26= 41cc Q4hr. Able to bottle 30cc at\nnoon well. Abdomen benign. Voiding and having heme\nnegative stools. Buttocks remain excoriated; using mineral\noil and criticaid oint. Having small to moderate spits with\nfeeds. No aspirates. Continue to encourage PO; alt PO/PG\nat this time and monitor tolerance to feeds.\n\n3. Temp stable swaddled in off isolette. and\nirritable with cares. Settles well with pacifier and\nswaddling. Infant is jittery and mottles with cares. Upper\nextremities are more hypertonic than lower extremities. NAS\nis up from to 5 this shift; see flowsheet for details.\nTeam is aware and will continue to monitor if infant needs\nDTO back. Continue to promote development.\n\n5. in to visit and updated on plan of care. Mom\nunable to make it in for 1200 bottle due to traffic; was\nable to hold infant and change clothes and diaper\nindependently. Continue to support, update, and educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-07 00:00:00.000", "description": "Report", "row_id": 1719992, "text": "Neonatalogy SNNP Note\nPE:\n\nNEURO: Infant swaddled in an off isolette, AFOS, sutures sl , x4, NAS off DTO since .\n\nCARDIO: Color pink, no audible murmur, RRR, HR 140-160's, pulses palp = x4, cap refill < 3 secs.\n\nRESP: Infant in R/A, breath sounds = clear, RR 40-60's\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses, stooling guiac (-), diaper area sl excoriated, criticaid being applied with diaper changes.\n\nGU: Voiding in diapers, normal male genitalia\n\n SNNP\n" }, { "category": "Nursing/other", "chartdate": "2179-07-31 00:00:00.000", "description": "Report", "row_id": 1719955, "text": "Neonatology Attending Progress Note\n\nNow day of life 4, CA 4/7 weeks.\nIn RA with RR 50-70s.\nO2 sats 95-100%\n3 episodes of apnea and bradycardia in past 24 hours.\n\nHR 140-170s BP 80/49 59\n\nWt. 1530gm down 50gm on 150ml/kg/d on SSC20\nFeedings fairly well tolerated by gavage with occasion spitting noted.\nFeeding skills noted to be immature.\nDS 47-57\nNormal urine and stool output.\n\nBili 7.2/0.2 - on phototherapy\n\nSocial - 51A filed for maternal cocaine use and suboxone treatment(methadone analog) - mother had past oxycodone addiction\nNAS scores - - highest 8 this morning\n\nAssessment/plan:\nPreterm infant with in utero exposure to cocaine.\nFeedings held back to 140ml/kg/d with close monitoring of tolerance.\nWill trial off phototherapy.\nNAS to continue for evidence of withdrawal syndrome.\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-31 00:00:00.000", "description": "Report", "row_id": 1719956, "text": "Nursing progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, 1 spell to time of report. A;\nbreathing fast but comfortably. P: Continue to monitor.\n#2 O: Total fluids 140cc/kg/day. FEeds of SC given\nevery 4 hours over 1 hour and 15 min. Baby had several\nspits this morning. Max aspirate 4cc (milky), voiding well,\nstool transitional. Abdomen soft, bowel sounds active, no\nloops, girth stable. A: Tolerating full feeds with some\nspitting. P: continue with feeds at 140cc/kg/day and\nmonitor for any feeding intolerance.\n#3 O: Baby warm in isolette on servo. Baby and active\nwith cares and sleeps for 1 to 2 hours after feeds. Baby is\nawake and fussy for long periods of time requiring repeated\nattention to settle. NAS scores increased today to 9 and\n10, MD aware and will follow. A: NAS scores increased\ntoday. P: Continue to monitor and provide support.\n#5 O; up to visit. Dad changed baby and mother held\nand fed baby. Questions were answerd. A: Involved family.\nP: Continue to keep informed.\n#6 O: Bili decreasing, phototherapy discontintued. A:\nImproving. P: Check bili in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-13 00:00:00.000", "description": "Report", "row_id": 1720016, "text": "NPN 1900-0700\n\n\n1. RESP: Infant remains in RA with RR 30-50's and sats\n>94%. Lung sounds are clear. Mild baseline retractions.\nNo spells so far this shift. Will monitor.\n\n2. F&N: TF remain at 150cc/k/d of SC26. He has bottled\nhis whole feeds X 2 well with yellow nipple. Abd benign.\nBS+. A/G stable. No spits and no aspirates noted. Voiding\nwell and passed a small green stool. Weight gain 35 grams.\n\n3. DEV: Will is active and during his cares. Temp\nstable swaddled in open crib. NAS scores have been so\nfar this shift. Small excoriated area remains on right\nbuttock. Criticaid applied with each diaper change.\n\n5. PAR: Mom called for update X1. She asked appropriate\nquestions adn spoke lovingly of Will. She stated that she\nwill be in to visit later today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-13 00:00:00.000", "description": "Report", "row_id": 1720017, "text": "Attending Note\nDay of life 17 PMA 36 \nin room air RR 30-50\nmild retractions no spells\nHR 130-150 no murmur BP 87/32 mean 53\nweight up 35 grams on 150 cc/kg/day of SSC 26 cal/oz taking po and remainder pg\nvoiding and stooling\nstable temp in crib\nNAS overnight but scored a 9 this am\n\nImp-stable making some progress\nwill continue to encouarge po feeds\nwill continue to monitor for spells\nwill continue NAS scores (he is high now but not high enough to treat)\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-27 00:00:00.000", "description": "Report", "row_id": 1719929, "text": "Neonatology Attending Admission\n34 week GA infant admitted with respiratory distress\n\nMaternal hx - 26 year old G3P0->1 woman with POBHx notable for SAB x 2. PMHx notable for asthma (on prn albuterol); remote cigarette smoking 2 ppd (quit ); abnormal PAP; oxycodone addiction following surgery. For the latter, she is treated with subutext (buprenorphine) and subutext (combination buprenorphine/naloxone). Prenatal screens were as follows: A positive, DAT negative, HBsAg negative, RPR non-reactive, rubella immune, GC/chlamydia negative, HIV negative, varicella negative, CF negative, toxoplasmosis IgM negative, quad screen 'negative,' GBS negative.\n\nAntenatal Hx - by 13-week ultrasound with uncertain LMP. Pregnancy complicated by breech presentation and by oligohydramnios (AFI 3). Presented with spontaneously resolving fetal heart rate deceleration that recurred leading to cesarean section under epidural anesthesia. There was no intrapartum fever or other clinical evidence of chorioamnionitis. ROM occurred at delivery, yielding clear amniotic fluid. Intrapartum antibiotics were administered at delivery.\n\nNeonatal course - Infant emerged with good tone and cry. He was orally and nasally bulb suctioned, dried and tactile stim was provided. he required transient free-flow supplemental oxygen but subsequently was pink in room air with only mild intercostal retractions. Apgars were 8 at one minute and 8 at five minutes. Following admission to the NICU, he was noted to have increasing intercostal retractions and was placed on CPAP.\n\nPE\npreterm infant with examination consistent with 34 weeks GA\nBW 1745g (25th %ile) OFC 30cm (25th %ile) LN 42 cm (10-25th %ile)\nhr 140 rr 30-50 T 98.4 BP 49/39 (42) SaO2 97% in room air\nHEENT AFSF; prominent occiput but all sutures appear open; mild retrocgnathia but facies non-dysmorphic; palate intact; neck/mouth normal; mild nasal flaring\nCHEST no retractions; fair bs bilat; no adventitious sounds\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; liver 1 cm BRCM; no splenomegaly; no masses; bs active; anus appears patent; 3-vessel umbilical cord\nGU normal penis; testes descended bilaterally\nCNS active, alert, resp to stim; tone AGA and symmetrical; MAE symmetrically; suck/gag intact; grasp symm\nINTEG small bruising right inguinal area; otherwise within normal limits\nMSK normal spine/limbs/hips/clavicles\n\nINV\nd-stick 42 prior to IV fluids\n\nIMPRESSION\n34 week GA infant with\n1. Respiratory distress, currently appears comfortable on CPAP. Differential diagnosis includes surfactant deficiency (given gestational age); retained fetal lung fluid (given cesarean section); pneumonia (less likely given no sepsis risk factors); and other less common pathologies such as pneumothorax.\n2. Sepsis risk, based on post-natal respiratory symptoms\n3. Risk for neonatal withdrawal syndrome. Due to the combined agonist/antagonist effects of buprenorphine/naloxone, the risk for neonatal withdrawal is lower than with tr\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720053, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed; elongated occiput; right neck mass without change, known fibromatosis , full range of motion in nect; eyes clear\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; umbilicus healed\nGU: circumcision clean, no oozing or drainage; testes descended\nExt: moving all\nNeuro: ; + suck; + grasps; normal tone\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720054, "text": "NPN 0700-1900\n\n\n#1Resp: Pt. remains stable in RA, RR30-50's, sats 99-100%.\nNo spells or desats so far this shift. Pt. day 0 of 5 day\nspell countdown. Lungs clear & equal w/ mild SCR. P:Cont\nto monitor for spells.\n\n#2FEN: Pt. adlib w/ TF min 130cc/kg/d of Neosure 24. Pt.\ntook 65-75cc Q 4hrs using soothie bottle. Tolerating feeds\nwell, no spits. Abd soft & round, +BS, no loops. Pt.\nvoiding well, no stool. Desitin applied to slightly\nreddened bottom. P: cont to monitor FEN.\n\n#3G&D: Temps stable swaddled in OAC. Pt. active & w/\ncares. from PT in to assess R round mass known to be\nfibromatosis . See PT note. Pt. has full ROM of neck\n& moves head to both sides. Pt. will be followed by EI\noutpatient. Roll placed between legs per OT. MAE. AFSF.\nLoves pacifier. P: cont to support dev needs.\n\n#5Social: Mom in for noon cares. Mom independent w/\nbottling pt. Mom asking questions. Updates given.\n in to speak w/ mom. DSS scheduled to visit mom at\nhome next week when pt. has been d/c'd. Mom & grandmom both\n towards pt. P: Cont to support & update.\n\n#7Circ: Circ site red & slightly swollen but appears to be\nhealing well. No bleeding or drainage noted. Vaseline &\nguaze applied Q diaper chg. Pt. receiving tylenol & sucrose\nprn for pain r/t circ. Pt. managed well w/ these measures.\nP: Cont to monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-13 00:00:00.000", "description": "Report", "row_id": 1720018, "text": "NP NOTE\nPE: small well appearing growing preterm infantswaddled in open crib. PLae pink well perfused in RA.\nAFOF sutures approximated, eyes clear, ng in pace, MMMP\nChest is clear, equal bs.\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs cord healing\nGU: testes in scrotum, excoriated buttocks\nEXT: , \nNeuro: active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-13 00:00:00.000", "description": "Report", "row_id": 1720019, "text": "Nursing progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions. No spells today. A: Doing well in\nroom air. P: Continue to monitor.\n#2 O: Total fluids 150cc/kg/day Of SC26. Feeds given\nevery 4 hours. 2 bottles completed and 1 mostly taken by\nmouth and completed by gavage. Abdomen soft, bowel sounds\nactive, no loops, girth stable, voiding and stooling.\nBottom remains excoriated. Criticaid applied, appears to be\nslightly improving. A: Taking mostly all PO feeds today.\nP: Continue to encourage PO feeding.\n#3 O: Temp stable in open crib. Baby is and active\nwith cares. He was fussy this morning with increased tone,\nmottled, yawning and sneezing and did not sleep well at all,\nsucking constantly. Baby has slept better this afternoon.\nNAS scores were 9, 8 and 4. A: Fussy today. P: Continue to\nsupport development.\n#5 O: Mother and grandmother in to visit this afternoon.\nMother did baby cares and diaper rash care and fed baby. CPR\nplanned for next Thursday. Mother to bring in car seat. A:\nInvolved family. P: continue to keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-25 00:00:00.000", "description": "Report", "row_id": 1720078, "text": "Attending Note\nDay of life 29 PMA 38 \nin room air RR 30-50\nno retractions\nday of spell count\nHR 120-150's BP 68/40 mean 45\nweigth 2435 up 40 grams on ad lib feeds took in 211 cc/kg/day of 22 cal/oz\nvoiding and stooling heme negative\ngetting desitin to buttock\ncirc healed\nstable temp\npassed hearing\npassed car seat\ns/p hep B\n took CPR last night\n\nImp-stable making progress\nwill plan to discharge to home today (>30 min)\nwill have PT via EI\nwill have follow up with DSS this weekend\n" }, { "category": "Nursing/other", "chartdate": "2179-08-25 00:00:00.000", "description": "Report", "row_id": 1720079, "text": "NP NOTE\nDischarge EXam\nGrowing preterm infant swaddled in open crib. PInk well perfused in RA. Active and responsive, mottled with exam.\nAFOF, prominent occiput, sutures approximayed, eyes clear with bilateral red reflex present, PERRL, nares patent, intact palate, MMMP\nNeck is with limited ROM, tight rifgt>left, unable to palpate fibromatosis .\nChest is clear, equal bs, comfortable\nCV: RRR, no murmur, pulses+2=\nAbd:soft, active bs, no hepatospleenomegaly\nGU: left hydrocele, testes ins crotum, circ healed\nSpine is smooth with no dimples, \nEXT: , , normal digits nails\nNeuro: mildly hyprttonic, symmetric primitev reflexes\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-25 00:00:00.000", "description": "Report", "row_id": 1720080, "text": "PT/Rehab Services\nMet with family to instruct in cervical ROM excercises and issues activities packet for home. discussed developmental play activities. Recommend EI follow-up upon discharge.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-06 00:00:00.000", "description": "Report", "row_id": 1719986, "text": "Clinical Nutrition:\nO:\n~35 week CGA BB on DOL 10.\nWT: 1700g(+50)(<10th %ile); BWT: 1745g. Average WT gain over past week ~10g/kg/day. Wt is down ~3% from BWT.\nHC: 30cm(10-25th %ile); HC @ Birth: 30cm\nLN: 43cm(10-25th %ile); LN @ Birth: 42cm\nMeds include Fe.\nLabs noted.\nNutrition: 140cc/kg/day as SSC 26 (no promod); po/pg over 1hr d/t hx spits. Took ~35-10cc po of ~41cc. Projected intake for next 24hrs ~140cc/kg/day(121kcal/kg/day & ~3.6g pro/kg/day).\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; /pg & takes ~ - volumes. Labs noted w/ elevated K+ but reported as hemolyzed; will f/u w/ next labs. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is not yet meeting recs for all parameters; gained good WT today, may need promod if does not cont. to gain good WT over the w/e. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-06 00:00:00.000", "description": "Report", "row_id": 1719987, "text": "NICU NSG NOTE\n\n\n#1. Resp. O/ RA. LS clear and equal. EE 40-60's. Mild SubC\nretractions. No spells since 0700. A/ Stable in RA. P/ Cont\nto monitor resp status closely.\n\n#2. FEN. O/ TF 140cc/k/d. Receiving q4h volumes SC26.\nAttempting po feeds q12h. Took 25cc (with Dr bottle)\nfor mom at 1200. When gavaged, gavaged over 1h. Abd soft and\nround. Voiding and stooling. No spits. Min asps. AG\n22.5-23cm. No loops. Buttocks red, but not excoriated.\nCriticaid applied. Fe as ordered. A/ Tolerating feeds.\nLearning to po. P/ Cont to monitor for feeding intolerances.\nDaily wts. Encourage po feeds.\n\n#3. G&D. O/ NAS scores . Last dose DTO given at 1600.\nTemps stable in off isolette. MAE. Increased tone in UE.\nIrritable with cares, but settles with swaddling. A/\nMonitoring for s/s w/d. P/ Cont to support developmental\nneeds of infant.\n\n#5. Parenting. O/ Mom in with Ma Grandmother. changed\ndiaper and took temp. Also fed and held infant. Speaking\nlovingly to infant, taking pictures of Will. Asking if Will\nreceived \"his medication\". Mom noting that Will is \"more\nawake\" today. Mom stated she met with DSS SW \"\" and\n\"everything is all set\". Mom met with SW at\nbedside. A/ Updated, involved mom. P/ Cont to provide\nsupport and info to family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-30 00:00:00.000", "description": "Report", "row_id": 1719951, "text": "NPN 7a-7p\n\n\n#1: remains in RA, easily maintaining sats >/= 93%.\nRR stable. Breathing with mild retractions. BBS cl/=.\nBrady spell x1, no apnea. Recovered with mild stim. A:\nstable in RA P:Cont to monitor and provide support as\nneeded.\n\n#2: TF's increased to goal of 150cc/k/d. At 08care infant's\nIV infiltrated and d/s 47. Removed IV and adv'ed enteral\nfeeds to 100cc/k/d. D/S 81. Infant now receiving 29cc SC20\nq4hrs gavaged over 1hr. 2 small spits noted. Min benign\nasps. Abd soft, +, no loops. AG stable. Voiding qs.\nStooling with each diaper change- heme negative. A: adv'ing\nfeeds P:Cont to adv enteral feeds by 20cc/k/ to goal of\nTF 150cc/k/d. Monitor tol to feeds. Follow wt and exam.\n\n#3: Temps stable while swaddled in servo isolette. Infant is\nnested on sheepskin within boundaries. Irritable at times.\nSettles best with tight boundaries and pacifier. Noted to\nhave increased tone and is jittery at times. See flowsheet\nfor NAS scores. MAE. Fonts soft/flat. Tol'ed being held by\nMom. A: stable for age P:Cont to support dev needs.\n\n#5: Dad in for 08 and 16cares. Participated at both cares\nand was updated. At 12 care Mom and . grandmother came\nin. Mom was updated. Mom learning to take temp and change\ndiaper. Mom held infant for over and hour. Mom asking\nappropriate questions. Also some other visitors in through\nthe day. A: Involved family P:Cont to support and educate.\n\n#6: Infant remians jaundice. Conts under single phototherapy\nwith eye shields on. Voiding qs. Stooling with each diaper\nchange. Tol'ing enteral feeds and adv'ing. A: hyperbili\nP:Cont with phototherapy as ordered. Check bili level in\nam.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-31 00:00:00.000", "description": "Report", "row_id": 1719952, "text": "NPN Nights 7pm-7am\n\n\n#1 O: Infant remains in roomair with O2 sats ~95-100%.\nLungs sounds remain clear and equal with resp rates 50s-70s,\ncontinued mild retractions. No episodes of desat thus far\nthis shift. A: maintaining sats well in roomair. P:\nContinue to moniter.\n#3 O: Infant is and active with cares, irrtiable at\ntimes but does settle with containment and with sucking on\nhis pacifier. Temp was elevated at the begiining of shift\nafter temp probe noted to have come off skin - temp came\ndown slowly over several hours - have also switched to\nNeoBlue phototx. (instead of spotlight) and temp has\nremained WNL. Ant font remains soft and flat. Infant\nbottled X 1 Infant waking between cares at times. NAS have\nbeen 4 and 4 thus far this shift (increased tone, some\nsneezing, waking between feeds). No episodes of As or Bs\nthus far this shift. Antibiotic ointment applied to scabbed\nareas in left axilla and left antecub areas (r/t irritation\nfrom B/P cuff) - sites with intact scabs/no oozing and\ndecreased erythema. A: AGA, NAS WNL. Doing some/minimal\nbottling. P: Continue to moniter for milestones.\n#5 O: Infant's were in for a visit at 8pm cares,\npaternal g. also here. asking appr\nquestiosn, updates given and dad signed consents for State\nScreen testing and Hep B immunizations. Assisted dad in\nbottling infant. A: involved and invested . P:\nContinue to support.\n#6 O; Remains under single phototherapy with eye pathces on.\nWas changed from spotlight to NeoBlue bank phototherapy.\nSkin remains slightly jaundiced. Bilirubin levels drawn\nthis shift were down to 7.2/.2/7.0. A: resolving hyperbili.\n P: Continue to moniter.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-25 00:00:00.000", "description": "Report", "row_id": 1720081, "text": "Nursing Discharge Note:\n\nD/C to home on 22. D/C teaching completed with\n. ID bands checked. Mom states she has made\npediatrician for tomorrow () at 1pm. Mom met with\nsocial worker and PT before d/c. Consults to visiting nurses\nand EIP complete. Discharge home to mom and MGM in carseat\nat 1225.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720048, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 97-100%.RR 30-40's.LS\nremain clear and equal with sc retractions.Infant with 1\nspell thus far.HR 75 with a saturation 98%.QSR.\n\nF/N:Infant cont's on Ad lib demand shedule with a Min.\n130cc's/kg/day.TF over 24 hrs.168cc's/kg/day.Weight=2.230 up\n55 grams.Abd. soft with pos bs,no loops or spits.Infant\nwaking q 3-4 hrs. and bottling 35-75cc's of Neosure\n24.Infant appears well coordinated.Voiding and stooling heme\nnegative.Buttocks greatly improved slightly red.\n\nG/D:AF soft and flat. and active with cares.Earlier\nthis shift appeared fussey question r/t Circ.Adm. Sucrose\nwith good effectiveness.Infant appeared to settle and was\nless irritable.Infant also rec'd Tylenol at 2400 with good\nrelief.Infant remains in open crib;swaddled.Temp.\nstable.MAE.Bringing hands to face and sucking . on\npacifier.\n\nSocial:Mom called and updated by this RN.Asking appropriate\nquestions appears loving and invested.\n\nCIRC:Site appears red and slightly swollen.Site with blood\non 2x2.Presently no bleeding.Appears to be healing well with\nno drainage.Vaseline and 2x2 applied.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720049, "text": "Neonatology Attending Progress Note:\nDOl #24\nPMA 37 4/7 weeks\nremains in RA, clear/equal, mild sc retx\n2 spells in 24 hours\nno murmur, HR=120-140's, pink, BP 70/40\nwt=2230g (inc 55g), ad lib po min of 130cc/kg/d Neosure 24 took 168\nvoiding, stooling\nImp/Plan: infant with apnea of prematurity, tolerating all pos\n--encourage po feeds, monitor weight\n--monitor for spells\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720050, "text": "PT/Rehab Services\nCalled to see this baby, , at 34 weeks gestation via c-section for breech presentation and fetal decels. Newly found R side neck mass, identified as fibromatosis .\nBaby rec'd in active /crying state. Head is midline and baby actively turns to both sides with normal ROM. also normal ROM and tone t/o extremities. Palpable round mass R side neck.\nOT is aware and met with and educated mom. Currently baby is not exhibiting any ROM or movement issues due to the mass. Early intervention to follow upon discharge.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720051, "text": "SOCIAL WORK\nDSS social worker, , office has authorized d/c of baby to mother's care when ready for discharge. She has spoke with mother and and will continue to monitor home environement. Will plan to speak with mom when she is here for visit today.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-20 00:00:00.000", "description": "Report", "row_id": 1720052, "text": "SOCIAL WORK\nMet with mother at bedside, aware of delay in d/c and appopriately disappointed. Discussed DSS ongoing involvement and mother amenable, has appt for next week. Mother asked for suggestion of therapist near her who specializes in addiction tx; will research and get names to her prior to d/c next Wed.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-30 00:00:00.000", "description": "Report", "row_id": 1719948, "text": "Neonatology Attending\nDOL 3 / PMA 34-3/7 weeks\n\nIn room air with no distress. Eight bradycardias in 2 clusters (not on caffeine).\n\nNo murmur. BP 65/46 (52).\n\noff antibiotics following 48-hour course.\n\nBilirubin 10.1/0.3; phototherapy started overnight.\n\nWt 1580 (-65) on TFI 100 cc/kg/day SC20 PG. D-stick 47 with infiltrated IV; repeat pending. Abd benign. Voiding 3.5 cc/kg/hr and stooling normally. Lytes 139/6.4/108/21 (hemolyzed).\n\nMildly irritable with NAS .\n\nA&P\n34 week GA infant with respiratory and feeding immaturity, antenatal exposure to opiate and cocaine\n-We met with both yesterday afternoon to discuss the positive cocaine assay on urine toxicology. Mother denies use of cocaine and informed us that she continues to attend her program with Dr. . They are aware that we are in the process of filing 51-A.\n-Continue to monitor frequency and severity of apnea/bradycardia, and consider starting\n-Advance enteral feeds by 20 cc/kg/day as tolerated to goal of TFI 150 cc/kg/day\n-Continue to observe closely for signs of withdrawal\n-Continue phototherapy and repeat bilirubin in 24 hours\n" }, { "category": "Nursing/other", "chartdate": "2179-07-30 00:00:00.000", "description": "Report", "row_id": 1719949, "text": "SOCIAL WORK\nDSS/ contact today to file 51A at . Will start investigation over next 10 days and contact regarding finding of cocaine toxicity. may continue to have full access to baby and continue all parental rights. Mother visiting today with extended family, informed that she would be going to stay at her mother's home after discharge, FOB apparently will remain at his parent's also in . Mother hoping to stay inparent's rm after d/c on Sat and perhaps in a local hotel through RAFH program if availability(presumably with FOB). DSS did not reveal if family was cxurrently active however did correlate DOB's for both in their system. Will cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-11 00:00:00.000", "description": "Report", "row_id": 1720011, "text": "NP NOTE\nPE: growing preterm infant pale pink well perfused in RA. and responsive, mottles with exam. AFOF sutyures approximated, eyes bright, ng in place, MMMP\nChest is clear, equa bs\nCV:RRR, no murmur, pulses+2=\nAbd: soft active bs\nGU: testes in scroitum, criticaid barrier to excoriatyed buttocks\nEXT: , \nNeuro; symmetric tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2179-08-12 00:00:00.000", "description": "Report", "row_id": 1720012, "text": "NPN\n\n\n#1RESP: Infant remains stable in room air. Lung sounds are\nclear/=. Mild subcostal retractions noted. RR's= 20-50's. No\nspells thus far this shift. A:Stable in room air P:Continue\nto monitor for spells\n\n#2FEN: Weight 1875g, up 35g. Tf's remain at 150cc's/kg/d of\nSC 26. 47cc's q 4 hours. Infant bottled 46cc's at 2400 with\ngood coordination. Abdomen is soft and round, no loops,\nsmall spit x1, minimal aspirates, +bowel sounds, voiding and\nstooling. Criticaid being applied with each diaper change.\nInfant remains on Fe. A:Tolerating feeds well P:Continue to\nmonitor for feeding intolerance\n\n#3DEVE: Temp stable. Infant is swaddled in the open crib.\n and active with cares. Wakes for feedings. Settles\nwell with binki. MAE. Fontanels are soft and flat. Brings\nhands to face. NAS 3 x2 thus far. A/P:Continue to support\ng/d of infant\n\n#5SOCIAL: Mom called x1. Update given. A/P:Continue to\nsupport family needs\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-12 00:00:00.000", "description": "Report", "row_id": 1720013, "text": "Neonatology Attending\nDOL 16\n\nInfant remains in room air with one bradycardia in the past 24 hours.\n\nNo murmur. BP 62/32 (39).\n\nWt 1875 (+35) on TFI 150 cc/kg/day SC26, tolerating well PO/PG. Abd benign. Voiding and stooling normally.\n\nNAS 3,3,4.\n\nA&P\n34 week GA infant with respiratory and feeding immaturity, antenatal cocaine and opiate exposure\n-Continue to monitor for apnea of prematurity\n-Continue with NAS \n-No changes in management as detailed above\n" }, { "category": "Nursing/other", "chartdate": "2179-08-12 00:00:00.000", "description": "Report", "row_id": 1720014, "text": "Neonatology - NNP PRogress Note\n\nInfant is active with good tone. Less irritability today. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air, breath sounds clear and equal. He is tolerating enteral feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-12 00:00:00.000", "description": "Report", "row_id": 1720015, "text": "NPN 0700-1900\n\n\n1. Remains in RA, ls cl/=, mild scr. No A/B's.\nContinue to monitor resp status.\n\n2. TF 150/k. PO/pg, SSC26. Bottled 50, 45cc using yellow\nnipple. Occasionally needs a gavage to supplement. Belly\nbenign. Voiding and stooling. Bottom remains excoriated on\nR side, criticaid applied. Area appears improved.\nContinue to offer po's as tolerated.\n\n3. Temps stable in OAC, swaddled w/hat. /active.\nNAS's 3 at all cares today. Roll placed b/w legs as per T\nrecommendations.\nContinue to support needs.\n\n5. MOm in visiting today, fed and held infant. Given brief\nupdate. Plans to come in again tomorrow.\nContinue to support social needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-30 00:00:00.000", "description": "Report", "row_id": 1719950, "text": "NP NOTE\nPE: small preterm infant nested in isolette under phototherapy. Active and responsive with exam. Irritable though easily consoles with boundaries and pacifier.\nAFOF sutures overriding. Eyes clear, protected. ng in place. MMMP\nChest is clear, equal bs, comfortable\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs no HSM, cord dry\nGU: testes in canals\nEXT: abrasion on left arm. at edsges of blod pressure cuff, dried, minimal erythema.\nNeuro: active with symmetric tone, intatc primitive relfexes\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-11 00:00:00.000", "description": "Report", "row_id": 1720007, "text": "SOCIAL WORK\nSpoke with DSS investigator today regarding assignment of case to an assessment worker. This should occur within the week and DSS will provide name of new social worker to NICU. DSS investigator felt mother was forthcoming with statements regarding her use of cocaine during pregnancy and that she is willing to work with DSS regarding a drug tx program. Apparently have indicated their commitment towards grandchild should mother have inability to care for infant in the future. Mother and child will be living with her . Discussed concern re mother's deisre to breastfeed after discharge/ DSS aware and will try to follow up with this issue as much as feasible.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-11 00:00:00.000", "description": "Report", "row_id": 1720008, "text": "Rehab/OT\n\nWill seen for follow up. Mom and grandmother present at the bedside. Noted infant crossing his legs in both sleep and awake states. Tremors noted in quiet . Mom reporting that infant was breech in utero. Tone is WNL for GA. Infant able to achieve quiet . Enjoys pacifier but settles well without it. Full, reciprocal motion observed.\n\nA: Infant doing well off DTO. Few signs of withdrawal seen. Continues to benefit from developmental interventions (low stim and maximum boundaries).\n\nP: OT to follow. Recommend roll in between his legs to align hips in neutral.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-11 00:00:00.000", "description": "Report", "row_id": 1720009, "text": "Neonatology Attending\nDOL 15\n\n remains in room air with two bradycardias in 24 hours.\n\nNo murmur. BP 60/37 (45).\n\nWt 1840 (+20) on TFI 150 cc/kg/day SC26, tolerating well PO/PG. Voiding and stooling. Abd benign.\n\nNAS . Not on DTO.\n\nA&P\n34 week GA infant with respiratory and feeding immaturity, antenatal cocaine and opiate exposure\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Continue to monitor NAS per protocol\n-SW involved; continue to provide parental support\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720074, "text": "Clinical Nutrition:\nO:\n~38 week CGA BB on DOL 28.\nWT: 2395g(+65)(~10th %ile); BWT: 1745g. Average wt gain over past week ~46g/day.\nHC: 33cm(25-50 %ile); last: 32.5cm\nLN: 45cm( %ile); last: 45cm\nMeds include Fe.\nLabs noted.\nNutrition: Adlib/Min. 130cc/kg/day as 22; all po's. Projected intake for next 24hrs based on average of past 3-day intake ~259cc/kg/day providing ~190kcal/kg/day & ~5g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; all po's. Labs noted & within acceptable ranges. Current feeds & supps exceeds weaned recs for kcal/pro/vits/mins as infant is taking large volumes. Plan d/w team & kcals decreased today. HC gain is meeting recs. Growth is exceeding recs of ~20-35g/day for WT gain; represents catch-up growth but may need to consider decreasing to 20kcal/oz if continues to gain excessive WT gain w/ large volume intake & also to avoid excess protein. LN gain is not meeting recs of ~1cm/wk. Will follow long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720075, "text": "Instructed mom and Grandmother in infant CPR And Choking. Family viewed video and on manikin by this RN. Family returned on manikin. Time allowed for questions to be answered. Revewed Back to Sleep guidelines. Handouts given. Family states adequete understanding of techniques for infant CPR and Choking.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720076, "text": "Nursing progress Notes\n\n\n#1 O; Baby remains in room air. Breath sounds clear and\nequal, mild retractions, no spells. A; Day 4 of 5 day count\ndown. P: Continue spell count down.\n#2 O: Baby continues to feed ad lib demand with neosure22.\nFeeds offered every 4 hours when baby woke. spits or\nlarge apspirates. Abdomen benign, voiding and stooling.\nCirc healed. No diaper rash. A: Feeding well on demand.\nP: Continue to feed on demand and watch weight on 22 cal.\n#3 O; Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares. Car seat\nscreening in progress. EI and VNA referals called in. A:\nPreparing for discharge home in am. P: Continue to support\ndevelopment.\n#5 O: Mother and grandmother in to visit this afternoon.\nCPR taken and mother brought in car seat. Mother and father\nplan to visit again this evening. A: Involved family. P:\ncontinue to keep informed. Discharge home with Dss\ninvolvment.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-25 00:00:00.000", "description": "Report", "row_id": 1720077, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: WILL REMAINS IN RA WITH CL & = BS AND NO AUDIBLE MURMER. NO A&B'S OR DESATS TONIGHT. DAD OF SPELL COUNTDOWN. BP 68/40-45. COLOR PALE/ PINK AND WELL PERFUSED.\n\nFEN: WEIGHT UP 40GMS TO 2435GMS TONIGHT. BOTTLING 90-100CC OF 22CAL. VOIDING AND STOOLING WNL. CIRC SITE HEALED.\n\nSOCIAL: MOM CALLED FOR UPDATE. WILL BE IN AFTER 11AM DR . TO HOPEFULLY DISCHARGE WILL. VNA AND EI CALLED IN. MOM WILL MAKE PEDI . TODAY. ALL DISCHARGE TEACHING COMPLETED. CPR INSTRUCTION ATTENDED. PASSED HEARING AND CAR SEAT CHALLENGE. HEP B GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 1719946, "text": "Nursing progress Notes\n\n\n#1 O: Baby was in nasal cannula oxygen until 1500, currently\ntrialling out of oxygen. Breath sounds clear and equal,\nmild retractions, 4 spells noted this morning. A: Weaning\noff oxygen this afternoon. P: Continue to monitor and\nprovide support as required.\n#2 O: Total fluids increased to 80cc/kg/day. IV fluids of\nD10W with lytes infusing well via scalp IV. Feeds advanced\nto 70cc/kg/day. Feeds given every 4 hours over 30min. No\nspits or large aspirates. Abdomen soft, bowel sounds\nactive, no loops, girth stable, voiding and stooling.\nBottle offered, not interested, baby refused to suck. A:\nTolerating advancing feedds. P: Continue to advance feeds\nas tolerated and ordered.\n#3 O: Temp stable in isolette on servo. BAby is and\nactive with cares and sleeps fairly well with a dark blanket\nover is isolette for 2 to 3 hours after feeds. Baby\ntolerated being held well. No interested in bottle\nfeeeding. NAS scores 2 to 4 every 4 hours. A: Appropriate\nfor age. P: continue to support development.\n#4 O: 48 hour rule out sepsis completed. P: Antibiotics\ndiscontinued.\n#5 O: up to visit and mother held baby this\nafternoon. Father participated in cares every 4 hours.\n met with MD today. A: Involved family. P:\nContinue to keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-11 00:00:00.000", "description": "Report", "row_id": 1720010, "text": "Nursing progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, 1 brady that was self resolved\ntoday. A: Occasional spells. P: Continue to monitor.\n#2 O: Total fluids 150cc/kg/day of SimSC26. Feeds given\nevery 4 hours. Bottle offered at 2 feedings and baby did\nbetter taking 35 and 46cc. Full gavage given over 45 min\nand was tolerated without any spits. Abdomen soft, bowel\nsounds active, girth stable. Voiding well, stool soft.\nBottom remains excoriated, criticaid applied at each diaper\nchanged and mineral oil used as needed. A: Learning to PO\nfeed, better volumes taken when given a rest with a gavage\nfeeding. Tolerating feeds well. P: Continue with 2 /3 Po\nfeeds for 24 hours and then reassess.\n#3 O: Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares. If he woke early\ntoday is was less than an hour early. Baby has normal tone.\n Legs do frequently cross. Baby wrapped with washcloth\nbetween knees to prevent crossing as suggested by OT. NAS\nscores today. A: Appropriate for age. P: continue to\nsupport development.\n#5 O: Mother and grandmother in to visit today.\nDemonstration bath given. Mom has signed up for CPR on\nThursday. Temp taking discussed. Mother dressed and fed\nbaby. A: Involved mother preparing for discharge home in\nnext few weeks. P: Continue to keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720069, "text": "Attending Note\nDay of life 27 PMA 38 0/7\nday spell count\nin room air RR 30-60 sat 96-100% mild retractions\nHR 130-160 intermittent murmur BP 77/30 mean 46\nweight 2395 up 65 grams took in 259 cc/kg/day all po of 24 cal/oz\nvoiding and heme negative stools\ncirc healing well stable temp in open crib\n visit daily\n\nImp-infant making progress\nwill continue to monitor for spells\nwill continue physical therapy for fibromatosis coli\nneeds car seat test\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720070, "text": "Attending Note\nPhysical Exam\nGen active well appearing\nskin mottled with exwill decrease to 22 cal/ozposures pale\nlungs clear bilaterally\nneck supple 1-2 cm mass in left sternocleidomastoid\nCV regular rate and rhythm no murmur\nAbd soft with active bowel no masses or distention\nGU normal male circ healing well\nExt warm well perfused brisk cap refill\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720071, "text": "Attending Note\nPhysical Exam\nGen active well appearing\nskin mottled with exwill decrease to 22 cal/ozposures pale\nlungs clear bilaterally\nneck supple 1-2 cm mass in left sternocleidomastoid\nCV regular rate and rhythm no murmur\nAbd soft with active bowel no masses or distention\nGU normal male circ healing well\nExt warm well perfused brisk cap refill\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720072, "text": "SOCIAL WORK\nSpoke with team caring for infant. Concern about mother's follow through as she has been told numerous times to bring in car seat for infant's car seat test. Called DSS, left message for worker to let her know about concern. Ms will be out of office until Thurs. Requested she speak with LICSW on Thurs, and f/u with family in community as infant is sched for d/c on Wed. Will leave message for Ms as well. Thank you.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-30 00:00:00.000", "description": "Report", "row_id": 1719947, "text": "NPN Nights 7pm-7am\n\n\n#1 O: Infant remains in roomair with O2 sats 94-99%. Lung\nsounds remain clear and equal with resp rates 20s-60s,\ncontinued mild retractions at times. A: maintaining sats\nwell in roomair. P: Continue to moniter.\n#2 O: Wgt down 65g to 1580g. Tf increased to 100cc/k/day.\nIVF are D10W with added lytes, infusing peripherally at\n30cc/k/d currently. Feeds of SSC 20 casl/oz currently at\n70cc/k/day. Tolerating gavage feeds well with 2 , \naspirate 5cc of partially digested formula. Abd remains\nsoftly round, +bs, no loops, Ag stable. Voiding adeq amts.\nLytes drawn tonight were 139/6.4/108/21 (moderately\nhemolyzed) and d-stick was 52. A; tolerating advancing of\nfeeds. P: Continue to moniter.\n#3 Infant is and active with cares. Temp is stable in\nservo controlled isolette. Sucking well on his pacifier.\nNAS scores have been 6 and 6 thus far this shift (see flow\nsheet). INfant has had 2 episodes of bradys thus far this\nshift, with apnea and needing stim to resolve. A: AGA,\nhaving occasional spells, NAS scores slightly increased. P:\nContinue to moniter.\n#5 O: Infant's dad was in to visit during the evening\nportion of the shift. He checked infant's temp and changed\nthe diaper indpened. He asked appr. questions and was\nupdated at the bedside. invested . P: Continue\nto support.\n#6 O: Infant was started on single photherapy tonight for a\nbilirubin level of 10.1/.3/9.8. Eye pathces are in place.\nSkin is slightly jaundiced. A: hyperbilirubinemia.\nP:Continue to moniter.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-10 00:00:00.000", "description": "Report", "row_id": 1720004, "text": "Clinical Nutrition\nO:\n~36 wk CGA BB on DOL 14.\nWT: 1820 g (+35)(<10th %Ile) ;birth wt: 1745 g. Average wt gain over past wk ~18 g/kg/day.\nHC: 32 cm (~25th to 50th %Ile); last: 30 cm\nLN: 44.5 cm (~10th to 25th %Ile); last: 43 cm\nMeds include Fe\nLabs not due yet\nNutrition: 150 cc/kg/day SSC 26, po/pg over 1 hr feeds due to hx of spits. Infant po feeds w/ q care, taking ~ to volume when po fed. Projected intake for next 24hrs ~130 kcal/kg/day and ~3.3 g pro/kg/day.\nGI: ABdomen benign. 2 small spits.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems except continued occasional small spits. Adjusting feeding times as needed to minimize spits. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are both exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. WIll follow long term trends for growth. WIll continue to follow w/team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-10 00:00:00.000", "description": "Report", "row_id": 1720005, "text": "Neonatology - NNP Progress Note\n\nInfant is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air, breath sounds clear and equal. He is tolerating enteral feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720073, "text": "Case Management Note\nReferral called today to Centrus Premier Home Care (/fax ) and spoke to in intake. Team anticipating a home d'c Wednesday and home visit for VNA arranged for Thursday. If this date needs to be changed, please call VNA to reschedule. Will need referral pages 1,2,3 faxed to above # at d'c. Will need EIP referral called. I will cont to follow and assist w/any d'c planning needs along with team & family\n" }, { "category": "Nursing/other", "chartdate": "2179-08-11 00:00:00.000", "description": "Report", "row_id": 1720006, "text": "NPN\n\n\n#1RESP: Infant remains stable in room air. Lung sounds are\nclear/=. Mild subcostal retractions noted. RR's= 30-60's. No\nspells thus far this shift. A:Stable in room air P:Continue\nto monitor for spells\n\n#2FEN: Weight 1840g, up 20g. TF's remain at 150cc's/kg/d. of\nSC 26. 46cc's q 4 horus gavaged over 1 hour. Infant bottled\n19-20cc's thus far and was gavaged the remainder. Infant\nbottled with yellow nipple with good coordination but tired\nwhile bottling. Abdomen is soft and round, no loops, no\nspits thus far, +bowel sounds, voiding and stooling.\nCriticaid being applied with each diaper change. Infant\nremains on Fe. A:Tolerating feeds well P:Continue to monitor\nfor feeding intolerance.\n\n#3DEVE: Temp stable. Infant is swaddled in the open crib.\n and active with cares. Wakes for feedings. Can be\nirritable at times. Settles well with binki and firm\nboundaries. NAS score thus far this shift. MAE.\nFontanels are soft and flat. A/P:Continue to support g/d of\ninfant. Continue to score infant as ordered.\n\n#5SOCIAL: Both in to visit with infant this shift.\nDad able to bottle infant with minimal assistance. Mom\nindependent with temp and diaper. Asking appropriate\nquestions. Mom asking questions related to NAS .\nUpdate given by this RN. A:Loving P:Continue to support\nfamily needs\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-23 00:00:00.000", "description": "Report", "row_id": 1720067, "text": "Nursing Progress Note:\n\nRESP:\nO: No a/b spells noted so far this shift. Today day on\ncountdown. RR 30-60's with sats 96-100% in RA. LS clear and\nequal. Mild SC retractions. Color pale pink, mottles with\ncares.\nA: Stable in RA\nP: Cont to monitor. D/C to home wednesday (26th) if infant\ncont with no spells.\n\nFEN:\nO: TF min 130cc/kg of neo 24, ad-lib. Total 24hr intake=\n233cc/kg. Infant is waking Q3-4 hours. Taking 70-75cc with\neach feeding. Infant is well coordinated using his soothie\nbottle. No spits noted so far this shift. Abdominal exam\nbenign. Infant voiding and passing heme negative stool.\nA: Tolerating feeds well.\nP: Cont infant on ad-lib demand schedule.\n\nDEV:\nO: Infant temps stable; swaddled in an OAC. Font s/f. Infant\na/a with cares; waking for all feeds. Tone within normal\nlimits. Small 1.5cm mass palpated on R side of neck; no\ndecreased ROM noted. OT examined infant today.\nInfant will follow-up with EI after d/c. Infant passed\nhearing screen today.\nA: Appropriate for gestational age.\nP: Cont to support development.\n\nSOC:\nO: Mom called x3 thus far. Updated regarding infant's status\nand plan of care. Mom asked to bring in carseat for infant.\nStates she will be in to visit today. Mom needs to schedule\npedi appt prior to d/c. Mom to take CPR tomorrow.\nA: Ivolved in infant care.\nP: Cont to support, educate and keep informed. Cont d/c\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 1719942, "text": "Neonatology Attending\nDOL 2\n\n remains in NC 13 cc/min of 100% Fi2 with wall-maintained SaO2 and no significant distress. Six bradycardias in 24 hours.\n\nNo murmur. BP 85/53 (64).\n\nCulture remains negative.\n\nWt 1645 (-100) on TFI 60 cc/kg/day including enteral feeds SC20 at 50 cc/kg/day, tolerating well. Abd benign. D-stick 59. Urine output 2.7 cc/kg/day over 24 hours. Stooling normally\n\nBilirubin 7/0.2 (not under phototherapy).\n\nTemp stable on servo isolette.\n\nNAS .\n\nA&P\n34 week GA infant with resolving TTN, respiratory immaturity, resolved sepsis risk, feeding immaturity, mild hyperbilrubinemia, positive urine toxicology screen for cocaine\n-Monitor frequency and severity of apnea/bradycardia and consider caffeine therapy as indicated\n-Await maturation of oral feeding skills\n-Repeat bilirubin in 24 hours\n-Increase TFI to 80 cc/kg/day\n-Continue to monitor NAS\n-Will discuss result of cocaine screen with mother today. She feels that this is a cross reaction to lidocaine received during dental procedures, but chemistry resident has confirmed that the assay used at does not cross-react.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 1719943, "text": "Rehab/OT\n\nOT receiving consult. OT to assess on Monday. History noted, NAS in place. RN reporting infant not sleeping well in between his cares and increased irritability with stimulation. Gave a dark blanket and recommended low stim environment to optimize infant comfort. OT to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-24 00:00:00.000", "description": "Report", "row_id": 1720068, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-100%.RR 30-60'S.LS\nremain clear and equal with mild sc retractions.No A's and\nB's or desats thus far.Day # Brady Count.\n\nF/N:Infant cont's on Ad lib demand schedule with a\nMin.130cc's/kg/day.Infant to rec. 24 52cc's q 4 hrs\nand 39cc's q 3 hrs.Ingant bottling 85-100cc's q 4\nhrs.Appears well coordinated.TF over 24 hrs\n259cc's/kg/day.Weight=2.395 up 65.Abd.soft with pos bs,no\nloops or spits.Voiding no stool thus far.\n\nG/D:AF soft and flat.Sleeping well b/t cares.MAE.Bringing\nhands to face and mouth.Sucking on pacifier.Infant presently\nswaddled in flex. position.Tone improved.Roll b/t legs d/t\nbreech.Noted coli on R side of neck\napprox.1.5cm.No redness or increased swelling observed.OT\nfollowing.\n\nSocial:Mother and FOB in tonight.Sighned up for CPR on \nat 1730.Telephone numbers as to where infant will being\nliving after d/c in front of chart.Explained to this RN that\nthe infant's grandmother,s house is being done over\ntherefore, 2 numbers.Plan to bring in car seat tonight after\npolice fit seat.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 1719944, "text": "NP NOTE\nPE: preterm infant neslted in isolette. Pink, sl jaundiced, active, irritable with exam.\nAFOF sutures sl overriding. Eyes without drainage, ng and canula in place. MMMP, sucking on placifier when offered. PIV in scalp vein.\nChest is clear with equal bs, mils SCR\nCV: RRR, no murmur, pulses+2=\nAbd: soft, NTND, active bs, cord healed.\nGU: testes in scrotum\nEXT: , \nNeuro: irritable, very active, consoles with boundaries, pacifier.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-29 00:00:00.000", "description": "Report", "row_id": 1719945, "text": "SOCIAL WORK\nMet with both today with Dr regarding verified positive cocaine screen. Mother again related that she had had dental work and was told by doctor treating her pain addiction withdrawal that a drug screen would be positive. She neither admitted or denied use of cocaine. Father, , appeared restless and agitated during the meeting but was otherwise quiet. When asked his thoughts regarding involvement of DSS, he related that he has had prior involvement with DSS and knew someone at the office whom he intended to contact. declined to provide more information about this history with DSS. FOB has a 6yo son who lives with them on weekends. are aware that DSS will be contact and then be in touch with them probably next week. Mother asked several times whether they would be allowed to take home with them. Mother again that she wants what is best for her baby. providers reiterated that NICU team wants to continue to work with them towards getting the baby home. DSS office is . Will be avail on Fri .\n" }, { "category": "Nursing/other", "chartdate": "2179-08-10 00:00:00.000", "description": "Report", "row_id": 1720000, "text": "NPN\n\n\n#1RESP: Infant remains stable in room air. Lung sounds are\nclear/=. Mild subcostal retractions noted. RR's=30-50's. No\nspells thus far this shift. A:Stable in room air P:Continue\nto monitor for spells\n\n#2FEN: Weight 1820g, up 35g. TF's remain at 150cc's/kg/d of\nSC26. 46cc's q 4 hours. Infant bottled 25-35cc's thus far\nand was gavaged the remainders. Infant bottled with good\ncoordination but tired. Abdomen is soft and round, no loops,\nno spits thus far, +bowel sounds, voiding and stooling.\nCriticaid applied with each diaper change. A:Tolerating\nfeeds well P:Continue to monitor for feeding intolerance\n\n#3DEVE: Temp stable. Infant is swaddled in the open crib.\n and active with cares. Infant can be irritable at\ntimes. Settles well with binki. Fontanels are soft and flat.\nBrings hands to face. NAS score of 6 x2 thus far. See\nflowsheet for details. A/P:Continue to support g/d of\ninfant\n\n#5SOCIAL: Dad called x1. Update given by this RN.\nA/P:Continue to support family needs\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-10 00:00:00.000", "description": "Report", "row_id": 1720001, "text": "Neonatology Attending\nDOL 14 / PMA 36 weeks\n\nIn room air with no distress. Five bradycardias yesterday, not on caffeine.\n\nNo murmur. BP 74/42 (54).\n\nWt 1820 (+35) on TFI 150 cc/kg/day SC26. Bottling partial volumes at each feed, with remainder by gavage. Abd benign. Voiding and stooling. D-stick 62\n\nOff NOS with NAS 6 - 9.\n\nA&P\n34 week GA infant with respiratory and feeding immaturity, antenatal cocaine and opiate exposure s/p NOS therapy\n-Continue to monitor for recurrence of withdrawal symptoms\n-Monitor for respiratory maturity\n-Continue to encourage development of oral feeding skills\n-Social work involved\n" }, { "category": "Nursing/other", "chartdate": "2179-08-10 00:00:00.000", "description": "Report", "row_id": 1720002, "text": "NPN 0700-1900\n\n\n1. INfant remains in RA, cl/=, rr 30-50's, mild scr. Brady\nx1, QSR. Not on caffiene.\nContinue to monitor resp status.\n\n2. TF150/k/d, SSC26, po/pg. Infant using yellow nipple,\nwell coordinated, but tires. Belly benign. Voiding and\npassing formed yellow/grn stools. Bottom excoriated,\napplying criticaid. Mom states this appears improved.\nContinue to monitor intake, offer po's as tolerated,\nsupplement w/NGT as required.\n\n3. Temp stable in OAC. Abstinence scores ranging from .\nINfant awake majority of morning requiring consolation,\nsucking excessively on paci. Appears better this afternoon,\nsleeping well at time of note.\nContinue to support needs, monitor infant s/p narc\nexposure.\n\n5. Mom in visiting, indep w/most cares. Asking appropriate\nquestions. Loving and caring w/infant. Held infant during\ngavage feed.\nContinue to support and update .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-10 00:00:00.000", "description": "Report", "row_id": 1720003, "text": "Neonatology NP Note\n\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\nirritable but consolable today\n" }, { "category": "Nursing/other", "chartdate": "2179-08-23 00:00:00.000", "description": "Report", "row_id": 1720063, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS 98%. BS CLEAR. RESP RATE 32-58\nWITH MILD SC RETRACTIONS.NO SPELLS--LAST SPELL AT 0215\nA:STABLE\nP:CONTINUE TO MONITOR FOR SPELLS\n\n#3F/E/N\nO:ON MINIMUM 130CC/KG AD LIB DEMAND FEEDS 24. BABY\nWAKING Q3-4HR AND BOTTLING 90-95CC. ABDOMEN SOFT, FULL WITH\nGOOD BS. LARGE SPIT X1. VOIDING WELL; NO STOOL THUS FAR. WT\nUP 120GM (CHECKED X2). TOOK IN 233CC/KG PAST 24HR.\nA:FEEDING WELL AND GAINING WT\nP:CONTINUE TO ENCOURAGE PO'S, MONITOR WT GAIN\n\n#3G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH. WAKING Q3-4HR TO EAT, BOTTLING WELL COORDINATED\nWITHOUT CHOKING/SPELLS. RIGHT NECK \nUNCHANGED--BABY WITH FULL ROM.\nA:AGA\nP:PT/OT TODAY, MONITOR AND SUPPORT\n\n#5SOCIAL\nO:MOM X1 FOR UPDATE. ASKED MOM TO BRING IN CAR SEAT,\nMAKE PEDI APPT FOR THURSDAY/FRIDAY. PLANNING ON TAKING CPR\nON TUESDAY AND WILL CALL IN AM WITH PLANNED TIME TO VISIT SO\nSHE CAN HAVE A MEETING WITH RE:NECK MASS AND\nTHEIR CONCERNS ABOUT IT\nA:INVOLVED MOM PREPARING FOR D/C, DSS INVOLVED\nP:CONTINUE TO EDUCATE AND PREPARE FOR D/C, CALL EIP TODAY\nAND CONTACT DSS TO SCHEDULE HOME VISIT UPON D/C\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-23 00:00:00.000", "description": "Report", "row_id": 1720064, "text": "Neonatology Attending PE:\nactive infant in open crib\nAfof\nright neck mass without change, no erythema\nnormal s1s2, no murmur, breath sounds clear\nabdomen slightly distended yet soft, nontender\next well perfused. tone aga.\n" }, { "category": "Nursing/other", "chartdate": "2179-08-16 00:00:00.000", "description": "Report", "row_id": 1720031, "text": "Clinical Nutrition\nO:\n~37 wk CGA BB on DOL 20.\nWt: 2035 g (+40)(<10th %Ile); birth wt: 1745 g. Average wt gain over past wk ~18 g/kg/day\nHC: 32.5 cm (~25th to 50th %Ile); last: 32 cm\nLN: 45 cm (~10th to 25th %Ile); last: 44.5 cm\nMEds include Fe\nLabs due this wk\nNutrition: 130 cc/kg/day SSC 26, all po. Infant just changed from 150 cc/kg/day to ad lib minimum. INfant took 156 cc/kg/day all po yesterday. Projected minimum intake for next 24hrs ~113 kcal/kg/day and ~2.9 g pro/kg/day.\nGI: ABdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. Taking all po feeds. Labs due this wk. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN gain is not meeting recommended ~1 cm/wk, but overall trend on LN growth chart is acceptable. Will follow long term trends. WIll continue to follow w/ team and participate in nutrition plans.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2179-08-16 00:00:00.000", "description": "Report", "row_id": 1720032, "text": "Nursing Progress Notes\n\n\n#1 O: Baby remains in room air. Breath sounds clear and\nequal, mild retractions, 3 spells today, 1 needing mild\nstim. A: Continues to have spells. P:Continue to monitor.\n#2 O: Changed to ad lib feeds with min 130cc/kg/day. Baby\nwoke every 3 to 4 hours and exceeded his min so far taking\n50 to 65cc per feeding. Abdomen soft, bowel sounds active,\nno loops. Voiding well, no stool yet today. A: All PO\nfeeds today. P: Continue to encourage PO feeding.\n#3 O: Temp stable in open crib. BAby is and active\nwith cares and slept well between cares. Mother into feed\nbaby and gave baby a . During time a pea sized\nlump was noted on the right side of baby's neck. Dr \n notified and examined baby and spoke with mother. Baby\nswaddled with small roll between legs as requested by OT.\nA: Baby sleeping well between cares. NAS \ndiscontinued. P: Continue to support development and follow\nsmall cyst on right side of neck.\n#5 O: Mother and grandmother in to visit and feed baby.\nMother was with feeding and gave baby his \nwith a little prompting. Iron dose was demonstrated. A:\nInvolved mother. P: Continue to keep informed.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-08-01 00:00:00.000", "description": "BABYGRAM AP ABD ONLY", "row_id": 918382, "text": " 12:16 PM\n BABYGRAM AP ABD ONLY Clip # \n Reason: evaluate bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Premature infant with loose stools\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN.\n\n The child with narcotic withdrawal with loose stool.\n\n A nasogastric tube reaches the stomach. There is mild diffuse distension of\n large and small bowel. There is no evidence of obstruction or other specific\n signs of necrotizing enterocolitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-07-27 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 917763, "text": " 5:22 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: 34 weeker with respiratory distress on CPAP\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress\n REASON FOR THIS EXAMINATION:\n 34 weeker with respiratory distress on CPAP\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable view of the chest.\n\n CLINICAL HISTORY: Newborn 34-week premature infant with respiratory distress.\n This is the initial film on day of life 1.\n\n The lung volumes are quite low. There is focal atelectasis in the left lower\n lobe. Hazy bilateral opacity is also identified. There is no pneumothorax.\n No pleural effusions are seen.\n\n IMPRESSION: Findings are most compatible with mild hyaline membrane disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-08-17 00:00:00.000", "description": "P NECK,SOFT TISSUE US PORT", "row_id": 920477, "text": " 8:44 AM\n NECK,SOFT TISSUE US PORT Clip # \n Reason: preterm infant with right sided neck mass\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with as above\n REASON FOR THIS EXAMINATION:\n preterm infant with right sided neck mass\n ______________________________________________________________________________\n FINAL REPORT\n A PORTABLE NECK ULTRASOUND PERFORMED ON AT 8:57 A.M.\n\n FINDINGS: There is a focal mass within the right sternocleidomastoid muscle\n with overall measurements of approximately 1.4 in the sagittal plane by 0.7 cm\n anterior to posterior and approximately 3.5 cm in transverse dimension. The\n mass moves with the sternocleidomastoid muscle and is most likely torticollis.\n The thyroid was well seen as separate from the mass. The left\n sternocleidomastoid muscle was normal.\n\n IMPRESSION: A focal mass within the right sternocleidomastoid muscle,\n consistent with torticollis.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2185-11-29 00:00:00.000", "description": "Report", "row_id": 82246, "text": "PATIENT/TEST INFORMATION:\nIndication: Assess for pericardial effusion/perforation, and degree of AI.\nWeight (lb): 200\nBP (mm Hg): 111/60\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 18:13\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic dysfunction.\nMildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nThe left ventricular cavity size is normal. There is mild regional left\nventricular systolic dysfunction with inferior/inferolateral hypokinesis.\nOverall left ventricular systolic function is mildly depressed. Right\nventricular chamber size and free wall motion are probably normal (suboptimal\nviews). The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2185-12-05 00:00:00.000", "description": "Report", "row_id": 82082, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 204\nBSA (m2): 2.13 m2\nBP (mm Hg): 108/75\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 09:56\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\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses and cavity\nsize are normal. There is mild to moderate regional left ventricular systolic\ndysfunction with basal to mid inferior and infero-lateral hypokinesis. No\nmasses or thrombi are seen in the left ventricle. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is moderately dilated.\nThe ascending aorta is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no major change.\n\n\n" }, { "category": "Echo", "chartdate": "2185-11-30 00:00:00.000", "description": "Report", "row_id": 82083, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 71\nWeight (lb): 204\nBSA (m2): 2.13 m2\nBP (mm Hg): 93/66\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 10:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\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. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\nNormal LV inflow pattern for age.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses and cavity size are normal.\nThere is mild to moderate regional left ventricular systolic dysfunction with\ninferior and infero-lateral hypokinesis. No masses or thrombi are seen in the\nleft ventricle. Right ventricular chamber size is normal. Right ventricular\nsystolic function is borderline normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets\nare mildly thickened. There is mild pulmonary artery systolic hypertension.\nThere is a small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of , overall LVEF\nappears lower.\n\n\n" }, { "category": "ECG", "chartdate": "2185-12-06 00:00:00.000", "description": "Report", "row_id": 205773, "text": "Sinus rhythm\nInferoposterolateral myocardial infarction, age indeterminate - possible\nacute/recent/in evolution\nSince previous tracing of , further ST-T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2185-12-04 00:00:00.000", "description": "Report", "row_id": 206010, "text": "Sinus rhythm\nInferoposterolateral myocardial infarction, age indeterminate - possible\nacute/recent/in evolution\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2185-12-02 00:00:00.000", "description": "Report", "row_id": 206011, "text": "Sinus rhythm. No significant change compared to the previous tracing\nof .\n\n" }, { "category": "ECG", "chartdate": "2185-12-01 00:00:00.000", "description": "Report", "row_id": 206012, "text": "Sinus rhythm. Since the previous tracing sinus rhythm has been restored.\nRelative to the previous sinus rhythm tracing on there is\ninfero-posterolateral infarction in evolution with more prominent ST segment\ndepression in the early precordial leads. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-12-01 00:00:00.000", "description": "Report", "row_id": 206013, "text": "Regular wide complex tachycardia with broad R waves in the early precordial\nleads. Probable ventricular tachycardia. Since the previous tracing of \nventricular tachycardia is now apparent. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2185-11-30 00:00:00.000", "description": "Report", "row_id": 206014, "text": "Sinus rhythm. Infero-posterolateral myocardial infarction, possibly acute.\nSince the previous tracing of sinus tachycardia and ventricular ectopy\nare absent and further ST-T wave changes are now seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-11-29 00:00:00.000", "description": "Report", "row_id": 206015, "text": "Sinus tachycardia. Ventricular premature beats. Inferior (and question lateral)\nmyocardial infarction with ST-T wave configuration suggesting acute/recent/in\nevolution process. Clinical correlation is suggested. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2185-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934997, "text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for pulmonary edema before extubation\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with STEMI, s/p Intubation and IABP placement.\n\n REASON FOR THIS EXAMINATION:\n Eval for pulmonary edema before extubation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Post myocardial infarct. Evaluate for failure.\n\n Comparison is made with the prior chest x-ray of the 3rd. While\n failure is still present, the degree of pulmonary edema has decreased\n considerably since the prior chest x-ray.\n\n The position of the various lines and tubes is satisfactory.\n\n IMPRESSION: Improving failure.\n\n" }, { "category": "Radiology", "chartdate": "2185-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935167, "text": " 2:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pulmonary edema, infiltrate\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with STEMI s/p extubation, low-grade temp\n REASON FOR THIS EXAMINATION:\n Please assess for pulmonary edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Low-grade temperature.\n\n Portable AP chest radiograph compared to .\n\n The patient was extubated, the NG tube and the Swan-Ganz catheter were removed\n in the meantime interval. The left lower lobe atelectasis is unchanged.\n There is improvement in the pulmonary edema which is now mild and\n interstitial. The left pleural effusion is small. There is no sizeable large\n pleural effusion. There is no pneumothorax.\n\n IMPRESSION: Improvement of the pulmonary edema. _____ left lower lobe\n atelectasis. No evidence of new area of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935296, "text": " 11:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for etiology of acute SOB\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with STEMI s/p extubation, low-grade temp. now with acute\n SOB\n REASON FOR THIS EXAMINATION:\n Eval for etiology of acute SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Myocardial infarction, status post extubation. Shortness of\n breath.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP: There has been interval development of interstitial\n and alveolar opacities predominantly in the perihilar distribution consistent\n with pulmonary edema. Small bilateral pleural effusions have slightly\n increased with increased left lower lobe collapse/consolidation. There is no\n pneumothorax.\n\n IMPRESSION: Worsening pulmonary edema and left lower lobe collapse.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935426, "text": " 10:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of infiltrate\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with STEMI s/p extubation, low-grade temp. now with acute\n SOB\n REASON FOR THIS EXAMINATION:\n progression of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 62-year-old man status post extubation, now with low-grade temp and\n acute shortness of breath.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been improvement of the pulmonary edema. There are small bilateral\n pleural effusions. The effusion on the left side has decreased. The\n confluent opacity within the right lower lung fields has improved since the\n previous study as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-12-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 935525, "text": " 9:49 AM\n CHEST (PA & LAT) Clip # \n Reason: progression of infiltrate\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with new infiltrate on exam\n REASON FOR THIS EXAMINATION:\n progression of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 60-year-old man with new infiltrate on exam.\n\n FINDINGS: Compared to previous study from .\n\n There is no significant interval change. There is again seen small bilateral\n pleural effusions. There is mild prominence of the pulmonary vascular\n markings without overt pulmonary edema. Vascular pedicle is not widened and\n the cardiac silhouette is normal.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2185-11-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 934898, "text": " 8:35 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval for NGT and ETT placement.\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with STEMI, s/p Intubation and IABP placement.\n REASON FOR THIS EXAMINATION:\n Eval for NGT and ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of NG tube and ET tube placement.\n\n Portable AP chest radiograph was reviewed with no benefit of comparison to the\n previous films. The ET tube tip is 3 cm above the carina. The NG tube passes\n below the diaphragm and ends out of the field of view. The Swan-Ganz catheter\n was inserted through the femoral approach with its tip most likely in the\n right lower lobe pulmonary artery, too proximal. There is no radiographic\n evidence of presence of the intra-aortic balloon pump. The heart size is\n normal. The widespread bilateral predominantly perihilar opacities are most\n likely due to pulmonary edema. There is no sizable pleural effusion or\n pneumothorax. The ET tube cuff is overinflated.\n\n IMPRESSION: Low position of the ET tube, should be pulled back for 1-2 cm.\n Slightly distal position of the pulmonary catheter.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-04 00:00:00.000", "description": "Report", "row_id": 1463264, "text": "resp care note\n\nPt asleep and breathing comfortably most of night. Around 2400 there was some audible wheezing which resolved after atrovent neb. Pt given second neb ~ 0600. SpO2 in the low to mid 90's on 5 L nc + open face tent. RR 18-24.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-04 00:00:00.000", "description": "Report", "row_id": 1463265, "text": "CCU Nursing Progress Note\nS-\"I am having some pressure here in the middle of my chest.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. Anxious watching the monitor alot, wanting to know if those are good numbers.\nAdmits he is nervous of leaving the intensive care unit and having different nurses and doctors. Explained that the physicians will remain the same and he will be monitored by cardiac step down nurses.\nReceived tylenol 650mg po for right hip pain with improvement of walking and weight bearing pain.\nCV-VS HR 68-88 NSR with one episode of 95 NSR with pain. Lopressor 25mg po BID unchanged and started captopril 6.25mg TID. Tolerated first does without change in BP. Heparin at 1100u/hr started coumadin . c/o epigastric pain with HR 95 with SBP up 122. EKG continue to have 1mm ST depressions V2-4 but TW are flatter c/w recent EKG . Received 2 sl NTG with relief of most of discomfort. Intern/resident called and examined pt.\nResp-LS rales 1/3 up bilaterally with bronchial BS LLL. Occ productive cough thick tan secretions. PA/lateral CXR small bilateral pleural effusions, improved CHF, RML opacity. Received lasix 40mg IVB with good results ~1500cc. O2 requirements while sitting in the chair most of the day 3l np sats 94-97%. Returned to bed and fell asleep on left side and sats dropped to 87%. Face tent placed on.\nID afebrile 99.6po. Sputum +moraxcela with sensitivities pnd.\nRepeat sputum 3+GNR 1+ yeast, culture pnd.\nGU-foley draining well, BUN/Cr 24/.9, K+3.8 received 20meq KCL po\nGI-Appetite good, no BM today. (had 3 soft BM's ). Abd soft and less distended +BS x4.\nSkin-intact bilateral groins eccymotic.\nSocial-wife into visit.\nAccess-1 PIV\nCode Status-full\nA/P-RI STEMI ILMI succ stent LCX/PTCA OM1 c/b cardiogentic shock requiring ETT/IABP pressors. Now with CHF/pneumonia receiving lasix/abx.\nContinue to monitor for further O2 desaturation while sleeping. Diurese as needed and replete electrolytes. Increase lopressor and captopril as VS tolerates.\nKeep pt and family aware of and results of tests, as discussed in multi disciplanary rounds.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nS\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-05 00:00:00.000", "description": "Report", "row_id": 1463266, "text": "ptt 37.7, hep gtt increased to 1300/u hr. next ptt at 12 noon.\ninr 1.2, Potassium 3.3, will replete.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-05 00:00:00.000", "description": "Report", "row_id": 1463267, "text": "CCU NPN 1900-0700\ns/o: Please see carevue for complete obj data. See admit note and transfer note for full CCU coarse.\n\nPt A&Ox3, pleasant and co-op w/ care, slightly anxious about leaving unit.\n\nCV: HR 72, BP 106/60 (70). Tolerating PO lopressor, and captopril. Captopril dose not increased last eve per team. 40mg IV lasix given w/ stable BP.\nHep gtt cont at 1100 units/hr, On Coumadin q pm.\nBilat groin stable post angio, +pp.\n\nResp: strong cough, LS cta upper w/ FAINT rales as bases at start of shift, o2 sat's Mid 90's on 3lnc. Nebs at 00, and 06.\nLouder rales bibasilar at 0200, clear upper BS. 40mg iv lasix given w/ good u/o response.\nSputum cx from G+C in Pairs/Clusters/Chains, G-Rods, yeasts.\nPt desat's to mid 80's if lying on Left side only, face tent applied if on left side prn.\n\nGI: tolerating PO's\nGU: adequate u/o, >1100cc in response to lasix. Creat 0.9.\nID: on ceftriaxone, afebrile. T max 100.1\nPain: Hip pain relieved w/ 650mg tylenol.\n\nA: CHF/PNA post MI(w/intervention)/cardiogenic shock(ballooned)/intubation.\nStable o2 requirements over night, 3lnc.\nLow grade temp max on IV abx. Good response to lasix, creat stable.\nGroin stable on heparin and coumadin.\nP: Cardiopulm assessment and O2 requirements, follow ptt/inr on coumadin w/ heparin bridge. Follow temp curve.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-05 00:00:00.000", "description": "Report", "row_id": 1463268, "text": "resp care note\n\nPt slept well overnight, atrovent nebs Q 6 hrs @ 2400 and 0600. Pt was w/o wheezing overnight, Spo2 on 5 L NC was mid to high 90's. RR 12-18, regular.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-05 00:00:00.000", "description": "Report", "row_id": 1463269, "text": "CCU NSG NOTE: ALT IN CV-MI/ALT IN RESP-PNA\nS: \"I feel so much better today\".\nO: For complete VS see CCU flow sheet.\nID: PT afebrile. IV abx changed to po.\nCV: Pt has remained pain free. He conts on low dose BB and ace. HR in 70-80s NSR with rare PVCs. BP ranging 100-120/50-60s. Both groin sites dry and intact with DSD. All pulses palpable. He conts on coumadin at increased 7.5mg QD. Heparin conts at increased 1650/hr and he is due for PTT and lytes at . He received lasix 40mg at 11am with good diuretic response.\nRESP: He initially had BBR, but post diuresis has clear bs on 2L. Sating 96-99%. He conts to cough up thick rusty sputum. He is using IS.\nGI: Pt eating and drinking without problem. Had BM today.\nRENAL: Foley out. He is neg 2 liters for the day and 5 liters LOS.\nENDO: Last finger stick 113. he has not required ss insulin today.\nACT: Pt took first walks today and tolerated it well. PT to see him.\nMS: Pt A & O X 3, in good spirits. Wife in to visit and is very supportive.\nA: Stabble post MI\nP: Check lytes and PTT at . Monitor for pain. Cont to increase activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-01 00:00:00.000", "description": "Report", "row_id": 1463255, "text": "Respiratory Care\nPt remains intubated with 7.5 ETT. Pt alert and able to follow commands. Pt currently on CPAP+PS mode of ventilation, weaned to this shift. ABG pending on new vent settings, prior ABG WNL. Pt had episode of V-tach earlier in shift, which was corrected with meds. BS coarse bilaterally, suctioning for small amounts of thick yellow/blood tinged secretions. Morning RSBI on 0peep,5 ps= 49. See CareVue for details and specifics.\nPlan: ? SBT, wean to extubate with removal of aortic balloon.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-01 00:00:00.000", "description": "Report", "row_id": 1463256, "text": "ccu nsg progress note.\no:neuro=responsive/appropriate/cooperative. wo restraints. sedated w fent/versed gtts, but easily arousable/appropriate.\n pulm=intubated/vented. am rsbi=48.9. peep/pressure support decreased to . sats remains upper 90's w abg-7.41/40/91/0/26. breath sounds= deminished throughout. sx=scant amt tannish secretions.\n cv=episodes x2 of vt w rate into 130's & decrease in sbp from 100 to 80's. 1st (0235) episode rxed w increase amiodarone gtt to 1mg & 150mg bolus w 2nd (0250) episode rxed w additional bolus of 150mg. wo recurrance. present rhythm-sr wo ectopy. dopamine gtt dced @ 0100-#'s off dopa on iabp 1:1-maps 70-80, pad 22, cvp 14, w 19, & co/ci/svr 5.3/2.42/1117. iabp 1:1 intermittent augmentation w periodic sys/ diastolic unloading. heparin gtt increased to 750u w repeat ptt theraputic-51.0.\n gi=npo. ogt-bilious. wo stool.\n endo=insulin gtt presently @ 1.5u w bs 90-110.\n gu=foley. overall i&o-positive. lasix 40mg iv given @ 0200.\n id=low grade t-99.3 core.\n access=piv's x3. paline/aline/iabp. l fem w modified pressure dsg. r fem w transparent dsg. pulses +2/dop bilaterally. feet cool/pale.\n labs=am-ica 1.23. mg 2.1. k 4.2 (replaced w 20meq for k 3.7). bl sugar 96.\n\na:tolerated dopa wean dc. episodes slow vt not requiring cardioversion, but required rebolus & increase of amiodarone.\n\np:contin present management. goal-dc iabp & ett. ?add captopril/beta blocker. support as indicated.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-02 00:00:00.000", "description": "Report", "row_id": 1463258, "text": "ccu nsg progress note.\no:comfortable night. tolerated lopressor. remains on amiodarone gtt. diureses w lasix 20 w excellent effect. am labs sent.\n\na:tolerated extubation & iabp dc. wo further vt while on amiodarone.\n\np:contin present management. support as indicated. progressively increase activity level. ?addition ace. ?call-out.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-02 00:00:00.000", "description": "Report", "row_id": 1463259, "text": "CCU NPN 0700-1500\nADDENDUM:\nheparin gtt restarted d/t h/o arterial thrombosis, PTT due @ 1600.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-03 00:00:00.000", "description": "Report", "row_id": 1463262, "text": "CCU Nursing Progress Note\nS-\"My hip is really sore, I can't stand on it very well.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. Denies SOB or chest pain.\nCV- VSS on lopresor 25mg po BID. HR 68-95 NSR no VEA/VT noted off amioderone. Heparin at 1100u/hr.\nResp-This am found pt SOB rr 40 labored. Denies feeling SOB. LS rales 3/4 up bilaterally with bronchial BS LLL. +E to ascultation. CXR + penumonia with CHF. Received lasix 20mg IVB x1 with good diuresis 1000cc. O2 started at 100% face tent and 5lNP, weaned O2 to 3lNP and 70% face tent with O2 sats 92-96%. Noted when pt was lying on left side O2 sat dropped to 87%. Bedside nebs improving LS and cough.\nSputum is thick/rust colored small-moderate amounts. Still having exertional SOB and desats to mid 80's off face tent.\nID low grade temp 99 po on cetraxone for pneumonia.\nGU-foley draining well with diuresis, amber colored urine.\nGI-Appetite good with soft BM after each meal, OB-. Abd soft/distended\nSkin-right groin eccymotic. Pedal pulses intact.\nActivity-OOB chair with 2 assist. Unable to put full weight on right leg d/t hip discomfort. Will take tylenol 650mg at HS.\nSocial-wife and son in to visit. Wife is very attentive to pt needs and appears to be less anxious now that pt is doing better.\nAccess-1 PIV\nCode Status-Full\nA/P-AMI c/b VF arrest, cardiogenic shock requiring ETT/IABP/pressors.\nContinue to monitor CHF/pneumonia and O2 requirements, wean as tolerates. Follow urine output and continue to diurese.\nContinue to keep pt and family aware of as discussed in multi disciplanary rounds.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-04 00:00:00.000", "description": "Report", "row_id": 1463263, "text": "CCU NPN 1900-0700\n\nS/O:\n\nCV: REC'D 25MG OF LOPRESSOR LAST EVE, HR IN 70'S BP 98/55 (65). 40MG IV LASIX GIVEN W/ GOOD U/O: >1LTR RESPONSE.\n40MEQ OF KCL GIVEN PRIOR TO IV LASIX. CONT'S ON HEP GTT AT 1100 UNITS/HR. COUMADIN STARTED LAST EVE. ECCHYMOTIC GROIN UNCHANGED.\n\nRESP: LS CLEAR UPPER W/ RALES AT BASES. STRONG COUGH, SPUTUM PRODUCED AND SPEC SENT. O2SATS DROP TO 86% ON RA. PER CCU TEAM, WOULD LIKE TO REDUCE O2 REQUREMNTS. O2 SAT REMAINS 89-92 ON 4-5LNC. LOWER SATS WHEN POSITIONED ON LEFT SIDE. HUMIDIFIED FACE TENT REAPPLIED W/ SATS UP TO 98%. WHEEZY IN AM, NEB TREATMENT GIVEN.\n\nGI/GU: CREAT 1.1, K+4.2. GOOD RESPONSE TO 40MG IV LASIX. TOLERATING PO'S + BS. BLOOD SUGARS 158 & 106.\n\nTYLENOL GIVEN FOR PAIN IN RIGHT HIP. TEMP 100.5, DOWN TO 98.0.\n\nA: O2 REQUIREMENT UNCHANGED AFTER 40IV LASIX. HR AND BP TOLERATING LOPRESSOR. NO ECTOPY.\nP: MONITOR RESP STATUS. NEBS. IV HEPARIN/COUMAIDIN, FOLLOW COAGS. FOLLOW TEMP\n? PLANS FOR EP DEVICE THIS ADMIT.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-01 00:00:00.000", "description": "Report", "row_id": 1463257, "text": "CCU NPN 0700-1900\nS: \"I feel much better.\"\nO: Please see carevue for complete assessment data\nEVENTS: IABP/PA line d/c'd, extubated\nNEURO: A&Ox3, c/o soreness in back/shoulder d/t positioning, relieved w/ back rub/repositioning. MAE, equal grasp. Fent/versed d/c'd w/ extubation.\n\nCV: HD stable, CO/CI on 1:2 improved, MAP maintained >75, CP free. Last PAD 20, CVP 9. Lines d/c'd w/o incident @ 0930. Hemostasis achieved after manual compression. R groin site w/ ecchymosis, R/L w/o ooze/hematoma. Distal pulses 3+/dop. NBP correlated well w/ ABP, cont to maintain MAP >70. Hct stable. 1 6 beat run NSVT, pads on, defib off @ bedside. Cont amio @ 1mg/min.\n\nRESP: tolerated PSV 5/5 w/o complaint. LS coarse/dim, sxn'd for thick tan secretions. Strong productive cough. Extubated to face tent @ 1445, weaned to NC. Encouraging CDB and use of IS(pt instructed and demonstrated proper use).\n\nGI: abd soft, nontender, distended. +BS/-BM. Tol ice chips and sips water. + gag.\n\nGU: foley draining CYU. To recieve 20mg lasix this eve, already -1.2L since MN.\n\nENDO: insulin gtt off, BG wnl no RISS coverage needed.\n\nID: Tmax 100.3, pan cultured. Came down w/o intervention. No abx started.\n\nSKIN: bilat groin sites as above, no new breakdown noted. PIV x 3 patent and intact.\n\nSOC: wife and dtr in to visit throughout the day, updated given by RN and MD. Case manager also in to speak w/ family.\n\nA: 62yo w/ inf/lat STEMI, HD and resp stable s/p removeal of IABP and extubation. No further sustained VT.\nP: cont present management, amio overnight, to be d/c'd tomorrow. Potential EP eval if cont VT off amio. Encourage TCDB and IS, ADAT and ^ activity as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-12-02 00:00:00.000", "description": "Report", "row_id": 1463260, "text": "CCU NPN 0700-1500\nS: \"My breathing feels hard, like I need more oxygen.\"\nO: please see carevue for complete assessment data\nNEURO: denies pain, MAE assists w/ turning. No focal neuro deficits.\n\nCV: HD stable, tolerating 12.5mg lopressor, may increase tonight if BP tolerated. Denies CP, + dyspnea-> diureses w/ 20mg lasix w/ fair effect. Bilat groin sites d/i, distal pulses 2+/dop. K and Mg repleted this am. Amio gtt d/c'd @ 0930, no further episodes of VT.\n\nRESP: Episode of dyspnea this am SpO2 down to mid 80s on 3l NC, LS clear w/ rales 1/2 up bases bilaterally. Changed to cool mist fact tent, FiO2 100% w/ improvement in spo2 but cont dyspnea. CXR w/ ^ chf v. infectious process-> 20mg lasix, 3mg morphine and atrovent neb w/ improvement in resp sts. LS cont w/ coarse rales @ bases. Cough productive of thick rusty sputum. Sputum culture + for GN diplococci, culture neg.\n\nGI: Abd soft, nontender, distended. +BS/mod loose brown BM, OB(-). Tolerating heart healthy diet w/o complaint.\n\nGU: foley draining amber urine, fair response to 20mg lasix, -800cc since MN.\n\nENDO: BG covered w/ RISS as needed.\n\nID: low grade 100.0, resolved w/o intervention. Starting ceftriaxone for (+) sputum culture. WBC up slightly this am.\n\nSKIN: w/d/i, no breakdown noted. PIV x 3 patent and intact.\n\nSOC: family in to visit, updated on and pt condition by RN and MD.\n\nA: s/p inf/lat STEMI, HD stable w/o further VT off amio gtt. Pulm edema d/t volume overload.\nP: cont to monitor resp sts, wean O2 as tol, encourage CDB and IS. ? ^ lopressor tonight, start ACE in am if BP tolerated. Monitor for further VT off amio. ^ activity as tolerated. Abx->f/u culture data.\n" }, { "category": "Nursing/other", "chartdate": "2185-12-03 00:00:00.000", "description": "Report", "row_id": 1463261, "text": "CCU NPN 7p-7a\nCV: denies CP or SOB, HR 70's NSR no ectopy, BP 90-120/40-50 lopressor increased to 25mg po bid, tol well. Cont on Hep gtt, increased to 900units/hr(no bolus) repeat PTT pnd. R&L groin C&D, some eccymosis, no hematoma. Pulses palpable, feet warm.\n\nResp: LS with crackles at dependent base, otherwise clear. Cough dry initially, by AM prod of thick blood tinged sputum. Enc to cough and DB. Sats to 88% while asleep, up to 94-98% when awake. 4L NC and 100% face tent.\n\nID: T 99.6 po, cont on ceftriaxone IV q 24hrs for pna. WBC 15.\n\nNeuro/Coping: A&Ox3, pleasant and cooperative. Verbalizing re: recent events and changes he will have to make once home, states he usually rushes around to get lots of things done.\n\nAccess: 3 old peripheral IV's dc'd, replaced with # 20 in LL arm.\n\nsoc: wife was in yesterday, will be back today, daughter called during the night.\n\nA/P: 62 yr old s/p inferolateral STEMI/ VT/VF, DCCV x10 s/p cath with stent to L cx, angioplasty OM, was intubated and on IABP on Dopa, now hemodynamically stable, extubated. Being treated for pna, doing well. transfer to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2185-11-30 00:00:00.000", "description": "Report", "row_id": 1463251, "text": "CCU Nursing adm/progress note\n62 yr old presented to OSH with SSCP, ECG changes consistant with inferolateral STEMI, given ASA, NTG gtt, integrellin, went into VT/VF in ew, DCCVx10, intubated to cath lab, found to have TO of L CX, stented, OM1 ballooned. Pt hypotensive, req 5L NS, dopa, placement of IABP, CO/CI 10/4.75, PCWP 25, PAP 46/24, RA , ?sepsis as well with pulm process, cough at home, CXR: ?pneumonitis, infectious process as well as pul edema. To CCU for further care.\n\nCV: arrived with BP 120/60 on 1:1 IABP, poor augmentation, some sys/diastolic unloading, IV dopa at 15 mcg/kg/min, Amio gtt at 1mg/hr, integ at 2mcg/kg/min. Through night have weaned dopa to 6mcg/kg/min with maps 70-80's, remains on IABP, decreased to 1:2 for short interval(~20min) with gradual drop in MAP to 70, decreasing HR to 48-50, increased ectopy and loss of pleth on sat monitor, placed back on 1:1, CI drawn during this time was down to 1.9, Pleth returned and HR increased to 60 with less ectopy very shortly after placing pt back on 1:1(dramatic). Integ dc'd after 6 hrs per attending, and pt placed on hep gtt at 1100 units/hr. R groin IABP site oozing upon arrival, replaced pressure dressing and has remainsed without further oozing, no hematoma, L groin with bruised area, D&I. Pulses are dopplerable(DP's are palp stronger on the R). Pt denies CP. K+ 3.3 with diuresis(20mg lasix x2), given 40 KCL IV\n\nNeuro: Pt is alert, responsive appropriately to questions, follow commands, MAE. Has been able to keep legs straight without immobilizers. Added versed gtt at 2mg initially, backed off to 1mg/hr with good effect. Sleeping, arouses easily. Strong gag reflex.\n\nResp: vented, initially with poor oxygenation on 100% po2 was 50's, increased peep to 10 and suctioned for thick blood tinged sputum, sats improved to 98-100% remainder of night and able to wean FIO2 to 50%. Last ABG: 7.41/30/111, cont to require suctioning q 2-3 hrs for thick blood tinged sputum.\n\nID: pt started on IV vanco and zosyn given cxr and h/o cough at home, difficulty with initial oxygentation, also vomited in cath lab during OGT placement attempts. Vomitted once more up here when coughing.\n\nGI: no stool, BS (+), abd dist/soft, NGT in place, to LIS after vomitted again. Pt denies nausea, seems to have been more from gaging.\n\nGU: foley in place, cr 1.1, UO 70-100cc/hr, good responce to 1st lasix dose, less to second dose.\n\nSkin: intact\n\nSoc: wife and children in and updated. Wife stayed the night in solarium.\n\nA/P: 62 yr old with acute inferolateral STEMI remains on pressor, IABP, vented, appears to be neurologically intact s/p DCCVx10 for VT/VF at OSH. Cont close monitoring of hemodynamics, titration of pressor, hep, cont IABP, wean vent as able. Support and inform pt/family. Care as discussed on multidisciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2185-11-30 00:00:00.000", "description": "Report", "row_id": 1463252, "text": "Pt recieved a lot of fluid during resiesation. he was unable at this time to come down on the ballon pump. ( CI droped when changed from 1:1 to 1:2 ) BS are equal with faint crackles in the bases. pt suctioned for scant anoumts of sputum. He seems to be tolerating present vent settings well suggest his setting stay as is till his\nHemodynamic status improves. And his lungs dry out some\n" }, { "category": "Nursing/other", "chartdate": "2185-11-30 00:00:00.000", "description": "Report", "row_id": 1463253, "text": "Respiratory Care\nBreath sounds clear and diminished, suctioned for moderate thick yellowish and old blood-tinged secretion, awake and alert, patient was afebrile whole shift, heart rhythm alternated between normal sinus rhythm and sinus bradycardia and ranged 59 to 63, WBC 19.3, consistent with bacterial infection, was switched from AC to CPAP + PS 40% tolerates it well, plan is to have him rest on current settings overnight, have an early morning RSBI and weaned down to 5/5 then, extubate after heart baloon is removed.\n" }, { "category": "Nursing/other", "chartdate": "2185-11-30 00:00:00.000", "description": "Report", "row_id": 1463254, "text": "CCU NPN 0700-1900\nS: orally intubated, nonverbal\nO: please see carevue for complete assessment data\nNEURO: Alert most of day, easily arousable to verbal stim. C/o generalized aches, fent/versed gtts titrated to comfort. MAE, equal strength, following commands. SWR as needed to maintain integrity of lines.\n\nCV: Hemodynamically stable; diuresed w/ 40mg lasix x 1, w/ effect, PAD down 16-18 from 20, maintaining MAP >70 and tolerating slow dopamine wean. CO/CI improved, 6.3/2.88/800->tolerated IABP wean 1:2 x 1hr, placed back on 1:1 in attempt to cont weaning dopamine tonight. Waveform fair, syst/diastolic unloading 0-7 pts. R groin site ecchymotic w/o ooze or palpable hematoma, L groin w/ pressure dsg intact, no further ooze noted. Distal pulses 3+/1+ DPs, PTs dop bilat, L foot cont cooler (per pts wife he has a h/o Raynauds and thrombus in this leg). 1 run NSVT this am, occas isolated PVCs/PACs noted on tele, lytes repleted as indicated, cont amio gtt @ 0.5mg/min. Hct down 5 points this afternoon, no know source of bleeding. Repete TTE, LVEF 40%. Hep gtt titrated, PTT cont supratherapeutic.\n\nRESP: tol vent wean to PSV 8/8, FiO2 .4. Last ABG revealing comp metabolic acidosis and excellent oxygenation. Resps even and non-labored (pt had c/o SOB this am w/ episode CP->relieved w/ morphine/lasix). CXR revealing improved pulm edema. RR 16-20, Vt 550-600, Mv , Pip mid teens. LSCTA, faint dependent rales improved slightly w/ diuresis, sxn'd infreq for thick yellow secretions, old blood tinged. No further SOB.\n\nGI: abd soft, nontender, distended, +BS/-BM. NGT w/ minimal CG aspirate. Remains NPO. LFTs cont elevated.\n\nGU: foley draining adequate amts CYU, good response to 40mg lasix. Cr cont ^ 1.2.\n\nENDO: cont insulin gtt, titrated protocol. 3-3.5u/hr.\n\nID: afebrile, abx d/c'd d/t no identified source of infection.\n\nSKIN: PIV x 3 patent and intact, R fem art and PA line and l fem IABP\nw/o ooze/hematoma. No breakdown noted.\n\nSOC: wife and dtr in throughout the day, may call overnight for updates. Updated on by RN and MD.\n\nA: 62yo s/p inf/lat STEMI and multiple VT/VF arrests @ OSH req PCI to dominant TO LCx, c/b hypotension/CG shock requiring pressors/IABP. Improved hemodynamics and resp stable on PSV.\nP: PM labs (PTT, Hct, CO/CI due -2100). Cont sedation for comfort throughout night, titrate dopamine to maintain SBP >90/MAP >70; goal PAD 16-18. Cont IABP, anticipate d/c tomorrow if pt remains stable. RSBI and SBT in am followed by PSV 5/5 in anticipation of extubation. Cont emotional support to pt/family as indicated.\n\n" } ]

[ { "category": "Nutrition", "chartdate": "2173-08-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 484213, "text": "Subjective\n Unable to assess due to intubation.\n Per extended care facility records - was on regular house diet\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 60 kg\n 85.3 kg ( 04:00 AM)\n 20.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 98%\n Diagnosis: tromvectomy\n PMHx: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n Food allergies and intolerances: none noted\n Pertinent medications: Pantoprazole, LR @ 50ml/hr, Fentanyl drip,\n Lasix, Argatroban drip, SS lytes - no repletions required\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 09:26 AM\n Glucose Finger Stick\n 106\n 06:00 AM\n BUN\n 37 mg/dL\n 03:34 AM\n Creatinine\n 1.4 mg/dL\n 03:34 AM\n Sodium\n 148 mEq/L\n 03:34 AM\n Potassium\n 3.8 mEq/L\n 09:26 AM\n Chloride\n 116 mEq/L\n 03:34 AM\n TCO2\n 24 mEq/L\n 03:34 AM\n PO2 (arterial)\n 122 mm Hg\n 09:26 AM\n PCO2 (arterial)\n 41 mm Hg\n 09:26 AM\n pH (arterial)\n 7.37 units\n 09:26 AM\n pH (urine)\n 7.0 units\n 08:32 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 09:26 AM\n Albumin\n 3.4 g/dL\n 03:34 AM\n Calcium non-ionized\n 8.4 mg/dL\n 03:34 AM\n Phosphorus\n 2.8 mg/dL\n 03:34 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:54 AM\n Magnesium\n 2.0 mg/dL\n 03:34 AM\n ALT\n 26 IU/L\n 03:34 AM\n Alkaline Phosphate\n 40 IU/L\n 03:34 AM\n AST\n 116 IU/L\n 03:34 AM\n Amylase\n 64 IU/L\n 03:34 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:34 AM\n WBC\n 10.9 K/uL\n 03:34 AM\n Hgb\n 10.7 g/dL\n 03:34 AM\n Hematocrit\n 32.4 %\n 03:34 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Replete with FIber @ 10ml/hr\n GI: soft, absent bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO, recent surgery, low % IBW\n Estimated Nutritional Needs\n Calories: 1500-1800 (BEE x or / 25-30 cal/kg)\n Protein: 66-78 (1.1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: ?? Adequate\n Estimation of current intake: Inadequate due to NPO/trophic tube feed\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement:\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2173-08-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 484215, "text": "Subjective\n Unable to assess due to intubation.\n Per extended care facility records - was on regular house diet\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 60 kg\n 85.3 kg ( 04:00 AM)\n Increased due to fluid\n 20.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 98%\n Diagnosis: tromvectomy\n PMHx: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n Food allergies and intolerances: none noted\n Pertinent medications: Pantoprazole, LR @ 50ml/hr, Fentanyl drip,\n Lasix, Argatroban drip, SS lytes - no repletions required\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 09:26 AM\n Glucose Finger Stick\n 106\n 06:00 AM\n BUN\n 37 mg/dL\n 03:34 AM\n Creatinine\n 1.4 mg/dL\n 03:34 AM\n Sodium\n 148 mEq/L\n 03:34 AM\n Potassium\n 3.8 mEq/L\n 09:26 AM\n Chloride\n 116 mEq/L\n 03:34 AM\n TCO2\n 24 mEq/L\n 03:34 AM\n PO2 (arterial)\n 122 mm Hg\n 09:26 AM\n PCO2 (arterial)\n 41 mm Hg\n 09:26 AM\n pH (arterial)\n 7.37 units\n 09:26 AM\n pH (urine)\n 7.0 units\n 08:32 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 09:26 AM\n Albumin\n 3.4 g/dL\n 03:34 AM\n Calcium non-ionized\n 8.4 mg/dL\n 03:34 AM\n Phosphorus\n 2.8 mg/dL\n 03:34 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:54 AM\n Magnesium\n 2.0 mg/dL\n 03:34 AM\n ALT\n 26 IU/L\n 03:34 AM\n Alkaline Phosphate\n 40 IU/L\n 03:34 AM\n AST\n 116 IU/L\n 03:34 AM\n Amylase\n 64 IU/L\n 03:34 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:34 AM\n WBC\n 10.9 K/uL\n 03:34 AM\n Hgb\n 10.7 g/dL\n 03:34 AM\n Hematocrit\n 32.4 %\n 03:34 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Replete with Fiber @ 10ml/hr\n GI: soft, absent bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO, recent surgery, low % IBW\n Estimated Nutritional Needs\n Calories: 1500-1800 (BEE x or / 25-30 cal/kg)\n Protein: 66-78 (1.1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: ?? Adequate\n Estimation of current intake: Inadequate due to NPO/trophic tube feed\n Specifics:\n 77 YO female admitted with cold right foot. s/p ileofem.,.,tibial\n embolectomy/ RLE fasciotomy complicated by post-op hypotension.\n Tube feed started for nutrition support. Currently, remains at\n 10ml/hr, tolerating with residuals of 0-5ml. Noted elevated Na\n receiving water flushes 150ml every 6 hours. Noted patient also (+) ~\n 25 L for length of stay. Consider changing to fluid restricted tube\n feed formula. Current tube feed formula would provide excessive\n protein to reach calorie goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Change to Nutren Pulmonary\n with goal of 45ml/hr = 1620 calories and 73g protein\n 1. Check residuals, hold tube feed if greater than 200ml\n 2. Monitor abdominal exam\n Multivitamin / Mineral supplement: multi-vitamin via tube\n feed once Nutren Pulmonary at goal\n Check chemistry 10 panel daily\n replete lytes PRN\n Monitor hydration, adjust water flushes PRN\n Will follow, page if questions *\n" }, { "category": "Echo", "chartdate": "2173-08-10 00:00:00.000", "description": "Report", "row_id": 88218, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function.\nWeight (lb): 154\nBP (mm Hg): 133/56\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 14:34\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, cavity size, and global systolic\nfunction (LVEF>55%). Mild (non-obstructive) focal hypertrophy of the basal\nseptum. Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Moderate (2+)\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). There is mild\n(non-obstructive) focal hypertrophy of the basal septum. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nTissue Doppler imaging suggests a normal left ventricular filling pressure\n(PCWP<12mmHg). Right ventricular chamber size is normal. with mild global free\nwall hypokinesis. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Moderate\n(2+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Preserved left ventricular systolic function. Mild right\nventricular hypokinesis. Moderate aortic regurgitation. Mild to moderate\nmitral regurgitation. Borderline pulmonary hypertension.\n\n\n" }, { "category": "Physician ", "chartdate": "2173-08-10 00:00:00.000", "description": "Intensivist Note", "row_id": 483783, "text": "CVICU\n HPI:\n HD2 POD 1-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Post-op pulse exam:\n Dopplerable R. PT and peroneal; no DP\n Current medications:\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W 5. Albuterol 0.083% Neb Soln 6.\n Artificial Tears\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Cisatracurium Besylate 10. DOPamine\n 11. Digoxin 12. Fentanyl Citrate 13. Gentamicin 14. Heparin 15. Insulin\n 16. Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19.\n Midazolam 20. Norepinephrine 21. Pantoprazole 22. Pneumococcal Vac\n Polyvalent\n 25. Sodium Bicarbonate 27. Vancomycin 28. Vasopressin 29. Vecuronium\n Bromide\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:34 AM\n ARTERIAL LINE - START 01:41 AM\n MULTI LUMEN - START 01:42 AM\n TRANSTHORACIC ECHO - At 06:33 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Insulin - Regular - 7 units/hour\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Cisatracurium - 0.06 mg/Kg/hour\n Other ICU medications:\n Insulin - Regular - 03:00 AM\n Pantoprazole (Protonix) - 04:15 AM\n Sodium Bicarbonate 8.4% (Amp) - 06:13 AM\n Midazolam (Versed) - 06:34 AM\n Fentanyl - 06:34 AM\n Vecuronium - 06:34 AM\n Other medications:\n Flowsheet Data as of 09:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.1\nC (95.2\n T current: 34.7\nC (94.5\n HR: 82 (79 - 135) bpm\n BP: 95/69(79) {77/59(66) - 129/98(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (11 - 21) mmHg\n Bladder pressure: 25 (25 - 25) mmHg\n Total In:\n 18,763 mL\n PO:\n Tube feeding:\n IV Fluid:\n 15,621 mL\n Blood products:\n 3,042 mL\n Total out:\n 0 mL\n 1,260 mL\n Urine:\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 17,503 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 37 cmH2O\n Plateau: 28 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 96%\n ABG: 7.32/43/190/29/-3\n Ve: 7 L/min\n PaO2 / FiO2: 380\n Physical Examination\n General Appearance: intubated, paralyzed\n HEENT: PERRL, pupils sluggish response\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Distended, firm, bladder pressure 25\n Left Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Absent), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 139 K/uL\n 11.0 g/dL\n 105 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 84 mg/dL\n 109 mEq/L\n 146 mEq/L\n 39.3 %\n 13.1 K/uL\n [image002.jpg]\n 02:01 AM\n 03:21 AM\n 03:26 AM\n 04:05 AM\n 04:18 AM\n 05:57 AM\n 06:05 AM\n 06:31 AM\n 08:51 AM\n 08:58 AM\n Hct\n 22.2\n 30.0\n 35.8\n 39.3\n TCO2\n 30\n 26\n 20\n 18\n 22\n 23\n Glucose\n 292\n 178\n 202\n \n Other labs: PT / PTT / INR:24.3/150.0/2.3, CK / CK-MB / Troponin\n T:4001/55/0.02, Lactic Acid:3.1 mmol/L, Ca:7.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Fentanyl and Versed for sedation,\n started on Cisatracurium due to instability\n Cardiovascular: Cont vasopressor support and obtain formal ECHO.\n Bedside ECHO appeared to demonstrate low end-diastolic volume but good\n cardiac output by LVOT trace.\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Cont CMV with lung\n protective ventilation with low tidal volume and increase PEEP to keep\n PaO2 > 60 given elevated bladder pressure.\n Gastrointestinal / Abdomen: Cont to follow bladder pressure. Will keep\n surgery informed if bladder pressures rise further or urine output\n stops despite adequate volume resuscitation\n Nutrition: Full liquids, NPO\n Renal: Foley, Oliguria --> cont to follow with volume resuscitation.\n Metabolic acidosis with elevated lactate, cont to trend.\n Hematology: Serial Hct, Cont to transfuse PRBC's for unstable blood\n volume. Agree with FFP for PTT > 150 with active bleeding from leg\n fasciotomies\n follow coags.\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: Would d/c Vanco / Gentamycin.\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Heme-soaked dressings --> will need to address via coagulation.\n Imaging: CXR today\n Fluids: KVO with blood products prn.\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments: Unable to perform wake-up and RSBI on paralytics for\n ventilation and hemodynamics.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 67 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2173-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483945, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Afib rate in the 80\ns with SBP 80-120 on dopamine 5mcg\n Bilateral pedal pulses present by Doppler Right foot warm with purple\n large toe area appears to have decreased a small amount in size. Left\n foot pale but warm\n Hands cyanotic and cool to touch\n Pt on Versed 2 mg and Fentanyl 5o mcg pt very light becoming agitated\n with any stimulation. Shaking pulling arms away and tensing body. Pt\n moving all extremities except for left leg\n Heparin at 300units/hr\n Hct decreased to 27 this am\n Sodium up to 151\n Action:\n Pt given an additional 500cc of 5% Albumin,\n Dopamine weaned off and Levo started to support SBP >100\n Versed and Fentany titrated up to 4mg of versed and 100mcg of Fentanyl\n Repeat Ptt x2 with PTT increasing to 84 dose decreased to 250units\n Pt to receive 1 unit of prbc\n Response:\n Sedation increased overnight pt more sedated but still wakes with\n stimulation but settles back down once left alone.\n Pt on low dose levo 0.04mcg with SBP around 100-120\n Circulation improving in left leg fingers remain cyanotic and cool but\n pulses present in hands\n Plan:\n Repeat PTT at 0900, Monitor sedation level and response and obtain\n orders to increase if needed. kjTransfuse 1 unit of prbc\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484330, "text": "S/p ileofem., ., tibial embolectomy/RLE fasciotomy\n Assessment:\n Neuro: grimacing, pulling at restraints, opens eyes at times, no\n interaction with husband\n Resp: Attempted to wean to extubate. CS diminished in bases.\n Action:\n Resp: Placed back on 5 peep 10 pressure support, re try in am.\n Suctioned orally for thick bldy, via ET for small thin white.\n Response:\n Plan:\n Neuro: reorient as needed.\n Resp: Suction as needed. Reposition q 2 h\n" }, { "category": "Nursing", "chartdate": "2173-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483869, "text": "POD 1-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n pt cold and coagulopathic this am. Oozy from IV sites, nares etc.\n remains in afib (chronic). Rt extrems cool, cyanotic. Left extrems\n cool, dusky. Rt foot increasingly demarcated, w/ toes becoming dark\n purple. Pedal pulses by doppler though rt DP absent much of shift. Rt\n lower leg fasciotomy oozing sang dng though decreasing amts. Hct\n stable, 42 at noon. CK remain sharply elevated though trending down.\n Sedated throughout shift. Uop as noted-> couple of low uop hrs->\n responding to albumin. Lungs clear, dim. Remains on full vent support.\n Acidosis resolved w/ lactate down. Abd, firm distended. No bsp. Last\n bladder pressure 14. ogt w/ min bilous dng. Husband at bedside this\n afternoon, updated by cvicu as well as vasc team.\n Action:\n Transfuse 2 unit FFP\n 1.5 L crystalloid\n Vasopressin weaned to off.\n Dopamine titrated\n Briefly on paralytic\n Albumin 500cc 5%\n Restart low dose heparin\n Monitor labs.\n Total IV intake 100cc/hr\n Response:\n Pt remains critical though improved\n Plan:\n Monitor vs\n Titrate dopamine to off as able\n If pressor need restart-> levophed\n Albumin for fluid resus\n Monitor labs/coags\n" }, { "category": "Nursing", "chartdate": "2173-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 483760, "text": "Peripheral vascular disease (PVD) with critical limb ischemia/ Shock:\n femoral thrombectomy and RLE fasciotomy\n Assessment:\n Pt arrived from OR approx 0100 on dopamine/prop/heparin. Orally\n intubated and sedated. Tachycardic to 120\ns and Hypotensive with SBP\n 80\ns. bilat LE\ns cold. RLE purple toes +PT by Doppler. LLE mottling\n with DP and PT + by Doppler. Unable to obtain temp orally or\n axillary. RLE with sang drainage saturating dressing. Lactate\n rising. Became tachycardic to 160 in native a fib.\n Action:\n Hemodynamics supported with volume totaling 12 L crystalloid over noc.\n Pressors: levo, neo, dopa. Rec\nd 4 PRBC\ns. heparin held for\n bleeding. RLE fasciotomy explored at bedside by MD MD,\n re packed and re dressed. Amio bloused and gtt initiated for a fib.\n This AM echo done at bedside by MD and 6 PRBC\ns rapid infused,\n pitressin started and levo/neo off. Dopa weaned. Amio gtt off.\n Bladder pressure 25. pt paralyzed and changed to fent/versed gtts.\n Response:\n Still unable to obtain body temp despite warm fluids and bair hugger.\n Remains Hemodynamically unstable. RLE remains with large amounts sang\n drainage. Bladder pressure elevated.\n Plan:\n Treat with volume/pressors. ?vascular team to have family meeting re\n plan of care.\n" }, { "category": "Respiratory ", "chartdate": "2173-08-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 483876, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Patient remains on mechanical ventilation , cxr shows\n elevated (L) hemi-diaphram. Eho-cardiogram done today has # 7 ETT taped\n @ 20. Vent changed to heated circuit.\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484331, "text": "S/p ileofem., ., tibial embolectomy/RLE fasciotomy\n Assessment:\n Neuro: grimacing, pulling at restraints, opens eyes at times, no\n interaction with husband\n Resp: Attempted to wean to extubate. CS diminished in bases.\n Cardiac: Argatroban continues. Heart rate Afib, rate up to 110 despite\n IV Lopressor.\n GI: OG in place, fding restarted at 30 ml qh\n GU: Foley in place, patent for clear yellow urine.\n Endo; 1800 glucose within range.\n Pain: Fentanyl gtt stopped.\n Skin: Dopplerable pulses, rt great toe inflammed, quarter sized blister\n intact-left side of toe. Large inflamed are rt arm, below antecubital\n area- reported present prior to this evening per night nurse.\n Action:\n Resp: Placed back on 5 peep 10 pressure support, re try in am.\n Suctioned orally for thick bldy, via ET for small thin white. Fentanyl\n gtt stopped.\n Cardiac: Ptt drawn at , stable, no change in dose.\n GI: No residual\n GU: Extra dose of IV Lasix given per vascular.\n Pain: grimacing, unable to tell if patient in pain but heart rate, s\n b/p up with any/all stimulation.- Fentanyl 25 mcg given x 1 and versed\n 1 mg given later.\n Response:\n Plan:\n Neuro: reorient as needed.\n Resp: Suction as needed. Reposition q 2 h\n Cardiac: PTT redraw q 6h-due at 2 am.\n Monitor urine output- notify HO if urine decreases\n Endo: Follow protocol.\n Pain: Medicate as needed with fentanyl/versed.\n" }, { "category": "Physician ", "chartdate": "2173-08-14 00:00:00.000", "description": "Intensivist Note", "row_id": 484670, "text": "CVICU\n HPI:\n HD6 POD 5-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day6\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Current medications:\n Albuterol-Ipratropium 5. Albuterol 0.083% Neb Soln 6. Argatroban 7.\n Artificial Tears\n 8. Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate\n 13. Furosemide 14. HydrALAzine 15. Insulin 16. Ipratropium Bromide Neb\n 17. Levothyroxine Sodium\n 18. Losartan Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Midazolam 22. Pantoprazole\n 23. Pneumococcal Vac Polyvalent 24. Potassium Chloride 25. Quetiapine\n Fumarate 26. Sertraline\n 24 Hour Events:\n --extubated successfully.\n --improved diuresis\n --Mental status improving\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Infusions:\n Argatroban - 0.75 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Furosemide (Lasix) - 08:30 AM\n Fentanyl - 05:21 AM\n Metoprolol - 06:23 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 84 (80 - 119) bpm\n BP: 126/75(95) {106/66(81) - 175/112(138)} mmHg\n RR: 18 (15 - 29) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 14 (8 - 17) mmHg\n Total In:\n 1,014 mL\n 434 mL\n PO:\n Tube feeding:\n 81 mL\n IV Fluid:\n 533 mL\n 284 mL\n Blood products:\n 100 mL\n Total out:\n 3,700 mL\n 940 mL\n Urine:\n 3,250 mL\n 820 mL\n NG:\n Stool:\n Drains:\n 450 mL\n 120 mL\n Balance:\n -2,686 mL\n -506 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n FiO2: 70%\n SPO2: 99%\n ABG: 7.35/49/141//0\n PaO2 / FiO2: 201\n Physical Examination\n General Appearance: Appears anxious at times.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : anterior)\n Abdominal: Soft, nontender, nondistended bowel sounds hypoactive\n Left Extremities: (Edema: +), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: +), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies, demarcation on right big toe with\n skin blister on foot\n Neurologic: Following commands inconsistently; Reponding to voice and\n verbalizing minimally; Moves upper ext's and left lower spont and to\n stim; Opens eyes to voice.\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 109\n 1.6 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.2 %\n 13.1 K/uL\n [image002.jpg]\n 03:41 PM\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n WBC\n 11.2\n 13.1\n Hct\n 28.3\n 30.2\n Plt\n 83\n 126\n Creatinine\n 1.6\n TCO2\n 22\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n Other labs: PT / PTT / INR:28.8/56.1/2.8, CK / CK-MB / Troponin\n T:1632/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:9.2 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan: 77 year old female s/p ileofem.,.,tibial\n embolectomy/ RLE fasciotomy\n Neurologic: Pain controlled, Cont Sertraline and minimize sedatives to\n assess mental status. Cont to treat pain with Fentanyl PRN.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Cont\n Argatroban gtt and lopressor for rate control with Afib.\n Pulmonary: Extubated successfully. ABG looks good this AM, but remains\n on high flow O2 mask.\n Gastrointestinal / Abdomen: Standard bowel regimen; Restart TF today.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO with good urine output\n decrease lasix to\n keep only 1-1.5 liters negative QD with mildly elevated creatinine and\n cont to follow renal function.\n Hematology: Mild anemia; Plt count improving --> follow up with repeat\n HIT antibody test.\n Endocrine: RISS, Cont Levothyroxine.\n Infectious Disease: Cont Cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging: CXR today\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2173-08-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 484029, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2173-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484535, "text": "Presents with painful cold R leg at facility AM sent to \n hospital and transferred to for trx. Of note: Has been\n lethargic and confused of late, is being treated for UTI with cipro\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lower leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Neuro: MAE, PERRLA 2mm brisk, not speaking this am, tracking but only\n making incomprehensible sounds, constant moaning and grimace with every\n touch, extremely anxious and stiff\n CV: HTN BP 160\ns/low 100\ns MAP 110\ns HR 90\ns-120\ns AF with no other\n ectopy, anasarca edema, extremities warm and dry, known PVD and big toe\n on the right foot purple with intact blisters in multiple areas\n Resp: LSCTA, congested in the upper chest/back of the throat, cough\n intact but unable to raise secretions, RR18-20, sating 92-100% on cool\n aerosol mist open face tent {extubated earlier in the morning (0630)}\n GI: Absent BS, NPO, no gag\n GU: Patient foley draining clear yellow urine\n Endo: BS WNL\n Pain: Grimacing with every touch, even very slight, right hand soar\n and right leg very soar, unable to score\n Action:\n Neuro: Emotional support, frequent neuro checks. Restarted on\n anti-pysch meds, {Depakote, sertraline and Seroquil}\n CV: Lopressor increased to 10mg , Coreg and Digoxin added to\n regimen, also receiving lasix\n Resp: Inhalers ordered, but patient doesn\nt follow commands, making\n for difficult administration, sats decreased to 89-90%, O2\n concentration increased to 70%, monitored ABG\n GI: Monitored for the return of BS, tested gag several times with\n yankuaer\n GU: Monitored diuresis\n Pain: Receiving fentanyl for pain\n Response:\n Neuro: Eyes open for greater part of the day, more aware of\n surroundings but says nothing except\nhelp me\n, does not follow\n commands, continues to moan and grimace with touch or movement,\n continues with anxiety\n CV: BP under better control, 110-130\ns, upon anyone entering the room\n she becomes hypertensive instantly up to 140-160\ns, remains in AF 90\n with occasional PVC\ns, monitored lytes and repleted K and Mag IV.\n Resp: During the afternoon, patient LS became extremely rhonchorous\n throughout, bilateral CPT and NT suctioning \\e, but remains very\n rhonchorous\n GI: +BS in all 4 quads, remains NPO no return of gag\n GU: Good HUO, at 1800 -1775 liters\n Pain: Patient appears to rest comfortably after fentanyl\n Plan:\n Continue to monitor, ? speech and swallow consult, wean O2, ? tube\n feeds if gag doesn\nt return or failed speech and swallow.\n" }, { "category": "Respiratory ", "chartdate": "2173-08-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 483843, "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: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Now patient extubated\n Assessment of breathing comfort: No claim of dyspnea); Comments: Done\n well\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: Patient with multiple PMHX: CAD,CHF,HTN ,Coarctation of\n aorta,OSA but does not have CPAP or BIPAP machine.S/P CABG*3. Weaned to\n PSV now extubated on 40% Open Face mask.\n" }, { "category": "ECG", "chartdate": "2173-08-09 00:00:00.000", "description": "Report", "row_id": 234044, "text": "Atrial fibrillation. Left anterior fascicular block. Early precordial\nQRS transition is non-specific. Diffuse ST-T wave abnormalities are\nnon-specific but cannot exclude ischemia. Clinical correlation is suggested.\nNo previous tracing available for comparison.\n\n" }, { "category": "Physician ", "chartdate": "2173-08-11 00:00:00.000", "description": "Intensivist Note", "row_id": 483989, "text": "CVICU\n HPI:\n HD3 POD 2-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Current medications:\n Albuterol-Ipratropium, Artificial Tears, Fentanyl Citrate, Insulin,\n Midazolam, Norepinephrine, Pantoprazole\n 24 Hour Events:\n Remains in ICU intubated and on pressors\n Increased pressors requirement and fluid resuscitation then able to\n wean pressors\n Echocardiogram revealed normal EF\n TRANSTHORACIC ECHO - At 01:11 PM\n INVASIVE VENTILATION - START 04:39 PM\n pt remained intubated throughout shift.. charting error\n INVASIVE VENTILATION - STOP 04:43 PM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Heparin Sodium - 250 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 04:35 AM\n Flowsheet Data as of 07:20 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: 36.7\nC (98\n HR: 83 (62 - 104) bpm\n BP: 107/57(71) {79/50(62) - 163/103(123)} mmHg\n RR: 14 (8 - 19) insp/min\n SPO2: 79%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83 kg (admission): 60 kg\n CVP: 10 (8 - 22) mmHg\n Bladder pressure: 14 (14 - 22) mmHg\n Total In:\n 23,097 mL\n 1,159 mL\n PO:\n Tube feeding:\n IV Fluid:\n 18,455 mL\n 1,007 mL\n Blood products:\n 4,542 mL\n 158 mL\n Total out:\n 1,935 mL\n 400 mL\n Urine:\n 1,485 mL\n 280 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 21,162 mL\n 767 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 79%\n ABG: 7.44/34/122/23/0\n Ve: 6.4 L/min\n PaO2 / FiO2: 305\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, pupils sluggish response\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, nontender, nondistended Bladder pressure 14 absent\n bowel sounds\n Left Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies\n Neurologic: Sedated, moves upper extremeties and left leg spontaneously\n no movement right leg\n Labs / Radiology\n 69 K/uL\n 9.8 g/dL\n 100 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 45 mg/dL\n 118 mEq/L\n 151 mEq/L\n 27.6 %\n 11.1 K/uL\n [image002.jpg]\n 08:58 AM\n 10:15 AM\n 12:25 PM\n 12:38 PM\n 06:20 PM\n 06:30 PM\n 10:28 PM\n 02:53 AM\n 03:00 AM\n 04:51 AM\n WBC\n 11.1\n Hct\n 42.3\n 34.9\n 30.3\n 27.6\n Plt\n 69\n Creatinine\n 1.3\n 1.3\n TCO2\n 23\n 25\n 25\n 24\n 24\n Glucose\n 105\n 78\n 94\n 99\n 100\n Other labs: PT / PTT / INR:17.9/84.5/1.6, CK / CK-MB / Troponin\n T:4271/37/0.02, ALT / AST:22/82, Alk-Phos / T bili:33/0.7, Amylase /\n Lipase:137/139, Lactic Acid:1.3 mmol/L, Albumin:3.1 g/dL, LDH:286 IU/L,\n Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Fentanyl and Versed for sedation\n Cardiovascular: Post-op Hypotension / SIRS\n Wean levophed for SBP >\n 90, hold on betablockers while on pressors\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Cont CMV with lung\n protective ventilation with low tidal volume\n consider change to PS\n later this afternoon.\n Gastrointestinal / Abdomen: Cont to follow bladder pressure.\n Nutrition: start TF today and advance slowly.\n Renal: Foley, monitor urine output, check urine lytes output 20-40\n ml/hr\n Hematology: Serial Hct, Cont to transfuse PRBC's for unstable blood\n volume. Argatroban gtt per surgery while awaiting HIT result for\n thrombocytopenia, although this is probably from consumption. Transfuse\n platelets for active bleeding and hold anticoagulants if Hct drops.\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: WBC 11 check urine cx and start Cipro given UA\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Heme-soaked dressings\n change as needed.\n Fluids: LR with albumin PRN for low UOP.\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484766, "text": "Admitted with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment.\n Of note: Has been lethargic and confused of late, is being treated\n for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lower leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm and , intact and moves everything. Very minimal\n movement with right leg, however it is very endematous with a medial\n and lateral incisions.\n Action:\n Pulses are strongly dopplerable, 4+ pitting edema on the right leg,\n minimal edema to left leg, vascular team exchanged the wound vac sponge\n and assessed the healing of the underlying muscle/tissue, receiving\n lasix for diuresis\n Response:\n Vascular MD\n healing very well, muscle reperfused and pink,\n one small area of darker deep tissue, diuresing well 1500- of\n UO/day generally. Lasix decreased to 10mg \n Plan:\n Possible mid week closure to both incisions, possibly at the bedside if\n enough swelling has gone down\n Altered mental status (not Delirium)\n Assessment:\n History of psych issues and anxiety, PERRLA, inconsistently follows\n commands, yells out inappropriately, isn\nt oriented or just wont answer\n question appropriately. When asked any questions she just closes her\n eyes.\n Action:\n Receives seroquel, sertraline, depakote as ordered, husband at bedside,\n emotional support, frequent positive reassurance.\n Response:\n Patient remains confused\n Plan:\n Continue to monitor and maintain patient safety\n" }, { "category": "Respiratory ", "chartdate": "2173-08-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 483956, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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 Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions; Comments: Pt remains on vent, with changes made to tidal\n volume and Fi02 for ABG findings showing respiratory alkalosis. Pt\n remains stable, with vital signs all within normal limits. Pt has\n small/moderate secretions, but peak airway pressures within normal\n limits. Pt to continue current support and to be assessed by MD team.\n" }, { "category": "Physician ", "chartdate": "2173-08-11 00:00:00.000", "description": "Intensivist Note", "row_id": 483961, "text": "SICU\n HPI:\n HD3 POD 2-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol-Ipratropium, Artificial Tears, Fentanyl Citrate, Insulin,\n Midazolam, Norepinephrine, Pantoprazole\n 24 Hour Events:\n Remains in ICU intubated and on pressors\n Increased pressors requirement and fluid resuscitation then able to\n wean pressors\n Echocardiogram revealed normal EF\n TRANSTHORACIC ECHO - At 01:11 PM\n INVASIVE VENTILATION - START 04:39 PM\n pt remained intubated throughout shift.. charting error\n INVASIVE VENTILATION - STOP 04:43 PM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Heparin Sodium - 250 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 04:35 AM\n Other medications:\n Flowsheet Data as of 07:20 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: 36.7\nC (98\n HR: 83 (62 - 104) bpm\n BP: 107/57(71) {79/50(62) - 163/103(123)} mmHg\n RR: 14 (8 - 19) insp/min\n SPO2: 79%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83 kg (admission): 60 kg\n CVP: 10 (8 - 22) mmHg\n Bladder pressure: 14 (14 - 22) mmHg\n Total In:\n 23,097 mL\n 1,159 mL\n PO:\n Tube feeding:\n IV Fluid:\n 18,455 mL\n 1,007 mL\n Blood products:\n 4,542 mL\n 158 mL\n Total out:\n 1,935 mL\n 400 mL\n Urine:\n 1,485 mL\n 280 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 21,162 mL\n 767 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 79%\n ABG: 7.44/34/122/23/0\n Ve: 6.4 L/min\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 69 K/uL\n 9.8 g/dL\n 100 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 45 mg/dL\n 118 mEq/L\n 151 mEq/L\n 27.6 %\n 11.1 K/uL\n [image002.jpg]\n 08:58 AM\n 10:15 AM\n 12:25 PM\n 12:38 PM\n 06:20 PM\n 06:30 PM\n 10:28 PM\n 02:53 AM\n 03:00 AM\n 04:51 AM\n WBC\n 11.1\n Hct\n 42.3\n 34.9\n 30.3\n 27.6\n Plt\n 69\n Creatinine\n 1.3\n 1.3\n TCO2\n 23\n 25\n 25\n 24\n 24\n Glucose\n 105\n 78\n 94\n 99\n 100\n Other labs: PT / PTT / INR:17.9/84.5/1.6, CK / CK-MB / Troponin\n T:4271/37/0.02, ALT / AST:22/82, Alk-Phos / T bili:33/0.7, Amylase /\n Lipase:137/139, Lactic Acid:1.3 mmol/L, Albumin:3.1 g/dL, LDH:286 IU/L,\n Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-11 00:00:00.000", "description": "Intensivist Note", "row_id": 483962, "text": "CVICU\n HPI:\n HD3 POD 2-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Current medications:\n Albuterol-Ipratropium, Artificial Tears, Fentanyl Citrate, Insulin,\n Midazolam, Norepinephrine, Pantoprazole\n 24 Hour Events:\n Remains in ICU intubated and on pressors\n Increased pressors requirement and fluid resuscitation then able to\n wean pressors\n Echocardiogram revealed normal EF\n TRANSTHORACIC ECHO - At 01:11 PM\n INVASIVE VENTILATION - START 04:39 PM\n pt remained intubated throughout shift.. charting error\n INVASIVE VENTILATION - STOP 04:43 PM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Heparin Sodium - 250 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 04:35 AM\n Flowsheet Data as of 07:20 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: 36.7\nC (98\n HR: 83 (62 - 104) bpm\n BP: 107/57(71) {79/50(62) - 163/103(123)} mmHg\n RR: 14 (8 - 19) insp/min\n SPO2: 79%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83 kg (admission): 60 kg\n CVP: 10 (8 - 22) mmHg\n Bladder pressure: 14 (14 - 22) mmHg\n Total In:\n 23,097 mL\n 1,159 mL\n PO:\n Tube feeding:\n IV Fluid:\n 18,455 mL\n 1,007 mL\n Blood products:\n 4,542 mL\n 158 mL\n Total out:\n 1,935 mL\n 400 mL\n Urine:\n 1,485 mL\n 280 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 21,162 mL\n 767 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 79%\n ABG: 7.44/34/122/23/0\n Ve: 6.4 L/min\n PaO2 / FiO2: 305\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, pupils sluggish response\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, nontender, nondistended Bladder pressure 14 absent\n bowel sounds\n Left Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies\n Neurologic: Sedated, moves upper extremeties and left leg spontaneously\n no movement right leg\n Labs / Radiology\n 69 K/uL\n 9.8 g/dL\n 100 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 45 mg/dL\n 118 mEq/L\n 151 mEq/L\n 27.6 %\n 11.1 K/uL\n [image002.jpg]\n 08:58 AM\n 10:15 AM\n 12:25 PM\n 12:38 PM\n 06:20 PM\n 06:30 PM\n 10:28 PM\n 02:53 AM\n 03:00 AM\n 04:51 AM\n WBC\n 11.1\n Hct\n 42.3\n 34.9\n 30.3\n 27.6\n Plt\n 69\n Creatinine\n 1.3\n 1.3\n TCO2\n 23\n 25\n 25\n 24\n 24\n Glucose\n 105\n 78\n 94\n 99\n 100\n Other labs: PT / PTT / INR:17.9/84.5/1.6, CK / CK-MB / Troponin\n T:4271/37/0.02, ALT / AST:22/82, Alk-Phos / T bili:33/0.7, Amylase /\n Lipase:137/139, Lactic Acid:1.3 mmol/L, Albumin:3.1 g/dL, LDH:286 IU/L,\n Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Fentanyl and Versed for sedation\n Cardiovascular: Wean levophed for SBP > 90, hold on betablockers while\n on pressors\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Cont CMV with lung\n protective ventilation with low tidal volume\n Gastrointestinal / Abdomen: Cont to follow bladder pressure.\n Nutrition: NPO\n Renal: Foley, monitor urine output, check urine lytes output 20-40\n ml/hr\n Hematology: Serial Hct, Cont to transfuse PRBC's for unstable blood\n volume.\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: WBC 11 afebrile no evidence of infection\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Heme-soaked dressings\n Fluids: LR\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2173-08-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 484293, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\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 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": "2173-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484060, "text": "HD3 POD 2-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt VS as per flowsheet. Remains in afib (chronic) 70-100\ns. no vea\n noted. Cvp low teens. Hands cyanotic, cool . pulses present. Pedal\n pulses present by doppler. Rt gt toe dark purple and blistering.\n Blisters extend medial/lat down foot. rt ft warm & pink. Lt ft cool,\n color wnl. Hypernatremic, decreasing platelets. cpk 4000\ns w/ slow\n trend down. RLE fasciotomy w/ min sang dng today. Lungs clear, remains\n sedate and on full vent support. does awaken and become tremulous,\n biting of ETT w/ reposition. Abd firm. Bladder pressures normalized.\n Uop marg.\n Action:\n HIT sent prior shift.\n Heparin d/c\n Heparin free line placed over wire\n Argatroban gtt began-> PTT drawn\n LR cont at 100cc/hr\n Levophed weaned\n Response:\n Stable day w/ drop in plts.\n Plan:\n Monitor PTT\n Sedation overnoc\n Wean levophed as able\n Follow CK\n \n" }, { "category": "Nursing", "chartdate": "2173-08-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484061, "text": "HD3 POD 2-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt VS as per flowsheet. Remains in afib (chronic) 70-100\ns. no vea\n noted. Cvp low teens. Hands cyanotic, cool . pulses present. Pedal\n pulses present by doppler. Rt gt toe dark purple and blistering.\n Blisters extend medial/lat down foot. rt ft warm & pink. Lt ft cool,\n color wnl. Hypernatremic, decreasing platelets. cpk 4000\ns w/ slow\n trend down. RLE fasciotomy w/ min sang dng today. Lungs clear, remains\n sedate and on full vent support. does awaken and become tremulous,\n biting of ETT w/ reposition. Abd firm. Bladder pressures normalized.\n Uop marg.\n Action:\n HIT sent prior shift.\n Heparin d/c\n Heparin free line placed over wire\n Argatroban gtt began-> PTT drawn\n LR cont at 100cc/hr\n Levophed weaned\n Response:\n Stable day w/ drop in plts.\n Plan:\n Monitor PTT\n Sedation overnoc\n Wean levophed as able\n Follow CK\n Monitor csm of extrems\n w-d fasciotomy dsg\n \n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484101, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 2 Right femoral thrombectomy with fasciotomy of lower leg.\n Remains intubated. Sedated with fentanyl and versed drip.\n Total of 9 units of RBC and 2 units of FFP since admission.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. HIT sent\n yesterday.PTT goal 60-90.\n Levo at beginning of shift. BP>100 syst.\n Urine output slightly improved.\n LR@ 100 c/hr for elevated CK\ns 4000\n Chronic AFib. Rate 90-110.\n No Bowel sound noted. Abdomen firm. TF @ 10 cc/hr(Goal for now)\n Hypernatremia. Sodium 150.\n HOH.Grimacing with care. Bit ETT with mouth care.\n Doppler pulses both lower extremities. Right big toe purple with\n blister.\n Right lower leg dressing changed wet to dry.\n Anasarca.\n Action:\n Levo turned off at beginning of shift.\n LR @ 100cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n No vent changes overnight. Bits on ETT during mouth care and\n stimulation.\n Argatroban titrated MD.PTT every 4 hrs until therapeutic.\n Monitor labs.\n Fentanyl and versed bolus with care.\n Response:\n BP stable off pressors.\n Hemodynamic stable overnight.\n Grimacing with care.\n Plan:\n Wean and extubate if tolerated.\n Monitor labs. Advance tube feeding MD.\n PTT goal 60-80.\n Monitor urine output.\n ? VAC right lower leg.\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484168, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 2 Right femoral thrombectomy with fasciotomy of lower leg.\n Post-op course complicated by bleeding. Total of 9 units RBC and 2\n units FFP since OR.\n Remains intubated. Sedated with fentanyl and versed drip.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. Plt up from 72 to\n 82.HIT sent yesterday. Results pending.\n Levo at beginning of shift. BP>100 syst.\n Urine output slightly improved.+ sediments.\n LR@ 100 c/hr for elevated CK\ns 4000\ns down to 3697 this am..\n Chronic AFib. Rate 90-110. No ectopy.\n No Bowel sound noted at beginning of shift. Hypoactive by am.. Abdomen\n firm. TF @ 10 cc/hr(Goal for now)\n Hypernatremia. Sodium down from 150 to 148.\n HOH. Grimacing with care. Bits on ETT with mouth care. Intermittent\n mouth block needed. Old clots in back of throat.\n Doppler pulses both lower extremities. Right big toe purple with\n blister.\n Right lower leg dressing changed wet to dry. Large amount\n sero-sanguionous.\n Anasarca.\n Low grade temp am. 100.9 po.\n Action:\n Levo turned off at beginning of shift.\n LR @ 100cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n No vent changes overnight.\n Argatroban titrated MD.PTT every 4 hrs until therapeutic. Last PTT\n 58. MD notified. No changes made.\n Monitor labs.\n Fentanyl and versed bolus with care.\n 3rd dose of albumin given.\n Right leg up on pillow. Skin care.\n Response:\n BP stable off pressors.\n Hemodynamic stable overnight.\n Grimacing with care.\n WBC wnl.10.9.\n Plan:\n Wean and extubate if tolerated.\n Monitor labs.\n Advance tube feeding MD.\n Titrate Argatroban MD\n Monitor urine output.\n ? VAC right lower leg.\n Urine culture pending.\n Monitor hemodynamic and temp.\n ------ Protected Section ------\n Sedation weaned down to do full wakeup. Patient hypertensive and\n tachycardic with stimulation. HOH. Does not follow commands. Moves\n upper extremities with strong grip.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:49 ------\n" }, { "category": "Respiratory ", "chartdate": "2173-08-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 484379, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Physician ", "chartdate": "2173-08-10 00:00:00.000", "description": "Intensivist Note", "row_id": 483762, "text": "SICU\n HPI:\n HD2 POD 1-Redo CABG/AVR cancelled 2'GIB\n Pre-Op Weight:0 lbs 0 kgs\n CAD s/p CABG x 3 (LIMA-LAD, SVG-OM, SVG-RCA),\n PCI's: RCA , Cypher Stent (3.5mm x 18 mm) to thrombotic\n SVG-PDA stenosis and (3.5mm) LCX , Cypher stent (2.5mm) LCX\n , BMS SVG-RCA 3/09, NSTEMI in setting of GIB\n PVD s/p right fem- bypass , Left SFA stent , DM type 2, CRI\n Atrial Fibrillation noted only once in chart(and not by primary);\n pt unsure of this diagnosis although does recall being on\n Warfarin, which was stopped with GIB in . Currently in SR\n Hyperlipidemia, HTN, AAA, s/p L CEA , severe AS, hemolytic anemia,\n gastritis, sm. bowel AVM-s/p laser ablation requiring 5 UPRBC,\n Right total hip replacement, hiatal hernia\n Medications at home: Norvasc 10mg tablet daily, Calcitonin 200 units\n nasal spray daily, Plavix 75mg tablet daily,Cyanocobalamin 1000mcg sq\n bimonthly, Digoxin 125 mcg tablet daily,Procrit 40,000 units weekly,\n Tricor 145mg tablet daily, Novolog Insulin 70/30 30 units ,\n Isosorbide Dinitrate 10mg tablet , Toprol XL 50mg tablet daily,\n Nitroglycerin 0.4 mg tablet PRN chest pain,Pantoprazole 40mg tablet\n , Zocor 40mg tablet daily, Sucralfate 1gm tablet QID, Aspirin 81mg\n tablet daily, Ferrous Sulfate 325mg tablet daily, Multivitamin 1 tablet\n daily, Vitamin C/Vitamin E/Copper/Zinc Oxide/Lutein(PreserVision) One\n tablet daily\n Chief complaint:\n PMHx:\n Current medications:\n Aspirin 2. Ferrous Sulfate 3. HydrALAzine 4. Insulin 5. Isosorbide\n Dinitrate 6. Magnesium Sulfate\n 7. Metoprolol Tartrate 8. Morphine Sulfate 9. Nitroglycerin 10.\n Ondansetron 11. Pantoprazole 12. Simvastatin\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:34 AM\n ARTERIAL LINE - START 01:41 AM\n MULTI LUMEN - START 01:42 AM\n TRANSTHORACIC ECHO - At 06:33 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Insulin - Regular - 7 units/hour\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Insulin - Regular - 03:00 AM\n Pantoprazole (Protonix) - 04:15 AM\n Sodium Bicarbonate 8.4% (Amp) - 06:13 AM\n Midazolam (Versed) - 06:34 AM\n Fentanyl - 06:34 AM\n Vecuronium - 06:34 AM\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.1\nC (95.2\n T current: 35.1\nC (95.2\n HR: 91 (91 - 135) bpm\n BP: 94/75(83) {77/59(66) - 116/98(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (11 - 17) mmHg\n Bladder pressure: 25 (25 - 25) mmHg\n Total In:\n 18,355 mL\n PO:\n Tube feeding:\n IV Fluid:\n 15,506 mL\n Blood products:\n 2,749 mL\n Total out:\n 0 mL\n 1,200 mL\n Urine:\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 17,155 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n SPO2: 96%\n ABG: 7.30/43/184/29/-4\n Ve: 5.9 L/min\n PaO2 / FiO2: 368\n Physical Examination\n Labs / Radiology\n 139 K/uL\n 11.0 g/dL\n 175 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 84 mg/dL\n 109 mEq/L\n 146 mEq/L\n 35.8 %\n 13.1 K/uL\n [image002.jpg]\n 12:08 AM\n 01:52 AM\n 02:01 AM\n 03:21 AM\n 03:26 AM\n 04:05 AM\n 04:18 AM\n 05:57 AM\n 06:05 AM\n 06:31 AM\n WBC\n 13.1\n Hct\n 39\n 34.0\n 22.2\n 30.0\n 35.8\n Plt\n 139\n Creatinine\n 1.6\n Troponin T\n 0.02\n TCO2\n 34\n 30\n 26\n 20\n 18\n 22\n Glucose\n 353\n 309\n 292\n 178\n 202\n 228\n 175\n Other labs: PT / PTT / INR:24.3/150.0/2.3, CK / CK-MB / Troponin\n T:4001/55/0.02, Lactic Acid:4.4 mmol/L, Ca:7.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-10 00:00:00.000", "description": "Intensivist Note", "row_id": 483763, "text": "SICU\n HPI:\n HD2\n POD 1-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Chief complaint:\n PMHx:\n Current medications:\n 3. 1000 mL NS 4. 150 mEq Sodium Bicarbonate/ 1000 mL D5W 5. Albuterol\n 0.083% Neb Soln 6. Artificial Tears\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Cisatracurium Besylate 10. DOPamine\n 11. Digoxin 12. Fentanyl Citrate 13. Gentamicin 14. Heparin 15. Insulin\n 16. Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Midazolam 19. Midazolam 20. Norepinephrine 21. Pantoprazole 22.\n Pneumococcal Vac Polyvalent\n 23. Potassium Chloride 24. Sodium Chloride 0.9% Flush 25. Sodium\n Bicarbonate 26. Sodium Chloride 0.9% Flush\n 27. Vancomycin 28. Vasopressin 29. Vecuronium Bromide\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:34 AM\n ARTERIAL LINE - START 01:41 AM\n MULTI LUMEN - START 01:42 AM\n TRANSTHORACIC ECHO - At 06:33 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Insulin - Regular - 7 units/hour\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Insulin - Regular - 03:00 AM\n Pantoprazole (Protonix) - 04:15 AM\n Sodium Bicarbonate 8.4% (Amp) - 06:13 AM\n Midazolam (Versed) - 06:34 AM\n Fentanyl - 06:34 AM\n Vecuronium - 06:34 AM\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.1\nC (95.2\n T current: 35.1\nC (95.2\n HR: 91 (91 - 135) bpm\n BP: 94/75(83) {77/59(66) - 116/98(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (11 - 17) mmHg\n Bladder pressure: 25 (25 - 25) mmHg\n Total In:\n 18,355 mL\n PO:\n Tube feeding:\n IV Fluid:\n 15,506 mL\n Blood products:\n 2,749 mL\n Total out:\n 0 mL\n 1,200 mL\n Urine:\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 17,155 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n SPO2: 96%\n ABG: 7.30/43/184/29/-4\n Ve: 5.9 L/min\n PaO2 / FiO2: 368\n Physical Examination\n Labs / Radiology\n 139 K/uL\n 11.0 g/dL\n 175 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 84 mg/dL\n 109 mEq/L\n 146 mEq/L\n 35.8 %\n 13.1 K/uL\n [image002.jpg]\n 12:08 AM\n 01:52 AM\n 02:01 AM\n 03:21 AM\n 03:26 AM\n 04:05 AM\n 04:18 AM\n 05:57 AM\n 06:05 AM\n 06:31 AM\n WBC\n 13.1\n Hct\n 39\n 34.0\n 22.2\n 30.0\n 35.8\n Plt\n 139\n Creatinine\n 1.6\n Troponin T\n 0.02\n TCO2\n 34\n 30\n 26\n 20\n 18\n 22\n Glucose\n 353\n 309\n 292\n 178\n 202\n 228\n 175\n Other labs: PT / PTT / INR:24.3/150.0/2.3, CK / CK-MB / Troponin\n T:4001/55/0.02, Lactic Acid:4.4 mmol/L, Ca:7.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-10 00:00:00.000", "description": "Intensivist Note", "row_id": 483772, "text": "CVICU\n HPI:\n HD2 POD 1-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Post-op pulse exam:\n Dopplerable R. PT and peroneal; no DP\n Chief complaint:\n PMHx:\n Current medications:\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W 5. Albuterol 0.083% Neb Soln 6.\n Artificial Tears\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Cisatracurium Besylate 10. DOPamine\n 11. Digoxin 12. Fentanyl Citrate 13. Gentamicin 14. Heparin 15. Insulin\n 16. Magnesium Sulfate 17. Metoprolol Tartrate 18. Midazolam 19.\n Midazolam 20. Norepinephrine 21. Pantoprazole 22. Pneumococcal Vac\n Polyvalent\n 25. Sodium Bicarbonate 27. Vancomycin 28. Vasopressin 29. Vecuronium\n Bromide\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:34 AM\n ARTERIAL LINE - START 01:41 AM\n MULTI LUMEN - START 01:42 AM\n TRANSTHORACIC ECHO - At 06:33 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Insulin - Regular - 7 units/hour\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Cisatracurium - 0.06 mg/Kg/hour\n Other ICU medications:\n Insulin - Regular - 03:00 AM\n Pantoprazole (Protonix) - 04:15 AM\n Sodium Bicarbonate 8.4% (Amp) - 06:13 AM\n Midazolam (Versed) - 06:34 AM\n Fentanyl - 06:34 AM\n Vecuronium - 06:34 AM\n Other medications:\n Flowsheet Data as of 09:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.1\nC (95.2\n T current: 34.7\nC (94.5\n HR: 82 (79 - 135) bpm\n BP: 95/69(79) {77/59(66) - 129/98(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (11 - 21) mmHg\n Bladder pressure: 25 (25 - 25) mmHg\n Total In:\n 18,763 mL\n PO:\n Tube feeding:\n IV Fluid:\n 15,621 mL\n Blood products:\n 3,042 mL\n Total out:\n 0 mL\n 1,260 mL\n Urine:\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 17,503 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 37 cmH2O\n Plateau: 28 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 96%\n ABG: 7.32/43/190/29/-3\n Ve: 7 L/min\n PaO2 / FiO2: 380\n Physical Examination\n General Appearance: intubated, paralyzed\n HEENT: PERRL, pupils sluggish response\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Distended, firm, bladder pressure 25\n Left Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Absent), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 139 K/uL\n 11.0 g/dL\n 105 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 84 mg/dL\n 109 mEq/L\n 146 mEq/L\n 39.3 %\n 13.1 K/uL\n [image002.jpg]\n 02:01 AM\n 03:21 AM\n 03:26 AM\n 04:05 AM\n 04:18 AM\n 05:57 AM\n 06:05 AM\n 06:31 AM\n 08:51 AM\n 08:58 AM\n Hct\n 22.2\n 30.0\n 35.8\n 39.3\n TCO2\n 30\n 26\n 20\n 18\n 22\n 23\n Glucose\n 292\n 178\n 202\n \n Other labs: PT / PTT / INR:24.3/150.0/2.3, CK / CK-MB / Troponin\n T:4001/55/0.02, Lactic Acid:3.1 mmol/L, Ca:7.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Fentanyl and Versed for sedation,\n started on Cisatricarium due to instability\n Cardiovascular: Cont vasopressor support and obtain formal ECHO. Bed\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Cont CMV with lung\n protective ventilation with low tidal volume and increase PEEP to keep\n PaO2 > 60 given elevated bladder pressure.\n Gastrointestinal / Abdomen: Cont to follow bladder pressure. Will keep\n surgery informed if bladder pressures rise further or urine output\n stops despite volume re\n Nutrition: Full liquids, NPO\n Renal: Foley, Oliguria --> cont to follow with volume resuscitation.\n Hematology: Serial Hct, Cont to transfuse PRBC's for unstable blood\n volume. Agree with FFP for PTT > 150 with active bleeding from leg\n fasciotomies.\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: Would d/c Vanco / Gentamycin as no clear indication\n at this time.\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Heme-soaked dressings --> will need to address via coagulation.\n Imaging: CXR today\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments: Unable to perform wake-up and RSBI on paralytics for\n ventilation and hemodynamics.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 47 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-10 00:00:00.000", "description": "Intensivist Note", "row_id": 483774, "text": "SICU\n HPI:\n HD2\n POD 1-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Chief complaint:\n PMHx:\n Current medications:\n 3. 1000 mL NS 4. 150 mEq Sodium Bicarbonate/ 1000 mL D5W 5. Albuterol\n 0.083% Neb Soln 6. Artificial Tears\n 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9.\n Cisatracurium Besylate 10. DOPamine\n 11. Digoxin 12. Fentanyl Citrate 13. Gentamicin 14. Heparin 15. Insulin\n 16. Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Midazolam 19. Midazolam 20. Norepinephrine 21. Pantoprazole 22.\n Pneumococcal Vac Polyvalent\n 23. Potassium Chloride 24. Sodium Chloride 0.9% Flush 25. Sodium\n Bicarbonate 26. Sodium Chloride 0.9% Flush\n 27. Vancomycin 28. Vasopressin 29. Vecuronium Bromide\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:34 AM\n ARTERIAL LINE - START 01:41 AM\n MULTI LUMEN - START 01:42 AM\n TRANSTHORACIC ECHO - At 06:33 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Insulin - Regular - 7 units/hour\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Insulin - Regular - 03:00 AM\n Pantoprazole (Protonix) - 04:15 AM\n Sodium Bicarbonate 8.4% (Amp) - 06:13 AM\n Midazolam (Versed) - 06:34 AM\n Fentanyl - 06:34 AM\n Vecuronium - 06:34 AM\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.1\nC (95.2\n T current: 35.1\nC (95.2\n HR: 91 (91 - 135) bpm\n BP: 94/75(83) {77/59(66) - 116/98(106)} mmHg\n RR: 14 (12 - 23) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 16 (11 - 17) mmHg\n Bladder pressure: 25 (25 - 25) mmHg\n Total In:\n 18,355 mL\n PO:\n Tube feeding:\n IV Fluid:\n 15,506 mL\n Blood products:\n 2,749 mL\n Total out:\n 0 mL\n 1,200 mL\n Urine:\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 17,155 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 17 cmH2O\n SPO2: 96%\n ABG: 7.30/43/184/29/-4\n Ve: 5.9 L/min\n PaO2 / FiO2: 368\n Physical Examination\n Labs / Radiology\n 139 K/uL\n 11.0 g/dL\n 175 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 84 mg/dL\n 109 mEq/L\n 146 mEq/L\n 35.8 %\n 13.1 K/uL\n [image002.jpg]\n 12:08 AM\n 01:52 AM\n 02:01 AM\n 03:21 AM\n 03:26 AM\n 04:05 AM\n 04:18 AM\n 05:57 AM\n 06:05 AM\n 06:31 AM\n WBC\n 13.1\n Hct\n 39\n 34.0\n 22.2\n 30.0\n 35.8\n Plt\n 139\n Creatinine\n 1.6\n Troponin T\n 0.02\n TCO2\n 34\n 30\n 26\n 20\n 18\n 22\n Glucose\n 353\n 309\n 292\n 178\n 202\n 228\n 175\n Other labs: PT / PTT / INR:24.3/150.0/2.3, CK / CK-MB / Troponin\n T:4001/55/0.02, Lactic Acid:4.4 mmol/L, Ca:7.3 mg/dL, Mg:1.9 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /\n Post-op), Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 01:42 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n ------ Protected Section------\n error\n ------ Protected Section Error Entered By: , NP\n on: 09:46 ------\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484332, "text": "S/p ileofem., ., tibial embolectomy/RLE fasciotomy\n Assessment:\n Neuro: grimacing, pulling at restraints, opens eyes at times, no\n interaction with husband\n Resp: Attempted to wean to extubate. CS diminished in bases.\n Cardiac: Argatroban continues. Heart rate Afib, rate up to 110 despite\n IV Lopressor.\n GI: OG in place, fding restarted at 30 ml qh\n GU: Foley in place, patent for clear yellow urine.\n Endo; 1800 glucose within range.\n Pain: Fentanyl gtt stopped.\n Skin: Dopplerable pulses, rt great toe inflammed, quarter sized blister\n intact-left side of toe. Large inflamed are rt arm, below antecubital\n area- reported present prior to this evening per night nurse.\n Action:\n Resp: Placed back on 5 peep 10 pressure support, re try in am.\n Suctioned orally for thick bldy, via ET for small thin white. Fentanyl\n gtt stopped.\n Cardiac: Ptt drawn at , stable, no change in dose.\n GI: No residual\n GU: Extra dose of IV Lasix given per vascular.\n Pain: grimacing, unable to tell if patient in pain but heart rate, s\n b/p up with any/all stimulation.- Fentanyl 25 mcg given x 1 and versed\n 1 mg given later.\n Response:\n Plan:\n Neuro: reorient as needed.\n Resp: Suction as needed. Reposition q 2 h\n Cardiac: PTT redraw q 6h-due at 2 am.\n GI: increase tube fd q 6, goal 60\n GU: Monitor urine output- notify HO if urine decreases\n Endo: Follow protocol.\n Pain: Medicate as needed with fentanyl/versed.\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484335, "text": "S/p ileofem., ., tibial embolectomy/RLE fasciotomy\n Assessment:\n Neuro: grimacing, pulling at restraints, opens eyes at times, no\n interaction with husband\n Resp: Attempted to wean to extubate. CS diminished in bases.\n Cardiac: Argatroban continues. Heart rate Afib, rate up to 110 despite\n IV Lopressor.\n GI: OG in place, fding restarted at 30 ml qh\n GU: Foley in place, patent for clear yellow urine.\n Endo; 1800 glucose within range.\n Pain: Fentanyl gtt stopped.\n Skin: Dopplerable pulses, rt great toe inflammed, quarter sized blister\n intact-left side of toe. Large inflamed are rt arm, below antecubital\n area- reported present prior to this evening per night nurse.\n Action:\n Resp: Placed back on 5 peep 10 pressure support, re try in am.\n Suctioned orally for thick bldy, via ET for small thin white. Fentanyl\n gtt stopped.\n Cardiac: Ptt drawn at , stable, no change in dose.\n GI: No residual\n GU: Extra dose of IV Lasix given per vascular.\n Pain: grimacing, unable to tell if patient in pain but heart rate, s\n b/p up with any/all stimulation.- Fentanyl 25 mcg given x 1 and versed\n 1 mg given later.\n Response:\n Plan:\n Neuro: reorient as needed.\n Resp: Suction as needed. Reposition q 2 h\n Cardiac: PTT redraw q 6h-due at 2 am.\n GI: increase tube fd q 6, goal 60\n GU: Monitor urine output- notify HO if urine decreases\n Endo: Follow protocol.\n Pain: Medicate as needed with fentanyl/versed.\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484730, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm and , intact and moves everything. Very minimal\n movement with right leg, however it is very endematous with a medial\n and lateral incisions.\n Action:\n Pulses are strongly dopplerable, 4+ pitting edema on the right leg, no\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484731, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm and , intact and moves everything. Very minimal\n movement with right leg, however it is very endematous with a medial\n and lateral incisions.\n Action:\n Pulses are strongly dopplerable, 4+ pitting edema on the right leg,\n minimal edema to left leg, vascular team exchanged the wound vac sponge\n and assessed the healing of the underlying muscle/tissue, receiving\n lasix for diuresis\n Response:\n Vascular MD\n healing very well, muscle reperfused and pink,\n one small area of darker deep tissue, diuresing well 1500- of\n UO/day generally. Lasix decreased to 10mg \n Plan:\n Possible mid week closure to both incisions\n" }, { "category": "Physician ", "chartdate": "2173-08-15 00:00:00.000", "description": "Intensivist Note", "row_id": 484920, "text": "CVICU\n HPI:\n HD7 POD 6-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day7\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol-Ipratropium 5. Albuterol 0.083% Neb Soln 6. Argatroban 7.\n Artificial Tears\n 8. Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate\n 13. Furosemide 14. HydrALAzine 15. Insulin 16. Ipratropium Bromide Neb\n 17. Levothyroxine Sodium\n 18. Losartan Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Metoprolol Tartrate 22. Midazolam\n 23. Pantoprazole 24. Pneumococcal Vac Polyvalent 25. Potassium Chloride\n 26. Quetiapine Fumarate 27. Sertraline\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:50 PM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:04 AM\n Infusions:\n Argatroban - 1 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 AM\n Furosemide (Lasix) - 08:29 AM\n Metoprolol - 12:00 PM\n Fentanyl - 04:28 AM\n Other medications:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.3\nC (99.1\n HR: 82 (69 - 98) bpm\n BP: 116/79(86) {104/58(70) - 149/93(104)} mmHg\n RR: 19 (12 - 26) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 82 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 12 (6 - 17) mmHg\n Total In:\n 1,466 mL\n 736 mL\n PO:\n Tube feeding:\n 450 mL\n 437 mL\n IV Fluid:\n 716 mL\n 299 mL\n Blood products:\n Total out:\n 2,820 mL\n 680 mL\n Urine:\n 2,700 mL\n 680 mL\n NG:\n Stool:\n Drains:\n 120 mL\n Balance:\n -1,354 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RLE:\n No movement), Disoriented; Intermittent follows commands; responds to\n verbal stim.\n Labs / Radiology\n 165 K/uL\n 10.2 g/dL\n 112 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 39 mg/dL\n 107 mEq/L\n 146 mEq/L\n 30.4 %\n 13.2 K/uL\n [image002.jpg]\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n 04:21 AM\n WBC\n 11.2\n 13.1\n 13.2\n Hct\n 28.3\n 30.2\n 30.4\n Plt\n 83\n 126\n 165\n Creatinine\n 1.6\n 1.6\n 1.6\n TCO2\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n 94\n 112\n Other labs: PT / PTT / INR:31.9/62.1/3.2, CK / CK-MB / Troponin\n T:474/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.8 mg/dL, Mg:1.8 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), PERIPHERAL VASCULAR DISEASE (PVD)\n WITH CRITICAL LIMB ISCHEMIA, SHOCK, OTHER\n Assessment and Plan: 77 year old female s/p ileofem.,.,tibial\n embolectomy/ RLE fasciotomy\n Neurologic: Cont Sertraline and change narcotic to Roxicet PRN.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n Remain hemodynamically stable and tolerating diuresis.\n Pulmonary: Remains extubated and ventilating and extubating well.\n Gastrointestinal / Abdomen: Cont TF and standard bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Mild anemia; Thrombocytopenia improving. Does not have HIT\n antibody given two negative antibody screen tests; have heparin\n associated thrombocytopenia which is not antibody mediated and does not\n have concern for thrombosis. Would recommend switching anticoag. back\n to heparin gtt and following plt counts.\n Endocrine: RISS\n Infectious Disease: Cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op complication\n ICU Care\n Nutrition:\n Replete (Full) - 04:08 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-15 00:00:00.000", "description": "Intensivist Note", "row_id": 484923, "text": "CVICU\n HPI:\n HD7 POD 6-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day7\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Current medications:\n Albuterol-Ipratropium 5. Albuterol 0.083% Neb Soln 6. Argatroban 7.\n Artificial Tears\n 8. Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate\n 13. Furosemide 14. HydrALAzine 15. Insulin 16. Ipratropium Bromide Neb\n 17. Levothyroxine Sodium\n 18. Losartan Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Metoprolol Tartrate 22. Midazolam\n 23. Pantoprazole 24. Pneumococcal Vac Polyvalent 25. Potassium Chloride\n 26. Quetiapine Fumarate 27. Sertraline\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:50 PM\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:04 AM\n Infusions:\n Argatroban - 1 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 AM\n Furosemide (Lasix) - 08:29 AM\n Metoprolol - 12:00 PM\n Fentanyl - 04:28 AM\n Other medications:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.3\nC (99.1\n HR: 82 (69 - 98) bpm\n BP: 116/79(86) {104/58(70) - 149/93(104)} mmHg\n RR: 19 (12 - 26) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 82 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 12 (6 - 17) mmHg\n Total In:\n 1,466 mL\n 736 mL\n PO:\n Tube feeding:\n 450 mL\n 437 mL\n IV Fluid:\n 716 mL\n 299 mL\n Blood products:\n Total out:\n 2,820 mL\n 680 mL\n Urine:\n 2,700 mL\n 680 mL\n NG:\n Stool:\n Drains:\n 120 mL\n Balance:\n -1,354 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Anxious at times, otherwise resting.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: CTA but diminished left base : ),\n (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: +), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: +), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies, demarcation on right big toe with\n skin blister on foot\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RLE:\n No movement), Disoriented; Intermittent follows commands; responds to\n verbal stim.\n Labs / Radiology\n 165 K/uL\n 10.2 g/dL\n 112 mg/dL\n 1.6 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 39 mg/dL\n 107 mEq/L\n 146 mEq/L\n 30.4 %\n 13.2 K/uL\n [image002.jpg]\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n 04:21 AM\n WBC\n 11.2\n 13.1\n 13.2\n Hct\n 28.3\n 30.2\n 30.4\n Plt\n 83\n 126\n 165\n Creatinine\n 1.6\n 1.6\n 1.6\n TCO2\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n 94\n 112\n Other labs: PT / PTT / INR:31.9/62.1/3.2, CK / CK-MB / Troponin\n T:474/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.8 mg/dL, Mg:1.8 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), PERIPHERAL VASCULAR DISEASE (PVD)\n WITH CRITICAL LIMB ISCHEMIA, SHOCK, OTHER\n Assessment and Plan: 77 year old female s/p ileofem.,.,tibial\n embolectomy/ RLE fasciotomy\n Neurologic: Cont Sertraline and change narcotic to Roxicet PRN.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n Remain hemodynamically stable and tolerating diuresis.\n Pulmonary: Remains extubated and ventilating and extubating well.\n Gastrointestinal / Abdomen: Cont TF and standard bowel regimen.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO good diuresis, cont lasix for goal 1 liter\n negative again today.\n Hematology: Mild anemia; Thrombocytopenia improving. Does not have HIT\n antibody given two negative antibody screen tests; have heparin\n associated thrombocytopenia which is not antibody mediated and does not\n have concern for thrombosis. Would recommend switching anticoag. back\n to heparin gtt and following plt counts.\n Endocrine: RISS\n Infectious Disease: Cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op complication\n ICU Care\n Nutrition:\n Replete (Full) - 04:08 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2173-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485021, "text": "Admitted with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment.\n Of note: Has been lethargic and confused of late, is being treated\n for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lower leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm and , intact and moves everything. Very minimal\n movement with right leg, however it is very endematous with a medial\n and lateral incisions.\n Action:\n Pulses are strongly dopplerable, 4+ pitting edema on the right leg,\n minimal edema to left leg, vascular team exchanged the wound vac sponge\n and assessed the healing of the underlying muscle/tissue, receiving\n lasix for diuresis\n Response:\n Vascular MD\n healing very well, muscle reperfused and pink,\n one small area of darker deep tissue, diuresing well 1500- of\n UO/day generally. Lasix decreased to 10mg \n Plan:\n Possible mid week closure to both incisions, possibly at the bedside if\n enough swelling has gone down\n Altered mental status (not Delirium)\n Assessment:\n History of psych issues and anxiety, PERRLA, inconsistently follows\n commands, yells out inappropriately, isn\nt oriented or just wont answer\n question appropriately. When asked any questions she just closes her\n eyes.\n Action:\n Receives seroquel, sertraline, depakote as ordered, husband at bedside,\n emotional support, frequent positive reassurance.\n Response:\n Patient remains confused and calling out for help, also calls out names\n of people, family do not know.\n Plan:\n Continue to monitor and maintain patient safety\n" }, { "category": "Respiratory ", "chartdate": "2173-08-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 484136, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: when more awake pt bites and chews at ET tube\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 monitor\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484141, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 2 Right femoral thrombectomy with fasciotomy of lower leg.\n Post-op course complicated by bleeding. Total of 9 units RBC and 2\n units FFP since OR.\n Remains intubated. Sedated with fentanyl and versed drip.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. Plt up from 72 to\n 82.HIT sent yesterday. Results pending.\n Levo at beginning of shift. BP>100 syst.\n Urine output slightly improved.+ sediments.\n LR@ 100 c/hr for elevated CK\ns 4000\ns down to 3697 this am..\n Chronic AFib. Rate 90-110. No ectopy.\n No Bowel sound noted at beginning of shift. Hypoactive by am.. Abdomen\n firm. TF @ 10 cc/hr(Goal for now)\n Hypernatremia. Sodium down from 150 to 148.\n HOH. Grimacing with care. Bits on ETT with mouth care. Intermittent\n mouth block needed. Old clots in back of throat.\n Doppler pulses both lower extremities. Right big toe purple with\n blister.\n Right lower leg dressing changed wet to dry. Large amount\n sero-sanguionous.\n Anasarca.\n Low grade temp am. 100.9 po.\n Action:\n Levo turned off at beginning of shift.\n LR @ 100cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n No vent changes overnight.\n Argatroban titrated MD.PTT every 4 hrs until therapeutic. Last PTT\n 58. MD notified. No changes made.\n Monitor labs.\n Fentanyl and versed bolus with care.\n 3rd dose of albumin given.\n Right leg up on pillow. Skin care.\n Response:\n BP stable off pressors.\n Hemodynamic stable overnight.\n Grimacing with care.\n WBC wnl.10.9.\n Plan:\n Wean and extubate if tolerated.\n Monitor labs.\n Advance tube feeding MD.\n Titrate Argatroban MD\n Monitor urine output.\n ? VAC right lower leg.\n Urine culture pending.\n Monitor hemodynamic and temp.\n" }, { "category": "Physician ", "chartdate": "2173-08-12 00:00:00.000", "description": "Intensivist Note", "row_id": 484272, "text": "SICU\n HPI:\n HD4 POD 3-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Current medications:\n Albuterol-Ipratropium, Albumin 25%, Argatroban, Artificial Tears,\n Divalproex Sod. Sprinkles, Fentanyl Citrate, Furosemide, Insulin,\n Levothyroxine Sodium, Midazolam, Pantoprazole, Quetiapine Fumarate,\n Sertraline\n 24 Hour Events:\n Remains in ICU intubated and sedated\n Weaned off levophed\n HITT sent, line changed and switched to argatroban due to\n thrombocytopenia\n URINE CULTURE - At 09:28 AM\n MULTI LUMEN - STOP 11:34 AM\n MULTI LUMEN - START 11:34 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Argatroban - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:56 AM\n Fentanyl - 04:00 AM\n Furosemide (Lasix) - 09:08 AM\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100.1\n HR: 96 (79 - 110) bpm\n BP: 99/54(69) {97/53(68) - 150/91(115)} mmHg\n RR: 11 (11 - 20) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 351 (8 - 351) mmHg\n Total In:\n 3,688 mL\n 1,574 mL\n PO:\n Tube feeding:\n 95 mL\n 108 mL\n IV Fluid:\n 2,894 mL\n 1,066 mL\n Blood products:\n 550 mL\n 100 mL\n Total out:\n 944 mL\n 590 mL\n Urine:\n 824 mL\n 590 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 2,744 mL\n 984 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): 377 (377 - 377) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 95\n PIP: 15 cmH2O\n Plateau: 17 cmH2O\n Compliance: 37.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.37/41/122/24/-1\n Ve: 4.5 L/min\n PaO2 / FiO2: 305\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, pupils sluggish response\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, nontender, nondistended bowel sounds hypoactive\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies, demarcation on right big toe\n Neurologic: Sedated, moves upper extremeties and left leg spontaneously\n no movement right leg\n Labs / Radiology\n 82 K/uL\n 10.7 g/dL\n 97 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 37 mg/dL\n 116 mEq/L\n 148 mEq/L\n 32.4 %\n 10.9 K/uL\n [image002.jpg]\n 01:00 PM\n 02:15 PM\n 02:29 PM\n 06:00 PM\n 12:00 AM\n 03:34 AM\n 03:54 AM\n 05:46 AM\n 06:00 AM\n 09:26 AM\n WBC\n 11.2\n 10.9\n Hct\n 29.9\n 32.4\n Plt\n 71\n 82\n Creatinine\n 1.4\n 1.4\n TCO2\n 25\n 25\n 24\n 25\n Glucose\n 109\n 104\n 93\n 114\n 99\n 99\n 82\n 97\n Other labs: PT / PTT / INR:26.9/64.5/2.6, CK / CK-MB / Troponin\n T:3697/19/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.3 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.4 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Fentanyl and Versed for sedation,\n wean off versed continue fentanyl for pain\n Cardiovascular: Post-op Hypotension / SIRS\n levophed weaned off, start\n low dose beta-blockers for rate control\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Wean to CPAP, Spontaneous\n breathing trial today for possible extubation.\n Gastrointestinal / Abdomen: no issues\n Nutrition: TF continue to advance slowly.\n Renal: Foley, monitor urine output, give Lasix x1 to attempt diuresis\n given exam and increased weights and goal to extubate in the next 2\n hours if possible.\n Hematology: Stable anemia; Cont Argatroban gtt per surgery while\n awaiting HIT result for thrombocytopenia, although this is probably\n from consumption.\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: WBC 10.9 Cipro for gram neg UTI awaiting\n sensitives\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: right leg fasciotomies change \n Fluids: LR\n decrease and KVO late today.\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 PM 10 mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n" }, { "category": "Nursing", "chartdate": "2173-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484423, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 3 Right femoral thrombectomy with fasciotomy of lower leg.\n Post-op course complicated by bleeding from leg. Total of 9 units RBC\n and 2 units FFP since OR with multiple fluid bolus.\n Remains intubated. Sedated with fentanyl and versed bolus.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. Plt 83 .\n Urine output improved with lasix.\n LR@ 10 c/hr.\n Chronic AFib. Rate 90-130. No ectopy.\n Hypoactive bowel sound. No stools since admission. Abdomen soft/obese.\n TF stopped @ 2:00 am for potential extubation.\n Hypernatremia. Sodium up from 148 to 149.\n HOH. Grimacing with care. Bits on ETT with mouth care. HR and BP up\n with minimal stimulation. Agitated and combative at times.\n Doppler pulses both lower extremities. Right big toe pink with blister.\n Color has improved. Right foot and leg edematous.\n Right lower leg incisions VAC\ned yesterday. Moderate amount\n sero-sanguionous.\n Anasarca.\n CPAP overnight. Failed weaning yesterday. .\n Baseline demented and HOH.\n CPK treading down. 1632 this am.(Were in the 4000\n Action:\n LR @ 10cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n Argatroban titrated MD.PTT every 6 hrs until therapeutic.\n Monitor labs.\n Fentanyl and versed bolus with care.\n Right leg up on pillow. Skin care.\n Lasix and Lopressor started.\n Restarted psych meds.\n Cipro for positive UTI.\n CPAP 5/5 since 5:00.Repeat abg wnl. Taking good volumes. >95%\n Lopressor for BP and HR. Extra dose given for HTN.\n Response:\n Episodes of hypertension and tachycardia with care.\n Hemodynamic stable overnight.\n WBC wnl.10.9. Afebrile.\n Good response to lasix. BUN 34/Creat 1.6(up from 1.4)\n Plan:\n Wean and extubated.\n Monitor labs.\n Titrate Argatroban MD\n Monitor urine output.\n VAC right lower leg.\n Monitor hemodynamic.\n Repeat PTT @ 8:00am\n ------ Protected Section ------\n 7:00 am.Extubated. O2 50 % open face mask.O2sat 95%. RR 20\ns. OG\n removed.\n ------ Protected Section Addendum Entered By: , RN\n on: 07:03 ------\n" }, { "category": "Respiratory ", "chartdate": "2173-08-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 484529, "text": "Pt extubated today at change of shift to 40% face tent. Pt has stable\n ABGs but has required NTS x 3 post- extubation. Diuresing with lasix.\n Will cont to follow closely.\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484127, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 2 Right femoral thrombectomy with fasciotomy of lower leg.\n Remains intubated. Sedated with fentanyl and versed drip.\n Total of 9 units of RBC and 2 units of FFP since admission.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. HIT sent\n yesterday.PTT goal 60-90.\n Levo at beginning of shift. BP>100 syst.\n Urine output slightly improved.\n LR@ 100 c/hr for elevated CK\ns 4000\n Chronic AFib. Rate 90-110.\n No Bowel sound noted. Abdomen firm. TF @ 10 cc/hr(Goal for now)\n Hypernatremia. Sodium 150.\n HOH.Grimacing with care. Bit ETT with mouth care.\n Doppler pulses both lower extremities. Right big toe purple with\n blister.\n Right lower leg dressing changed wet to dry.\n Anasarca.\n Action:\n Levo turned off at beginning of shift.\n LR @ 100cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n No vent changes overnight. Bits on ETT during mouth care and\n stimulation.\n Argatroban titrated MD.PTT every 4 hrs until therapeutic.\n Monitor labs.\n Fentanyl and versed bolus with care.\n Last dose albumin given.\n Response:\n BP stable off pressors.\n Hemodynamic stable overnight.\n Grimacing with care.\n Plan:\n Wean and extubate if tolerated.\n Monitor labs. Advance tube feeding MD.\n PTT goal 60-80.\n Monitor urine output.\n ? VAC right lower leg.\n Urine culture pending.\n" }, { "category": "Nursing", "chartdate": "2173-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484247, "text": "HD4 POD 3-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt VS as per flowsheet. Perl. Mue equal + strong, grabs at gown, etc.\n does not follow commands. Localizes to ETT. Hr 90-120\ns chronic afib.\n Sbp 100 t-> hypertensive to 160\ns w/ stimuli. Cvp mid teens. PTT\n therapeutic. CK remains 3000\ns. sodium trending down. Fingers cyanotic\n though improved since prev days. Rt foot warm, pink w/ purple blistered\n great toe. Blisters also extend medial /lat down foot. Lt foot wnl.\n Pedal pulses bilat by doppler. Lungs clear bilat. Abd soft. Very rare\n BSP. No BM. Uop improved w/ lasix. + UTI. Fasciotomy inc -> dng min\n serosang via vac.\n Action:\n Fentanyl gtt for comfort -> 100mcq prn bolus w/ dsg change, etc\n Argatroban gtt-> serial PTT\n Vac dsg app\n Low dose beta blockade began\n LR decrease to 50cc/hr\n Lasix dosing started\n Vent settings to cpap as noted\n Advancing tube feeds\n Cipro dosing x5d began\n Response:\n Stable day. Tol cpap + ips\n Agitated w/ physical stimui /care\n Plan:\n Cont to monitor PTT/labs\n Mainatain cpap as able\n Prep for extubation in am\n Advance tube feeds as ordered\n" }, { "category": "Nursing", "chartdate": "2173-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484363, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 3 Right femoral thrombectomy with fasciotomy of lower leg.\n Post-op course complicated by bleeding from leg. Total of 9 units RBC\n and 2 units FFP since OR with multiple fluid bolus.\n Remains intubated. Sedated with fentanyl and versed bolus.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. Plt up from to\n 83.HIT sent .\n Urine output improved with lasix.\n LR@ 10 c/hr.\n Chronic AFib. Rate 90-130. No ectopy.\n Hypoactive bowel sound.No BM.. Abdomen soft/obese. TF stopped @ 2:00 am\n for potential extubation.\n Hypernatremia. Sodium down from 150 to 148.\n HOH. Grimacing with care. Bits on ETT with mouth care. HR and BP up\n with minimal stimulation.\n Doppler pulses both lower extremities. Right big toe pink with blister.\n Colour has improved.\n Right lower leg incisions VAC\ned yesterday. Moderate amount\n sero-sanguionous.\n Anasarca.\n CPAP overnight.Failed weaning yesterday.ABG acidosis.\n Baseline demented and HOH.\n Action:\n LR @ 10cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n No vent changes overnight.\n Argatroban titrated MD.PTT every 6 hrs until therapeutic.\n Monitor labs.\n Fentanyl and versed bolus with care.\n Right leg up on pillow. Skin care.\n Lasix and Lopressor started.\n Restarted psych meds.\n Cipro for positive UTI.\n Response:\n Episodes of hypertension and tachycardia with care.\n Hemodynamic stable overnight.\n WBC wnl.10.9.\n Plan:\n Wean and extubated.\n Monitor labs.\n Titrate Argatroban MD\n Monitor urine output.\n VAC right lower leg.\n Monitor hemodynamic.\n" }, { "category": "Physician ", "chartdate": "2173-08-14 00:00:00.000", "description": "Intensivist Note", "row_id": 484644, "text": "CVICU\n HPI:\n HD6 POD 5-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day6\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol-Ipratropium 5. Albuterol 0.083% Neb Soln 6. Argatroban 7.\n Artificial Tears\n 8. Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate\n 13. Furosemide 14. HydrALAzine 15. Insulin 16. Ipratropium Bromide Neb\n 17. Levothyroxine Sodium\n 18. Losartan Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Midazolam 22. Pantoprazole\n 23. Pneumococcal Vac Polyvalent 24. Potassium Chloride 25. Quetiapine\n Fumarate 26. Sertraline\n 24 Hour Events:\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Infusions:\n Argatroban - 0.75 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Furosemide (Lasix) - 08:30 AM\n Fentanyl - 05:21 AM\n Metoprolol - 06:23 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 84 (80 - 119) bpm\n BP: 126/75(95) {106/66(81) - 175/112(138)} mmHg\n RR: 18 (15 - 29) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 14 (8 - 17) mmHg\n Total In:\n 1,014 mL\n 434 mL\n PO:\n Tube feeding:\n 81 mL\n IV Fluid:\n 533 mL\n 284 mL\n Blood products:\n 100 mL\n Total out:\n 3,700 mL\n 940 mL\n Urine:\n 3,250 mL\n 820 mL\n NG:\n Stool:\n Drains:\n 450 mL\n 120 mL\n Balance:\n -2,686 mL\n -506 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n FiO2: 70%\n SPO2: 99%\n ABG: 7.35/49/141//0\n PaO2 / FiO2: 201\n Physical Examination\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 109\n 1.6 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.2 %\n 13.1 K/uL\n [image002.jpg]\n 03:41 PM\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n WBC\n 11.2\n 13.1\n Hct\n 28.3\n 30.2\n Plt\n 83\n 126\n Creatinine\n 1.6\n TCO2\n 22\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n Other labs: PT / PTT / INR:28.8/56.1/2.8, CK / CK-MB / Troponin\n T:1632/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:9.2 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan: 77 year old female s/p ileofem.,.,tibial\n embolectomy/ RLE fasciotomy\n Neurologic: Pain controlled, Cont Sertraline and minimize sedatives to\n assess mental status. Cont to treat pain with Fentanyl PRN.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Cont\n Argatroban gtt and lopressor for rate control with Afib.\n Pulmonary: Extubated successfully. ABG looks good this AM, but remains\n on high flow O2 mask.\n Gastrointestinal / Abdomen: Standard bowel regimen; Restart TF today.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Mild anemia; Plt count improving --> follow up with repeat\n HIT antibody test.\n Endocrine: RISS, Cont Levothyroxine.\n Infectious Disease: Cont Cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging: CXR today\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-14 00:00:00.000", "description": "Intensivist Note", "row_id": 484646, "text": "CVICU\n HPI:\n HD6 POD 5-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day6\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Current medications:\n Albuterol-Ipratropium 5. Albuterol 0.083% Neb Soln 6. Argatroban 7.\n Artificial Tears\n 8. Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate\n 13. Furosemide 14. HydrALAzine 15. Insulin 16. Ipratropium Bromide Neb\n 17. Levothyroxine Sodium\n 18. Losartan Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate\n 21. Midazolam 22. Pantoprazole\n 23. Pneumococcal Vac Polyvalent 24. Potassium Chloride 25. Quetiapine\n Fumarate 26. Sertraline\n 24 Hour Events:\n --extubated successfully.\n --improved diuresis\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Infusions:\n Argatroban - 0.75 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Furosemide (Lasix) - 08:30 AM\n Fentanyl - 05:21 AM\n Metoprolol - 06:23 AM\n Other medications:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 84 (80 - 119) bpm\n BP: 126/75(95) {106/66(81) - 175/112(138)} mmHg\n RR: 18 (15 - 29) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 14 (8 - 17) mmHg\n Total In:\n 1,014 mL\n 434 mL\n PO:\n Tube feeding:\n 81 mL\n IV Fluid:\n 533 mL\n 284 mL\n Blood products:\n 100 mL\n Total out:\n 3,700 mL\n 940 mL\n Urine:\n 3,250 mL\n 820 mL\n NG:\n Stool:\n Drains:\n 450 mL\n 120 mL\n Balance:\n -2,686 mL\n -506 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n FiO2: 70%\n SPO2: 99%\n ABG: 7.35/49/141//0\n PaO2 / FiO2: 201\n Physical Examination\n General Appearance: Appears anxious at times.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : anterior)\n Abdominal: Soft, nontender, nondistended bowel sounds hypoactive\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies, demarcation on right big toe\n Neurologic: Sedated, Not following commands; Moves upper ext's and\n left lower spont and to stim; Opens eyes to voice.\n Labs / Radiology\n 126 K/uL\n 9.9 g/dL\n 109\n 1.6 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.2 %\n 13.1 K/uL\n [image002.jpg]\n 03:41 PM\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n WBC\n 11.2\n 13.1\n Hct\n 28.3\n 30.2\n Plt\n 83\n 126\n Creatinine\n 1.6\n TCO2\n 22\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n Other labs: PT / PTT / INR:28.8/56.1/2.8, CK / CK-MB / Troponin\n T:1632/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:9.2 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan: 77 year old female s/p ileofem.,.,tibial\n embolectomy/ RLE fasciotomy\n Neurologic: Pain controlled, Cont Sertraline and minimize sedatives to\n assess mental status. Cont to treat pain with Fentanyl PRN.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Cont\n Argatroban gtt and lopressor for rate control with Afib.\n Pulmonary: Extubated successfully. ABG looks good this AM, but remains\n on high flow O2 mask.\n Gastrointestinal / Abdomen: Standard bowel regimen; Restart TF today.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Mild anemia; Plt count improving --> follow up with repeat\n HIT antibody test.\n Endocrine: RISS, Cont Levothyroxine.\n Infectious Disease: Cont Cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging: CXR today\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484649, "text": "77 F who resides in a long-term care facility was found with\na cold right foot this morning. She presented to \nHospital at approximately 2 PM and transferred to . She has\nbeen lethargic and confused for the past 1 week and treated for a\nUTI. Currently she is unable to give a history herself. According\nto her husband and daughter, the patient had been on coumadin but\nthis was stopped in due to a splenic bleed.\nPMH: Afib (was on coumadin but stopped due to splenic\nhematoma), COPD, CRI, mitral regurgitation, depression, HTN,\nmonoclonal gammopathy, bipolar, hearing impaired\nPSH: hysterectomy, lumpectomy, cataracts\n: digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\nnadolol 80', advair, albuterol prn, abilify 2' started ,\nprilosec, mnacrobid for UTI (treated for 8 days)\nFH: NC\nSH: resides at nursing home in , husband and daughter\n( ) make medical decisions for her\nAll: PCN, Ergot, Morphine, Latex\nOPERATION PERFORMED: Right iliofemoral popliteal tibial\nthrombectomy and right lower extremity fasciotomy for\ncompartment.\nFINDINGS: Thrombosis to right femoral popliteal and tibial\narteries and evidence of thrombus within the right common\nfemoral and superficial femoral artery.\n Of note: Has been lethargic and confused of late, is being treated for\n UTI with cipro\n VAC placed to Right lower leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Patient very confused tonight, swinging punches at us with turns, on\n Argatroban with goal 60-80, wound vac in place, foley, art line and\n RIJ. Afib in 80\ns-90\n Action:\n Meds per orders, PTT below therapeutic level, increased Argatroban per\n protocol. Fentanyl 25mcg x 4 through the night. Patient c/o pain with\n all cares. NP suctioned x 2\n Response:\n Patient slept well in-between cares. Yelling out at times, confused.\n Combative at times. Sats in mid to high 90\n Plan:\n CXR today, Fentanyl for pain, TF to start. ?Wound vac dsg to be\n changed.\n .\n" }, { "category": "Physician ", "chartdate": "2173-08-12 00:00:00.000", "description": "Intensivist Note", "row_id": 484222, "text": "SICU\n HPI:\n HD4 POD 3-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol-Ipratropium, Albumin 25%, Argatroban, Artificial Tears,\n Divalproex Sod. Sprinkles, Fentanyl Citrate, Furosemide, Insulin,\n Levothyroxine Sodium, Midazolam, Pantoprazole, Quetiapine Fumarate,\n Sertraline\n 24 Hour Events:\n URINE CULTURE - At 09:28 AM\n MULTI LUMEN - STOP 11:34 AM\n MULTI LUMEN - START 11:34 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Argatroban - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:56 AM\n Fentanyl - 04:00 AM\n Furosemide (Lasix) - 09:08 AM\n Other medications:\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100.1\n HR: 96 (79 - 110) bpm\n BP: 99/54(69) {97/53(68) - 150/91(115)} mmHg\n RR: 11 (11 - 20) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 351 (8 - 351) mmHg\n Total In:\n 3,688 mL\n 1,574 mL\n PO:\n Tube feeding:\n 95 mL\n 108 mL\n IV Fluid:\n 2,894 mL\n 1,066 mL\n Blood products:\n 550 mL\n 100 mL\n Total out:\n 944 mL\n 590 mL\n Urine:\n 824 mL\n 590 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 2,744 mL\n 984 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): 377 (377 - 377) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 95\n PIP: 15 cmH2O\n Plateau: 17 cmH2O\n Compliance: 37.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.37/41/122/24/-1\n Ve: 4.5 L/min\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 82 K/uL\n 10.7 g/dL\n 97 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 37 mg/dL\n 116 mEq/L\n 148 mEq/L\n 32.4 %\n 10.9 K/uL\n [image002.jpg]\n 01:00 PM\n 02:15 PM\n 02:29 PM\n 06:00 PM\n 12:00 AM\n 03:34 AM\n 03:54 AM\n 05:46 AM\n 06:00 AM\n 09:26 AM\n WBC\n 11.2\n 10.9\n Hct\n 29.9\n 32.4\n Plt\n 71\n 82\n Creatinine\n 1.4\n 1.4\n TCO2\n 25\n 25\n 24\n 25\n Glucose\n 109\n 104\n 93\n 114\n 99\n 99\n 82\n 97\n Other labs: PT / PTT / INR:26.9/64.5/2.6, CK / CK-MB / Troponin\n T:3697/19/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.3 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.4 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 PM 10 mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n" }, { "category": "Physician ", "chartdate": "2173-08-12 00:00:00.000", "description": "Intensivist Note", "row_id": 484225, "text": "SICU\n HPI:\n HD4 POD 3-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\n nadolol 80', advair, albuterol prn, abilify 2' started ,\n prilosec, mnacrobid for UTI (treated for 8 days)\n Current medications:\n Albuterol-Ipratropium, Albumin 25%, Argatroban, Artificial Tears,\n Divalproex Sod. Sprinkles, Fentanyl Citrate, Furosemide, Insulin,\n Levothyroxine Sodium, Midazolam, Pantoprazole, Quetiapine Fumarate,\n Sertraline\n 24 Hour Events:\n Remains in ICU intubated and sedated\n Weaned off levophed\n HITT sent, line changed and switched to argatroban due to\n thrombocytopenia\n URINE CULTURE - At 09:28 AM\n MULTI LUMEN - STOP 11:34 AM\n MULTI LUMEN - START 11:34 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 06:52 AM\n Infusions:\n Argatroban - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:56 AM\n Fentanyl - 04:00 AM\n Furosemide (Lasix) - 09:08 AM\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100.1\n HR: 96 (79 - 110) bpm\n BP: 99/54(69) {97/53(68) - 150/91(115)} mmHg\n RR: 11 (11 - 20) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 351 (8 - 351) mmHg\n Total In:\n 3,688 mL\n 1,574 mL\n PO:\n Tube feeding:\n 95 mL\n 108 mL\n IV Fluid:\n 2,894 mL\n 1,066 mL\n Blood products:\n 550 mL\n 100 mL\n Total out:\n 944 mL\n 590 mL\n Urine:\n 824 mL\n 590 mL\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 2,744 mL\n 984 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): 377 (377 - 377) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 95\n PIP: 15 cmH2O\n Plateau: 17 cmH2O\n Compliance: 37.5 cmH2O/mL\n SPO2: 100%\n ABG: 7.37/41/122/24/-1\n Ve: 4.5 L/min\n PaO2 / FiO2: 305\n Physical Examination\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL, pupils sluggish response\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, nontender, nondistended bowel sounds hypoactive\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies, demarcation on right big toe\n Neurologic: Sedated, moves upper extremeties and left leg spontaneously\n no movement right leg\n Labs / Radiology\n 82 K/uL\n 10.7 g/dL\n 97 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 37 mg/dL\n 116 mEq/L\n 148 mEq/L\n 32.4 %\n 10.9 K/uL\n [image002.jpg]\n 01:00 PM\n 02:15 PM\n 02:29 PM\n 06:00 PM\n 12:00 AM\n 03:34 AM\n 03:54 AM\n 05:46 AM\n 06:00 AM\n 09:26 AM\n WBC\n 11.2\n 10.9\n Hct\n 29.9\n 32.4\n Plt\n 71\n 82\n Creatinine\n 1.4\n 1.4\n TCO2\n 25\n 25\n 24\n 25\n Glucose\n 109\n 104\n 93\n 114\n 99\n 99\n 82\n 97\n Other labs: PT / PTT / INR:26.9/64.5/2.6, CK / CK-MB / Troponin\n T:3697/19/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.3 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.4 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Fentanyl and Versed for sedation,\n wean off versed continue fentanyl for pain\n Cardiovascular: Post-op Hypotension / SIRS\n levophed weaned off, start\n betablockers for rate control\n Pulmonary: Cont ETT, (Ventilator mode: CMV), Wean to CPAP, Spontaneous\n breathing trial today\n Gastrointestinal / Abdomen: no issues\n Nutrition: TF continue to advance slowly.\n Renal: Foley, monitor urine output, start lasix for diuresis\n Hematology: Stable anemia\n Argatroban gtt per surgery while awaiting HIT result for\n thrombocytopenia, although this is probably from consumption.\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: WBC 10.9 Cipro for gram neg UTI awaiting\n sensitives\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: right leg fasciotomies change \n Fluids: LR\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op shock\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:32 PM 10 mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:41 AM\n 20 Gauge - 01:43 AM\n 18 Gauge - 04:23 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n" }, { "category": "Nursing", "chartdate": "2173-08-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484399, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n POD # 3 Right femoral thrombectomy with fasciotomy of lower leg.\n Post-op course complicated by bleeding from leg. Total of 9 units RBC\n and 2 units FFP since OR with multiple fluid bolus.\n Remains intubated. Sedated with fentanyl and versed bolus.\n Latex allergy and MRSA precaution.\n Heparin changed to Argatroban due to platelet drop. Plt 83 .\n Urine output improved with lasix.\n LR@ 10 c/hr.\n Chronic AFib. Rate 90-130. No ectopy.\n Hypoactive bowel sound. No stools since admission. Abdomen soft/obese.\n TF stopped @ 2:00 am for potential extubation.\n Hypernatremia. Sodium up from 148 to 149.\n HOH. Grimacing with care. Bits on ETT with mouth care. HR and BP up\n with minimal stimulation. Agitated and combative at times.\n Doppler pulses both lower extremities. Right big toe pink with blister.\n Color has improved. Right foot and leg edematous.\n Right lower leg incisions VAC\ned yesterday. Moderate amount\n sero-sanguionous.\n Anasarca.\n CPAP overnight. Failed weaning yesterday. .\n Baseline demented and HOH.\n CPK treading down. 1632 this am.(Were in the 4000\n Action:\n LR @ 10cc/hr and 150 cc free water free water via TF for hypernatremia\n and rabdo..\n Argatroban titrated MD.PTT every 6 hrs until therapeutic.\n Monitor labs.\n Fentanyl and versed bolus with care.\n Right leg up on pillow. Skin care.\n Lasix and Lopressor started.\n Restarted psych meds.\n Cipro for positive UTI.\n CPAP 5/5 since 5:00.Repeat abg wnl. Taking good volumes. >95%\n Lopressor for BP and HR. Extra dose given for HTN.\n Response:\n Episodes of hypertension and tachycardia with care.\n Hemodynamic stable overnight.\n WBC wnl.10.9. Afebrile.\n Good response to lasix. BUN 34/Creat 1.6(up from 1.4)\n Plan:\n Wean and extubated.\n Monitor labs.\n Titrate Argatroban MD\n Monitor urine output.\n VAC right lower leg.\n Monitor hemodynamic.\n Repeat PTT @ 8:00am\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484764, "text": "painful cold R leg at facility AM sent to hospital and\n transferred to for trx. of note has been lethargic and confused\n of late, is being treated for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm and , intact and moves everything. Very minimal\n movement with right leg, however it is very endematous with a medial\n and lateral incisions.\n Action:\n Pulses are strongly dopplerable, 4+ pitting edema on the right leg,\n minimal edema to left leg, vascular team exchanged the wound vac sponge\n and assessed the healing of the underlying muscle/tissue, receiving\n lasix for diuresis\n Response:\n Vascular MD\n healing very well, muscle reperfused and pink,\n one small area of darker deep tissue, diuresing well 1500- of\n UO/day generally. Lasix decreased to 10mg \n Plan:\n Possible mid week closure to both incisions, possibly at the bedside if\n enough swelling has gone down\n Altered mental status (not Delirium)\n Assessment:\n History of psych issues and anxiety, PERRLA, inconsistently follows\n commands, yells out inappropriately, isn\nt oriented or just wont answer\n question appropriately. When asked any questions she just closes her\n eyes.\n Action:\n Receives seroquel, sertraline, depakote as ordered, husband at bedside,\n emotional support, frequent positive reassurance.\n Response:\n Patient remains confused\n Plan:\n Continue to monitor and maintain patient safety\n" }, { "category": "Nursing", "chartdate": "2173-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484864, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt with stable blood pressure off pressors. good diuretic response to\n low dose lasix. Remains in baseline afib, rate controlled. Pedal\n pulses doppler. R foot cool, great toe purple tip with large blister\n on outer aspect. ACE wrap and vac dressing intact. Mildly febrile.\n Crying out with stimulation/care.\n Action:\n Monitored. Lasix diuresis. Pain treated with fent IV. Oral care.\n Metoprolol for rate control, anticoagulated on argatroban gtt. Cipro\n as ordered. Tubefeeds advanced to goal.\n Response:\n Crying out intermittently, periods of rest in between care. Rate\n controlled. +pedal pulses by doppler. Tolerating tubefeeds.\n Plan:\n Continue to monitor, PTT q 6 hours, due at ____. Continue abx, fent\n for pain control. Monitor csm to RLE. Skin care and oral care.\n Altered mental status (not Delirium)\n Assessment:\n Pt crying out throughout noc. Very hard of hearing. At times\n incoherent sounds, at times calling out for family members. at\n gown, thrashing arms with care. Inconsistently following commands.\n Action:\n Monitored for safety, bed alarm on. A line d/c for safety. Restraints\n for safety, integrity of NGT. Oriented PRN. Pain treated with fent\n IV. Headset for communication.\n Response:\n Pt remains confused, resting intermittently overnoc. Follows simple\n commands intermittently.\n Plan:\n Continue to monitor, orient PRN, treat pain; safety and fall\n precautions.\n" }, { "category": "Physician ", "chartdate": "2173-08-13 00:00:00.000", "description": "Intensivist Note", "row_id": 484502, "text": "CVICU\n HPI:\n HD5 POD 4-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day5\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Chief complaint:\n PMHx:\n Current medications:\n Albuterol-Ipratropium 5. Argatroban 6. Artificial Tears 7. Calcium\n Gluconate 8. Ciprofloxacin 9. Divalproex Sod. Sprinkles 10. Digoxin 11.\n Fentanyl Citrate 12. Fluticasone-Salmeterol Diskus (250/50) 13.\n Furosemide 14. HydrALAzine 15. Insulin 16. Levothyroxine Sodium 17.\n Losartan Potassium 18. Magnesium Sulfate 19. Metoprolol Tartrate 20.\n Midazolam 21. Pantoprazole 22. Pneumococcal Vac Polyvalent 23.\n Potassium Chloride 24. Quetiapine Fumarate 25. Sertraline\n 24 Hour Events:\n EXTUBATION - At 06:57 AM\n INVASIVE VENTILATION - STOP 06:58 AM\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:18 PM\n Infusions:\n Argatroban - 0.5 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 03:00 AM\n Pantoprazole (Protonix) - 08:30 AM\n Furosemide (Lasix) - 08:30 AM\n Fentanyl - 12:17 PM\n Metoprolol - 12:18 PM\n Other medications:\n Flowsheet Data as of 04:21 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.1\nC (98.8\n HR: 92 (86 - 119) bpm\n BP: 159/98(124) {114/66(84) - 175/112(138)} mmHg\n RR: 15 (9 - 25) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 13 (9 - 19) mmHg\n Total In:\n 3,200 mL\n 722 mL\n PO:\n Tube feeding:\n 606 mL\n 81 mL\n IV Fluid:\n 1,914 mL\n 391 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 2,690 mL\n 2,580 mL\n Urine:\n 2,690 mL\n 2,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 510 mL\n -1,858 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 448 (435 - 448) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 40\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.35/49/141/29/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 353\n Physical Examination\n General Appearance: Appears anxious at times.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : anterior)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 3+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished)\n Neurologic: Sedated, Not following commands; Moves upper ext's and\n left lower spont and to stim; Opens eyes to voice.\n Labs / Radiology\n 83 K/uL\n 9.7 g/dL\n 109\n 1.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 114 mEq/L\n 149 mEq/L\n 28.3 %\n 11.2 K/uL\n [image002.jpg]\n 02:42 PM\n 03:41 PM\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n WBC\n 11.2\n Hct\n 28.3\n Plt\n 83\n Creatinine\n 1.6\n TCO2\n 26\n 22\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n Other labs: PT / PTT / INR:28.8/69.1/2.8, CK / CK-MB / Troponin\n T:1632/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:9.2 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan: Assessment:77 year old female s/p\n ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Neurologic: Pain controlled, Fentanyl prn. Cont sertraline. Cont to\n have altered mental status. Most likely toxic metabolic encephalopathy\n as she is not focal with exam. Also unclear baseline mental status in\n nursing home.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Cont\n argatroban gtt; cont beta-blockers along with cozaar and digoxin.\n Pulmonary: Extubate today, Nebs PRN.\n Gastrointestinal / Abdomen: OGT d/c'd with extubation; Will need\n feeding tube.\n Nutrition: Speech and Swallow eval, Would restart TF after dobhoff in\n place.\n Renal: Foley, Adequate UO, Improved urine output. Cont lasix with\n albumin and consider lasix gtt. Mild elevation in creatinine, will\n cont to monitor.\n Hematology: Mild anemia, cont to follow.\n Endocrine: RISS, Levothyroxine.\n Infectious Disease: Cont cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-13 00:00:00.000", "description": "Intensivist Note", "row_id": 484503, "text": "CVICU\n HPI:\n HD5 POD 4-s/p ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Ejection Fraction:65\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:2.4\n Foley:Day5\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Current medications:\n Albuterol-Ipratropium 5. Argatroban 6. Artificial Tears 7. Calcium\n Gluconate 8. Ciprofloxacin 9. Divalproex Sod. Sprinkles 10. Digoxin 11.\n Fentanyl Citrate 12. Fluticasone-Salmeterol Diskus (250/50) 13.\n Furosemide 14. HydrALAzine 15. Insulin 16. Levothyroxine Sodium 17.\n Losartan Potassium 18. Magnesium Sulfate 19. Metoprolol Tartrate 20.\n Midazolam 21. Pantoprazole 22. Pneumococcal Vac Polyvalent 23.\n Potassium Chloride 24. Quetiapine Fumarate 25. Sertraline\n 24 Hour Events:\n EXTUBATION - At 06:57 AM\n INVASIVE VENTILATION - STOP 06:58 AM\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 12:18 PM\n Infusions:\n Argatroban - 0.5 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 03:00 AM\n Pantoprazole (Protonix) - 08:30 AM\n Furosemide (Lasix) - 08:30 AM\n Fentanyl - 12:17 PM\n Metoprolol - 12:18 PM\n Other medications:\n Flowsheet Data as of 04:21 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.1\nC (98.8\n HR: 92 (86 - 119) bpm\n BP: 159/98(124) {114/66(84) - 175/112(138)} mmHg\n RR: 15 (9 - 25) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 85.3 kg (admission): 60 kg\n Height: 67 Inch\n CVP: 13 (9 - 19) mmHg\n Total In:\n 3,200 mL\n 722 mL\n PO:\n Tube feeding:\n 606 mL\n 81 mL\n IV Fluid:\n 1,914 mL\n 391 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 2,690 mL\n 2,580 mL\n Urine:\n 2,690 mL\n 2,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 510 mL\n -1,858 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 448 (435 - 448) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 40\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.35/49/141/29/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 353\n Physical Examination\n General Appearance: Appears anxious at times.\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : anterior)\n Abdominal: Soft, nontender, nondistended bowel sounds hypoactive\n Left Extremities: (Edema: 2+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: right leg with fasciotomies, demarcation on right big toe\n Neurologic: Sedated, Not following commands; Moves upper ext's and\n left lower spont and to stim; Opens eyes to voice.\n Labs / Radiology\n 83 K/uL\n 9.7 g/dL\n 109\n 1.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 114 mEq/L\n 149 mEq/L\n 28.3 %\n 11.2 K/uL\n [image002.jpg]\n 02:42 PM\n 03:41 PM\n 05:56 PM\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n WBC\n 11.2\n Hct\n 28.3\n Plt\n 83\n Creatinine\n 1.6\n TCO2\n 26\n 22\n 22\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n Other labs: PT / PTT / INR:28.8/69.1/2.8, CK / CK-MB / Troponin\n T:1632/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:9.2 mg/dL, Mg:1.8 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, SHOCK,\n OTHER\n Assessment and Plan: Assessment:77 year old female s/p\n ileofem.,.,tibial embolectomy/ RLE fasciotomy\n Neurologic: Pain controlled, Fentanyl prn. Cont sertraline. Cont to\n have altered mental status. Most likely toxic metabolic encephalopathy\n as she is not focal with exam. Also unclear baseline mental status in\n nursing home.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Cont\n argatroban gtt; cont beta-blockers along with cozaar and digoxin.\n Pulmonary: Extubate today, Nebs PRN.\n Gastrointestinal / Abdomen: OGT d/c'd with extubation; Will need\n feeding tube.\n Nutrition: Speech and Swallow eval, Would restart TF after dobhoff in\n place.\n Renal: Foley, Adequate UO, Improved urine output. Cont lasix with\n albumin and consider lasix gtt. Mild elevation in creatinine, will\n cont to monitor.\n Hematology: Mild anemia, cont to follow.\n Endocrine: RISS, Levothyroxine.\n Infectious Disease: Cont cipro for UTI\n Lines / Tubes / Drains: Foley\n Wounds: Wound vacuum\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: Arrhythmia, (Respiratory distress: Failure), Post-op\n hypotension, Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:41 AM\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484565, "text": "77 F who resides in a long-term care facility was found with\na cold right foot this morning. She presented to \nHospital at approximately 2 PM and transferred to . She has\nbeen lethargic and confused for the past 1 week and treated for a\nUTI. Currently she is unable to give a history herself. According\nto her husband and daughter, the patient had been on coumadin but\nthis was stopped in due to a splenic bleed.\nPMH: Afib (was on coumadin but stopped due to splenic\nhematoma), COPD, CRI, mitral regurgitation, depression, HTN,\nmonoclonal gammopathy, bipolar, hearing impaired\nPSH: hysterectomy, lumpectomy, cataracts\n: digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\nnadolol 80', advair, albuterol prn, abilify 2' started ,\nprilosec, mnacrobid for UTI (treated for 8 days)\nFH: NC\nSH: resides at nursing home in , husband and daughter\n( ) make medical decisions for her\nAll: PCN, Ergot, Morphine, Latex\nOPERATION PERFORMED: Right iliofemoral popliteal tibial\nthrombectomy and right lower extremity fasciotomy for\ncompartment.\nFINDINGS: Thrombosis to right femoral popliteal and tibial\narteries and evidence of thrombus within the right common\nfemoral and superficial femoral artery.\n Of note: Has been lethargic and confused of late, is being treated for\n UTI with cipro\n VAC placed to Right lower leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2173-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484865, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt with stable blood pressure off pressors. good diuretic response to\n low dose lasix. Remains in baseline afib, rate controlled. Pedal\n pulses doppler. R foot cool, great toe purple tip with large blister\n on outer aspect. ACE wrap and vac dressing intact. Mildly febrile.\n Crying out with stimulation/care.\n Action:\n Monitored. Lasix diuresis. Pain treated with fent IV. Oral care.\n Metoprolol for rate control, anticoagulated on argatroban gtt. Cipro\n as ordered. Tubefeeds advanced to goal.\n Response:\n Crying out intermittently, periods of rest in between care. Rate\n controlled. +pedal pulses by doppler. Tolerating tubefeeds.\n Plan:\n Continue to monitor, PTT q 6 hours, due at 10:00, therapeutic x1.\n Continue abx, fent for pain control. Monitor csm to RLE. Skin care\n and oral care.\n Altered mental status (not Delirium)\n Assessment:\n Pt crying out throughout noc. Very hard of hearing. At times\n incoherent sounds, at times calling out for family members. at\n gown, thrashing arms with care. Inconsistently following commands.\n Action:\n Monitored for safety, bed alarm on. A line d/c for safety. Restraints\n for safety, integrity of NGT. Oriented PRN. Pain treated with fent\n IV. Headset for communication.\n Response:\n Pt remains confused, resting intermittently overnoc. Follows simple\n commands intermittently.\n Plan:\n Continue to monitor, orient PRN, treat pain; safety and fall\n precautions.\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484564, "text": "This is a 77-year-old woman who has\na history of atrial fibrillation. She presents with acute\nright lower extremity ischemia with loss of sensory and motor\nfunction. Her exam was consistent with that of an embolus.\nGiven these findings the patient was consented for a femoral\nembolectomy and possible angiogram and fasciotomy for limb\nsalvage.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484566, "text": "77 F who resides in a long-term care facility was found with\na cold right foot this morning. She presented to \nHospital at approximately 2 PM and transferred to . She has\nbeen lethargic and confused for the past 1 week and treated for a\nUTI. Currently she is unable to give a history herself. According\nto her husband and daughter, the patient had been on coumadin but\nthis was stopped in due to a splenic bleed.\nPMH: Afib (was on coumadin but stopped due to splenic\nhematoma), COPD, CRI, mitral regurgitation, depression, HTN,\nmonoclonal gammopathy, bipolar, hearing impaired\nPSH: hysterectomy, lumpectomy, cataracts\n: digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,\nnadolol 80', advair, albuterol prn, abilify 2' started ,\nprilosec, mnacrobid for UTI (treated for 8 days)\nFH: NC\nSH: resides at nursing home in , husband and daughter\n( ) make medical decisions for her\nAll: PCN, Ergot, Morphine, Latex\nOPERATION PERFORMED: Right iliofemoral popliteal tibial\nthrombectomy and right lower extremity fasciotomy for\ncompartment.\nFINDINGS: Thrombosis to right femoral popliteal and tibial\narteries and evidence of thrombus within the right common\nfemoral and superficial femoral artery.\n Of note: Has been lethargic and confused of late, is being treated for\n UTI with cipro\n VAC placed to Right lower leg fasciotomy.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Action:\n Response:\n Plan:\n .\n" }, { "category": "Nursing", "chartdate": "2173-08-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484753, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm and , intact and moves everything. Very minimal\n movement with right leg, however it is very endematous with a medial\n and lateral incisions.\n Action:\n Pulses are strongly dopplerable, 4+ pitting edema on the right leg,\n minimal edema to left leg, vascular team exchanged the wound vac sponge\n and assessed the healing of the underlying muscle/tissue, receiving\n lasix for diuresis\n Response:\n Vascular MD\n healing very well, muscle reperfused and pink,\n one small area of darker deep tissue, diuresing well 1500- of\n UO/day generally. Lasix decreased to 10mg \n Plan:\n Possible mid week closure to both incisions, possibly at the bedside if\n enough swelling has gone down\n" }, { "category": "Nursing", "chartdate": "2173-08-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485186, "text": "Arrived with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment. Of note: has been\n lethargic and confused of late, is being treated for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n Altered mental status (not Delirium)\n Assessment:\n Patient has baseline dementia and is confused and calls out for help,\n she is anxious and difficult to ease when she is worked up. Does not\n like most kinds of care, but is better than the past couple days. Some\n tasks she will allow when explained thoroughly to her with detail\n frequently.\n Action:\n Antipsychotic regimen of seroquel, sertraline and depakote\n Response:\n Patient remains confused, but is more calm then days past\n Plan:\n Continue to monitor and maintain patient safety\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n CV: HTN (160\ns/100\ns MAP 110\ns) and HR 100\ns with care, resting 80\n with SBP 120\ns, AF, no other ectopy, anasarca edema, dopplerable\n pulses, on Argatroban. Pedal pulses by doppler. Skin warm and dry.\n Resp: LSCTA, O2 3 liters Sats >92%, RR low 20\n GI: -Hoff through right nare with tube feed running at goal\n (60cc/hr), no residual\n GU: Patent foley with clear yellow urine Creat 1.5\n Endo: BS 130\ns-140\n Action:\n CV: Receives Lopressor, Digoxin, Cozaar as ordered, Hydralazine\n PRN,started on Coumadin , Agatroban increased to 1.25 @ 7:15 am,\n monitor PTT\ns every 6 hours, receives lasix 10mg \n GI: Monitored residuals, Continue TF\n Endo: Treated with CVICU RISS\n VAC dressing changed \n Cipro for UTI-needs 2 more doses at 12n and MN\n Response:\n CV: SBP 120\ns, HR 80\ns, diuresing well from the lasix, no other ectopy\n GI: No residuals, TF\ns at goal\n VAC dressing as ordered. Team changing every other day.\n Endo: Continue to monitor ACHS\n Plan:\n Plan to transfer to VICU. ? plan to close wounds later this week.\n" }, { "category": "Nursing", "chartdate": "2173-08-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485187, "text": "Arrived with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment. Of note: has been\n lethargic and confused of late, is being treated for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n PMHx:\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Altered mental status (not Delirium)\n Assessment:\n Patient has baseline dementia and is confused and calls out for help,\n she is anxious and difficult to ease when she is worked up. Does not\n like most kinds of care, but is better than the past couple days. Some\n tasks she will allow when explained thoroughly to her with detail\n frequently.\n Action:\n Antipsychotic regimen of seroquel, sertraline and depakote\n Response:\n Patient remains confused, but is more calm then days past\n Plan:\n Continue to monitor and maintain patient safety\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n CV: HTN (160\ns/100\ns MAP 110\ns) and HR 100\ns with care, resting 80\n with SBP 120\ns, AF, no other ectopy, anasarca edema, dopplerable\n pulses, on Argatroban. Pedal pulses by doppler. Skin warm and dry.\n Resp: LSCTA, O2 3 liters Sats >92%, RR low 20\n GI: -Hoff through right nare with tube feed running at goal\n (60cc/hr), no residual\n GU: Patent foley with clear yellow urine Creat 1.5\n Endo: BS 130\ns-140\n Action:\n CV: Receives Lopressor, Digoxin, Cozaar as ordered, Hydralazine\n PRN,started on Coumadin , Agatroban increased to 1.25 @ 7:15 am,\n monitor PTT\ns every 6 hours, receives lasix 10mg \n GI: Monitored residuals, Continue TF\n Endo: Treated with CVICU RISS\n VAC dressing changed \n Cipro for UTI-needs 2 more doses at 12n and MN\n Response:\n CV: SBP 120\ns, HR 80\ns, diuresing well from the lasix, no other ectopy\n GI: No residuals, TF\ns at goal\n VAC dressing as ordered. Team changing every other day.\n Endo: Continue to monitor ACHS\n Plan:\n Plan to transfer to VICU. ? plan to close wounds later this week.\n" }, { "category": "Nursing", "chartdate": "2173-08-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485188, "text": "Arrived with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment. Of note: has been\n lethargic and confused of late, is being treated for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n PMHx:\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Altered mental status (not Delirium)\n Assessment:\n Patient has baseline dementia and is confused and calls out for help,\n she is anxious and difficult to ease when she is worked up. Does not\n like most kinds of care, but is better than the past couple days. Some\n tasks she will allow when explained thoroughly to her with detail\n frequently.\n Action:\n Antipsychotic regimen of seroquel, sertraline and depakote\n Response:\n Patient remains confused, but is more calm then days past\n Plan:\n Continue to monitor and maintain patient safety\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n CV: HTN (160\ns/100\ns MAP 110\ns) and HR 100\ns with care, resting 80\n with SBP 120\ns, AF, no other ectopy, anasarca edema, dopplerable\n pulses, on Argatroban. Pedal pulses by doppler. Skin warm and dry.\n Resp: LSCTA, O2 3 liters Sats >92%, RR low 20\n GI: -Hoff through right nare with tube feed running at goal\n (60cc/hr), no residual\n GU: Patent foley with clear yellow urine Creat 1.5\n Endo: BS 130\ns-140\n Action:\n CV: Receives Lopressor, Digoxin, Cozaar as ordered, Hydralazine\n PRN,started on Coumadin , Agatroban increased to 1.25 @ 7:15 am,\n monitor PTT\ns every 6 hours, receives lasix 10mg \n K and Mag repleted.\n GI: Monitored residuals, Continue TF\n Endo: Treated with CVICU RISS\n VAC dressing changed . Ace wrap removed by team this am..\n Cipro for UTI-needs 2 more doses at 12n and MN\n Response:\n CV: SBP 120\ns, HR 80\ns, diuresing well from the lasix, no other ectopy\n GI: No residuals, TF\ns at goal\n VAC dressing as ordered. Team changing every other day.\n Endo: Continue to monitor ACHS\n Plan:\n Plan to transfer to VICU. ? plan to close wounds later this week.\n" }, { "category": "Nursing", "chartdate": "2173-08-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 485190, "text": "Arrived with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment. Of note: has been\n lethargic and confused of late, is being treated for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n PMHx:\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Altered mental status (not Delirium)\n Assessment:\n Patient has baseline dementia and is confused and calls out for help,\n she is anxious and difficult to ease when she is worked up. Does not\n like most kinds of care, but is better than the past couple days. Some\n tasks she will allow when explained thoroughly to her with detail\n frequently.\n Action:\n Antipsychotic regimen of seroquel, sertraline and depakote\n Response:\n Patient remains confused, but is more calm then days past\n Plan:\n Continue to monitor and maintain patient safety\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n CV: HTN (160\ns/100\ns MAP 110\ns) and HR 100\ns with care, resting 80\n with SBP 120\ns, AF, no other ectopy, anasarca edema, dopplerable\n pulses, on Argatroban. Pedal pulses by doppler. Skin warm and dry.\n Resp: LSCTA, O2 3 liters Sats >92%, RR low 20\n GI: -Hoff through right nare with tube feed running at goal\n (60cc/hr), no residual\n GU: Patent foley with clear yellow urine Creat 1.5\n Endo: BS 130\ns-140\n Action:\n CV: Receives Lopressor, Digoxin, Cozaar as ordered, Hydralazine\n PRN,started on Coumadin , Agatroban increased to 1.25 @ 7:15 am,\n monitor PTT\ns every 6 hours, receives lasix 10mg \n K and Mag repleted.\n GI: Monitored residuals, Continue TF\n Endo: Treated with CVICU RISS\n VAC dressing changed . Ace wrap removed by team this am..\n Cipro for UTI-needs 2 more doses at 12n and MN\n Response:\n CV: SBP 120\ns, HR 80\ns, diuresing well from the lasix, no other ectopy\n GI: No residuals, TF\ns at goal\n VAC dressing as ordered. Team changing every other day.\n Endo: Continue to monitor ACHS\n Plan:\n Plan to transfer to VICU. ? plan to close wounds later this week.\n Demographics\n Attending MD:\n MARK C.\n Admit diagnosis:\n TROMVECTOMY\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 60 kg\n Daily weight:\n 80.6 kg\n Allergies/Reactions:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Precautions:\n PMH: COPD, Renal Failure\n CV-PMH: Arrhythmias, Hypertension\n Additional history: a on coumadin stopped d/t splenic hematoma,\n HTN, COPD, CRI, MR, bipolar, hearing loss, monoclonal gammopathy,\n hysterectomy, lumpectomy, cataract . dementia. lives in ECF. of\n note is being treated for UTI.\n Surgery / Procedure and date: : R femoral\n thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:91\n D:57\n Temperature:\n 99.5\n Arterial BP:\n S:117\n D:66\n Respiratory rate:\n 18 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 96% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 972 mL\n 24h total out:\n 1,315 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:26 AM\n Potassium:\n 3.9 mEq/L\n 03:26 AM\n Chloride:\n 106 mEq/L\n 03:26 AM\n CO2:\n 30 mEq/L\n 03:26 AM\n BUN:\n 42 mg/dL\n 03:26 AM\n Creatinine:\n 1.5 mg/dL\n 03:26 AM\n Glucose:\n 114 mg/dL\n 03:26 AM\n Hematocrit:\n 29.5 %\n 03:26 AM\n Finger Stick Glucose:\n 102\n 06:00 PM\n Additional pertinent labs:\n K and Mag repleted\n Lines / Tubes / Drains:\n Foley, Pedi feeding tube, RIJ TLCL\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: CVICU A 696\n Transferred to: VICU 525\n Date & time of Transfer: 10:00 AM\n" }, { "category": "Nursing", "chartdate": "2173-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484849, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\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": "2173-08-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 484857, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt with stable blood pressure off pressors. good diuretic response to\n low dose lasix. Remains in baseline afib, rate controlled. Pedal\n pulses doppler. R foot cool, great toe purple rip with large blister\n on outer aspect. ACE wrap and vac dressing intact. Mildly febrile.\n Crying out with stimulation/care.\n Action:\n Monitored. Lasix diuresis. Pain treated with fent IV. Oral care.\n Metoprolol for rate control, antocoagulated on argatroban gtt.\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2173-08-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 485151, "text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Extremities warm/ dry. Rt lower leg with lateral & media VAC drg\n system intact and drg seroussang fluid.\n Rt TMT jt and great toe with large intact blisters. Upper portion of\n foot slighty dusky colored but warm with strong dopplerable pulses.\n 6+ edema on RLE. 4+ edema bilateral upper extremities.\n Action:\n BLE elevated off bed. Lasix 10mg .\n Response:\n Diuresing well. Vascular MD into see pt and pleased with progress.\n Plan:\n Continue to diurese. Possible closure of vac areas mid week. Transfer\n to VICU when bed available.\n" }, { "category": "Nursing", "chartdate": "2173-08-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 484972, "text": "Demographics\n Attending MD:\n MARK C.\n Admit diagnosis:\n TROMVECTOMY\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 60 kg\n Daily weight:\n 82 kg\n Allergies/Reactions:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Precautions:\n PMH: COPD, Renal Failure\n CV-PMH: Arrhythmias, Hypertension\n Additional history: a on coumadin stopped d/t splenic hematoma,\n HTN, COPD, CRI, MR, bipolar, hearing loss, monoclonal gammopathy,\n hysterectomy, lumpectomy, cataract . dementia. lives in ECF. of\n note is being treated for UTI.\n Surgery / Procedure and date: : R femoral\n thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:55\n Temperature:\n 98.2\n Arterial BP:\n S:117\n D:66\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 1,348 mL\n 24h total out:\n 1,460 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 04:21 AM\n Potassium:\n 3.5 mEq/L\n 04:21 AM\n Chloride:\n 107 mEq/L\n 04:21 AM\n CO2:\n 29 mEq/L\n 04:21 AM\n BUN:\n 39 mg/dL\n 04:21 AM\n Creatinine:\n 1.6 mg/dL\n 04:21 AM\n Glucose:\n 112 mg/dL\n 04:21 AM\n Hematocrit:\n 30.4 %\n 04:21 AM\n Finger Stick Glucose:\n 142\n 12:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with: none\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: \n Transferred to: VICU\n Date & time of Transfer: 09.20/09 1300\n Arrived with painful cold R leg at facility AM sent to \n hospital and transferred to for treatment. Of note: has been\n lethargic and confused of late, is being treated for UTI.\n : R femoral thrombectomy/fasciotomy.\n VAC placed to Right lowere leg fasciotomy.\n Altered mental status (not Delirium)\n Assessment:\n Patient has baseline dementia and is confused and calls out for help,\n she is anxious and difficult to ease when she is worked up. Does not\n like most kinds of care, but is better than the past couple days. Some\n tasks she will allow when explained thoroughly to her with detail\n frequently.\n Action:\n Antipsychotic regimen of seroquel, sertraline and depakote\n Response:\n Patient remains confused, but is more calm then days past\n Plan:\n Continue to monitor and maintain patient safety\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n CV: HTN (160\ns/100\ns MAP 110\ns) and HR 100\ns with care, resting 80\n with SBP 120\ns, AF, no other ectopy, anasarca edema, dopplerable\n pulses, on Argatroban\n Resp: LSCTA, O2 3 liters Sats >92%, RR low 20\n GI: -Hoff through right nare with tube feed running at goal\n (60cc/hr), no residual\n GU: Patent foley with clear yellow urine\n Endo: BS 130\ns-140\n Action:\n CV: Receives Lopressor, Cozaar as ordered, Hydralazine PRN, will be\n started on Coumadin at 1600 today, monitored PTT\ns every 6 hours,\n receives lasix \n GI: Monitored residuals\n Endo: Treated with CVICU RISS\n Response:\n CV: SBP 120\ns, HR 80\ns, diuresing well from the lasix, no other\n ectopy, PTT therapeutic\n GI: No residuals, maintain goal level\n Endo: Continue to monitor ACHS\n Plan:\n Plan to transfer to VICU\n" }, { "category": "Physician ", "chartdate": "2173-08-16 00:00:00.000", "description": "Intensivist Note", "row_id": 485162, "text": "SICU\n HPI:\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Micro/Imaging:\n urine Morganella morganii - cipro started \n MRSA positive - placed on precautions\n Events:\n HITT negative, versed gtt stopped, CPAP\n weaned off levo, changed line heparin free, and to argatroban\n fluid resus, pressors weaned, bleeding from right leg\n Assessment:77 year old female s/p ileofem.,.,tibial embolectomy/ RLE\n fasciotomy\n Plan:-better MS/resp. Decreasing rate diuresis. IN CVICU per vasc\n sx\n Chief complaint:\n PMHx:\n Current medications:\n 1.Albuterol 0.083% Neb Soln 6. Argatroban 7. Artificial Tears 8.\n Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate 13. Furosemide 14. HydrALAzine 15. Insulin\n 16. Ipratropium Bromide Neb 17. Levothyroxine Sodium 18. Losartan\n Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate 21. Metoprolol\n Tartrate 22. Midazolam 23. Pantoprazole 24. Pneumococcal Vac Polyvalent\n 25. Potassium Chloride 26. Quetiapine Fumarate 27. Sertraline 31.\n Warfarin\n 24 Hour Events:\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:54 AM\n Infusions:\n Argatroban - 1 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Pantoprazole (Protonix) - 08:35 AM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37\nC (98.6\n HR: 100 (70 - 100) bpm\n BP: 125/74(83) {86/55(60) - 129/92(94)} mmHg\n RR: 16 (16 - 27) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 60 kg\n Height: 67 Inch\n Total In:\n 2,426 mL\n 294 mL\n PO:\n Tube feeding:\n 1,440 mL\n 199 mL\n IV Fluid:\n 836 mL\n 95 mL\n Blood products:\n Total out:\n 2,470 mL\n 715 mL\n Urine:\n 2,470 mL\n 715 mL\n NG:\n Stool:\n Drains:\n Balance:\n -44 mL\n -421 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: Large bullae oon rt leg\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n No(t) Moves all extremities, (RUE: No movement), (LUE: Weakness)\n Labs / Radiology\n 187 K/uL\n 9.7 g/dL\n 114 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 42 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n 04:21 AM\n 03:26 AM\n WBC\n 11.2\n 13.1\n 13.2\n 14.5\n Hct\n 28.3\n 30.2\n 30.4\n 29.5\n Plt\n 83\n 126\n 165\n 187\n Creatinine\n 1.6\n 1.6\n 1.6\n 1.5\n TCO2\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n 94\n 112\n 114\n Other labs: PT / PTT / INR:28.5/58.6/2.8, CK / CK-MB / Troponin\n T:474/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.5 mg/dL, Mg:1.9 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), PERIPHERAL VASCULAR DISEASE (PVD)\n WITH CRITICAL LIMB ISCHEMIA, SHOCK, OTHER\n Assessment and Plan: Improving. transferto VICU\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Full anticoagulation, Beta-blocker\n Pulmonary: OOB and CPT\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Continue lasix\n Hematology: Coumadin started. Continue argatroban till INR 4\n Endocrine: RISS\n Infectious Disease: Check cultures, Ciprofloxacin for UTI. Day 5 today,\n will D?C\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Vascular surgery\n Billing Diagnosis: Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2173-08-16 00:00:00.000", "description": "ICU Note - CVI", "row_id": 485163, "text": "CVICU\n HPI:\n 77yoW s/p illeo-fem--tibial embolectomy\n PMHx:\n PMH: Afib (was on coumadin but stopped due to splenic\n hematoma), COPD, CRI, mitral regurgitation, depression, HTN,\n monoclonal gammopathy, bipolar, hearing impaired\n PSH: hysterectomy, lumpectomy, cataracts\n : digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar 50mg/D,\n nadolol 80mg/D', advair, albuterol prn, abilify 2' started ,\n prilosec\n Current medications:\n Albuterol-Ipratropium 5. Albuterol 0.083% Neb Soln 6. Argatroban 8.\n Calcium Gluconate 9. Ciprofloxacin 10. Divalproex Sod. Sprinkles 11.\n Digoxin 12. Fentanyl Citrate 13. Furosemide 14. HydrALAzine 15. Insulin\n 16. Ipratropium Bromide Neb 17. Levothyroxine Sodium 18. Losartan\n Potassium 19. Magnesium Sulfate 20. Metoprolol Tartrate 21. Metoprolol\n Tartrate 22. Midazolam 23. Pantoprazole 24. Pneumococcal Vac Polyvalent\n 25. Potassium Chloride 26. Quetiapine Fumarate 27. Sertraline Warfarin\n :\n Post operative day:\n pod 7 illeo-fem--tibial embolectomy\n Allergies:\n Morphine\n Unknown;\n Codeine\n Unknown;\n Latex\n Unknown;\n Penicillins\n Unknown;\n Naloxone\n Unknown;\n Ergonovine\n Unknown;\n Opioids-Morphine Related\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 11:54 AM\n Infusions:\n Argatroban - 1 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Pantoprazole (Protonix) - 08:35 AM\n Fentanyl - 12:00 AM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37\nC (98.6\n HR: 100 (70 - 100) bpm\n BP: 125/74(83) {86/55(60) - 129/92(94)} mmHg\n RR: 16 (16 - 27) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 80.6 kg (admission): 60 kg\n Height: 67 Inch\n Total In:\n 2,426 mL\n 293 mL\n PO:\n Tube feeding:\n 1,440 mL\n 199 mL\n IV Fluid:\n 836 mL\n 95 mL\n Blood products:\n Total out:\n 2,470 mL\n 715 mL\n Urine:\n 2,470 mL\n 715 mL\n NG:\n Stool:\n Drains:\n Balance:\n -44 mL\n -422 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases bilat)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: 4+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: rt groin incision with staple-CDI. right calf w/VAC\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RLE: No movement), (LLE: Weakness)\n Labs / Radiology\n 187 K/uL\n 9.7 g/dL\n 114 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 42 mg/dL\n 106 mEq/L\n 143 mEq/L\n 29.5 %\n 14.5 K/uL\n [image002.jpg]\n 12:00 AM\n 02:06 AM\n 02:13 AM\n 05:39 AM\n 06:00 AM\n 08:50 AM\n 02:27 PM\n 06:01 AM\n 04:21 AM\n 03:26 AM\n WBC\n 11.2\n 13.1\n 13.2\n 14.5\n Hct\n 28.3\n 30.2\n 30.4\n 29.5\n Plt\n 83\n 126\n 165\n 187\n Creatinine\n 1.6\n 1.6\n 1.6\n 1.5\n TCO2\n 26\n 27\n 27\n 28\n Glucose\n 144\n 117\n 109\n 94\n 112\n 114\n Other labs: PT / PTT / INR:28.5/58.6/2.8, CK / CK-MB / Troponin\n T:474/8/0.02, ALT / AST:26/116, Alk-Phos / T bili:40/0.7, Amylase /\n Lipase:64/31, Lactic Acid:1.5 mmol/L, Albumin:3.4 g/dL, LDH:354 IU/L,\n Ca:8.5 mg/dL, Mg:1.9 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), PERIPHERAL VASCULAR DISEASE (PVD)\n WITH CRITICAL LIMB ISCHEMIA, SHOCK, OTHER\n Assessment and Plan: s/p illeofem--tibeal embolectomy and\n fasciotomies.\n Neurologic: Pain controlled, fentanyl for pain control\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, tube feeds at goal rate\n Renal: Foley, Adequate UO\n Hematology: stable anemia\n Hit screen pending\n Endocrine: RISS\n Infectious Disease: Morganella in urine on Cipro will stop today(5day\n course)\n Afebrile\n Lines / Tubes / Drains: Foley, NGT, VAC dressing right leg\n Wounds: Dry dressings, Wound vacuum, VAC rt leg\n rt groin with staples CDI\n Consults: Vascular surgery, CT surgery, Nutrition\n ICU Care\n Nutrition: tube feeds at goal rate\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 11:34 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R), Argatroban (TM))\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, ICU consent signed Comments: Transfer to VICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Respiratory ", "chartdate": "2173-08-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 483719, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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 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: Not triggering\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Cannot protect\n airway, Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Radiology", "chartdate": "2173-08-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1097975, "text": " 1:30 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line position\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with new CVL\n REASON FOR THIS EXAMINATION:\n line position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New central venous access line. Evaluation for line position.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, an endotracheal tube has\n newly been placed. The tip of the tube projects roughly 2.5 cm above the\n carina. A new central venous access line has been introduced over the right\n internal jugular vein. The course of the catheter is unremarkable. The tip\n of the catheter projects over the lower SVC. There is no evidence of\n complications, notably no pneumothorax.\n\n As compared to the previous radiograph, the pre-existing elevation of the left\n hemidiaphragm has slightly increased. There is no evidence of focal\n parenchymal opacity suggesting pneumonia. No evidence of overhydration.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-08-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1098233, "text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p line change overwire rt ij\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p embolectomy right leg\n REASON FOR THIS EXAMINATION:\n s/p line change overwire rt ij\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh WED 3:35 PM\n PFI: Right IJ catheter tip in lower SVC without evidence of pneumothorax;\n small left pleural effusion with associated left lower lobe atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old female, status post embolectomy of the right leg, now\n with a recent right IJ line change over a wire.\n\n STUDY: Semi-upright portable AP chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The right IJ catheter tip is seen in the lower SVC. The\n endotracheal tube is 3.5 cm above the carina. An NG tube courses inferiorly,\n and its tip projects over the stomach. The side port is beneath the\n gastroesophageal junction. The cardiac size is on the high end of normal. The\n course of the aorta is tortuous. The left hemidiaphragm contour is obscured\n suggestive of a left-sided pleural effusion with associated left lower lobe\n atelectasis. There is no evidence for focal or lobar consolidation. There is\n no evidence of pneumothorax.\n\n IMPRESSION: Right IJ catheter tip in lower SVC without evidence of\n pneumothorax; small left pleural effusion with associated left lower lobe\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2173-08-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1098234, "text": ", C. CSRU 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p line change overwire rt ij\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p embolectomy right leg\n REASON FOR THIS EXAMINATION:\n s/p line change overwire rt ij\n ______________________________________________________________________________\n PFI REPORT\n PFI: Right IJ catheter tip in lower SVC without evidence of pneumothorax;\n small left pleural effusion with associated left lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2173-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1098587, "text": " 9:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chack DHT location\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with ischemic leg\n REASON FOR THIS EXAMINATION:\n chack DHT location\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ischemic leg, for Dobbhoff placement.\n\n FINDINGS: In comparison with the study of , the endotracheal tube has\n been removed. Nasogastric tube has been removed and replaced with a Dobbhoff\n tube, which extends to the body of the stomach, then coils back on itself so\n that the tip lies just below the esophagogastric junction.\n\n Persistent opacification at the left base most likely reflects a combination\n of atelectasis and effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1099011, "text": " 11:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with fevers\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n CXR SINGLE AP FILM SEMI-UPRIGHT.\n\n HISTORY: 77-year-old woman with fevers.\n\n Prior comparison film is from .\n\n FINDINGS: Heart size is difficult to assess due to AP projection and patient\n rotation. There is decrease in the density adjacent to the left lower heart\n border compared to . No congestive heart failure. Support lines are\n satisfactory and unchanged.\n\n CONCLUSION: Improvement in the left atelectasis/infiltrate and the small left\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-08-19 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1099582, "text": " 10:59 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: r/o DVT\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with wit Left upper arm swelling\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 77-year-old female with left upper extremity swelling.\n Clinical concern for deep venous thrombosis.\n\n COMPARISON: None.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of the left upper\n extremity veins were obtained.\n\n FINDINGS: The left internal jugular vein demonstrates normal compressibility\n and color flow, however there is blunting of the waveform. The left subclavian\n vein demonstrates normal color flow however a monophasic waveform is present\n which differs markedly from the normal variation which is seen on the right.\n The left cephalic, brachial, basilic veins demonstrate normal compressibility,\n color and Doppler flow. The axillary vein could not be imaged due to patient\n inability to position for the examination.\n\n IMPRESSION:\n\n Limited study due to limited patient mobility. Blunting of venous waveforms in\n the imaged veins of left upper extremity, particularly left subclavian in\n comparison with right, suggests the possibility of a more central stenosis or\n clot. However, no thrombus is seen in the imaged veins of the left upper\n extremity. A chest CT with contrast can be obtained for further evaluation.\n\n Above results were discussed with Dr. at 11:15 a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2173-08-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1097941, "text": " 6:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute proces\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with cold r foot\n REASON FOR THIS EXAMINATION:\n eval for acute proces\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old female with cold right foot, evaluate for acute process.\n\n No prior studies available for comparison.\n\n SINGLE AP VIEW OF THE CHEST: The heart is top normal in size, with an\n unfolded aorta. The lungs are clear without consolidation or edema. There is\n no pleural effusion or pneumothorax. The bones are mildly demineralized.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2173-08-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1098475, "text": " 4:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: TROMVECTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p right leg embolectomy\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n WET READ: 11:45 PM\n ETT 2.7 cm above carina, Rt IJ CVL in mid SVC, and OGT withproximal port\n probably just above GE junction (recommend advancing by at least several cm\n for more optimal position). Lt small-to-mod pl effusion with Lt retrocardiac\n opacity probably pl effusion with atelectasis, redistributed since 3.5 hours\n prior. probably tiny rt pl effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-embolectomy, to evaluate for effusion.\n\n FINDINGS: In comparison with the study of , the endotracheal tube is\n about 2.7 cm above the carina. Right IJ catheter extends to the mid portion\n of the SVC and the orogastric tube extends to the stomach, with the side hole\n just above the GE junction. Advancing this by at least several centimeters is\n recommended.\n\n Continued opacification at the left base consistent with effusion and\n atelectasis.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2188-08-01 00:00:00.000", "description": "R KNEE (2 VIEWS) RIGHT", "row_id": 1247946, "text": " 1:58 PM\n KNEE (2 VIEWS) RIGHT; ANKLE (2 VIEWS) RIGHT Clip # \n Reason: ? septic arthritis. Bony Destruction?\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with MSSA endocarditis\n REASON FOR THIS EXAMINATION:\n ? septic arthritis. Bony Destruction?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endocarditis, to assess for septic arthritis or bone destruction.\n\n FINDINGS: Views of the right hip show the bony structures and joint spaces to\n be within normal limits. It is difficult to assess for possible effusion due\n to opaque foreign bodies overlying the region.\n\n In the ankle, no true frontal view is obtained. However, there is no evidence\n of acute bone abnormality or disruption of the ankle mortise. There is some\n soft tissue prominence anterior to the distal tibia and talus, of uncertain\n significance.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-01 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1247947, "text": " 1:58 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: ? septic arthritis. Bony destruction?\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with MSSA endocarditis\n REASON FOR THIS EXAMINATION:\n ? septic arthritis. Bony destruction?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old woman with history of endocarditis, question of\n septic arthritis or bony destruction.\n\n COMPARISON: CT abdomen and pelvis from .\n\n TECHNIQUE: Single AP view of the pelvis along with two additional views of\n the right hip.\n\n FINDINGS: There is no evidence of any fracture or dislocation. There is\n evidence of mild degenerative changes of the left hip with bony spurring as\n well as moderate degenerative changes of the right hip with spurring and joint\n space narrowing. No evidence of bony erosions or periosteal reaction. No SI\n joint or pubic symphysis diastasis identified. No soft tissue calcification\n or radiopaque foreign body is seen.\n\n IMPRESSION:\n 1. No evidence of acute fracture or dislocation.\n 2. No evidence of bony destruction, erosive, or periosteal reaction.\n 3. Degenerative changes in the hips bilaterally, right greater than left. If\n there is continued concern for infection, recommend further evaluation with\n MRI.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-05 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1248365, "text": " 2:16 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place right sided picc\n Admitting Diagnosis: QUESTION OF SEPSIS\n This is a power pick\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis, has ppm in left and per cards would like\n to abstain from left sided PICC placement\n REASON FOR THIS EXAMINATION:\n please place right sided picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old woman with endocarditis. Please place right-sided\n PICC. Patient has a pacemaker over her left chest and per cardiology, would\n like to abstain from a left-sided PICC placement.\n\n COMPARISON: Comparison is made to PICC placement attempt on .\n\n RADIOLOGISTS: , M.D. (resident), , M.D.\n (resident), and (attending), who was present and supervising\n throughout the procedure).\n\n PROCEDURE: A preprocedure timeout was performed per protocol. Using\n sterile technique and local anesthesia, the right basilic vein was punctured\n using a micropuncture set and under direct ultrasound guidance. A guide wire\n was then advanced into the cephalad portion of the inferior vena cava. Under\n fluoroscopic guidance, the micropuncture catheter was exchanged for a\n peel-away sheath and a single-lumen PICC line measuring 33 cm in length was\n placed through the peel-away sheath with its tip positioned in the distal SVC.\n Position of the catheter was confirmed by a fluoroscopic spot film of the\n chest. The peel-away sheath and guide wire were then removed. Catheter was\n secured to the skin, flushed and sterile dressings applied.\n\n In addition, sutures placed as part of recent cutdown procedure performed , were removed.\n\n The patient tolerated the procedure well, and there were no immediate\n complications. Line is ready for use.\n\n IMPRESSION:\n 1. Successful placement of a right-sided PICC line via right basilic vein\n approach.\n 2. The tip lies in the distal SVC and may be used immediately.\n\n (Over)\n\n 2:16 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place right sided picc\n Admitting Diagnosis: QUESTION OF SEPSIS\n This is a power pick\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2188-07-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1247172, "text": " 11:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Acute bleed? septic embolic?\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with likely endocarditis, new neurologic sxs\n REASON FOR THIS EXAMINATION:\n Acute bleed? septic embolic?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with likely endocarditis, now with altered mental status.\n\n COMPARISONS: CT head of and MR head of .\n\n FINDINGS:\n\n Study is limited due to motion artifact. Within this limitation, there is a\n focal hypodensity in right parietal lobe subcortical in location (2A:19, 18),\n which appears new since prior exam. There is no evidence of intracranial\n hemorrhage, mass effect, or shift of normal midline structures. A focal\n hypodensity in the left cerebellar hemisphere is also seen (2A:2). There is\n no shift of normal midline structures. There is no hydrocephalus. The basal\n cisterns are patent. The imaged paranasal sinuses and mastoid air cells are\n well aerated. No suspicious osseous lesion is seen.\n\n IMPRESSION:\n\n Focal hypodensities in right parietal and left cerebellar hemispheres are new\n since exam, and may represent areas of infarction or infectious\n focus. Correlate with MRI Head without and with contrast if not CI.\n\n Findings discussed with Dr. by Dr. at 2:11 p.m. on \n by phone at the time of discovery.\n\n" }, { "category": "Radiology", "chartdate": "2188-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1247156, "text": " 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? septic emboli to lungs.\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with h/o endocarditis, septic emboli, IVDA, now with AMS and\n relapse\n REASON FOR THIS EXAMINATION:\n ? septic emboli to lungs.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of endocarditis, septic emboli, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the size of the cardiac\n silhouette is unchanged. Also unchanged is the alignment of the sternal wires\n and the course of the pacemaker leads. The previously seen multifocal\n parenchymal opacities have decreased in extent and severity. However,\n bilateral lower lung volumes are noted, and there is minimal blunting of the\n costophrenic sinuses, potentially suggesting small pleural effusions.\n Retrocardiac atelectasis. No evidence of pneumothorax.\n\n To assess the presence and extent of tension pleural effusions, a lateral\n radiograph would be helpful.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-07-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1247641, "text": " 9:26 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44cm right piccc. \n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 44cm right piccc. \n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY REPORT\n\n INDICATION: 29-year-old woman with new PICC line. Evaluate for placement.\n\n COMPARISON: A series of radiographs dating back to , most\n recently from .\n\n TECHNIQUE: Portable upright chest radiograph.\n\n FINDINGS: Small bibasilar pleural effusions are again noted. Evidence of\n increased pulmonary vascular congestion compared to the prior study.\n Cardiomediastinal silhouette remains unchanged. No pneumothorax identified.\n\n Interval removal of the endotracheal tube. The right internal jugular venous\n catheter is unchanged. There is interval placement of a right-sided PICC line\n that appears to traverse the midline and enter the left brachiocephalic vein.\n A dual-lead pacemaker is again noted with unchanged lead placement.\n\n IMPRESSION:\n 1. Interval removal of the endotracheal tube and increased pulmonary vascular\n congestion.\n 2. Interval placement of a right-sided PICC line with the tip terminating in\n the left brachiocephalic vein. Pulling the line back 6-7 cm, we will place\n the tip at the origin of the SVC. Ideally, the line should terminate in the\n SVC in the proximity of the cavoatrial junction.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-05 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1248397, "text": " 5:41 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o infection\n Admitting Diagnosis: QUESTION OF SEPSIS\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis (MSSA) with ongoing fevers concern for\n occult source (osteo vs abscess)\n REASON FOR THIS EXAMINATION:\n r/o infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa TUE 7:40 PM\n 1. left iliacus and psoas abscess(es) extending inferiorly to the iliopsoas.\n largest component measures up to 3.9 x 2.8 cm (TV) in the iliacus with smaller\n components in psoas and iliopsoas - unclear if all components communicate\n though they are closely approximated\n 2. smaller right psoas and iliacus abscess as compared to the left\n 3. splenic hypodensities, predominantly peripheral and some wedge-shaped\n could represent sequelae of infarct/septic emboli though these may be\n subacute.\n 4. persistent sequelae of previously noted lung septic embolic with bibasilar\n consolidations and moderate bilateral simple effusions which appear slightly\n increased in size from prior CT.\n 5. intra-abdominal ascites and anasarca\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old female with history of endocarditis (MSSA) with\n ongoing fevers and concern for occult source of underlying osteomyelitis or\n abscess formation, evaluate for infection.\n\n COMPARISON: CT chest from and CT abdomen and pelvis from\n . Renal ultrasound images from .\n\n TECHNIQUE:\n\n Contrast-enhanced axial CT images were obtained after administration of 130 cc\n of Omnipaque 350. Images were obtained from the level of the thoracic inlet\n down to below the ischium. Multiplanar reformatted images were obtained and\n reviewed.\n\n FINDINGS:\n\n CT CHEST:\n\n Right-sided PICC terminates in the mid SVC. Left pectoral pacer is noted.\n The thyroid is normal. No significant axillary lymphadenopathy.\n\n There has been overall improvement in the previously seen bilateral patchy\n nodular peripheral airspace disease since . A few patchy nodular\n areas of airspace disease are noted about the periphery, most notably in the\n posterior right upper lobe (2:12). However, this lesion's previously seen\n (Over)\n\n 5:41 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o infection\n Admitting Diagnosis: QUESTION OF SEPSIS\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n intrinsic cavitation has resolved. Mild interval progression of\n small-to-moderate bilateral pleural effusions and basilar relaxation\n atelectasis.\n\n Heart is enlarged with coronary artery calcification. Mildly enlarged\n pulmonary trunk measuring 3.2 cm in transverse dimension. The ascending and\n descending thoracic aorta at this level are normal in caliber. There are\n persistent prominent mediastinal lymph nodes, particularly the right\n paratracheal lymph node measuring 1 cm on short axis, previously 12 mm.\n\n CT ABDOMEN:\n\n Homogeneity of the liver without focal lesion.\n\n The spleen demonstrates a few small areas of peripheral linear, wedge shaped\n and a patchy nodular area of hypoattenuation relative to the remaining\n enhancing spleen. Given history and distribution, these findings are most\n consistent with splenic infarction, the largest area involving the\n posteroinferior aspect of the spleen. No evidence of thick nodular rim\n enhancement in this region to suggest developing splenic abscess formation.\n\n The gallbladder is partially decompressed with surrounding pericholecystic\n fluid. The pancreas is homogeneous without pancreatic ductal dilatation.\n Both adrenal glands are normal. Both kidneys demonstrate normal\n corticomedullary differentiation. No hydronephrosis or hydroureter.\n\n There is a moderate amount of intraperitoneal fluid, predominantly and\n diffusely noted about the mesentery extending into the lower pelvis. The\n portocaval lymph node measures 1 cm on short axis. A few small scattered\n paraaortic lymph nodes are noted.\n\n Mild ill definition and hypodensity involving the bilateral iliacus muscles,\n left greater than the right.\n\n The bowel is normal in caliber. Large amount of stool is noted within the\n rectum. There is a prominent 1-cm short axis short gastric lymph node.\n\n CT PELVIS: Ill-definition and hypoattenuation involving both iliacus muscles\n suggest underlying edema and/or inflammation. Additionally, intramuscular\n fluid collections are noted involving bilateral psoas and iliacus muscles,\n greater on the left and these are new. These fluid collections extend down\n inferiorly towards the lesser trochanteric insertion site. The largest of\n these fluid collections extends along the left iliacus muscles into the left\n iliac fossa with the largest area measuring 4.1 x 2.8 cm (2:105). A subtle\n rim of hyperattenuation is noted about these fluid collections and may suggest\n (Over)\n\n 5:41 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o infection\n Admitting Diagnosis: QUESTION OF SEPSIS\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n underlying inflammation or infection. These may connect to the iliopsoas\n bursas.\n\n Bladder is incompletely distended limiting evaluation for wall thickening.\n Uterus and both ovaries are grossly normal. Moderate amount of fluid is noted\n within the pelvis. Few scattered pelvic lymph nodes are noted. No pelvic or\n inguinal lymphadenopathy.\n\n Diffuse anasarca is noted.\n\n BONES: Midline sternotomy is noted. No evidence of osseous erosion involving\n the left iliac bone or lesser trochanter insertion sites to suggest CT\n evidence of osteomyelitis.\n\n IMPRESSION:\n 1. Interval development of small to moderate-sized intramuscular fluid\n collections involving both iliacus and psoas muscles, with the largest in the\n left iliacus with apparent connection to the underlying iliopsoas bursas.\n Suggestion of surrounding edema and hyperdense rim is concerning for\n underlying inflammation/infection. Differential considerations include\n abscess formation versus iliopsoas bursitis with developing infection.\n\n 2. Significant overall improvement of the intrapulmonary sequela of septic\n emboli with a few areas of residual nodularity and linear fibrosis.\n Previously seen peripheral nodules with intrinsic cavitation have mostly\n resolved. Moderate bilateral pleural effusions and basilar atelectasis\n persist.\n\n 3. Findings most consistent with subacute to chronic infarcts in the\n periphery of the spleen as detailed above. Vasculature is however grossly\n patent.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1248015, "text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluation for pneumonia, pulmonary edema\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with tricuspid endocarditis secondary to IVDU, increasing WBC\n and fevers concerning for possible septic embolic seeding lungs vs valve\n dysfunction\n REASON FOR THIS EXAMINATION:\n evaluation for pneumonia, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with tricuspid endocarditis\n secondary to intravenous drug abuse with increasing white blood cells and\n fevers with concern for possible septic emboli.\n\n AP radiograph of the chest was reviewed in comparison to .\n\n Since the prior study, there is interval development of pulmonary edema and\n increase in bilateral pleural effusions. The pulmonary edema is obscuring\n pulmonary nodules previously seen. The tubes and lines are in unchanged\n position. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-04 00:00:00.000", "description": "R HUMERUS (AP & LAT) SOFT TISSUE RIGHT", "row_id": 1248174, "text": " 8:27 AM\n HUMERUS (AP & LAT) SOFT TISSUE RIGHT Clip # \n Reason: The patient had an IR PICC attempted placement, but unsucces\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with failed PICC line placement\n REASON FOR THIS EXAMINATION:\n The patient had an IR PICC attempted placement, but unsuccessful. Part of\n guidewire sheared 2cm into subcutaneous tissue near basilic vein. Please\n perfrom xray to locate site of wire.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Two views of the right humerus .\n\n COMPARISON: Portable chest radiograph .\n\n INDICATION: IR PICC attempted placement but unsuccessful. Evaluate for\n guidewire piece.\n\n FINDINGS: A curved radiopaque density is seen within the posteromedial\n subcutaneous tissues, likely representing the guidewire fragment. No acute\n fractures. No definite dislocations. The AC joint is unremarkable.\n Subsegmental atelectasis and low lung volumes of the right lung. Small right\n pleural effusion.\n\n IMPRESSION: Subcutaneous foreign body as above.\n\n" }, { "category": "Radiology", "chartdate": "2188-07-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1247839, "text": " 5:44 PM\n CHEST (PA & LAT) Clip # \n Reason: Look at lead placement of pacer\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with endocarditis\n REASON FOR THIS EXAMINATION:\n Look at lead placement of pacer\n ______________________________________________________________________________\n WET READ: 8:59 PM\n The right PICC has been removed. The implanted pacemaker features 1 lead\n terminating within the right atrium and the other coursing through the\n coronary sinus and residing along the left ventricle. Small bilateral pleural\n effusions are unchanged.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Assess pacemaker leads. Patient with endocarditis.\n\n Left transvenous pacemaker leads terminate in the right atrium and through\n the coronary sinus. Right IJ catheter tip is at the cavoatrial junction.\n There are low lung volumes. Moderate bilateral pleural effusions are larger\n on the right side. Cardiomediastinal contours are unchanged. Large left\n lower lobe consolidation and right upper and lower lobe opacities are\n unchanged. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-01 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1247881, "text": " 8:14 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please assess for PICC placement.\n Admitting Diagnosis: QUESTION OF SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -58 SERVIC BY SAME MD DURING POST OP *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with endocarditis, pulled out PICC this morning, needs to be\n replaced\n REASON FOR THIS EXAMINATION:\n Please assess for PICC placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 29-year-old female with endocarditis in need of IV access after\n pulling her PICC.\n\n RADIOLOGISTS: MD (resident) and MD (attending, who\n was present and supervising).\n\n PROCEDURE: A preprocedure timeout was performed per protocol. Using\n sterile technique and local anesthesia, the right basilic vein was punctured\n under direct ultrasound guidance using a micropuncture set. A guidewire was\n then attempted to be advanced, although these attempts were unsuccessful.\n Attempts to remove the wire from the needle were also not successful. The\n needle was then retracted from the vein and as the wire and needle were\n removed, a small wire fragment had sheared within the soft tissue surrounding\n the vein. The fragment itself is approximately 1 cm in length.\n\n Using fluoroscopic guidance, a small incision in the skin was made after the\n application of local anesthesia, and a small set of clamps were\n used to bluntly dissect down to the level of the wire fragment which on\n ultrasound was confirmed to be 2 cm in depth from the skin surface. Attempts\n to retrieve the wire fragment were unsuccessful.\n\n The patient could not tolerate lying on the table due to chronic back\n problems, and a decision was made to leave this inert fragment rather than to\n advance the cutdown procedure. 2-0 silk sutures were used to close the\n incision.\n\n IMPRESSION:\n 1. Unsuccessful attempt at a PICC placement via the right basilic vein.\n 2. 1 cm wire fragment remaining in the soft tissues adjacent to the vein.\n Unable to be retrieved via a small cutdown procedure and an inability of the\n patient to tolerate lying on the angiography table despite sedation.\n\n These findings were discussed with Dr. immediately after the\n procedure by Dr. over the phone.\n (Over)\n\n 8:14 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please assess for PICC placement.\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2188-08-06 00:00:00.000", "description": "CT RETROPERITONEAL DRAINAGE", "row_id": 1248529, "text": " 6:17 PM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n Reason: please evaluate and drain left ileopsoas abscess seen on CT\n Admitting Diagnosis: QUESTION OF SEPSIS\n ********************************* CPT Codes ********************************\n * CT RETROPERITONEAL DRAINAGE CT GUIDANCE DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with MSSA endocarditis with persistent fevers, rigors and hip\n pain, CT abdomen shows bilateral ileopsoas abscesses, per ID should drain left\n sided (larger) lesion\n REASON FOR THIS EXAMINATION:\n please evaluate and drain left ileopsoas abscess seen on CT Torso dated \n (please send fluid for cell count and culture)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF THE PROCEDURE: .\n\n PROCEDURE TYPE: Percutaneous placement of an 8 French drainage catheter\n within a left iliopsoas muscle collection.\n\n OPERATORS: Dr. /Dr. .\n\n HISTORY AND INDICATION: 30-year-old woman with MSSA endocarditis with\n persistent fevers, rigors, and hip pain, CT abdomen showed bilateral iliopsoas\n abscesses; drainage of the larger left-sided iliopsoas abscess, which probably\n communicates with the iliopsoas bursa was requested.\n\n COMPARISON STUDIES: Recent CT of the Torso, dated .\n\n TECHNIQUE: The risks, benefits, and alternatives of the procedure were\n explained to the patient and written informed consent obtained. A\n pre-procedural timeout confirmed three patient identifiers and the side and\n type of the procedure to be performed. The patient was brought into the CT\n interventional suite. A preliminary preprocedure CT scan after placement of a\n grid over the left lower quadrant was performed. Left iliopsoas fluid\n collection, measuring approximately 4.2 x 3 cm in the axial plane was again\n noted.\n\n Moderate anesthesia care was provided by the anesthesia team. Please see\n separate report.\n\n The skin was draped and prepped in sterile usual manner. A 25-gauge needle\n was used for local anesthesia with 1% lidocaine. Then, an 18-gauge trocar\n needle was introduced along the selected tract. Using the Seldinger technique\n a wire and two sets of dilators 6 and 7 French were used to dilate the skin\n and the deeper tissues. Then, an 8 French catheter was placed within\n the fluid collection. A total of 30 cc of turbid fluid was aspirated and\n samples were sent for cell count and blood culture. The pigtail was deployed\n and the catheter was connected to a gravity bag and secured to the skin.\n\n (Over)\n\n 6:17 PM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n Reason: please evaluate and drain left ileopsoas abscess seen on CT\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Post-procedure scan without IV contrast was performed. Post-procedure scan\n demonstrates pigtail catheter within the nearly complete collapsed\n collection. There is again seen pelvic ascites with presence of\n hyperattenuating contrast within the bladder. The visualized aspect of the\n small and colonic loops of bowel demonstrate no gross abnormalities.\n\n Dr. was present throughout the entire procedure and performed crucial\n parts of it.\n\n The patient tolerated the procedure well without immediate complications. The\n patient left the department in good condition.\n\n IMPRESSION:\n\n Successful placement of an 8 French percutaneous catheter within a left-sided\n iliopsoas fluid collection.\n\n\n\n" }, { "category": "Echo", "chartdate": "2188-08-08 00:00:00.000", "description": "Report", "row_id": 94145, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis, known TVR endocarditis, eval for left sided vegetations\n: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 99/53\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 11:47\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was given 30 mg of propofol by anesthesia for sedation.\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. Normal interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No aortic valve abscess. No AR.\n\nMITRAL VALVE: Mitral valve annuloplasty ring. Moderate-sized vegetation on\nmitral valve. No mitral valve abscess. Mild (1+) MR.\n\nTRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Moderate vegetation on\ntricuspid valve. Moderate [2+] 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: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was monitored by a nurse throughout the procedure. The patient was monitored by a nurse throughout the procedure. No glycopyrrolate was administered. No\nTEE related complications.\n\nConclusions:\nNo masss/veg seen on pacer wires.The left atrium is normal in size. Overall\nleft ventricular systolic function is normal (LVEF>55%). The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion. No masses\nor vegetations are seen on the aortic valve. No aortic regurgitation is seen.\nA mitral valve annuloplasty ring is present. There is a moderate to large\nsized vegetation on the mitral valve. Mild (1+) mitral regurgitation is seen.\nA bioprosthetic tricuspid valve is present. There is a large vegetation on the\ntricuspid valve. Moderate [2+] tricuspid regurgitation is seen. No\nvegetation/mass is seen on the pulmonic valve.\n\nIMPRESSION: Bioprosthetic tricuspid valve endocarditis. Mitral\nvalve/annuloplasty ring endocarditis. Moderate tricuspid regurgitation.\n\nCompared with the prior study (images reviewed) of the mitral valve\nvegetation is new and tricuspid valve vegitation is increased in size. The\ntricuspid regurgitation is increased.\n\n\n" }, { "category": "Echo", "chartdate": "2188-08-02 00:00:00.000", "description": "Report", "row_id": 94146, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Prosthetic valve function. TVR ( Mosaic #23), mitral valve repair (26 mm CG Future Ring), PPM.\n: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 95/70\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 23:33\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Cannot assess RV systolic function. Paradoxic septal motion\nconsistent with prior cardiac surgery. Abnormal systolic septal\nmotion/position consistent with RV pressure overload.\n\nAORTIC VALVE: Three aortic valve leaflets. No masses or vegetations on aortic\nvalve, but cannot be fully excluded due to suboptimal image quality. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. No masses or vegetations on mitral valve, but cannot be\nfully excluded due to suboptimal image quality. Moderate thickening of mitral\nvalve chordae. Torn mitral chordae. Trivial MR. [Due to acoustic shadowing,\nthe severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Normal motion of TVR\nleaflets. No mass or vegetation on tricuspid valve. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Emergency study performed\nby the cardiology fellow on call.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). There is\nabnormal systolic septal motion/position consistent with right ventricular\npressure overload. There are three aortic valve leaflets. No masses or\nvegetations are seen on the aortic valve, but cannot be fully excluded due to\nsuboptimal image quality. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. A mitral valve annuloplasty ring is present. No\nmasses or vegetations are seen on the mitral valve, but cannot be fully\nexcluded due to suboptimal image quality. There is moderate thickening of the\nmitral valve chordae. Torn mitral chordae are present. Trivial mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] A bioprosthetic tricuspid\nvalve is present. The motion of the tricuspid prosthetic leaflets appears\nnormal. No vegetation is seen on the prosthetic tricuspid valve. There is no\npericardial effusion.\n\nIMPRESSION: SUBOPTIMAL IMAGE QUALITY, FOCUSED VIEWS: No clear evidence of\nprosthetic or native valve endocarditis in the setting of marked tachycardia\nand suboptimal image quality. Gradients were not obtained across prosthetic\nTVR and mitral annuloplasty ring.\n\nCompared with the prior study (images reviewed) of , heart rate is\nfaster. Tricuspid valve vegetation is no longer visualized.\n\n\n" }, { "category": "Echo", "chartdate": "2188-07-26 00:00:00.000", "description": "Report", "row_id": 94147, "text": "PATIENT/TEST INFORMATION:\nIndication: History of Tricuspid valve replacement (#23 Mosaic tissue), mitral valve repair (P2 resection,26mm CG Future Ring).PPM, now septic, rule out endocarditis\n: (in) 68\nWeight (lb): 166\nBSA (m2): 1.89 m2\nBP (mm Hg): 98/48\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 14:19\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was intubated prior to procedure. She also received 20mg propofol\nat the time of procedure.\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No aortic valve abscess. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. No mass or vegetation on mitral valve. Trivial MR.\n\nTRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Thickened TVR leaflets.\nSmall vegetation on tricuspid valve. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. No masses or vegetations are\nseen on the aortic valve. No aortic valve abscess is seen. No aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened. A\nmitral valve annuloplasty ring is present. No mass or vegetation is seen on\nthe mitral valve. Trivial mitral regurgitation is seen. A bioprosthetic\ntricuspid valve is present. There is a small (0.7x0.3), linear, mobile\nechodensity attached to the septal tricuspid leaflet consistent with a\nvegetation. The body of the antero-lateral and septal leaflets of the\nbioprosthesis appear thickened (clips 122, 126) suggesting more extensive\nleaflet involvement by the infectious process. The mean transtricuspid mean\ngradient and peak velocity are slightly higher than expected for the type of\nvalve. There are two pacer wires noted, one in the coronary sinus, and one in\nthe right atrium. No mass or vegetation seen on the pacer wires.\n\nIMPRESSION: Small vegetation on the septal leaflet of the bioprosthetic\ntricuspid valve with thickening of the anterolateral and septal leaflets and\nslightly higher than expected transvalvular gradients. These findings are new\ncompared with the prior study dated (images reviewed).\n\n\n" }, { "category": "Radiology", "chartdate": "2188-07-26 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1247222, "text": " 8:10 PM\n RENAL U.S. PORT Clip # \n Reason: acute kidney injury? spetic emboli? renal blood flow?\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with endocarditis and large increase in creatinine\n REASON FOR THIS EXAMINATION:\n acute kidney injury? spetic emboli? renal blood flow?\n ______________________________________________________________________________\n WET READ: LLTc SUN 2:27 AM\n Normal renal US exam.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of endocarditis with creatinine elevation.\n\n COMPARISON: No comparison studies available.\n\n TECHNIQUE: Grayscale ultrasonography of the kidneys and bladder.\n\n FINDINGS: The right and left kidneys measure 14.7 and 15.3 cm, respectively.\n There is no mass, stone or hydronephrosis. A Foley catheter lies within an\n unremarkable bladder.\n\n IMPRESSION:\n\n Normal grayscale ultrasound examination of the kidneys and bladder. Note that\n Doppler evaluation of blood flow was not performed, and can be performed\n separately as clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2188-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1247176, "text": " 12:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with ETT placement\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: ETT placement.\n\n COMPARISON: , 7:53 a.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 5.8 cm above the carina.\n The course of the nasogastric tube is unremarkable, the tip of the tube is not\n visualized on the image. The lung volumes have increased, likely reflecting\n the administration of ventilatory pressure. Unchanged size of the cardiac\n silhouette. Unchanged status post valvular repair and unchanged course of the\n pacemaker leads.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1249021, "text": " 3:12 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval previously noted psoas abscesses, now s/p IR gui\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis and large septic emboli burden\n REASON FOR THIS EXAMINATION:\n please eval previously noted psoas abscesses, now s/p IR guided drain to left\n abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRAf MON 5:11 PM\n 1. Near resolution of left psoas muscle fluid collection after drain\n placement. The drain could be removed if the output is less than 15 mL for a\n consecutive 48 hours.\n 2. Ill-defined fluid collections within the bilateral iliacus muscles have\n decreased in size from prior.\n 3. Significant volume overload marked by anasarca, gallbladder wall edema,\n mild ascites, bilateral moderate pleural effusions and intralobular septal\n thickening.\n 4. Unchanged intrapulmonary sequela of septic emboli with few areas of\n residual nodularity and fibrosis.\n 5. Unchanged splenic infarctions without evidence of abscess formation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old female with endocarditis and large septic emboli,\n please evaluate previously noted psoas abscess status post IR drain placement.\n\n COMPARISONS: .\n\n TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet\n to the pubic symphysis after the uneventful administration of IV contrast.\n Coronal and sagittal reformations were provided and reviewed.\n\n DLP: 947.53 mGy-cm.\n\n CHEST: The visualized thyroid is normal. Scattered axillary lymph nodes are\n again noted, measuring up to 8 mm. Prominent mediastinal nodes are again\n seen, measuring up to 1 cm. There is no hilar lymphadenopathy. There are\n bilateral moderate-sized pleural effusions, unchanged from prior. The\n adjacent compressive atelectasis and bilateral patchy nodular peripheral\n airspace disease is stable. A small ground glass nodule in the anterior\n portion of the right upper lobe measuring 6.5 mm is unchanged (2:31). The\n heart size is enlarged. There is no pericardial effusion. A left side\n pacemaker is noted with wires terminating in the right atrium and right\n ventricle. A right side central line is present with its distal tip in the\n mid SVC. Tricuspid and mitral valve prostheses are present. The pulmonary\n trunk is moderately enlarged, measuring 3.7 cm in the transverse dimension.\n\n ABDOMEN: The liver enhances homogeneously without focal lesions. The\n gallbladder wall is thickened and there is mild prominence of the intrahepatic\n biliary ducts, compatible with volume overload. There is no evidence of\n (Over)\n\n 3:12 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please eval previously noted psoas abscesses, now s/p IR gui\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cholecystitis. An infarction in the posterior aspect of the spleen is\n unchanged from prior. There is no evidence of rim formation to suggest\n development of an abscess. The adrenal glands are unremarkable. The kidneys\n enhance symmetrically and excrete contrast without hydronephrosis. There is a\n mild amount of ascites, unchanged. The stomach, large and small bowel are\n normal. A 1.1-cm gastric lymph node is again noted (2:55). There is no\n mesenteric lymphadenopathy or free air.\n\n PELVIS: The previously noted left psoas fluid collection has decreased in\n size after catheter placement, now measuring 3 x 1 cm (2:105). The\n ill-defined fluid collections within the iliacus muscles have decreased in\n size from prior. The bladder, uterus and rectum are normal. A moderate\n amount of stool is noted in the rectal vault. There is no inguinal or pelvic\n sidewall lymphadenopathy.\n\n BONES AND SOFT TISSUES: Diffuse anasarca is present. There are no suspicious\n osseous lesions. Midline sternotomy wires are present.\n\n IMPRESSION:\n 1. Near resolution of left psoas muscle fluid collection after drain\n placement. The drain could be removed if the output is less than 15 mL/day\n for a consecutive 48 hours.\n 2. Ill-defined fluid collections within the iliacus muscles have decreased in\n size from prior.\n 3. Significant volume overload marked by anasarca, gallbladder wall edema,\n mild ascites, bilateral moderate pleural effusions and intralobular septal\n thickening.\n 4. Unchanged intrapulmonary sequela of septic emboli with a few areas of\n residual nodularity and fibrosis.\n 5. Unchanged splenic infarctions without evidence of abscess formation.\n\n" }, { "category": "Radiology", "chartdate": "2188-07-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1247212, "text": " 5:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CVL placement, RIJ\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with new CVL\n REASON FOR THIS EXAMINATION:\n CVL placement, RIJ\n ______________________________________________________________________________\n WET READ: SHSf SAT 8:06 PM\n New RIJ, dual lead pacemaker, ET and NG tubes are in satisfactory position.\n Left basal atelectasis and effusion is increased along with mild pulmonary\n edema. Mild cardiomgaly is stable. No pneumothorax on this supine view.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Central venous line placement.\n\n COMPARISON: , 12:26 p.m.\n\n FINDINGS: New right internal jugular vein catheter. Unchanged dual-lead\n pacemaker. Endotracheal tube and nasogastric tube are in correct position.\n Left basal atelectasis and effusion is increased, mild pulmonary edema is\n present. Mild cardiomegaly that has not changed. No evidence of\n pneumothorax. The tip of the right internal jugular line projects over the\n cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-07-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1247655, "text": " 11:06 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc cross the chest. pulled guidewire back 7cm, power flu\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r picc cross the chest. pulled guidewire back 7cm, power flushed. repeat x-ray\n iv \n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: 29-year-old lady with PICC repositioning, evaluate new position.\n\n COMPARISON: Chest radiograph from earlier this morning.\n\n TECHNIQUE: Portable upright chest radiograph.\n\n FINDINGS: Tip of the right-sided PICC still remains in the left\n brachiocephalic vein approximately 2.5 cm from the origin of SVC. Position of\n the right internal jugular venous catheter is unchanged. Cardiomediastinal\n contours are unchanged from the previous exam. Pulmonary vascular congestion\n seen earlier is not significantly changed and increased density in the left\n lower lobe likely represents superimposed atelectasis. No pneumothorax\n\n IMPRESSION: Tip of right-sided PICC line terminates in the left\n brachiocephalic vein approximately 2.5 cm from the origin of the SVC.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-22 00:00:00.000", "description": "INJ/ASP MAJOR JT W/FLUORO", "row_id": 1250215, "text": " 10:28 AM\n INJ/ASP MAJOR JT W/FLUORO Clip # \n Reason: please tap R hip and r/o septic arthritis\n Admitting Diagnosis: QUESTION OF SEPSIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis c/o worsening R hip pain xdays, CT without\n evidence of abscess\n REASON FOR THIS EXAMINATION:\n please tap R hip and r/o septic arthritis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT HIP ASPIRATION\n\n CLINICAL INDICATION: 30 year old woman with endocarditis and worsening right\n hip pain. Recent CT showing small right hip joint effusion. Clinical concern\n for septic joint.\n\n COMPARISON: CT dated \n\n PROCEDURE: Written informed consent was obtained after explaining the\n procedure to be performed, risks, and alternatives. A preprocedure timeout\n confirmed the procedure to be performed and the identity of the patient using\n three patient identifiers.\n\n The skin entry site in the right anterior hip was chosen and the skin was\n prepped in standard sterile fashion. Approximately 2 mL of 1% lidocaine was\n infiltrated into the subcutaneous soft tissues overlying region of interest.\n Under intermittent fluoroscopic guidance, an 18 gauge spinal needle was\n advanced into the right hip joint space. Approximately 2 mL of yellowish\n nonpurulent right hip joint space fluid was aspirated.\n\n The needle was removed, pressure applied to needle entry site, and hemostasis\n achieved. Patient tolerated the procedure well. There were no immediate\n complications.\n\n FINDINGS: Moderate right superior joint space narrowing, articular surface\n sclerosis and marginal osteophytes. No fracture or dislocation.\n\n IMPRESSION:\n 1. Uneventful right hip joint aspiration of approximately 2 mL of yellowish\n nonpurulent right hip joint fluid. Specimens were obtained and carried\n directly to the pathology laboratory for microbiologic and fluid analysis.\n 2. Imaging shows moderate degenerative right hip joint disease.\n\n Dr. ,, the attending radiologist was present and supervising throughout\n the procedure.\n\n\n (Over)\n\n 10:28 AM\n INJ/ASP MAJOR JT W/FLUORO Clip # \n Reason: please tap R hip and r/o septic arthritis\n Admitting Diagnosis: QUESTION OF SEPSIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2188-08-18 00:00:00.000", "description": "R US EXTREMITY NONVASCULAR RIGHT", "row_id": 1249695, "text": " 1:39 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: rule out right thigh abscess\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis IVDA and iliopsoas abscess c/o\n increasing right hip and thigh pain, noted with asymmetric right lateral upper\n thigh soft tissue swelling\n REASON FOR THIS EXAMINATION:\n rule out right thigh abscess\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Ultrasound of the right lower extremity, nonvascular.\n\n COMPARISON: CT of the pelvis .\n\n FINDINGS: Soft tissue edema is present. There is no visualization of a fluid\n collection.\n\n IMPRESSION: No fluid collection present to suggest an abscess.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1249356, "text": " 4:41 PM\n CT PELVIS W/CONTRAST Clip # \n Reason: please eval previously drained left psoas abscess for recoll\n Admitting Diagnosis: QUESTION OF SEPSIS\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis, previous L psoas abscess s/p drain\n placement and removal, with increasing left hip pain.\n REASON FOR THIS EXAMINATION:\n please eval previously drained left psoas abscess for recollection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endocarditis with prior left psoas abscess post-drainage with\n increasing left hip pain.\n\n COMPARISON: CTs available from and 24, .\n\n TECHNIQUE:\n MDCT-acquired 5-mm axial images of the pelvis were obtained following the\n uneventful administration of 130 cc of Omnipaque intravenous contrast.\n Coronal and sagittal reformations were performed at 5-mm slice thickness.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n Since the CT examination, there has been interval removal of a\n left iliacus drain. A previously-seen small fluid collection at the\n termination point has enlarged slightly to 2.4 x 1.6 cm axially (2:26). Trace\n fluid is again seen within the lower psoas (2:35), unchanged from prior\n examinations. No new fluid collections are seen. Trace intrapelvic free\n fluid remains within physiological limits. A moderate amount of stool is\n again seen within the colon. The bladder and uterus are normal. There are no\n bony lesions suspicious for malignancy or infection. Moderate anasarca is\n unchanged.\n\n IMPRESSION:\n 1. Slight enlargement of a left iliacus fluid collection at the prior drain\n termination site, currently measuring 2.4 x 1.6 cm.\n 2. Trace lower psoas fluid appears unchanged since .\n 3. No new fluid collections.\n 4. Unchanged moderate anasarca.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-21 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1250111, "text": " 1:21 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please extend pelvic imaging to include lower femur. Thank y\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n At the request of house officer Olurinde Mobolaji, images were reviewed with\n attention to the right hip and femur.\n\n There is moderate to moderately severe diffuse narrowing of the right hip.\n This finding is assymetric -- the left hip joint space is grossly preserved.\n Small right > left marginal spurs are seen about the hip joint. No subchondral\n cyst formation, subchondral sclerosis, or bone erosion is seen in the right or\n left hip joints. There is a probable small right hip joint effusion. No\n evidence of fracture or osteonecrosis is detected about the right or left hip.\n The right femur is imaged to ~16.7 cm below the level of the hip joint.\n\n IMPRESSION:\n\n Osteorarthritis of the right hip, assymetrically worse on the right side, and\n progressed compared with and CT scans, with small right hip\n joint effusion. In the appropriate clinical setting, this would be concerning\n for septic arthritis. Note is made that the patient is s/p right hip\n aspiration, with negative micro lab results at this time.\n\n These findings were discussed with Subintern Mobolaji on the afternoon of\n (, phone).\n\n\n 1:21 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please extend pelvic imaging to include lower femur. Thank y\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with endocarditis and iliopsoas abscess IVDA, with\n persistent right hip/thigh pain x days.\n REASON FOR THIS EXAMINATION:\n Please extend pelvic imaging to include lower femur. Thank you. Please r/o\n right hip/thigh/psoas abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:51 PM\n 1. In this patient with known iliopsoas fluid collection, there has been no\n significant interval change.\n 2. No new intra-abdominal fluid collection or abscess.\n 3. Old splenic infarcts.\n 4. Moderate anasarca.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old woman with history of IV drug abuse, endocarditis and\n iliopsoas abscess, to assess for other sites of abdominopelvic abscess.\n\n COMPARISON: CT pelvis with contrast of and CT torso with contrast of\n .\n\n TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained\n after the administration of 130 cc of Omnipaque intravenous contrast.\n Sagittal and coronal reformations were performed and reviewed.\n\n DLP: 441.29 mGy-cm.\n\n FINDINGS: Small simple bilateral pleural effusions have decreased since the\n prior study. Bilateral mild compressive atelectasis of the imaged lung bases\n are noted. Mitral and tricuspid valvular prosthesis are noted.\n\n The liver enhances homogeneously, without focal lesions. There is no intra-\n or extra-hepatic biliary dilatation. The gallbladder is decompressed with\n mild wall edema, which likely relates to third spacing. Few peripheral\n hypodense areas in the spleen with the largest seen in the inferior pole, are\n consistent with old infarcts. The pancreas and adrenal glands are normal.\n Both kidneys enhance and excrete contrast symmetrically, without\n hydronephrosis. There is a small amount of perihepatic and pelvic ascites.\n No rim-enhancing intra-abdominal abscess is seen. There is no intra-abdominal\n free air. The abdominal aorta is normal in course and caliber. Small\n scattered retroperitoneal lymph nodes do not meet CT criteria for significant\n adenopathy.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, uterus, and\n adnexa are unremarkable. The rectum and sigmoid colon are normal. There is a\n small amount of pelvic ascites.\n\n (Over)\n\n 1:21 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please extend pelvic imaging to include lower femur. Thank y\n Admitting Diagnosis: QUESTION OF SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n A rim-enhancing fluid collection in the left iliacus muscle, extending into\n the iliopsoas tendon down to the level of its insertion, now measuring 2.0 x\n 1.3 cm, allowing for differences in technique, is stable since the prior\n study, 2.4 x 1.6 cm. A smaller fluid collection in the left psoas muscle\n (2:94) now measures 1.7 x 1.0 cm, and is not significantly changed since the\n prior study.\n\n BONES AND SOFT TISSUES: No bone lesions suspicious for infection or\n malignancy are detected. There is unchanged moderate anasarca of the\n abdominal and pelvic soft tissues.\n\n IMPRESSION:\n 1. In this patient with known left iliopsoas abscess, there has been no\n significant interval change. No new intra-abdominal fluid collection or\n abscess.\n 2. Old splenic infarcts.\n 3. Moderate anasarca.\n\n" }, { "category": "ECG", "chartdate": "2188-07-31 00:00:00.000", "description": "Report", "row_id": 249871, "text": "Atrial sensed ventricularly paced rhythm at 117 beats per minute. Compared to\nthe previous tracing of the rapid ventricular pacing is new.\n\n\n" }, { "category": "ECG", "chartdate": "2188-07-27 00:00:00.000", "description": "Report", "row_id": 249872, "text": "Sinus rhythm with intermittent ventricular pacing. Compared to the previous\ntracing occasional native conduction is seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2188-07-26 00:00:00.000", "description": "Report", "row_id": 249873, "text": "Sinus tachycardia with ventricular pacing. Compared to the previous tracing\npacemaker is seen.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2188-08-03 00:00:00.000", "description": "Report", "row_id": 249869, "text": "Sinus rhythm with ventricular pacing. Compared to the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2188-07-31 00:00:00.000", "description": "Report", "row_id": 249870, "text": "Atrially sensed ventricularly paced rhtyhm. Underlying rhythm is sinus rhythm.\nCompared to the previous tracing of there is no significant diagnostic\nchange.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2111-02-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 612568, "text": "Chief Complaint: Hypoxia\n 24 Hour Events:\n --Reconciled NH meds\n --Daughter says she makes medical decisions but is not officially\n HCP; does not know about DNR/DNI status and felt uncomfortable signing\n ICU consent.\n -Trial of Bipap; patient could not tolerate first attempt (also\n desatted to mid 80s when NC taken off), and then refused subsequent\n attempts.\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 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 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 107 (87 - 110) bpm\n BP: 151/77(94) {110/57(68) - 172/111(114)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 71.2 kg (admission): 72.8 kg\n Height: 65 Inch\n Total In:\n 1,117 mL\n 192 mL\n PO:\n 720 mL\n 120 mL\n TF:\n IVF:\n 397 mL\n 72 mL\n Blood products:\n Total out:\n 995 mL\n 375 mL\n Urine:\n 995 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 122 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///36/\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 315 K/uL\n 11.8 g/dL\n 178 mg/dL\n 0.5 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 27 mg/dL\n 101 mEq/L\n 144 mEq/L\n 37.3 %\n 10.5 K/uL\n [image002.jpg]\n 06:05 AM\n 05:36 AM\n WBC\n 9.8\n 10.5\n Hct\n 38.6\n 37.3\n Plt\n 255\n 315\n Cr\n 0.7\n 0.5\n Glucose\n 254\n 178\n Other labs: PT / PTT / INR:27.2/32.0/2.7, Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.9 mg/dL\n Microbiology: 11:28 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS, CHAINS, AND CLUSTERS.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n Blood and urine cultures pending.\n Assessment and Plan\n This is a 75-year-old woman with a history of significant obstructive\n lung disease (COPD) complicated by significant restrictive disease from\n obesity, who comes in with hypoxemia and respiratory acidosis from\n nursing home. Most likely mucous plugging and/or sleep apnea\n contributing to acute on chronic issue.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612513, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n She has been seen by speech and swallow in the past who recommend a\n soft diet, thin liquids OK and put pills in applesauce, crushed when\n possible. They recommend pt be watched closely for signs of aspiration\n while eating. She is tolerating a regular diet well today and we are\n choosing soft foods since this is what was recommended by speech and\n swallow eval in the past. Pt passed large stool once today.\n .H/O respiratory failure, chronic\n Assessment:\n Pt with history of COPD and uses inhalers and O2 3L NC at baseline.\n Baselline CO2 has been seen in the 50-70 range. This admission pt\n admitted with hypoxia, hypercapnea. CXR showing ?infiltrate in LUL with\n bilateral atelectasis and ?fluid overload. Treated with nebs,\n antibiotics, O2 supplemental. Pt improved quickly in EW. Remains with\n congested weak cough with infrequent production due to weakness and\n inability to do a strong cough. Lungs with crackles bilaterally with\n diminished breath sounds throughout due to poor insp effort.\n Action:\n Attempted to do IS with pt. Pt with very poor insp effort. Once she got\n ball up to 150cc\ns. CPT done as well without much success. Team\n decided to try Non-invasive ventilation on this pt and keep pt here for\n this reason. Apparently she was supposed to have sleep study done for\n possible OSA but they will take advantage of her hospitalization and\n attempt to try bi-pap while she is here. Antibiotics held for now since\n pt is afebrile and she is afebrile. Diuresis held for now as her fluid\n balance status is questionable.\n Response:\n Able to cough up thick yellow sputum for culture once. Culture sent.\n Plan:\n Bi-pap trial tonight to see if pt tolerates it with plan for Bi-pap\n overnight as tolerated. Follow her for resp decompensation/distress.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt admitted with history DM II. She was given steroids IV in EW and\n glucose was 280 this AM.\n Action:\n Currently being treated with sliding scale humolog insulin Q6hr\n Response:\n Pt\ns glucose was 234 at noon and pt given 4u H SC Glucose at 1800 was\n 421 and pt covered with 12 units and team notified.\n Plan:\n Continue to follow with QID coverage per sliding scale. Team is writing\n to restart her normal long acting insulin doses.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt confused and nervous about being out of her usual environment.\n Pulling off her O2 sat monitor and refused Pneumoboots. INR is 4.1 this\n AM so this is not a big concern. She is moaning a lot and asking me to\n stay with her at all times. She wines and says\nI think I am going to\n die tonight\n Action:\n Provided frequent reassurance and visits to this pt. Attempted to\n reorient and reassure her this visit is temporary to try to improve her\n breathing. I applied waffle boots because her heels are red\n bilaterally. I looked through her med list from the NH and found that\n pt is on Clonazapam .5mg PO BID so this was restarted.\n Response:\n Pt remains anxious but allows us to check her sat intermittently. She\n is OK with BP cuff and foley catheter. Has not been trying to climb OOB\n or pull IV\ns. Less anxiety after clonazapam.\n Plan:\n Continue to provide calming reassurance and provide as much attention\n to her as possible as she states that night time is usually bad for\n her.\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612503, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n She has been seen by speech and swallow in the past who recommend a\n soft diet, thin liquids OK and put pills in applesauce, crushed when\n possible. They recommend pt be watched closely for signs of aspiration\n while eating. She is tolerating a regular diet well today and we are\n choosing soft foods since this is what was recommended by speech and\n swallow eval in the past. Pt passed large stool once today.\n .H/O respiratory failure, chronic\n Assessment:\n Pt with history of COPD and uses inhalers and O2 3L NC at baseline.\n Baselline CO2 has been seen in the 50-70 range. This admission pt\n admitted with hypoxia, hypercapnea. CXR showing ?infiltrate in LUL with\n bilateral atelectasis and ?fluid overload. Treated with nebs,\n antibiotics, O2 supplemental. Pt improved quickly in EW. Remains with\n congested weak cough with infrequent production due to weakness and\n inability to do a strong cough. Lungs with crackles bilaterally with\n diminished breath sounds throughout due to poor insp effort.\n Action:\n Attempted to do IS with pt. Pt with very poor insp effort. Once she got\n ball up to 150cc\ns. CPT done as well without much success. Team\n decided to try Non-invasive ventilation on this pt and keep pt here for\n this reason. Apparently she was supposed to have sleep study done for\n possible OSA but they will take advantage of her hospitalization and\n attempt to try bi-pap while she is here. Antibiotics held for now since\n pt is afebrile and she is afebrile. Diuresis held for now as her fluid\n balance status is questionable.\n Response:\n Able to cough up thick yellow sputum for culture once. Culture sent.\n Plan:\n Bi-pap trial today to see if pt tolerates it with plan for Bi-pap\n overnight as tolerated. Follow her for resp decompensation/distress.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt admitted with history DM II. She was given steroids IV in EW and\n glucose was 280 this AM.\n Action:\n Currently being treated with sliding scale humolog insulin Q6hr\n Response:\n Pt\ns glucose was 234 at noon and pt given 4u H SC\n Plan:\n Continue to follow with QID coverage per sliding scale.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt confused and nervous about being out of her usual environment.\n Pulling off her O2 sat monitor and refused Pneumoboots. INR is 4.1 this\n AM so this is not a big concern. She is moaning a lot and asking me to\n stay with her at all times. She wines and says\nI think I am going to\n die tonight\n Action:\n Provided frequent reassurance and visits to this pt. Attempted to\n reorient and reassure her this visit is temporary to try to improve her\n breathing. I applied waffle boots because her heels are red\n bilaterally. I looked through her med list from the NH and found that\n pt is on Clonazapam .5mg PO BID so this was restarted.\n Response:\n Pt remains anxious but allows us to check her sat intermittently. She\n is OK with BP cuff and foley catheter. Has not been trying to climb OOB\n or pull IV\ns. Less anxiety after clonazapam.\n Plan:\n Continue to provide calming reassurance and provide as much attention\n to her as possible as she states that night time is usually bad for\n her.\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612516, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n She has been seen by speech and swallow in the past who recommend a\n soft diet, thin liquids OK and put pills in applesauce, crushed when\n possible. They recommend pt be watched closely for signs of aspiration\n while eating. She is tolerating a regular diet well today and we are\n choosing soft foods since this is what was recommended by speech and\n swallow eval in the past. Pt passed large stool once today.\n .H/O respiratory failure, chronic\n Assessment:\n Pt with history of COPD and uses inhalers and O2 3L NC at baseline.\n Baselline CO2 has been seen in the 50-70 range. This admission pt\n admitted with hypoxia, hypercapnea. CXR showing ?infiltrate in LUL with\n bilateral atelectasis and ?fluid overload. Treated with nebs,\n antibiotics, O2 supplemental. Pt improved quickly in EW. Remains with\n congested weak cough with infrequent production due to weakness and\n inability to do a strong cough. Lungs with crackles bilaterally with\n diminished breath sounds throughout due to poor insp effort.\n Action:\n Attempted to do IS with pt. Pt with very poor insp effort. Once she got\n ball up to 150cc\ns. CPT done as well without much success. Team\n decided to try Non-invasive ventilation on this pt and keep pt here for\n this reason. Apparently she was supposed to have sleep study done for\n possible OSA but they will take advantage of her hospitalization and\n attempt to try bi-pap while she is here. Antibiotics held for now since\n pt is afebrile and she is afebrile. Diuresis held for now as her fluid\n balance status is questionable.\n Response:\n Able to cough up thick yellow sputum for culture once. Culture sent.\n Plan:\n Bi-pap trial tonight to see if pt tolerates it with plan for Bi-pap\n overnight as tolerated. Follow her for resp decompensation/distress.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt admitted with history DM II. She was given steroids IV in EW and\n glucose was 280 this AM.\n Action:\n Currently being treated with sliding scale humolog insulin Q6hr\n Response:\n Pt\ns glucose was 234 at noon and pt given 4u H SC Glucose at 1800 was\n 421 and pt covered with 12 units and team notified.\n Plan:\n Team ordered to restart her normal long acting insulin doses. Pt\n given 22 units 70/30 at 1830. Please follow glucose closely tonight.\n Continue with sliding scale coverage.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt confused and nervous about being out of her usual environment.\n Pulling off her O2 sat monitor and refused Pneumoboots. INR is 4.1 this\n AM so this is not a big concern. She is moaning a lot and asking me to\n stay with her at all times. She wines and says\nI think I am going to\n die tonight\n Action:\n Provided frequent reassurance and visits to this pt. Attempted to\n reorient and reassure her this visit is temporary to try to improve her\n breathing. I applied waffle boots because her heels are red\n bilaterally. I looked through her med list from the NH and found that\n pt is on Clonazapam .5mg PO BID so this was restarted.\n Response:\n Pt remains anxious but allows us to check her sat intermittently. She\n is OK with BP cuff and foley catheter. Has not been trying to climb OOB\n or pull IV\ns. Less anxiety after clonazapam.\n Plan:\n Continue to provide calming reassurance and provide as much attention\n to her as possible as she states that night time is usually bad for\n her.\n" }, { "category": "Case Management ", "chartdate": "2111-02-04 00:00:00.000", "description": "Initial Patient Assessment", "row_id": 612476, "text": "Case Management Initial Assessment\n The patient is a 75F pt with hx of bilateral PE's, AF, COPD,\n Non-Obstructive CAD and Dementia, presenting with hypoxemia.\n The patient is a long-term care resident fo Health Care Center.\n She is on a 10-day Medicaid bed-hold at the facility. This nurse case\n manager has notified the liaison for HealthBridge and anticipate that\n the patient will return to NHCC once her condition has stabilized.\n This NCM will continue to follow the patient while she is in the ICU.\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612468, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n .H/O respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612479, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n .H/O respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt admitted with history DM II. She was given steroids IV in EW and\n glucose was 280 this AM.\n Action:\n Currently being treated with sliding scale humolog insulin Q6hr\n Response:\n Pt\ns glucose was 234 at noon and pt given 4u H SC\n Plan:\n Continue to follow with QID coverage per sliding scale.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt confused and nervous about being out of her usual environment.\n Pulling off her O2 sat monitor and refused Pneumoboots.\n Action:\n Provided frequent reassurance and visits to this pt. Attempted to\n reorient and reassure her this visit is temporary to try to improve her\n breathing.\n Response:\n Pt remains anxious but allows us to check her sat intermittently. She\n is OK with BP cuff and foley catheter. Has not been trying to climb OOB\n or pull IV\n Plan:\n Continue to provide calming reassurance and provide as much attention\n to her as possible as she states that night time is usually bad for\n her.\n" }, { "category": "Physician ", "chartdate": "2111-02-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 612480, "text": "Chief Complaint: Hypoxia\n HPI:\n 75F pt with a hx of COPD ( spirometry with (FVC 0.96, FEV1\n 0.47, ratio of 49, 71% predicted), on 3L 02, hx bilateral PE's (),\n AF (currently anticoagulated), non-obstructive CAD, EF 75% to 80%\n (), pacemaker and dementia (baseline AO ), presented today from\n with hypoxia.\n .\n Per records the pt was noted at 10:45pm to have the following\n vitalsL: 97.5 125/78, 89 RR24 and 83% on 3L (baseline 3L, usually in\n 90s). The pt received Albuterol Nebs x2 (10:55pm and 11:15pm) and was\n subsequently sent to the ED.\n .\n Upon arrival to the ED 96.2 94 139/90 20 94. Pt reported to have\n Crackles L>R. Denied SOB. ABG 7.42/64/62. The pt was given neb,\n Solumedrol 125mg IVx1. ED was concerned for LUL infiltrate and thus\n drew BCx and treated pt with Vancomycin 1gm IV, Levofloxacin 750mg\n IVx1. Vitals prior to transfer to the floor 92 150/90 22 94% on 4L.\n .\n The patient unable to adeuately answer the following review of\n symptoms: fever, chills, night sweats, loss of appetite, fatigue, chest\n pain, palpitations, rhinorrhea, nasal congestion, hemoptysis, dyspnea,\n orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea,\n constipation, hematochezia, melena, dysuria, urinary frequency, urinary\n urgency, focal numbness, focal weakness, myalgias, arthralgias\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PER OMR\n - AF on coumadin\n - CAD (per chart; however had non-obstructive CAD on previous cath)\n - Multiple bilateral PE's ()\n - DMII\n - Dyslipidemia\n - COPD\n - Anemia with basline HCT 31-33\n - Osteoporosis\n - Chronic joint pain\n - GERD\n - Dementia\n - anxiety / depression\n - Dysphagia per records though not noted to be on special diet\n - Dementia\n - MRSA PNA req. ICU admission with ETT\n - Acute Cholangitis ( with acute cholangitis due to\n choledocolithiasis underwent urgent ERCP with stenting)\n - Pulmonary Nodule Noted on CT : 6-mm left lower lobe nodule\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\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: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 106 (93 - 106) bpm\n BP: 153/96(108) {153/79(101) - 164/96(108)} mmHg\n RR: 18 (16 - 18) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 65 Inch\n Total In:\n 220 mL\n PO:\n TF:\n IVF:\n 220 mL\n Blood products:\n Total out:\n 0 mL\n 265 mL\n Urine:\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -45 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : L>R, No(t) Wheezes : ,\n Diminished: R>L)\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 255\n 11.9\n 254\n 0.7\n 35\n 39\n 98\n 4.2\n 143\n 38.6\n 9.8\n [image002.jpg]\n Assessment and Plan\n 75F pt with hx of bilateral PE's, AF, COPD, Non-Obstructive CAD and\n Dementia, presenting with hypoxemia.\n .\n # Hypoxemia: Pt on baseline 3L at , presented to the MICU this AM on\n 3L. ED ABG with p02 of 62, pCO2 of 64 indicative of A-a gradient. No\n clear evidence of infiltrate on CXR, although could not exclude\n retrocardiac opacity as source of infection. Pt now at baseline 02\n requirement. Unclear precipitating events for transient hypoxia (COPD\n excerbation resolving with steroids, atelectasis, mucous plugging,\n fluid overload, PE). Another possibility is that patient has\n obstructive sleep apnea and vitals at NH were taken while patient\n asleep. Pt now at baseline without appreciable wheezes on exam. No\n increase in sputum production from baseline. No reported fevers of\n chills.\n - Will d/c Vanc/Levaquin as pt is currently without fever, leukocytosis\n or increased sputum production.\n - Cont 3L NC\n - OOB to chair\n - Trial of Bipap with f/u ABG if patient tolerates\n - guafenesin, Chest PT\n .\n # Hypercarbia: Pt with PFTs suggestive of COPD (FVC 0.96, FEV1 0.47,\n ratio of 49, 71% predicted), however pt with tachypnea, wheezing.\n ?increase in productive cough. Pt with hx of pCO2 50-70s. Currently\n breathing comfortably and mentating likely close to baseline. HC)3 of\n 39 is at patients approximate baseline.\n - Trial of bipap as above\n - Will hold off steroids currently, given no audible wheezes.\n - Repeat ABG\n .\n # Fluid Status: Pt with initial Hct of 38 (baseline approx 30), in\n setting of increase BUN and slightly increased pt may be\n intravascularly depleted, however this is difficult to assess given\n crackles on physical exam and suggestion of fluid overload on CXR.\n - Follow UOP\n - hold of on fluid boluses unless UOP drops\n .\n # +UA: Pt with +Nitrites, neg Leuks, although 0-2 WBCs. Currently\n asymptomatic. Received dose of Levaquin in ED. Denied dysuria on exam.\n - f/u Ucx\n - hold of on abx for now\n .\n #. Mental Status: Non-focal neuro exam. Baseline reported to be AOx1-2.\n Patient currently calm. Unclear if patient altered from baseline.\n - Contact daughter in AM to assess patient and provide baseline MS\n .\n # DM II:ISS while in house\n .\n # AF: Currently rate controlled on Metoprolol and Diltiazem. INR\n currently supratherapeutic without signs of bleeding.\n - Anticipate jump in INR given pt received Levaquin this PM, will hold\n Coumadin\n - Cont Metoprolol/Diltiazem\n .\n # Code status: Presumed Full confirmed at 10/27\n .\n # Contacts: daughter \n .\n # Dispo: patient was discharged to HCC with follow up\n appointments with pulmonology and for sleep study.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: insulin SS\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT: supratherapeutic on coumadin\n Stress ulcer: None\n VAP:\n Comments: bowel regimen, nebs\n Communication: Comments: daugher\n Code status: presumed full, will confirm with daugher\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612483, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n .H/O respiratory failure, chronic\n Assessment:\n Pt with history of COPD and uses inhalers and O2 3L NC at baseline.\n Baselline CO2 has been seen in the 50-70 range. This admission pt\n admitted with hypoxia, hypercapnea. CXR showing ?infiltrate in LUL with\n bilateral atelectasis and ?fluid overload. Treated with nebs,\n antibiotics, O2 supplemental. Pt improved quickly in EW. Remains with\n congested weak cough with infrequent production due to weakness and\n inability to do a strong cough. Lungs with crackles bilaterally with\n diminished breath sounds throughout due to poor insp effort.\n Action:\n Attempted to do IS with pt. Pt only able to move the diaphragm\n slightly. Once she got it up to 150cc\ns. CPT done as well without much\n success. Team has decided to try Non-invasive ventilation on this pt.\n Apparently she was supposed to have sleep study done for possible OSA\n but they will take advantage of her hospitalization and attempt to try\n bi-pap while she is here. Antibiotics held for now. Diuresis held for\n now as her fluid balance status is questionable.\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt admitted with history DM II. She was given steroids IV in EW and\n glucose was 280 this AM.\n Action:\n Currently being treated with sliding scale humolog insulin Q6hr\n Response:\n Pt\ns glucose was 234 at noon and pt given 4u H SC\n Plan:\n Continue to follow with QID coverage per sliding scale.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt confused and nervous about being out of her usual environment.\n Pulling off her O2 sat monitor and refused Pneumoboots.\n Action:\n Provided frequent reassurance and visits to this pt. Attempted to\n reorient and reassure her this visit is temporary to try to improve her\n breathing.\n Response:\n Pt remains anxious but allows us to check her sat intermittently. She\n is OK with BP cuff and foley catheter. Has not been trying to climb OOB\n or pull IV\n Plan:\n Continue to provide calming reassurance and provide as much attention\n to her as possible as she states that night time is usually bad for\n her.\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612484, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin/vanco. pt with hr in 90s afib.\n inr 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n PMH: COPD on chronic O2 3L NC at NH, A-fib, CAD, Dementia, DM II, S/P\n , 75% 2/09, PE on coumadin, MRSA PNA /, acute\n cholangitis recently s/p stent\n Allergies: , Morphine\n Pt is on sliding scale humolog insulin QID. She is in a-fib and has\n been restarted on her regular diltiazem and lopressor PO for rate\n control.\n .H/O respiratory failure, chronic\n Assessment:\n Pt with history of COPD and uses inhalers and O2 3L NC at baseline.\n Baselline CO2 has been seen in the 50-70 range. This admission pt\n admitted with hypoxia, hypercapnea. CXR showing ?infiltrate in LUL with\n bilateral atelectasis and ?fluid overload. Treated with nebs,\n antibiotics, O2 supplemental. Pt improved quickly in EW. Remains with\n congested weak cough with infrequent production due to weakness and\n inability to do a strong cough. Lungs with crackles bilaterally with\n diminished breath sounds throughout due to poor insp effort.\n Action:\n Attempted to do IS with pt. Pt only able to move the diaphragm\n slightly. Once she got it up to 150cc\ns. CPT done as well without much\n success. Team has decided to try Non-invasive ventilation on this pt.\n Apparently she was supposed to have sleep study done for possible OSA\n but they will take advantage of her hospitalization and attempt to try\n bi-pap while she is here. Antibiotics held for now. Diuresis held for\n now as her fluid balance status is questionable.\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt admitted with history DM II. She was given steroids IV in EW and\n glucose was 280 this AM.\n Action:\n Currently being treated with sliding scale humolog insulin Q6hr\n Response:\n Pt\ns glucose was 234 at noon and pt given 4u H SC\n Plan:\n Continue to follow with QID coverage per sliding scale.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt confused and nervous about being out of her usual environment.\n Pulling off her O2 sat monitor and refused Pneumoboots. INR is 4.1 this\n AM so this is not a big concern. She is moaning a lot and asking me to\n stay with her at all times.\n Action:\n Provided frequent reassurance and visits to this pt. Attempted to\n reorient and reassure her this visit is temporary to try to improve her\n breathing. I applied waffle boots because her heels are red\n bilaterally.\n Response:\n Pt remains anxious but allows us to check her sat intermittently. She\n is OK with BP cuff and foley catheter. Has not been trying to climb OOB\n or pull IV\n Plan:\n Continue to provide calming reassurance and provide as much attention\n to her as possible as she states that night time is usually bad for\n her.\n" }, { "category": "Physician ", "chartdate": "2111-02-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 612566, "text": "Chief Complaint: Hypoxia\n 24 Hour Events:\n --Reconciled NH meds\n --Daughter says she makes medical decisions but is not officially\n HCP; does not know about DNR/DNI status and felt uncomfortable signing\n ICU consent.\n -Trial of Bipap; patient could not tolerate first attempt (also\n desatted to mid 80s when NC taken off), and then refused subsequent\n attempts.\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 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 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 107 (87 - 110) bpm\n BP: 151/77(94) {110/57(68) - 172/111(114)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 71.2 kg (admission): 72.8 kg\n Height: 65 Inch\n Total In:\n 1,117 mL\n 192 mL\n PO:\n 720 mL\n 120 mL\n TF:\n IVF:\n 397 mL\n 72 mL\n Blood products:\n Total out:\n 995 mL\n 375 mL\n Urine:\n 995 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 122 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///36/\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 315 K/uL\n 11.8 g/dL\n 178 mg/dL\n 0.5 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 27 mg/dL\n 101 mEq/L\n 144 mEq/L\n 37.3 %\n 10.5 K/uL\n [image002.jpg]\n 06:05 AM\n 05:36 AM\n WBC\n 9.8\n 10.5\n Hct\n 38.6\n 37.3\n Plt\n 255\n 315\n Cr\n 0.7\n 0.5\n Glucose\n 254\n 178\n Other labs: PT / PTT / INR:27.2/32.0/2.7, Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.9 mg/dL\n Microbiology: 11:28 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS, CHAINS, AND CLUSTERS.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n Blood and urine cultures pending.\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n .H/O DIABETES MELLITUS (DM), TYPE II\n .H/O RESPIRATORY FAILURE, CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2111-02-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 612570, "text": "Chief Complaint: Hypoxia\n 24 Hour Events:\n --Reconciled NH meds\n --Daughter says she makes medical decisions but is not officially\n HCP; does not know about DNR/DNI status and felt uncomfortable signing\n ICU consent.\n -Trial of Bipap; patient could not tolerate first attempt (also\n desatted to mid 80s when NC taken off), and then refused subsequent\n attempts.\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 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 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 107 (87 - 110) bpm\n BP: 151/77(94) {110/57(68) - 172/111(114)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 71.2 kg (admission): 72.8 kg\n Height: 65 Inch\n Total In:\n 1,117 mL\n 192 mL\n PO:\n 720 mL\n 120 mL\n TF:\n IVF:\n 397 mL\n 72 mL\n Blood products:\n Total out:\n 995 mL\n 375 mL\n Urine:\n 995 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 122 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///36/\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 315 K/uL\n 11.8 g/dL\n 178 mg/dL\n 0.5 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 27 mg/dL\n 101 mEq/L\n 144 mEq/L\n 37.3 %\n 10.5 K/uL\n [image002.jpg]\n 06:05 AM\n 05:36 AM\n WBC\n 9.8\n 10.5\n Hct\n 38.6\n 37.3\n Plt\n 255\n 315\n Cr\n 0.7\n 0.5\n Glucose\n 254\n 178\n Other labs: PT / PTT / INR:27.2/32.0/2.7, Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.9 mg/dL\n Microbiology: 11:28 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS, CHAINS, AND CLUSTERS.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n Blood and urine cultures pending.\n Assessment and Plan\n This is a 75-year-old woman with a history of significant obstructive\n lung disease (COPD) complicated by restrictive disease from obesity,\n who comes in with hypoxemia and respiratory acidosis from nursing\n home. Most likely mucous plugging and/or sleep apnea contributing to\n acute on chronic issue.\n # Hypoxemia/hypercarbia: Most likely from COPD exacerbated by\n obstructive sleep apnea and/or mucous plugging (other possibilities\n include atelectasis and fluid overload). Little concern for infection\n at this time, as patient is afebrile, no leukocytosis, and sputum is\n not increased signficantly from baseline. No clear evidence of\n infiltrate on CXR. We will try to maximize oxygenation with chest PT,\n bipap, and other non-invasive measures.\n --Continue albuterol, atrovent, and advair\n --Aggressive chest PT\n --Cont 3L NC\n --Patient did not tolerate BiPap last night, but could try again\n --Guaifenesin\n --Hold off on antibiotics for now, in absence of localizing\n signs/symptoms of infection\n # U/A with +nitrates, many pacteria, negative leukocytes, and 0-2 WBC.\n Patient had been mid-way through course of macrobid at nursing home.\n Received one dose of Levaquin in ED.\n --Follow-up urine culture\n --Consider antibiotics\n # Fluid Status: Patient still may be intravascularly depleted with hct\n of 37 (baseline is 30) and slightly elevated sodium. However, both Na\n and sodium are trending down.\n --Continue to follow urine output, and consider fluid if drops\n --Encourage po free water intake.\n .\n #. Mental Status: Non-focal neuro exam. Daughter states that patient\n baseline is conversant, intermittently oriented with appropriate\n responses. Unclear if Ms. is truly back at baseline.\n --Continue to monitor, orient\n -- consider treating UTI\n .\n # DM II:ISS while in house\n .\n # AF: Currently rate controlled on Metoprolol and Diltiazem. INR is 2.7\n today, down from 4.1 yesterday\n --Cont Metoprolol/Diltiazem\n --Restart coumadin\n .\n # Code status: Presumed Full confirmed at 10/27\n .\n # Contacts: daughter \n .\n # Dispo: patient was discharged to HCC with follow up\n appointments with pulmonology and for sleep study.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: insulin SS\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT: supratherapeutic on coumadin\n Stress ulcer: None\n VAP:\n Comments: bowel regimen, nebs\n Communication: Comments: daugher\n Code status: presumed full, will confirm with daugher\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2111-02-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 612590, "text": "Chief Complaint: Hypoxia\n 24 Hour Events:\n --Reconciled NH meds\n --Daughter says she makes medical decisions but is not officially\n HCP; does not know about DNR/DNI status and felt uncomfortable signing\n ICU consent.\n -Trial of Bipap; patient could not tolerate first attempt (also\n desatted to mid 80s when NC taken off), and then refused subsequent\n attempts.\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 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 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 107 (87 - 110) bpm\n BP: 151/77(94) {110/57(68) - 172/111(114)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 71.2 kg (admission): 72.8 kg\n Height: 65 Inch\n Total In:\n 1,117 mL\n 192 mL\n PO:\n 720 mL\n 120 mL\n TF:\n IVF:\n 397 mL\n 72 mL\n Blood products:\n Total out:\n 995 mL\n 375 mL\n Urine:\n 995 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 122 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///36/\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 315 K/uL\n 11.8 g/dL\n 178 mg/dL\n 0.5 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 27 mg/dL\n 101 mEq/L\n 144 mEq/L\n 37.3 %\n 10.5 K/uL\n [image002.jpg]\n 06:05 AM\n 05:36 AM\n WBC\n 9.8\n 10.5\n Hct\n 38.6\n 37.3\n Plt\n 255\n 315\n Cr\n 0.7\n 0.5\n Glucose\n 254\n 178\n Other labs: PT / PTT / INR:27.2/32.0/2.7, Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.9 mg/dL\n Microbiology: 11:28 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS, CHAINS, AND CLUSTERS.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n Blood and urine cultures pending.\n Assessment and Plan\n This is a 75-year-old woman with a history of significant obstructive\n lung disease (COPD) complicated by restrictive disease from obesity,\n who comes in with hypoxemia and respiratory acidosis from nursing\n home. Most likely mucous plugging and/or sleep apnea contributing to\n acute on chronic issue. However, an infection is possible in setting\n of productive cough.\n # Hypoxemia/hypercarbia: Most likely from COPD exacerbated by\n obstructive sleep apnea and/or mucous plugging (other possibilities\n include atelectasis and fluid overload). Minimal concern for infection\n at this time, as patient is afebrile/noleukocytosis, but bronchitis is\n still possible. Treat with 5 days of levaquin and discharge.\n --Levaquin 750mg x5 days for bronchitis\n --Continue albuterol, atrovent, and advair\n --Aggressive chest PT\n --Cont 3L NC\n --Patient did not tolerate BiPap last night, but could try again\n --Guaifenesin\n # U/A with +nitrates, many pacteria, negative leukocytes, and 0-2 WBC.\n Patient had been mid-way through course of macrobid at nursing home.\n Received one dose of Levaquin in ED.\n --Follow-up urine culture\n --Patient on levaquin regardless for bronchitis; should cover most UTI\n bugs\n .\n #. Mental Status: Non-focal neuro exam. Daughter states that patient\n baseline is conversant, intermittently oriented with appropriate\n responses. Unclear if Ms. is truly back at baseline.\n --Continue to monitor, orient\n --Antibiotics for possible infection\n .\n # DM II:ISS while in house\n .\n # AF: Currently rate controlled on Metoprolol and Diltiazem. INR is 2.7\n today, down from 4.1 yesterday\n --Cont Metoprolol/Diltiazem\n --Continue to hold coumadin in setting of levaquin.\n --Restart coumadin at 0.5 on , then INR check on .\n .\n # Code status: Confirmed with daughter on \n .\n # Contacts: daughter \n .\n # Dispo: Discharge to HCC\n ICU Care\n Nutrition: regular diet\n Glycemic Control: insulin SS\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT: On coumadin\n Stress ulcer: None\n VAP:\n Comments: bowel regimen, nebs\n Communication: Comments: daugher\n Code status: presumed full, will confirm with daugher\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2111-02-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 612592, "text": "Chief Complaint: Hypoxia\n 24 Hour Events:\n --Reconciled NH meds\n --Daughter says she makes medical decisions but is not officially\n HCP; does not know about DNR/DNI status and felt uncomfortable signing\n ICU consent.\n -Trial of Bipap; patient could not tolerate first attempt (also\n desatted to mid 80s when NC taken off), and then refused subsequent\n attempts.\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 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 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 107 (87 - 110) bpm\n BP: 151/77(94) {110/57(68) - 172/111(114)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 71.2 kg (admission): 72.8 kg\n Height: 65 Inch\n Total In:\n 1,117 mL\n 192 mL\n PO:\n 720 mL\n 120 mL\n TF:\n IVF:\n 397 mL\n 72 mL\n Blood products:\n Total out:\n 995 mL\n 375 mL\n Urine:\n 995 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 122 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///36/\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 315 K/uL\n 11.8 g/dL\n 178 mg/dL\n 0.5 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 27 mg/dL\n 101 mEq/L\n 144 mEq/L\n 37.3 %\n 10.5 K/uL\n [image002.jpg]\n 06:05 AM\n 05:36 AM\n WBC\n 9.8\n 10.5\n Hct\n 38.6\n 37.3\n Plt\n 255\n 315\n Cr\n 0.7\n 0.5\n Glucose\n 254\n 178\n Other labs: PT / PTT / INR:27.2/32.0/2.7, Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.9 mg/dL\n Microbiology: 11:28 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS, CHAINS, AND CLUSTERS.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n Blood and urine cultures pending.\n Assessment and Plan\n This is a 75-year-old woman with a history of significant obstructive\n lung disease (COPD) complicated by restrictive disease from obesity,\n who comes in with hypoxemia and respiratory acidosis from nursing\n home. Most likely mucous plugging and/or sleep apnea contributing to\n acute on chronic issue. However, an infection is possible in setting\n of productive cough.\n # Hypoxemia/hypercarbia: Most likely from COPD exacerbated by\n obstructive sleep apnea and/or mucous plugging (other possibilities\n include atelectasis and fluid overload). Minimal concern for infection\n at this time, as patient is afebrile/noleukocytosis, but bronchitis is\n still possible. Treat with 5 days of levaquin and discharge.\n --Levaquin 750mg x5 days for bronchitis\n --Continue albuterol, atrovent, and advair\n --Aggressive chest PT\n --Cont 3L NC\n --Patient did not tolerate BiPap last night, but could try again\n --Guaifenesin\n # U/A with +nitrates, many pacteria, negative leukocytes, and 0-2 WBC.\n Patient had been mid-way through course of macrobid at nursing home.\n Received one dose of Levaquin in ED.\n --Follow-up urine culture\n --Patient on levaquin regardless for bronchitis; should cover most UTI\n bugs\n .\n #. Mental Status: Non-focal neuro exam. Daughter states that patient\n baseline is conversant, intermittently oriented with appropriate\n responses. Unclear if Ms. is truly back at baseline.\n --Continue to monitor, orient\n --Antibiotics for possible infection\n .\n # DM II:ISS while in house\n .\n # AF: Currently rate controlled on Metoprolol and Diltiazem. INR is 2.7\n today, down from 4.1 yesterday\n --Cont Metoprolol/Diltiazem\n --Continue to hold coumadin in setting of levaquin.\n --Restart coumadin at 0.5 on , then INR check on .\n .\n # Code status: Confirmed with daughter on \n .\n # Contacts: daughter \n .\n # Dispo: Discharge to HCC\n ICU Care\n Nutrition: regular diet\n Glycemic Control: insulin SS\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT: On coumadin\n Stress ulcer: None\n VAP:\n Comments: bowel regimen, nebs\n Communication: Comments: daugher\n Code status: presumed full, will confirm with daugher\n Disposition: ICU for now\n ------ Protected Section ------\n Physical Exam:\n General: Alert, cooperative, NAD, junky cough\n Chest: Clear aside from crackles at right lower base\n Cardiac: Irregularly, irregular\n Abdomen: +BS, soft, non-tender, non-distended\n Extremities: Warm, well-perfused.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:15 ------\n" }, { "category": "Nursing", "chartdate": "2111-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612551, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin. pt with hr in 90s afib. inr\n 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt comfortable , Denies sob. Lungs clear with crackles/ diminished\n bases. 02 sats 95-99% on 3lnc. Expectorated small amt thick white\n secretions. . Denies pain. Hr in 90s-100s afib ,no pacing spikes noted\n . pt with baseline dementia. Received clonazepam 1 dose in the\n afternoon, requesting again for Klonopin and ambien for sleep. Ambien\n given and slept throughout the night, asleep and difficult to arouse at\n midnight ,Klonopin and other PO medications held at midnight.\n Action:\n Continued with NC O2 3 lit/min and nebs as ordered. No resp distress\n or desats noted. Dilt and lopressor held at midnight and schedule\n time changed as unable to give anything after ambien .refused for\n BIPAP.\n Response:\n VSS, comfortable,slept well. Urine output adequate. Bilateral pedal\n edema.\n Plan:\n Continue to moitor resp status, f/u with am labs, continue with dilt\n and lopressor for rate control.\n" }, { "category": "Physician ", "chartdate": "2111-02-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 612580, "text": "Chief Complaint: Respiratory Failure\n Hypoxia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 12:01 PM\n -Patient unable to tolerate BIPAP despite nursing and respiratory\n therapy efforts which were maximal\n -With supplemental oxygen patient able to maintain adequate oxygen\n saturations.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:20 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: Cough\n Flowsheet Data as of 09:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 107 (87 - 110) bpm\n BP: 151/77(94) {110/57(68) - 156/111(114)} mmHg\n RR: 23 (16 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 71.2 kg (admission): 72.8 kg\n Height: 65 Inch\n Total In:\n 1,117 mL\n 216 mL\n PO:\n 720 mL\n 120 mL\n TF:\n IVF:\n 397 mL\n 96 mL\n Blood products:\n Total out:\n 995 mL\n 375 mL\n Urine:\n 995 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 122 mL\n -159 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///36/\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Crackles : , Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\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 11.8 g/dL\n 315 K/uL\n 178 mg/dL\n 0.5 mg/dL\n 36 mEq/L\n 3.5 mEq/L\n 27 mg/dL\n 101 mEq/L\n 144 mEq/L\n 37.3 %\n 10.5 K/uL\n [image002.jpg]\n 06:05 AM\n 05:36 AM\n WBC\n 9.8\n 10.5\n Hct\n 38.6\n 37.3\n Plt\n 255\n 315\n Cr\n 0.7\n 0.5\n Glucose\n 254\n 178\n Other labs: PT / PTT / INR:27.2/32.0/2.7, Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.9 mg/dL\n Fluid analysis / Other labs: AG=7\n Imaging: CXR-\n Microbiology: Sputum--4+ GPC in pairs, chains, clusters.\n Assessment and Plan\n 75 yo patient admitted with acute hypoxia and now admitted with both\n hypercarbic and hypoxic compromise. She has not demonstrated\n substantial or durable insult in regards to pneumonia or flare of\n COPD. We have tried to implement ventilatory support with -level\n treatment but patient was quite clear she will not tolerate the mask.\n 1)COPD-Patient with history of obstructive lung disease and significant\n chest wall restriction now with improved oxygenation on persistent\n supplemental oxygen.\n -Fluticasone inhaled\n -Continue with supplemental oxygen as needed\n -Will continue with chest PT as needed\n -BIPAP has failed at this time with patient saying\nI can not stand\n things on my face\n and did trial it with good effort but was simply\n unable to wear the mask at this time.\n -We have had antibiotics held at this time and will follow across time\n for fevers or sputum and Rx with Azithro for any fever or increase in\n sputum production.\n 2)Urinary Tract Infection-\n -Will complete course of macrobid while in house\n ICU Care\n Nutrition: PO diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Will need to have adequate placement for\n patient at discharge which will have to work with patient and family\n for adequate disposition.\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 38 minutes\n" }, { "category": "Physician ", "chartdate": "2111-02-04 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 612461, "text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient last night had saturations of 83% on 3 lpm O2 (which is\n baseline amount) which was seen on routine check at nursing home and\n patient to ED for further care.\n In the ED here-->\n Patient Rx with Vanco/Levofloxacin\n Continued on supplemental oxygen and given persistent and severe\n respiratory compromise patient to ICU for further care.\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pulmonary Embolism\n S/P Pacer\n Dementia\n COPD--severe, on 3 lpm home O2, FEV1 <500cc\n Atrial Fibrillation\n DM\n Non-contributory\n Occupation: NH Resident\n Drugs: None\n Tobacco: None now\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: Tachycardia\n Respiratory: Cough, Tachypnea, weak cough\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:53 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: 36.5\nC (97.7\n HR: 93 (93 - 106) bpm\n BP: 172/86(101) {153/79(101) - 172/96(108)} mmHg\n RR: 21 (13 - 21) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 65 Inch\n Total In:\n 244 mL\n PO:\n TF:\n IVF:\n 244 mL\n Blood products:\n Total out:\n 0 mL\n 365 mL\n Urine:\n 365 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -121 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///39/\n Physical Examination\n General Appearance: Overweight / Obese\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Crackles : Left sided, Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 255 K/uL\n 38.6 %\n 11.9 g/dL\n 254 mg/dL\n 0.7 mg/dL\n 35 mg/dL\n 39 mEq/L\n 98 mEq/L\n 4.2 mEq/L\n 143 mEq/L\n 9.8 K/uL\n [image002.jpg]\n 06:05 AM\n WBC\n 9.8\n Hct\n 38.6\n Plt\n 255\n Cr\n 0.7\n Glucose\n 254\n Other labs: PT / PTT / INR:39.6/36.9/4.1\n Fluid analysis / Other labs: U/A pos-nitrites\n Imaging: CXR-decreased lung volumes with opacification at the left base\n with infiltrate in left upper lobe region\n Microbiology: BC and Urine Culture-sent\n ECG: Atrial Fibrillation\n Assessment and Plan\n 75 yo female with a significant history of obstructive lung disease\n which is complicated by significant chest wall restriction in the\n setting of obesity now admitted with significnat hypoxemia and\n respiratory acidosis which would apear to be a modest change from\n patient baseline severe compromise of respiratory status. She will\n need to be supported with Rx for possible infection, possible\n exacerbation of underlying pulmonary disease and with new left sided\n infiltrate which is concerning for infection or pulmonary edema.\n Patient has had rapid return towards baseline status. Mucus plugging,\n hypoventilation/obstructive apnea are pehaps most likely in the setting\n of transient event.\n 1) CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n -Will provide support through baseline medications\n -Will Rx with Advair, Atrovent, Albuterol as needed and favor nebs at\n this time\n -Will treat cough/infiltrate with antibiotics at this time given severe\n compromise in underlying lung function\nVanco/Zosyn--if any significant\n fever, sputum production seen.\n -Will send sputum GS C+S\n 2)Respiratory Failure-Acute and Chronic\n -Patient needs chest PT and incentive spirometry at this time\n -Will trial -level support this morning with non-invasive mask\n ventilation\n -Crackles improve with effort suggesting more likely that patient has\n had atelectasis rather the hydrostatic pulmonary edema\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 04:22 AM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612437, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin. pt with hr in 90s afib. inr\n 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt arrived from ew alert, oriented x2 to person and place, not date).\n Cooperative with care. Denies sob. Lungs clear with crackles at bases.\n 02 sats 95-99% on 3lnc. Expectorated small amt thick white secretions.\n Requesting robitussin for cough. Denies pain. Pt was medicated with iv\n vanco in route from ew. Hr in 90s-100s afib with no ectopy. Bp ranging\n 150s-160s. am inr 3.6. pt on coumadin at baseline. Held presently.\n Action:\n Pt medicated with po robitussin for cough and po diltiazem for hr\n control. Given diltiazem crushed in applesauce and robitussin via\n elixir without difficulty swallowing. No pacemaker spike noted.\n Medicated with 4 units humalog per dr. as pt npo. Am labs\n redrawn at 6am, pending.\n Response:\n Pt maintaining 02 sats in mid 90s on 3lnc. Denies sob. Breathing\n appearing comfortable. Hr elevated, in baseline afib, awaiting response\n from po diltiazem which pt takes at baseline.\n Plan:\n Continue to monitor lungs, monitor temp. robitussin prn. Monitor hr and\n bp, continue diltiazem qid and f/u with starting home dose of\n metoprolol 50mg daily if bp remains elevated. Qid fs and give\n dose if\n remains npo. Nebs prn. f/u with am labs.\n" }, { "category": "Nursing", "chartdate": "2111-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612531, "text": "75 y.o. woman admitted from nsg home to ew c/o increased sob,\n confusion, diaphoretic found with 02 sat of 82%. pt uses 02 3lnc at nsg\n home at baseline. pt was given neb x2 in route to ew. pt arrived to ew\n with 02 sat 90% on 3lnc, diaphoretic, denied sob. abg: 7.42/64/62. pt\n was given 125mg solumedrol and combivent with 02 sat up to 100%, then\n down to mid 90s. also given iv levoquin. pt with hr in 90s afib. inr\n 3.9. pt on coumadin for afib. temp 97.6po, crackles at bases.\n incontinent of urine, foley placed. sent to for further medical\n management.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt comfortable , Denies sob. Lungs clear with crackles/ diminished\n bases. 02 sats 95-99% on 3lnc. Expectorated small amt thick white\n secretions. . Denies pain. Hr in 90s-100s afib ,no pacing spikes noted\n . pt with baseline dementia. Received clonazepam 1 dose in the\n afternoon, requesting again for Klonopin and ambien for sleep. Ambien\n given and slept throughout the night, asleep and difficult to arouse at\n midnight ,Klonopin and other PO medications held at midnight.\n Action:\n Continued with NC O2 3 lit/min and nebs as ordered. No resp distress\n or desats noted. Dilt and lopressor held at midnight and schedule\n time changed as unable to give anything after ambien .\n Response:\n VSS, comfortable,slept well. Urine output adequate. Bilateral pedal\n edema.\n Plan:\n Continue to moitor resp status, f/u with am labs, continue with dilt\n and lopressor for rate control.\n" }, { "category": "Physician ", "chartdate": "2111-02-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 612432, "text": "Chief Complaint: Hypoxia\n HPI:\n 75F pt with a hx of COPD ( spirometry with (FVC 0.96, FEV1\n 0.47, ratio of 49, 71% predicted), on 3L 02, hx bilateral PE's (),\n AF (currently anticoagulated), non-obstructive CAD, EF 75% to 80%\n (), pacemaker and dementia (baseline AO ), presented today from\n with hypoxia.\n .\n Per records the pt was noted at 10:45pm to have the following\n vitalsL: 97.5 125/78, 89 RR24 and 83% on 3L (baseline 3L, usually in\n 90s). The pt received Albuterol Nebs x2 (10:55pm and 11:15pm) and was\n subsequently sent to the ED.\n .\n Upon arrival to the ED 96.2 94 139/90 20 94. Pt reported to have\n Crackles L>R. Denied SOB. ABG 7.42/64/62. The pt was given neb,\n Solumedrol 125mg IVx1. ED was concerned for LUL infiltrate and thus\n drew BCx and treated pt with Vancomycin 1gm IV, Levofloxacin 750mg\n IVx1. Vitals prior to transfer to the floor 92 150/90 22 94% on 4L.\n .\n The patient unable to adeuately answer the following review of\n symptoms: fever, chills, night sweats, loss of appetite, fatigue, chest\n pain, palpitations, rhinorrhea, nasal congestion, hemoptysis, dyspnea,\n orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea,\n constipation, hematochezia, melena, dysuria, urinary frequency, urinary\n urgency, focal numbness, focal weakness, myalgias, arthralgias\n Allergies:\n Penicillins\n Unknown;\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:23 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PER OMR\n - AF on coumadin\n - CAD (per chart; however had non-obstructive CAD on previous cath)\n - Multiple bilateral PE's ()\n - DMII\n - Dyslipidemia\n - COPD\n - Anemia with basline HCT 31-33\n - Osteoporosis\n - Chronic joint pain\n - GERD\n - Dementia\n - anxiety / depression\n - Dysphagia per records though not noted to be on special diet\n - Dementia\n - MRSA PNA req. ICU admission with ETT\n - Acute Cholangitis ( with acute cholangitis due to\n choledocolithiasis underwent urgent ERCP with stenting)\n - Pulmonary Nodule Noted on CT : 6-mm left lower lobe nodule\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\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: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 106 (93 - 106) bpm\n BP: 153/96(108) {153/79(101) - 164/96(108)} mmHg\n RR: 18 (16 - 18) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 65 Inch\n Total In:\n 220 mL\n PO:\n TF:\n IVF:\n 220 mL\n Blood products:\n Total out:\n 0 mL\n 265 mL\n Urine:\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -45 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\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: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : L>R, No(t) Wheezes : ,\n Diminished: R>L)\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 75F pt with hx of bilateral PE's, AF, COPD, Non-Obstructive CAD and\n Dementia, presenting with hypoxemia.\n .\n # Hypoxemia: Pt on baseline 3L at , presented to the MICU this AM on\n 3L. ED ABG with p02 of 62, pCO2 of 64 indicative of A-a gradient. No\n clear evidence of infiltrate on CXR, although could not exclude\n retrocardiac opacity as source of infection. Pt now at baseline 02\n requirement. Unclear precipitating events for transient hypoxia (COPD\n excerbation resolving with steroids, atelectasis, fluid overload, PE).\n Pt now at baseline without appreciable wheezes on exam. No increase in\n sputum production from baseline. No reported fevers of chills.\n - Will d/c Vanc/Levaquin as pt is currently without fever, leukocytosis\n or increased sputum production.\n - Cont 3L NC\n - OOB to chair\n - Consider repeat ABG in AM\n .\n # Hypercarbia: Pt with PFTs suggestive of COPD (FVC 0.96, FEV1 0.47,\n ratio of 49, 71% predicted), however pt with tachypnea, wheezing.\n ?increase in productive cough. Pt with hx of pCO2 50-70s. Currently\n breathing comfortably and mentating likely close to baseline. HC)3 of\n 39 is at patients approximate baseline.\n - Consider BiPap if pt decompensates\n - Will hold off steroids currently, given no audible wheezes.\n - Repeat ABG\n .\n # Fluid Status: Pt with initial Hct of 38 (baseline approx 30), in\n setting of increase BUN and slightly increased pt may be\n intravascularly depleted, however this is difficult to assess given\n crackles on physical exam and suggestion of fluid overload on CXR.\n - Follow UOP\n - Repeat AM labs\n .\n # +UA: Pt with +Nitrites, neg Leuks, although 0-2 WBCs. Currently\n asymptomatic. Received dose of Levaquin in ED. Denied dysuria on exam.\n - f/u UCx\n .\n #. Mental Status: Non-focal neuro exam. Baseline reported to be AOx1-2.\n Patient currently calm. Unclear if patient altered from baseline.\n - Contact daughter in AM to assess patient and provide baseline MS\n .\n # DM II:ISS while in house\n .\n # AF: Currently rate controlled on Metoprolol and Diltiazem. INR\n currently supratherapeutic without signs of bleeding.\n - Anticipate jump in INR given pt received Levaquin this PM, will hold\n Coumadin\n - Cont Metoprolol/Diltiazem\n .\n # Code status: Presumed Full confirmed at 10/27\n .\n # Contacts: daughter \n .\n # Dispo: patient was discharged to HCC with follow up\n appointments with pulmonology and for sleep study.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:22 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2111-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 612436, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt arrived from ew alert, oriented x2 to person and place, not date).\n Cooperative with care. Denies sob. Lungs clear with crackles at bases.\n 02 sats 95-99% on 3lnc. Expectorated small amt thick white secretions.\n Requesting robitussin for cough. Denies pain. Pt was medicated with iv\n vanco in route from ew. Hr in 90s-100s afib with no ectopy. Bp ranging\n 150s-160s. am inr 3.6. pt on coumadin at baseline. Held presently.\n Action:\n Pt medicated with po robitussin for cough and po diltiazem for hr\n control. Given diltiazem crushed in applesauce and robitussin via\n elixir without difficulty swallowing. No pacemaker spike noted.\n Medicated with 4 units humalog per dr. as pt npo. Am labs\n redrawn at 6am, pending.\n Response:\n Pt maintaining 02 sats in mid 90s on 3lnc. Denies sob. Breathing\n appearing comfortable. Hr elevated, in baseline afib, awaiting response\n from po diltiazem which pt takes at baseline.\n Plan:\n Continue to monitor lungs, monitor temp. robitussin prn. Monitor hr and\n bp, continue diltiazem qid and f/u with starting home dose of\n metoprolol 50mg daily if bp remains elevated. Qid fs and give\n dose if\n remains npo. Nebs prn.\n" }, { "category": "General", "chartdate": "2111-02-05 00:00:00.000", "description": "Generic Note", "row_id": 612608, "text": "TITLE: Rehab Services\n Physical Therapy\n Consult received and appreciated however, per CM note, Pt is currently\n a long term care resident and on a 10-day bed hold at her facility. Pt\n does not require acute PT consult for return to her facility. If\n status changes, please re-consult. Thank you.\n" }, { "category": "Respiratory ", "chartdate": "2111-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 612522, "text": "Demographics\n Day of intubation: 0\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Small\n Comments: Pt not very compliant w/ BIPAP today w/ 3 LPM O2 bleed.\n Will c/w gentle but persistent attempts to persuade pt to wear her\n BIPAP nasal mask at night.\n" }, { "category": "ECG", "chartdate": "2111-02-04 00:00:00.000", "description": "Report", "row_id": 224628, "text": "Atrial fibrillation with rapid ventricular responsed. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing of no diagnostic\ninterim change.\n\n" }, { "category": "Radiology", "chartdate": "2111-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1114247, "text": " 12:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pna, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with sob, hypoxia\n REASON FOR THIS EXAMINATION:\n assess for pna, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with shortness of breath and hypoxia.\n Evaluate for pneumonia or heart failure.\n\n COMPARISON: .\n\n UPRIGHT AP VIEW OF THE CHEST: Evaluation is limited by the position of the\n head over the upper chest and low lung volumes. Again noted is increased\n opacification at the left lung base, most likely atelectasis and increased\n pleural effusion, although underlying infection is not excluded. There is\n slight upper lobe redistribution, particularly on the left, with hilar\n fullness, but there is no overt pulmonary edema. The heart size is not\n significantly changed allowing for differences in technique. Two pacer leads\n follow a normal course from the right-sided battery pack terminating in the\n expected position of the right atrium and ventricle. Degenerative change of\n the bilateral glenohumeral joints is noted with unchanged inferior\n displacement of the right shoulder.\n\n IMPRESSION: Slight interval increase in left pleural effusion and basilar\n atelectasis. Cardiomegaly and probable mild failure, but no overt pulmonary\n edema.\n\n" } ]

[ { "category": "Echo", "chartdate": "2145-03-06 00:00:00.000", "description": "Report", "row_id": 88699, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 61\nWeight (lb): 282\nBSA (m2): 2.19 m2\nBP (mm Hg): 89/56\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 15:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThe aortic 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. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global left ventricular systolic function. Right ventricule\ninadequately visualized. Mild mitral regurgitation. Moderate pulmonary\nhypertension.\n\n\n" }, { "category": "Physician ", "chartdate": "2145-03-07 00:00:00.000", "description": "Intensivist Note", "row_id": 619884, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy (Hartmanns) complicated by\n ARF, ostomy retraction and wound infection. P/w hypotension and\n syncopal events, after colonic stent \"fell out\" . Now with sepsis,\n possibly from lower extremities\n Chief complaint:\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Calcium Gluconate, Heparin, Insulin, Magnesium Sulfate, Miconazole\n Powder 2%, Morphine Sulfate, Norepinephrine, Pantoprazole,\n Piperacillin-Tazobactam, Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:05 PM\n - vanc / zosyn started\n - fluid bolus\n - ECHO performed - EF > 55%, no systolic dysfunction\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Morphine Sulfate - 05:00 AM\n Other medications:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.8\nC (98.3\n HR: 81 (61 - 93) bpm\n BP: 113/79(87) {83/29(40) - 130/81(87)} mmHg\n RR: 19 (13 - 22) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 14 (8 - 25) mmHg\n Total In:\n 6,820 mL\n 1,356 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,820 mL\n 1,356 mL\n Blood products:\n Total out:\n 4,245 mL\n 770 mL\n Urine:\n 4,245 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,575 mL\n 586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: 7.25/40/90./19/-9\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n ostomy retracted\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), Moves all extremities\n Labs / Radiology\n 515 K/uL\n 8.9 g/dL\n 140 mg/dL\n 2.1 mg/dL\n 19 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 106 mEq/L\n 138 mEq/L\n 27.3 %\n 12.7 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n WBC\n 14.6\n 12.7\n Hct\n 25.3\n 27.3\n Plt\n 561\n 515\n Creatinine\n 4.0\n 2.8\n 2.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n Glucose\n \n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Lactic Acid:1.1 mmol/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60F s/p Hartmann's now with sepsis, ARF\n Neurologic: pain control with morphine\n Cardiovascular: on levophed, wean as tolerated\n Pulmonary: IS, on NC, stable\n Gastrointestinal / Abdomen: NPO, colostomy retracted with no output.\n Needs scope to find etiology\n Nutrition: NPO\n Renal: Foley, Adequate UO, Cr 2.1 from 2.8, check pm lytes\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, empiric vanc / zosyn\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Fluids: LR at 100. No more fluid boluses\n Consults: General surgery\n Billing Diagnosis: Sepsis, Acute renal failure\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: PPI\n Communication: Patient discussed on interdisciplinary rounds\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-03-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 619671, "text": "Chief Complaint: falling, no ostomy output\n HPI:\n 60 yo f s/p sigmoid resection w/ colostomy c/b ARF, ostomy\n retraction & wound infection, d/c to rehab & left AMA .\n Presents w/ hypotension & syncopal events after stent \"fell out\" &\n pt refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodgement, no uop since night prior to admission, BP\n 50s-60s in ER.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 02:00 AM\n Other medications:\n Past medical history:\n Family / Social history:\n HTN, Chronic Back Pain, morbid obesity, Immobility DDD causing weak\n LE, complicated diverticulitis, h/o ARF as above\n former smoker, no etoh/illicits\n Flowsheet Data as of 03:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 91) bpm\n BP: 109/54(73) {104/48(67) - 141/82(105)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (16 - 22)mmHg\n Total In:\n 5,500 mL\n 611 mL\n PO:\n TF:\n IVF:\n 611 mL\n Blood products:\n Total out:\n 500 mL\n 470 mL\n Urine:\n 300 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,000 mL\n 141 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, empty ostomy appliance\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment And Plan: 60 yo f s/p sigmoid resection w/ colostomy\n (Hartmanns) complicated by ARF, ostomy retraction & wound\n infection, d/c to rehab . P/w hypotension and syncopal events\n after stent \"fell out\" & pt refused readmission/intervention @ that\n time. Denies ostomy output since stent dislodged. No uop since night\n PTA.\n Neurologic: a&o, morphine prn pain\n Cardiovascular: bp 50s-60s in ED who started levophed & neo, now maps\n >65 on levophed gtt only. follow serial troponins, Echo in am for\n question of cardiac event.\n Pulmonary: satting 98% on 2L\n Gastrointestinal: no ostomy output, no stent in ostomy per . abd ct\n in am, npo.\n Renal: baseline cr~1, was max of 1.5 during ARF post ExLap . bun\n 51, cr 5.1 on admission, renal consulted. urine lytes pending.\n responded well to 5L ivf , uop 150-300 since sicu admission, decr LR\n from 100->50\n Hematology: Hct 26.3, baseline 25-26 during last admission. Now 25.3.\n will follow.\n Infectious Disease: blood,urine,sputum cx pending. suspicious for\n sepsis.\n Endocrine: riss\n Fluids: LR @ 50 from 100 after good uop & lactate 1.2\n Electrolytes: bun/cr as above, lytes o/w nl.\n Nutrition: npo\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n 18 Gauge - 11:56 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2145-03-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 619667, "text": "Chief Complaint: falling, no ostomy output\n HPI:\n 60 yo f s/p sigmoid resection w/ colostomy c/b ARF, ostomy\n retraction & wound infection, d/c to rehab & left AMA .\n Presents w/ hypotension & syncopal events after stent \"fell out\" &\n pt refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodgement, no uop since night prior to admission, BP\n 50s-60s in ER.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 02:00 AM\n Other medications:\n Past medical history:\n Family / Social history:\n HTN, Chronic Back Pain, morbid obesity, Immobility DDD causing weak\n LE, complicated diverticulitis, h/o ARF as above\n former smoker, no etoh/illicits\n Flowsheet Data as of 03:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 91) bpm\n BP: 109/54(73) {104/48(67) - 141/82(105)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (16 - 22)mmHg\n Total In:\n 5,500 mL\n 611 mL\n PO:\n TF:\n IVF:\n 611 mL\n Blood products:\n Total out:\n 500 mL\n 470 mL\n Urine:\n 300 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,000 mL\n 141 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, empty ostomy appliance\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment And Plan: 60 yo f s/p sigmoid resection w/ colostomy\n (Hartmanns) complicated by ARF, ostomy retraction & wound\n infection, d/c to rehab . P/w hypotension and syncopal events\n after stent \"fell out\" & pt refused readmission/intervention @ that\n time. Denies ostomy output since stent dislodged. No uop since night\n PTA.\n Neurologic: a&o, morphine prn pain\n Cardiovascular: bp 50s-60s in ED who started levophed & neo, now maps\n >65 on levophed gtt only. follow serial troponins, Echo in am for\n question of cardiac event.\n Pulmonary: satting 98% on 2L\n Gastrointestinal: no ostomy output, no stent in ostomy per . abd ct\n in am, npo.\n Renal: baseline cr~1, was max of 1.5 during ARF post ExLap . bun\n 51, cr 5.1 on admission, renal consulted. urine lytes pending.\n responded well to 5L ivf , uop 150-300 since sicu admission, decr LR\n from 100->50\n Hematology: Hct 26.3, baseline 25-26 during last admission\n Infectious Disease: blood,urine,sputum cx pending. suspicious for\n sepsis.\n Endocrine: riss\n Fluids: LR @ 50 from 100 after good uop.\n Electrolytes: bun/cr as above, lytes o/w nl.\n Nutrition: npo\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n 18 Gauge - 11:56 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2145-03-07 00:00:00.000", "description": "Intensivist Note", "row_id": 619873, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy (Hartmanns) complicated by\n ARF, ostomy retraction and wound infection. P/w hypotension and\n syncopal events, after colonic stent \"fell out\" . Now with sepsis,\n possibly from lower extremities\n Chief complaint:\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Calcium Gluconate, Heparin, Insulin, Magnesium Sulfate, Miconazole\n Powder 2%, Morphine Sulfate, Norepinephrine, Pantoprazole,\n Piperacillin-Tazobactam, Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:05 PM\n - vanc / zosyn started\n - fluid bolus\n - ECHO performed - EF > 55%, no systolic dysfunction\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:11 AM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Morphine Sulfate - 05:00 AM\n Other medications:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.8\nC (98.3\n HR: 81 (61 - 93) bpm\n BP: 113/79(87) {83/29(40) - 130/81(87)} mmHg\n RR: 19 (13 - 22) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 14 (8 - 25) mmHg\n Total In:\n 6,820 mL\n 1,356 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,820 mL\n 1,356 mL\n Blood products:\n Total out:\n 4,245 mL\n 770 mL\n Urine:\n 4,245 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,575 mL\n 586 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: 7.25/40/90./19/-9\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n ostomy retracted\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), Moves all extremities\n Labs / Radiology\n 515 K/uL\n 8.9 g/dL\n 140 mg/dL\n 2.1 mg/dL\n 19 mEq/L\n 3.6 mEq/L\n 32 mg/dL\n 106 mEq/L\n 138 mEq/L\n 27.3 %\n 12.7 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n WBC\n 14.6\n 12.7\n Hct\n 25.3\n 27.3\n Plt\n 561\n 515\n Creatinine\n 4.0\n 2.8\n 2.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n Glucose\n \n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Lactic Acid:1.1 mmol/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60F s/p Hartmann's now with sepsis, ARF\n Neurologic: pain control with morphine\n Cardiovascular: on levophed, wean as tolerated\n Pulmonary: IS, on NC, stable\n Gastrointestinal / Abdomen: NPO, colostomy retracted\n Nutrition: NPO\n Renal: Foley, Adequate UO, Cr 2.1 from 2.8, check pm lytes\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, empiric vanc / zosyn\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: Sepsis, Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2145-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 619976, "text": "60f s/p sigmoid resection w/ colostomy (Hartmanns) complicated by\n ARF, ostomy retraction and wound infection. P/w hypotension and\n syncopal events, after colonic stent \"fell out\" . Now with sepsis,\n possibly from lower extremities\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient alert, oriented and very talkative\n On .16 of levo this am with sbp abour 100\n Urine output around 100 cc hr\n All other vss stable\n Belly soft, +bowel sounds\n Legs red and hot with right leg cellulitis>left\n Action:\n Slowly wean levo\n D5W w/3 amps bicarb started at 75 cc hr\n Scoped via ostomy by GI\n PM lytes and abgs done\n Slowly weaning levo\n Response:\n No strictures or physical obstruction visualized by scope\n Formed stool seen\n Tolerated procedure well\n Tolerating weaning levo\n Plan:\n Advance diet to regular with ensure supplements\n Fleets enema via red rubber cath x2 tonight\n Begin senna and colace\n Medicate as needed for pain\n Call team w/any changes.\n" }, { "category": "Nursing", "chartdate": "2145-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 619865, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Remains alert and oriented\n - Tmax 99.5\n - Trending NBP d/t no art line and pt previously refusing to have\n additional attempts made\n - Levophed titrating up over evening to maintain MAPS > 60\n - Overnight MAPS maintaining in 50\ns despite SBP > 100\n - Hands appearing slightly mottled over evening and bottom of bil feet\n and toes slightly dusky this evening although good peripheral pulses\n and sensation\n - Lungs clear but diminished\n - No change in O2 requirment\n - Abd soft, nontender\n no stool out of ostomy, bowel sounds remain\n hypoactive\n - Good urine output > 100cc/hr\n - RLE cellulitis with purple area with several open areas left OTA\n drainage noted\n Action:\n - BP goal changed to SBP > 100 or MAP > 60\n - Levophed titrated down this am\n - Warm blankets to hands and feet\n - Continues on zosyn\n - Vanco level sent this am to check to dose for today\n - 500cc LR bolus x 2\n Response:\n - Maintianing SBP >100 on lower dose levo\n - Bil hands and feet with improved coloring overnight\n - BUN and CREAT unchanged this am\n - WBC down 12 (14)\n - Vanco level 9.3 @ 0400\n Plan:\n - Continue to wean levo as tolerated\n - Continue with IVF and monitor renal function\n - Continue on IV abx\n - Awaiting gen recs re: re stenting ostomy.\n" }, { "category": "Nursing", "chartdate": "2145-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 619720, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Alert and oriented, per report from pt was mentating\n during episodes of hypotension\n - Afebrile, SR 70-90\ns with occasional PAC\n - Arrived on neo and levo gtt to maintain MAP >65\n - Lungs clear but diminished, denies SOB\n - ABD soft, obese, no bowel sounds noted\n - Ostomy retracted and unable to visualize\n - Denies abd pain or tenderness\n - C/o back pain\n pt has chronic back pain and takes narcotics\n at home\n - Making adequate urine\n - Bottoms of feet cyanotic but +pulses, warm, + sensation\n Action:\n - Titrated down on neo to off and titrating down on levophed\n - PO contrast given and taken for ABD CT\n - Renal US done\n - No abx\n awaiting cx results per team\n - NC increased d/t pao2 76\n - Lytes repleated\n Response:\n - good response to fluid with increasing u/o and improving\n bun/creat\n - wbc 14 (up from 10)\n - hct stable @ 25\n Plan:\n - f/u with team regarding plan to stent ostomy\n - follow up on cultures\n - wean levo as tolerated\n" }, { "category": "Physician ", "chartdate": "2145-03-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 619711, "text": "Chief Complaint: falling, no ostomy output\n HPI:\n 60 yo f s/p sigmoid resection w/ colostomy c/b ARF, ostomy\n retraction & wound infection, d/c to rehab & left AMA .\n Presents w/ hypotension & syncopal events after stent \"fell out\" &\n pt refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodgement, no uop since night prior to admission, BP\n 50s-60s in ER.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 02:00 AM\n Other medications:\n Past medical history:\n Family / Social history:\n HTN, Chronic Back Pain, morbid obesity, Immobility DDD causing weak\n LE, complicated diverticulitis, h/o ARF as above\n former smoker, no etoh/illicits\n Flowsheet Data as of 03:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 84 (84 - 91) bpm\n BP: 109/54(73) {104/48(67) - 141/82(105)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (16 - 22)mmHg\n Total In:\n 5,500 mL\n 611 mL\n PO:\n TF:\n IVF:\n 611 mL\n Blood products:\n Total out:\n 500 mL\n 470 mL\n Urine:\n 300 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,000 mL\n 141 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, empty ostomy appliance\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment And Plan: 60 yo f s/p sigmoid resection w/ colostomy\n (Hartmanns) complicated by ARF, ostomy retraction & wound\n infection, d/c to rehab . P/w hypotension and syncopal events\n after stent \"fell out\" & pt refused readmission/intervention @ that\n time. Denies ostomy output since stent dislodged. No uop since night\n PTA. Admitted with septic shock.\n Neurologic: a&o, morphine prn pain\n Cardiovascular: bp 50s-60s in ED who started levophed & neo, now maps\n >65 on levophed gtt only. Aggressive fluid resuscitation.\n Pulmonary: Satting 98% on 2L\n Gastrointestinal: No ostomy output, no stent in ostomy per . abd ct\n in am, npo.\n Renal: baseline cr~1, was max of 1.5 during ARF post ExLap . bun\n 51, cr 5.1 on admission, renal consulted. urine lytes pending.\n responded well to 5L ivf , uop 150-300 since sicu admission, decr LR\n from 100->50\n Hematology: Hct 26.3, baseline 25-26 during last admission. Now 25.3.\n will follow.\n Infectious Disease: blood,urine,sputum cx pending. Start empiric ABX\n with vanco and zosyn. Will dose renally\n Endocrine: RISS\n Fluids: LR @ 100 after good uop & lactate 1.2\n Electrolytes: bun/cr as above, lytes o/w nl.\n Nutrition: npo\n Billing diagnosis: Septic shock\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n 18 Gauge - 11:56 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2145-03-09 00:00:00.000", "description": "Intensivist Note", "row_id": 620193, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP 24-48hours prior to admission.\n Chief complaint:\n ARF, constipation, hypotension\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Docusate Sodium\n Ferrous Sulfate\n FoLIC Acid\n Heparin\n Insulin\n Magnesium Citrate\n Morphine Sulfate\n Norepinephrine\n Pantoprazole\n Piperacillin-Tazobactam\n Senna Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 11:05 AM\n ARTERIAL LINE - START 01:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:37 AM\n Morphine Sulfate - 12:13 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.6\n HR: 73 (66 - 95) bpm\n BP: 112/54(75) {79/46(64) - 117/67(83)} mmHg\n RR: 16 (11 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 5 (1 - 25) mmHg\n Total In:\n 2,684 mL\n 88 mL\n PO:\n 1,260 mL\n Tube feeding:\n IV Fluid:\n 1,424 mL\n 88 mL\n Blood products:\n Total out:\n 3,160 mL\n 460 mL\n Urine:\n 3,160 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -476 mL\n -372 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Obese, stoma pink, perfused, brown stool output, midline abdominal\n wound granulating in w/exposed fasical sutures\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: RLE necrotic appearing area on shin, no drainage/pus\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 435 K/uL\n 7.8 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 106 mEq/L\n 143 mEq/L\n 24.9 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n 03:20 AM\n WBC\n 14.6\n 12.7\n 11.1\n 9.3\n Hct\n 25.3\n 27.3\n 24.7\n 24.9\n Plt\n 35\n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n 1.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n 95\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Differential-Neuts:66.4 %, Lymph:14.6 %, Mono:6.1 %,\n Eos:12.6 %, Lactic Acid:1.1 mmol/L, Ca:8.2 mg/dL, Mg:1.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60y F s/p ex lap sigmoid colectomy end colostomy\n () c/b retracted colostomy presents with no ostomy output and\n hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- morphine prn pain (consider switching to nonnarcotics pain meds)\n change to home oxycontin with morphine for btp\n Lexapro, valium home med\n Cardiovascular:\n -- levo, wean to off goal MAP 60\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n -- +/- vasopressin if unable to wean\n Pulmonary:\n -- sats 98% on RA\n Gastrointestinal / Abdomen:\n -- Mag citrate; large stool output\n -- Colonoscopy; to ascending colon. No lesions, no strictures\n -- regular diet with ensure supplements tid\n -- bowel regimen: senna, colace\n -- gi prophy: pantoprazole\n Nutrition: regular diet w/ ensure supplements tid\n Renal: baseline cr ~1\n -- Cr 5.1 on admission, normalizing, now 1.1\n -- replace electrolytes\n Hematology: Hct 24.7, baseline 25-26, transfuse if unable to wean\n pressors\n Endocrine: RISS\n ID:\n -- SIRS x2\n -- likely cellulitis with necrotic area b/l legs.\n -- empiric vanc/zosyn (start date ). vanc to 750 Q 12h (level\n high 30.2) repeat trough now.\n -- f/u BCx\n -- wbc 12.7 -> 11.1\n T/L/D: RIJ, foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: KVO\n Consults: gensurg, GI, nephro\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n Arterial Line - 01:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n" }, { "category": "Nursing", "chartdate": "2145-03-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 619782, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient continues on levophed for hypotension today. She was on 0.3\n mcg/kg/min this morning. She continues be neurologically intact and\n her pulmonary status remains intact and she is on 4 L NC. She is\n complaining of intermittent abdominal pain.\n Action:\n Weaned levophed to 0.22 mcg/kg/min. Her arterial line has been\n continually dampened today, and an attempt to replace the catheter\n several times was made unsuccessfully. A tube study was attempted on\n her colostomy with out success today. .\n Response:\n She has tolerated weaning the levophed relatively well today and we\n will continue to attempt to wean it as she tolerates.\n Plan:\n GI has been consulted and will attempt to scope her colostomy to gain\n more information regarding its function\n" }, { "category": "Nursing", "chartdate": "2145-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620342, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt alert and oriented. Afebrile, sb/p 90-112 by cuff pressure. Aline\n non-functioning\n Tolerating po\ns. no stool from colostomy this shift.\n c/o abd/back pain x2\n urine output 120-60cc/hr. k+/magnesium low\n Action:\n Morphine 2mg x2 and oxycontin scheduled dose given w/ good relief\n K+ and magnesium repleted.\n Vanco trough level sent\n Response:\n b/p stable off pressors.\n Plan:\n Transfer to floor if remain stable\n 60y F s/p ex lap sigmoid colectomy end colostomy () c/b retracted\n colostomy presents with no ostomy output and hypotension\n" }, { "category": "Physician ", "chartdate": "2145-03-10 00:00:00.000", "description": "Intensivist Note", "row_id": 620347, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n Chief complaint:\n sycopal episodes\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Calcium Gluconate, Diazepam, Docusate Sodium, Escitalopram, Ferrous\n Sulfate, FoLIC Acid, Furosemide, Heparin Insulin, Magnesium Sulfate,\n Miconazole Powder 2%, Morphine Sulfate, Oxycodone SR (OxyconTIN),\n Pantoprazole, zosyn, vanc, Potassium Chloride, Senna\n 24 Hour Events:\n weaned off pressors\n cont abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:28 PM\n Piperacillin/Tazobactam (Zosyn) - 10:54 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:08 PM\n Heparin Sodium (Prophylaxis) - 04:12 PM\n Morphine Sulfate - 04:43 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 35.6\nC (96.1\n HR: 70 (67 - 96) bpm\n BP: 93/87(89) {89/44(62) - 125/119(126)} mmHg\n RR: 19 (13 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 126.2 kg\n CVP: 11 (3 - 19) mmHg\n Total In:\n 2,104 mL\n 160 mL\n PO:\n 1,200 mL\n Tube feeding:\n IV Fluid:\n 904 mL\n 160 mL\n Blood products:\n Total out:\n 3,530 mL\n 310 mL\n Urine:\n 3,250 mL\n 310 mL\n NG:\n Stool:\n 280 mL\n Drains:\n Balance:\n -1,426 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: lower leg cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 415 K/uL\n 7.8 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 105 mEq/L\n 141 mEq/L\n 24.1 %\n 7.8 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n 03:20 AM\n 02:31 AM\n WBC\n 14.6\n 12.7\n 11.1\n 9.3\n 7.8\n Hct\n 25.3\n 27.3\n 24.7\n 24.9\n 24.1\n Plt\n 35\n 415\n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n 1.1\n 1.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n 95\n 91\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Differential-Neuts:66.4 %, Lymph:14.6 %, Mono:6.1 %,\n Eos:12.6 %, Lactic Acid:1.1 mmol/L, Ca:8.8 mg/dL, Mg:1.4 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60y F s/p ex lap sigmoidectomy, end colostomy\n () c/b retracted colostomy presents with no ostomy output and\n hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- pain control: oxycontin 80tid\n -- lexapro\n -- valium prn leg spasm\n Cardiovascular:\n -- off pressors\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n Pulmonary:\n -- sats 98% on RA\n Gastrointestinal / Abdomen:\n -- diabetic diet with ensure supplements tid\n -- bowel regimen: senna, colace\n -- gi prophy: pantoprazole\n Nutrition: regular diet w/ ensure supplements tid\n Renal: baseline cr ~1\n -- replete K, Mg\n - d/c foley\n Hematology:\n -- 24.1 stable\n Endocrine: RISS\n ID:\n -- empiric vanc/zosyn (start date ) - f/u vanc level\n -- f/u BCx\n -- wbc 12.7 -> 11.1 -> 9.3 -> 7.8\n T/L/D: RIJ, foley - d/c foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: KVO\n Consults: gensurg, GI, nephro\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 11:56 PM\n Arterial Line - 01:05 PM\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: floor\n Time spent: 35\n ICU Care\n" }, { "category": "Physician ", "chartdate": "2145-03-08 00:00:00.000", "description": "Intensivist Note", "row_id": 620053, "text": "TITLE:\n SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n Chief complaint:\n falling\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 2242\n 10. Miconazole Powder 2% 1 Appl TP QID:PRN yeast infection Order date:\n @ 1037\n 2. 150 mEq Sodium Bicarbonate/ 1000 mL D5W\n Continuous at 75 ml/hr Order date: @ 1038\n 11. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 0056\n 3. Calcium Gluconate IV Sliding Scale Order date: @ 0441\n 12. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO map>65 use\n as main pressor. add phenylephrine if needed. Order date: @ 2342\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 2242\n 13. Pantoprazole 40 mg IV Q24H Order date: @ 2242\n 5. Docusate Sodium 100 mg PO BID Order date: @ 1657\n 14. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 0905\n 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 2242\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1809\n 7. Heparin 5000 UNIT SC TID Order date: @ 2244\n 16. Senna 1 TAB PO/NG Order date: @ 1657\n 8. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2242\n 17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 2242\n 9. Magnesium Sulfate IV Sliding Scale Order date: @ 0441\n 18. Vancomycin 1000 mg IV Q 12H Start: PM\n ID Approval will be required for this order in 29 hours. Order date:\n @ 1441\n 24 Hour Events:\n COLONOSCOPY - At 04:11 PM\n bedside scope via colostomy showed no obstruction. Started on po diet\n and bowel regimen.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:00 AM\n Other medications:\n Flowsheet Data as of 04:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.7\nC (98.1\n HR: 76 (67 - 94) bpm\n BP: 75/33(44) {75/30(44) - 131/79(87)} mmHg\n RR: 17 (11 - 19) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 12 (10 - 22) mmHg\n Total In:\n 3,911 mL\n 397 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 3,671 mL\n 397 mL\n Blood products:\n Total out:\n 3,320 mL\n 560 mL\n Urine:\n 3,320 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 591 mL\n -163 mL\n Respiratory support\n SPO2: 95%\n ABG: 7.42/36/76./25/0\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n ostomy retracted\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). Right LE\n red, hot, below knee black appx 3x3cm area of sharp pain and\n discoloration. Pulses intact distally. 1x1cm finding on left calf.\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 484 K/uL\n 8.0 g/dL\n 142 mg/dL\n 1.4 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 25 mg/dL\n 105 mEq/L\n 138 mEq/L\n 24.7 %\n 11.1 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n WBC\n 14.6\n 12.7\n 11.1\n Hct\n 25.3\n 27.3\n 24.7\n Plt\n \n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Lactic Acid:1.1 mmol/L, Ca:8.6 mg/dL, Mg:1.7 mg/dL,\n PO4:2.4 mg/dL\n Imaging: endoscopy via colostomy: unprepped colonoscopy with\n EGD-scope through the ostomy to reach an area corresponding to her\n ascending colon. No lesions were seen amidst large amounts of solid\n stools, and no strictures were identified.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 60y F s/p ex lap sigmoidectomy, end colostomy () c/b\n retracted colostomy presents with no ostomy output and hypotension.\n SIRS criteria and Right LE cellulitis\n Neurologic:\n -- AOx3, no neurologic deficits\n -- morphine prn pain (consider switching to nonnarcotics pain meds)\n Cardiovascular:\n -- bp 90s/70s on levo with efforts to wean as tolerated\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n Pulmonary:\n -- satting 98% on 2L\n Gastrointestinal / Abdomen:\n -- no ostomy output.\n -- GI consulted: unprepped colonoscopy with EGD-scope through the\n ostomy to reach an area corresponding to her ascending colon. No\n lesions were seen amidst large amounts of solid stools, and no\n strictures were identified.\n -- started on regular diet with ensure supplements tid\n -- bowel regimen: senna, colace, fleet enema x 2. If no bowel movement,\n consider starting magnesium citrate.\n -- gi prophy: pantoprazole\n Nutrition: regular diet with ensure supplements tid\n Renal: baseline cr ~1,\n -- Cr 5.1 on admission. s/p aggressive IVF hydration. Cr currently 1.4\n -- replace electrolytes as needed\n Hematology: Hct 24.7, baseline 25-26 during last admission. Holding\n transfusion for now.\n Endocrine: RISS\n ID:\n -- SIRS: hypotension requiring aggressive IVF and pressor support with\n end organ effects of ARF.\n -- empiric vanc/zosyn (start date ). Continue due to right LE\n infection, continues afebrile\n -- f/u BCx\n -- wbc 12.7 -> 11.1\n T/L/D: RIJ, foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: D5W+150meqNaHCo3 @ 75cc/hr\n Consults: gensurg, GI, nephro\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2145-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620145, "text": "60 year old female who complains\nof COLOSTOMY ISSUE. Pt from Hosp. Pt had been in rehab\nuntil 2 days ago (left AMA family issues) today had syncopal\nepisode, hypotension, urinary retention. ? renal failure.\ncolostomy stent has not been functioning per pt. Has wound vac to\nosotmy now. MY HPI: c/o decreased output from ostomy over last\nday. Also w/ lightheadedness, syncopal episode at home this AM.\nDenies abd pain. Describes decreased UOP over last several days.\nDenies fevers. s/p recent admission for wound infections,\ndifficulties with ostomy.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620023, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received this pm on Levo to maintain SBP >90\n Pt afebrile\n Pt alert and oriented\n Pt with colostomy with retracted stoma (colonoscopy done\n during day via colostomy)\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620246, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient on 0.06 mcg/kg of levo this am MAP > 65, BP 100\ns-110,\n HR 70\ns-90\ns NSR.\n Afebrile\n Action:\n levo titrated off by 0900 am,\n continued on vanc, zosyn,\n Response:\n Patient has been off pressors all day with MAP > 65. SBP 90\ns-110\n afebrile\n Colostomy putting out 200 cc liquid brown stool during shift, c/o some\n abdominal cramping.\n Plan:\n continue to monitor, transfer out after staying off pressors for 24\n hours.\n Impaired Skin Integrity\n Assessment:\n Dead tissue area on R lower leg consuming a larger area than yesterday,\n still tender and warm around site.\n Abdominal wound pink with small area of yellow granulation tissue,\n ulcer on coccyx under cyst continues to have pink base, 3 x 2 x 0.5.\n Action:\n dressings changed,\n turned q 2 hours, barrier cream applied.\n SICU and surgical team in to assess cellulitis on Right leg ( initially\n made NPO for debridement then team decided against debridement\n today). Edges of black region outlined to measure spreading.\n OOB to chair with PT, able to stand.\n given 20 mg Lasix IV x 1\n Response:\n no change, no spreading beyond demarcations around cellulitic area of\n Right leg.\n good response to Lasix.\n Plan:\n continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2145-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620031, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received this pm on Levo to maintain SBP >90\n Pt afebrile\n Pt alert and oriented\n Pt with colostomy with retracted stoma (colonoscopy done\n during day via colostomy)\n D5W with bicarb running at 75cc/hr\n Action:\n Red rubber cath placed into stoma site by primary team.\n 2 Fleets enema\ns given overnight\n Levo titrated per parameters\n Morphine for pain mmgt\n Response:\n No results from fleets\n Levo down to as low as .08 but now back up to .12 due to\n hypotension.\n ? validity of noninvasive BP. Pt is obese and has\n inconsistent BP readings at times\n Pt states increased pain despite morphine\npt c/o of pain and\n the falling asleep. Morphine only given X3 over night.\n U/O remains >50cc/hr ? need for D5W with bicarb\n Plan:\n F/U with renal about bicarb gtt\n ? revisiting placing an aline\n Wean levo as tolerated.\n ? Vac to abd inc\n Cont with current plan of care\n" }, { "category": "Nursing", "chartdate": "2145-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620230, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient on 0.06 mcg/kg levo this am MAP > 65, BP 100\ns-110,\n HR 70\ns-90\ns NSR.\n Afebrile\n Action:\n levo titrated off by 0900 am,\n continued on vanc, zosyn,\n Response:\n Patient has been off pressors all day with MAP > 65.\n afebrile\n Colostomy putting out 200 cc liquid brown stool during shift.\n Plan:\n continue to monitor, transfer out after staying off pressors for 24\n hours.\n Impaired Skin Integrity\n Assessment:\n Dead tissue area on R lower leg consuming a larger area than yesterday,\n still tender and warm around site.\n Abdominal\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-03-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620400, "text": "HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n * in SICU since - on levo for hypotension, fluid resuscitated, given\n mag citrate to start bowel movement with good response approx I L stool\n output . Off levo since am.\n Chief complaint:\n sycopal episodes\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n SBP 100-120\ns, MAP > 60, HR 70-09 NSR, Afebrile.\n c/o generalized pain, back pain, pain on right lower leg and abdominal\n cramping,\n scant liquid golden output from colostomy. Abdomen soft with bowel\n sounds heard\n Abdominal dsg dry and intact,\n area of black scab/ inflammation on right lower leg has not extended\n beyond marked off area.\n Action:\n continued on regular diet,\n continued with vanc and zosyn\n blackend area on right leg seen by primary team.\n Response:\n continues to be stable.\n Plan:\n will get 75 ml mag citrate. Transfer to 5 \n" }, { "category": "Nursing", "chartdate": "2145-03-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620406, "text": "HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n * in SICU since - on levo for hypotension, fluid resuscitated, given\n mag citrate to start bowel movement with good response approx I L stool\n output . Off levo since am.\n Chief complaint:\n sycopal episodes\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n SBP 100-120\ns, MAP > 60, HR 70-09 NSR, Afebrile.\n c/o generalized pain, back pain, pain on right lower leg and abdominal\n cramping,\n scant liquid golden output from colostomy. Abdomen soft with bowel\n sounds heard\n Abdominal dsg dry and intact,\n area of black scab/ inflammation on right lower leg has not extended\n beyond marked off area.\n Action:\n continued on regular diet,\n continued with vanc and zosyn\n blackend area on right leg seen by primary team.\n Response:\n continues to be stable.\n Plan:\n will get 75 ml mag citrate. Transfer to 5 \n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n HYPOTENSION;ACUTE RENAL FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 126.2 kg\n Daily weight:\n 128 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: Hypertension, chronic back pain, morbid obesity,\n chronic constipation narcotics, immobility degenerative disc\n disease resulting in LLE weakness. Laminectomy and , repair\n of large incarcerated ventral hernia with mesh underlay complicated by\n wound infection requiring incision and drainage, debridement and VAC\n placement , pilonidal cyst excision complicated by persistant\n draiange , tubal ligation, sigmoid resection with left\n colostonly on .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:64\n Temperature:\n 96\n Arterial BP:\n S:111\n D:104\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 262 mL\n 24h total out:\n 740 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:31 AM\n Potassium:\n 3.4 mEq/L\n 02:31 AM\n Chloride:\n 105 mEq/L\n 02:31 AM\n CO2:\n 30 mEq/L\n 02:31 AM\n BUN:\n 15 mg/dL\n 02:31 AM\n Creatinine:\n 1.1 mg/dL\n 02:31 AM\n Glucose:\n 91 mg/dL\n 02:31 AM\n Hematocrit:\n 24.1 %\n 02:31 AM\n Finger Stick Glucose:\n 128\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: pocketbook and clothes transfered to .\n wound vac sent as well.\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 5\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2145-03-08 00:00:00.000", "description": "Intensivist Note", "row_id": 620018, "text": "TITLE:\n SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n Chief complaint:\n falling\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 2242\n 10. Miconazole Powder 2% 1 Appl TP QID:PRN yeast infection Order date:\n @ 1037\n 2. 150 mEq Sodium Bicarbonate/ 1000 mL D5W\n Continuous at 75 ml/hr Order date: @ 1038\n 11. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 0056\n 3. Calcium Gluconate IV Sliding Scale Order date: @ 0441\n 12. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO map>65 use\n as main pressor. add phenylephrine if needed. Order date: @ 2342\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 2242\n 13. Pantoprazole 40 mg IV Q24H Order date: @ 2242\n 5. Docusate Sodium 100 mg PO BID Order date: @ 1657\n 14. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 0905\n 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 2242\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1809\n 7. Heparin 5000 UNIT SC TID Order date: @ 2244\n 16. Senna 1 TAB PO/NG Order date: @ 1657\n 8. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2242\n 17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 2242\n 9. Magnesium Sulfate IV Sliding Scale Order date: @ 0441\n 18. Vancomycin 1000 mg IV Q 12H Start: PM\n ID Approval will be required for this order in 29 hours. Order date:\n @ 1441\n 24 Hour Events:\n COLONOSCOPY - At 04:11 PM\n bedside scope via colostomy showed no obstruction. Started on po diet\n and bowel regimen.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:00 AM\n Other medications:\n Flowsheet Data as of 04:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.7\nC (98.1\n HR: 76 (67 - 94) bpm\n BP: 75/33(44) {75/30(44) - 131/79(87)} mmHg\n RR: 17 (11 - 19) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 12 (10 - 22) mmHg\n Total In:\n 3,911 mL\n 397 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 3,671 mL\n 397 mL\n Blood products:\n Total out:\n 3,320 mL\n 560 mL\n Urine:\n 3,320 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 591 mL\n -163 mL\n Respiratory support\n SPO2: 95%\n ABG: 7.42/36/76./25/0\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n ostomy retracted\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), Moves all extremities\n Labs / Radiology\n 484 K/uL\n 8.0 g/dL\n 142 mg/dL\n 1.4 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 25 mg/dL\n 105 mEq/L\n 138 mEq/L\n 24.7 %\n 11.1 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n WBC\n 14.6\n 12.7\n 11.1\n Hct\n 25.3\n 27.3\n 24.7\n Plt\n \n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Lactic Acid:1.1 mmol/L, Ca:8.6 mg/dL, Mg:1.7 mg/dL,\n PO4:2.4 mg/dL\n Imaging: endoscopy via colostomy: unprepped colonoscopy with\n EGD-scope through the ostomy to reach an area corresponding to her\n ascending colon. No lesions were seen amidst large amounts of solid\n stools, and no strictures were identified.\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT: 60y F s/p ex lap sigmoidectomy, end colostomy () c/b\n retracted colostomy presents with no ostomy output and hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- morphine prn pain (consider switching to nonnarcotics pain meds)\n Cardiovascular:\n -- bp 90s/70s on levo with efforts to wean as tolerated\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n Pulmonary:\n -- satting 98% on 2L\n Gastrointestinal / Abdomen:\n -- no ostomy output.\n -- GI consulted: unprepped colonoscopy with EGD-scope through the\n ostomy to reach an area corresponding to her ascending colon. No\n lesions were seen amidst large amounts of solid stools, and no\n strictures were identified.\n -- started on regular diet with ensure supplements tid\n -- bowel regimen: senna, colace, fleet enema x 2. If no bowel movement,\n consider starting magnesium citrate.\n -- gi prophy: pantoprazole\n Nutrition: regular diet with ensure supplements tid\n Renal: baseline cr ~1,\n -- Cr 5.1 on admission. s/p aggressive IVF hydration. Cr currently 1.4\n -- replace electrolytes as needed\n Hematology: Hct 24.7, baseline 25-26 during last admission\n Endocrine: RISS\n ID:\n -- ?SIRS: hypotension requiring aggressive IVF and pressor support with\n end organ effects of ARF.\n -- empiric vanc/zosyn (start date ). Consider d/c'ing as no growth\n from cultures thus far.\n -- f/u BCx\n -- wbc 12.7 -> 11.1\n T/L/D: RIJ, foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: D5W+150meqNaHCo3 @ 75cc/hr\n Consults: gensurg, GI, nephro\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Nursing", "chartdate": "2145-03-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 620389, "text": "HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n Chief complaint:\n sycopal episodes\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Impaired Skin Integrity\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": "2145-03-10 00:00:00.000", "description": "Intensivist Note", "row_id": 620395, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n Chief complaint:\n sycopal episodes\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Calcium Gluconate, Diazepam, Docusate Sodium, Escitalopram, Ferrous\n Sulfate, FoLIC Acid, Furosemide, Heparin Insulin, Magnesium Sulfate,\n Miconazole Powder 2%, Morphine Sulfate, Oxycodone SR (OxyconTIN),\n Pantoprazole, zosyn, vanc, Potassium Chloride, Senna\n 24 Hour Events:\n weaned off pressors\n cont abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:28 PM\n Piperacillin/Tazobactam (Zosyn) - 10:54 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:08 PM\n Heparin Sodium (Prophylaxis) - 04:12 PM\n Morphine Sulfate - 04:43 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 35.6\nC (96.1\n HR: 70 (67 - 96) bpm\n BP: 93/87(89) {89/44(62) - 125/119(126)} mmHg\n RR: 19 (13 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 126.2 kg\n CVP: 11 (3 - 19) mmHg\n Total In:\n 2,104 mL\n 160 mL\n PO:\n 1,200 mL\n Tube feeding:\n IV Fluid:\n 904 mL\n 160 mL\n Blood products:\n Total out:\n 3,530 mL\n 310 mL\n Urine:\n 3,250 mL\n 310 mL\n NG:\n Stool:\n 280 mL\n Drains:\n Balance:\n -1,426 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: lower leg cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 415 K/uL\n 7.8 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 105 mEq/L\n 141 mEq/L\n 24.1 %\n 7.8 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n 03:20 AM\n 02:31 AM\n WBC\n 14.6\n 12.7\n 11.1\n 9.3\n 7.8\n Hct\n 25.3\n 27.3\n 24.7\n 24.9\n 24.1\n Plt\n 35\n 415\n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n 1.1\n 1.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n 95\n 91\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Differential-Neuts:66.4 %, Lymph:14.6 %, Mono:6.1 %,\n Eos:12.6 %, Lactic Acid:1.1 mmol/L, Ca:8.8 mg/dL, Mg:1.4 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60y F s/p ex lap sigmoidectomy, end colostomy\n () c/b retracted colostomy presents with no ostomy output and\n hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- pain control: oxycontin 80tid\n -- lexapro\n -- valium prn leg spasm\n Cardiovascular:\n -- off pressors\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n Pulmonary:\n -- sats 98% on RA\n Gastrointestinal / Abdomen:\n -- diabetic diet with ensure supplements tid\n -- bowel regimen: senna, colace\n -- gi prophy: pantoprazole\n Nutrition: regular diet w/ ensure supplements tid\n Renal: baseline cr ~1\n -- replete K, Mg\n - d/c foley\n Hematology:\n -- 24.1 stable\n Endocrine: RISS\n ID:\n -- empiric vanc/zosyn (start date )\n continue abx, vanc to 1250\n Q24h\n -- f/u BCx\n -- wbc 12.7 -> 11.1 -> 9.3 -> 7.8\n T/L/D: RIJ, foley - d/c foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: KVO\n Consults: gensurg, GI, nephro\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 11:56 PM\n Arterial Line - 01:05 PM\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: floor\n Time spent: 35\n ICU Care\n" }, { "category": "Physician ", "chartdate": "2145-03-10 00:00:00.000", "description": "Intensivist Note", "row_id": 620490, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP since night PTA.\n Chief complaint:\n sycopal episodes\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Calcium Gluconate, Diazepam, Docusate Sodium, Escitalopram, Ferrous\n Sulfate, FoLIC Acid, Furosemide, Heparin Insulin, Magnesium Sulfate,\n Miconazole Powder 2%, Morphine Sulfate, Oxycodone SR (OxyconTIN),\n Pantoprazole, zosyn, vanc, Potassium Chloride, Senna\n 24 Hour Events:\n weaned off pressors\n cont abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:28 PM\n Piperacillin/Tazobactam (Zosyn) - 10:54 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:08 PM\n Heparin Sodium (Prophylaxis) - 04:12 PM\n Morphine Sulfate - 04:43 AM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 35.6\nC (96.1\n HR: 70 (67 - 96) bpm\n BP: 93/87(89) {89/44(62) - 125/119(126)} mmHg\n RR: 19 (13 - 30) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 126.2 kg\n CVP: 11 (3 - 19) mmHg\n Total In:\n 2,104 mL\n 160 mL\n PO:\n 1,200 mL\n Tube feeding:\n IV Fluid:\n 904 mL\n 160 mL\n Blood products:\n Total out:\n 3,530 mL\n 310 mL\n Urine:\n 3,250 mL\n 310 mL\n NG:\n Stool:\n 280 mL\n Drains:\n Balance:\n -1,426 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: lower leg cellulitis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 415 K/uL\n 7.8 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 105 mEq/L\n 141 mEq/L\n 24.1 %\n 7.8 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n 03:20 AM\n 02:31 AM\n WBC\n 14.6\n 12.7\n 11.1\n 9.3\n 7.8\n Hct\n 25.3\n 27.3\n 24.7\n 24.9\n 24.1\n Plt\n 35\n 415\n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n 1.1\n 1.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n 95\n 91\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Differential-Neuts:66.4 %, Lymph:14.6 %, Mono:6.1 %,\n Eos:12.6 %, Lactic Acid:1.1 mmol/L, Ca:8.8 mg/dL, Mg:1.4 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60y F s/p ex lap sigmoidectomy, end colostomy\n () c/b retracted colostomy presents with no ostomy output and\n hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- pain control: oxycontin 80tid\n -- lexapro\n -- valium prn leg spasm\n Cardiovascular:\n -- off pressors\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n Pulmonary:\n -- sats 98% on RA\n Gastrointestinal / Abdomen:\n -- diabetic diet with ensure supplements tid\n -- bowel regimen: senna, colace\n -- gi prophy: pantoprazole\n Nutrition: regular diet w/ ensure supplements tid\n Renal: baseline cr ~1\n -- replete K, Mg\n - d/c foley\n Hematology:\n -- 24.1 stable\n Endocrine: RISS\n ID:\n -- empiric vanc/zosyn (start date )\n continue abx, vanc to 1250\n Q24h\n -- f/u BCx\n -- wbc 12.7 -> 11.1 -> 9.3 -> 7.8\n T/L/D: RIJ, foley - d/c foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: KVO\n Consults: gensurg, GI, nephro\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 11:56 PM\n Arterial Line - 01:05 PM\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition: floor\n Time spent: 35 minutes\n ICU Care\n" }, { "category": "Rehab Services", "chartdate": "2145-03-09 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 620205, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: sepsis / 038.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 60 yo F with recent\n prolonged admission for diverticulitis s/p colostomy and sigmoid\n resection and was discharged to rehab. She was home from rehab for 2\n days, now readmitted s/p several falls at home and no ostomy output\n following stent dislodgement, as well as hypotension.\n Past Medical / Surgical History: HTN, morbid obesity, DJD with h/o LLE\n weakness in the past, chronic back pain, diverticulitis, repair of\n large incarcerated ventral hernia c/b wound infection\n Medications: heparin, morphine, diazepam, oxycontin, vancomycin\n Radiology: CT - No acute intra-abdominal process\n Labs:\n 24.9\n 7.8\n 435\n 9.3\n [image002.jpg]\n Other labs:\n Activity Orders: Activity as tolerated\n Social / Occupational History: lives alone, son and daughter-in-law\n live above her\n Living Environment: lives in single-level home with several steps to\n enter\n Prior Functional Status / Activity Level: Ambulates short distances\n only with RW, also has w/c and commode\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x3, pleasant and\n cooperative\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 94\n 106/50\n 14\n 100% on RA\n Activity\n 102\n 110/50\n 26\n 99% on RA\n Recovery\n 92\n 100/78\n 16\n 99% on RA\n Total distance walked: 0\n Minutes:\n Pulmonary Status: lungs cta, diminished at bases, no cough noted\n Integumentary / Vascular: RLE with cellulitis wound open to air, L\n radial a-line, R IJ central line, foley, tele, ostomy\n Sensory Integrity: B LE's intact to light touch\n Pain / Limiting Symptoms: c/o LE wound pain with mobility\n Posture: morbidly obese, short stature\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B hip flexion \n B knee flex/ext \n B DF \n Motor Function: no abormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to stand, unable to take any steps in standing.\n Total assist slide transfer from bed to stretcher to chair.\n Rolling:\n\n\n\n\n T\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 x2\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: maintains static sitting at edge of bed with S, static\n standing with min A x2, unable to weight shift. Tolerated standing <10\n sec LE pain.\n Education / Communication: Reviewed PT and discussed d/c planning.\n Communicated with nsg re: status.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n Clinical impression / Prognosis: 60 yo F with sepsis p/w above\n impairments a/w deconditioning. She is most limited by general\n weakness a/w recent bedrest/hospitalization and is well below her\n baseline level. She is unsafe for d/c home given her several recent\n falls and recent failure at home. Would recommend rehab when medically\n stable to progress as able, anticipate rehab potential given\n her age. PT to continue to follow to progress as able.\n Goals\n Time frame: 1 week\n 1.\n Min A bed mobility and sit-to-stand, assess transfers/gait\n 2.\n Min A static/dynamic standing balance with UE support\n 3.\n Tolerate OOB >/= 3 hours/day\n 4.\n Tolerate daily LE strengthening\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n bed mobility, transfers, ambulation, balance, endurance, strengthening,\n education, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2145-03-09 00:00:00.000", "description": "Intensivist Note", "row_id": 620287, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP 24-48hours prior to admission.\n Chief complaint:\n ARF, constipation, hypotension\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Docusate Sodium\n Ferrous Sulfate\n FoLIC Acid\n Heparin\n Insulin\n Magnesium Citrate\n Morphine Sulfate\n Norepinephrine\n Pantoprazole\n Piperacillin-Tazobactam\n Senna Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 11:05 AM\n ARTERIAL LINE - START 01:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:37 AM\n Morphine Sulfate - 12:13 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.6\n HR: 73 (66 - 95) bpm\n BP: 112/54(75) {79/46(64) - 117/67(83)} mmHg\n RR: 16 (11 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 5 (1 - 25) mmHg\n Total In:\n 2,684 mL\n 88 mL\n PO:\n 1,260 mL\n Tube feeding:\n IV Fluid:\n 1,424 mL\n 88 mL\n Blood products:\n Total out:\n 3,160 mL\n 460 mL\n Urine:\n 3,160 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -476 mL\n -372 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Obese, stoma pink, perfused, brown stool output, midline abdominal\n wound granulating in w/exposed fasical sutures\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: RLE necrotic appearing area on shin, no drainage/pus\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 435 K/uL\n 7.8 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 106 mEq/L\n 143 mEq/L\n 24.9 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n 03:20 AM\n WBC\n 14.6\n 12.7\n 11.1\n 9.3\n Hct\n 25.3\n 27.3\n 24.7\n 24.9\n Plt\n 35\n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n 1.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n 95\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Differential-Neuts:66.4 %, Lymph:14.6 %, Mono:6.1 %,\n Eos:12.6 %, Lactic Acid:1.1 mmol/L, Ca:8.2 mg/dL, Mg:1.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60y F s/p ex lap sigmoid colectomy end colostomy\n () c/b retracted colostomy presents with no ostomy output and\n hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- morphine prn pain (consider switching to nonnarcotics pain meds)\n change to home oxycontin with morphine for btp\n Lexapro, valium home med\n Cardiovascular:\n -- levo, wean to off goal MAP 60\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n -- +/- vasopressin if unable to wean\n Pulmonary:\n -- sats 98% on RA\n Gastrointestinal / Abdomen:\n -- Mag citrate; large stool output\n -- Colonoscopy; to ascending colon. No lesions, no strictures\n -- regular diet with ensure supplements tid\n -- bowel regimen: senna, colace\n -- gi prophy: pantoprazole\n Nutrition: regular diet w/ ensure supplements tid\n Renal: baseline cr ~1\n -- Cr 5.1 on admission, normalizing, now 1.1\n -- replace electrolytes\n Hematology: Hct 24.7, baseline 25-26, transfuse if unable to wean\n pressors\n Endocrine: RISS\n ID:\n -- SIRS x2\n -- likely cellulitis with necrotic area b/l legs.\n -- empiric vanc/zosyn (start date ). vanc to 750 Q 12h (level\n high 30.2) repeat trough now.\n -- f/u BCx\n -- wbc 12.7 -> 11.1\n T/L/D: RIJ, foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: KVO\n Consults: gensurg, GI, nephro\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n Arterial Line - 01:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n" }, { "category": "Nursing", "chartdate": "2145-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620091, "text": "Impaired Skin Integrity\n Assessment:\n Patient has multiple skin issues:\n excoriation under polynidal cyst on coccyx.\n abdominal midline wound which used to have wound vac on, now pink\n granulation tissue and yellow tissue in middle, almost at level of\n surrounding skin.\n area of cellulitis on Right medial lower leg.\n Action:\n wound care/ ostomy nurse in to assess:\n criticaid ointment applied to cellulitic area.\n aquacelle silver with NS covered by DSD on midline abdominal wound.\n meplix applied to coccyx.\n Patient turned q 2 hours, skin/ back care frequently\n Response:\n patient states she is having less pain in coccyx region\n Plan:\n continue to monitor, change dsg\ns q 24 hours.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient on levo at 0.08 mg this am. SBP 90\ns-120\ns MAP > 60. HR\n No stool output from ostomy.\n Afebrile\n Action:\n attempted to wean levo, successful at 0.02 mcg/kg/min for a bit then\n required increased doses back to 0.06 mcg/kg/min in afternoon.\n - given mag citrate to facilitate bowel movement.\n Response:\n MAP > 60,\n able to have large BM\n Plan:\n continue to monitor,\n" }, { "category": "Physician ", "chartdate": "2145-03-09 00:00:00.000", "description": "Intensivist Note", "row_id": 620161, "text": "SICU\n HPI:\n 60f s/p sigmoid resection w/ colostomy complicated by ARF, ostomy\n retraction and wound infection, d/c to rehab . Presents w/\n hypotension and syncopal events, after stent \"fell out\" and pt\n refused readmission/intervention @ that time. Denies ostomy output\n since stent dislodged, no UOP 24-48hours prior to admission.\n Chief complaint:\n ARF, constipation, hypotension\n PMHx:\n HTN, Chronic back pain, Morbid obesity, Chronic constipation \n narcotics, Immobility degenerative disk disease resulting in weak\n LLE. h/o complicated diverticulitis, h/o AEF\n Current medications:\n Docusate Sodium\n Ferrous Sulfate\n FoLIC Acid\n Heparin\n Insulin\n Magnesium Citrate\n Morphine Sulfate\n Norepinephrine\n Pantoprazole\n Piperacillin-Tazobactam\n Senna Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 11:05 AM\n ARTERIAL LINE - START 01:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:37 AM\n Morphine Sulfate - 12:13 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.6\n HR: 73 (66 - 95) bpm\n BP: 112/54(75) {79/46(64) - 117/67(83)} mmHg\n RR: 16 (11 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 129 kg (admission): 126.2 kg\n CVP: 5 (1 - 25) mmHg\n Total In:\n 2,684 mL\n 88 mL\n PO:\n 1,260 mL\n Tube feeding:\n IV Fluid:\n 1,424 mL\n 88 mL\n Blood products:\n Total out:\n 3,160 mL\n 460 mL\n Urine:\n 3,160 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -476 mL\n -372 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n Obese, stoma pink, perfused, brown stool output, midline abdominal\n wound granulating in w/exposed fasical sutures\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: RLE necrotic appearing area on shin, no drainage/pus\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 435 K/uL\n 7.8 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 106 mEq/L\n 143 mEq/L\n 24.9 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 03:19 AM\n 06:00 AM\n 03:42 PM\n 03:04 AM\n 05:00 PM\n 05:24 PM\n 03:46 AM\n 03:20 AM\n WBC\n 14.6\n 12.7\n 11.1\n 9.3\n Hct\n 25.3\n 27.3\n 24.7\n 24.9\n Plt\n 35\n Creatinine\n 4.0\n 2.8\n 2.1\n 1.7\n 1.4\n 1.1\n Troponin T\n 0.09\n TCO2\n 18\n 18\n 24\n Glucose\n 43\n 142\n 95\n Other labs: PT / PTT / INR:15.3/32.2/1.3, CK / CK-MB / Troponin\n T:1839/35/0.09, Differential-Neuts:66.4 %, Lymph:14.6 %, Mono:6.1 %,\n Eos:12.6 %, Lactic Acid:1.1 mmol/L, Ca:8.2 mg/dL, Mg:1.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 60y F s/p ex lap sigmoid colectomy end colostomy\n () c/b retracted colostomy presents with no ostomy output and\n hypotension\n Neurologic:\n -- AOx3, no neurologic deficits\n -- morphine prn pain (consider switching to nonnarcotics pain meds)\n Cardiovascular:\n -- levo, wean goal MAP 60\n -- echo : Normal LF function. EF > 55%. Mild MR. HTN.\n -- +/- vasopressin if unable to wean\n Pulmonary:\n -- sats 98% on RA\n Gastrointestinal / Abdomen:\n -- Mag citrate; large stool output\n -- Colonoscopy; to ascending colon. No lesions, no strictures\n -- regular diet with ensure supplements tid\n -- bowel regimen: senna, colace\n -- gi prophy: pantoprazole\n Nutrition: regular diet w/ ensure supplements tid\n Renal: baseline cr ~1\n -- Cr 5.1 on admission, normalizing, now 1.1\n -- replace electrolytes\n Hematology: Hct 24.7, baseline 25-26, transfuse if unable to wean\n pressors\n Endocrine: RISS\n ID:\n -- SIRS x2\n -- likely cellulitis with necrotic area b/l legs\n -- empiric vanc/zosyn (start date ).\n -- f/u BCx\n -- wbc 12.7 -> 11.1\n T/L/D: RIJ, foley\n Wounds: colostomy, abdominal wound with wet->dry dressings\n Imaging:\n Fluids: KVO\n Consults: gensurg, GI, nephro\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sc heparin\n Stress ulcer: PPI ()\n VAP bundle: n/a\n Comments:\n Communication:\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:56 PM\n Arterial Line - 01:05 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2145-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 620149, "text": "60 year old female who complains\nof COLOSTOMY ISSUE. Pt from Hosp. Pt had been in rehab\nuntil 2 days ago (left AMA family issues) today had syncopal\nepisode, hypotension, urinary retention. ? renal failure.\ncolostomy stent has not been functioning per pt. Has wound vac to\nosotmy now. MY HPI: c/o decreased output from ostomy over last\nday. Also w/ lightheadedness, syncopal episode at home this AM.\nDenies abd pain. Describes decreased UOP over last several days.\nDenies fevers. s/p recent admission for wound infections,\ndifficulties with ostomy.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Labile b/p on Norepi as ordered.\n Action:\n Attempted to titrate Norepi gtt.\n Labs as ordered\n Turned every 2 hrs and PRN\n Monitor Ostomy output.\n Morphine for back pain and RLE pain\n Response:\n Minimal output via Ostomy tonight.\n Good UOP all night.\n Patient sleeping inbetween Morphine doses.\n Plan:\n Monitor B/P in setting of ? sepsis and the need for Norepi gtt.\n Monitor Blood levels.\n Impaired Skin Integrity\n Assessment:\n RLE red, flushed, and painful. Aprox 3 inch area to Right shin, Coccyx\n with mepeplex dsg in place, Ostomy intact and no leakage noted.\n Action:\n Turned every 2 hours and as needed\n Lotion to backside and RLE criticaid\n Push nutrition to promote wound healing.\n Response:\n No new breakdown noted,\n No new pressure areas noted.\n Plan:\n Monitor for skin breakdown\n Wound care per Wound nurse.\n Blood sugar as ordered, ss coverage per order.\n" }, { "category": "ECG", "chartdate": "2145-03-06 00:00:00.000", "description": "Report", "row_id": 231393, "text": "Sinus rhythm. Normal tracing. Compared to tracing #2 no change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2145-03-05 00:00:00.000", "description": "Report", "row_id": 231394, "text": "Sinus rhythm. Non-specific anterior ST-T wave changes. Compared to tracing #1\ncriteria for poor R wave progression and low precordial limb lead voltages are\nnot seen on the current tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-03-05 00:00:00.000", "description": "Report", "row_id": 231395, "text": "Sinus rhythm. Low QRS voltage in the precordial leads. Poor R wave\nprogression likely a normal variant. Compared to the previous tracing\nof baseline artifact is now present on the current tracing. The\nother findings are similar.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2145-03-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1120068, "text": " 9:26 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hypotension and ARF s/p ostomy stent fell out. New R IJ\n placed.\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n Comparison is made with a prior study from earlier today.\n\n CLINICAL HISTORY: Hypotension and acute renal failure, new right IJ central\n venous catheter, question line position.\n\n FINDINGS: Portable AP upright view of the chest is obtained. There is a new\n right IJ central venous catheter with its tip in the expected location of the\n superior vena cava. No pneumothorax is seen. The lungs remain clear\n bilaterally. Cardiomediastinal silhouette is stable.\n\n IMPRESSION: Appropriate placement of a new right IJ central venous catheter.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-06 00:00:00.000", "description": "RENAL U.S.", "row_id": 1120098, "text": " 3:46 AM\n RENAL U.S. Clip # \n Reason: Duplex of her renal arteries and r/o hydronephrous\n Admitting Diagnosis: HYPOTENSION;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/ with recurrent renal failure\n REASON FOR THIS EXAMINATION:\n Duplex of her renal arteries and r/o hydronephrous\n ______________________________________________________________________________\n WET READ: DLrc SAT 4:22 AM\n Extremely limited study secondary to patient's habitus. No evidence of\n hydronephrosis. Limited for evaluation of vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 60-year-old female with recurrent renal failure.\n Please evaluate for renal arteries and for hydronephrosis.\n\n EXAMINATION: RENAL ULTRASOUND WITH DOPPLER.\n\n COMPARISONS: Comparison is made to examination from .\n\n FINDINGS: Note that this is an extremely technically limited study secondary\n to the body habitus and subsequent poor penetration.\n\n The right kidney measures 9.5 cm.\n\n The left kidney measures 12.0 cm.\n\n Both kidneys are unremarkable, with no evidence of hydronephrosis,\n nephrolithiasis, or discrete masses. Duplex examinations were extremely\n limited in the setting of poor penetration with some suggestion of normal left\n renal arterial flow, though the rest of the vasculature is unable to be\n assessed.\n\n IMPRESSION: Technically limited study. No evidence of hydronephrosis.\n Doppler examination was limited.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-06 00:00:00.000", "description": "G/GJ/GI TUBE CHECK", "row_id": 1120142, "text": " 11:47 AM\n G/GJ/GI TUBE CHECK Clip # \n Reason: please flush contrast through red rubber catheter in ostomy\n Admitting Diagnosis: HYPOTENSION;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p hartmann's now with ostomy retraction\n REASON FOR THIS EXAMINATION:\n please flush contrast through red rubber catheter in ostomy to rule out\n obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n FINDINGS: Status post Hartmann's procedure, no ostomy retraction. Rubber\n catheter placed into the ostium. No radiographically apparent abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1120046, "text": " 7:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with retracted ostomy, obstipation, decreased urinary output,\n hypotension\n REASON FOR THIS EXAMINATION:\n ? acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: Retracted ostomy, obstipation, decreased urinary output,\n hypotension, question acute process in the chest.\n\n FINDINGS: AP upright portable chest radiograph is obtained. Patient is\n leaning towards the right, which somewhat limits evaluation. Also, left CP\n angle is excluded and underpenetrated technique limits evaluation. There is\n no definite evidence of pneumonia or CHF. No large pleural effusion or\n pneumothorax is seen. Cardiomediastinal silhouette is grossly stable.\n Osseous structures are intact. Degenerative AC joint arthropathy noted.\n There is a stable scoliotic curvature of the mid thoracic spine.\n\n IMPRESSION: No acute findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-08 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1120376, "text": " 9:05 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: BILAT LEG SWELLING ? DVT\n Admitting Diagnosis: HYPOTENSION;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman w/b/l lower extremity swelling, cellulitis\n REASON FOR THIS EXAMINATION:\n ?DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 60-year-old female with bilateral lower extremity swelling,\n 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, superficial femoral, and popliteal veins. Note is made that\n the tibial veins of the left calf could not be identified. In the right calf\n only the right posterior tibial veins could be identified. There is normal\n flow, compression, and augmentation in all of the visualized veins.\n\n In the right popliteal fossa, there is an oval avascular complex structure,\n which measures 5.8 x 2.1 x 3.8 cm. The appearance of this structure most\n likely represents a hemorrhage within cyst.\n\n IMPRESSION:\n 1. No evidence of deep vein thrombosis bilaterally.\n 2. Complex avascular structure in the right popliteal fossa, most likely\n consistent with a hemorrhage within cyst.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-05 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1120078, "text": " 11:08 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? free air. ? obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hypotension and obstipation after ostomy stent fell out\n several days ago\n REASON FOR THIS EXAMINATION:\n ? free air. ? obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 60-year-old female with hypertension, obstipation\n after ostomy. Evaluate for obstruction or free air.\n\n EXAMINATION: Supine and erect abdominal radiographs.\n\n COMPARISONS: Comparison to exams from .\n\n FINDINGS: There is a nonspecific bowel gas pattern without dilated loops of\n small or large bowel identified. No evidence of pneumoperitoneum. Lung bases\n are clear. Note is made of severe degenerative change involving the left hip\n with acetabular protrusio. Spinal fixation hardware is seen overlying the\n right L4-L5 region.\n\n IMPRESSION: Nonspecific bowel gas pattern without evidence of obstruction or\n ileus. No evidence of pneumoperitoneum.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-06 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1120086, "text": " 2:26 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? acute process\n Admitting Diagnosis: HYPOTENSION;ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hypotension and ARF s/p colostomy stent falling\n REASON FOR THIS EXAMINATION:\n ? acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc SAT 5:14 AM\n No acute intrabdominal process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 60-year-old female hypotension and acute renal\n failure status post colostomy stent falling out. Evaluate for acute process.\n\n EXAMINATION: CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY.\n\n COMPARISONS: Comparison is made to examination from .\n\n TECHNIQUE: Helically-acquired axial images were obtained from the lung bases\n to the pubic symphysis without the administration of intravenous contrast.\n Coronal and sagittal reformations were obtained.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n Other than bibasilar atelectasis, the lung bases are clear, without focal\n parenchymal consolidation, pleural effusions or pulmonary nodules. Note is\n made of atherosclerotic calcification within the visualized portion of the\n coronaries.\n\n The liver is borderline fatty. The gallbladder is distended with likely\n dependent stones, without associated stranding or pericholecystic fluid,\n likely related to fasting state. The spleen, pancreas, both adrenal glands,\n both kidneys, and visualized portions of intra-abdominal small and large bowel\n are unremarkable. There is no intra-abdominal free air, with resolution of\n previously noted free air. There is no intra-abdominal free fluid. There is\n no mesenteric or retroperitoneal lymphadenopathy.\n\n There is extensive atherosclerotic calcification involving the abdominal aorta\n and its major branches.\n\n The patient is status post colostomy and Hartmann's pouch. A thin linear\n radiopaque line is seen tracking from the ostomy site through to the\n anastomotic sutures from the Hartmann's pouch and is likely related to string\n material which marks the site.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The Hartmann's pouch appears\n (Over)\n\n 2:26 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? acute process\n Admitting Diagnosis: HYPOTENSION;ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable. The uterus is unremarkable. There is no pelvic free fluid.\n There is no pelvic or inguinal lymphadenopathy. Air seen within the bladder\n and the bladder is relatively collapsed about a Foley catheter. There is no\n pelvic free fluid.\n\n BONE WINDOWS: There is post-traumatic injury seen in the region of the left\n hip. The patient is noted to be status post partial posterior fusion of\n L4-L5. There are extensive degenerative changes involving the thoracolumbar\n spine with vacuum phenomenon seen at the levels of L3-L4 and L5-S1.\n\n IMPRESSION:\n\n 1. No acute intra-abdominal process.\n\n 2. Linear radiopaque foreign body seen traversing from the colostomy site to\n the Hartmann's pouch likely related to expected post-surgical string which\n marks the Hartmann's pouch.\n\n 3. Distended gallbladder, likely related to fasting state.\n\n 4. Borderline fatty liver.\n\n" } ]

[ { "category": "ECG", "chartdate": "2111-08-18 00:00:00.000", "description": "Report", "row_id": 283028, "text": "Sinus rhythm. Non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of heart rate now somewhat slower and left\nbundle-branch block no longer present.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-08-19 00:00:00.000", "description": "Report", "row_id": 1303708, "text": "NPN 4-7am\n\nMr was at home last night and consumed 1 pint of whiskey and 6 beers. He was feeling depressed and called EMS. In the ER lactate 7.1, WBC 13.8 and an anion gap of 28. Transferred to MICU for further care.\n\nneuro: Pt is axox3. He seems very anxious, is visibly shaking and cannot sit still. No c/o pain or discomfort.\n\nresp: LS clear. Sats 97% on RA.\n\ncv: SR in the 60-70. Tachycardic as his anxiety increases. Hypertensive to 180's and received 25mg po lopressor at 0530.\n\naccess: # 18 L hand.\n\ngi/gu: Belly is soft with + BS. Voiding clear, yellow urine in urinal. No stool. NPO except meds.\n\nendo: no issues.\n\nskin: intact.\n\ndispo: Pt is DNR/DNI.\n\nSocial: Pt called and informed his son that he is in the hospital. Pt lives alone and is widowed.\n\nPlan: Possible call out today. Abdominal CT this am.\n" }, { "category": "Nursing/other", "chartdate": "2111-08-19 00:00:00.000", "description": "Report", "row_id": 1303709, "text": "NPN 07:00-19:00 MICU\n*DNR/DNI\nC/o to floor, transfer note written\n*No Ct done, patient refused to drink baricet.\n\nROS:\nNeuro: A/o x3, mae's, no c/o pain,n/v,HA, CIWA scale q2hr,no Valium given.\nCV: HR ~58-mid 60's, SBP 140's-180's (when anxious). low grade temp at noon, now 98.4 po.\nResp: RA, LS clear throghout, O2 sat's high 90's. RR~16. Atrovent at bedside.\nGI/GU: Advance diet as tolerated, patient stating that he is not hungry. +BS, multiple bm all day, guiac (-). U/O ~100cc q4hr, received total of 3L of fluid since admit, Lactate pndg.\nAccess: PIV, x1 wnl.\nSocial: Son in to visit, updated on plan of care/c/o to floor.\n" }, { "category": "Nursing/other", "chartdate": "2111-08-20 00:00:00.000", "description": "Report", "row_id": 1303710, "text": "npn 7-7am\n\nMr is called out to the floor. He had an abdominal xray last evening.\n\nUneventful night. Slept all night, no c/o pain or discomfort.\nVSS.\n\nPlease see transfer note for a complete review of systems.\n" }, { "category": "Nursing/other", "chartdate": "2111-08-20 00:00:00.000", "description": "Report", "row_id": 1303711, "text": "NURSING MICU NOTE 7A-7P\n\nPT BEING D/C HOME THIS AFTERNOON. DISCHARGE PLANNING FINISHED. PT DENIES ANY PAIN. OOB TO COMODE W/ CANE. PT SPOKE W/ SON AND ARRANGED HIM TO TAKE HIM HOME.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2188-12-06 00:00:00.000", "description": "Report", "row_id": 1601916, "text": "Shift Summary\nN: Continues with sedated affect, sleeping and arousable by painful stimuli. Occasional vocalization, Russian speaking, incomprehensble words per translator at bedside. PERL, OD 5-6mm sluggish, OS 4mm brisk. Continues with eaqual nonpurposeful movement bilaterally.\n\nCV: L radial aline placed after multiple bilateral sticks with bilateral hematomas, continued palpable radial pulses with slow capillary refill and finger tips cool to touch. . Continued labile BP stable last 3hrs MAP>60 SBP 100-110. Trace anasarca. Telemtry w/ BBB HR 50-65, occasional PVC, sinus arrythmia/NSR. + Sys murmur. TLC placment on hold d/t unpredictable periods of restlessness and Ativan given in ER thought as possible cause for continued sedate state.\n\nGI: NGT placed this afternoon with emesis, and approximately 100cc bilelike brown secretions, placement auscultated/verified RN and resident, OK to use for meds MD. brown BM, unable to obtain enough for lab specimen currently requested. BS + to hyperactive, abdomin soft.\n\nR: LS on arrival with intermittent I/E wheezes, now bilateral upper lobes remain clear, bibasilar LS diminished. Maintaining sats >95% on 2L NC. Problable aspiration noted during NGT placement, has not affected respiratory status as yet, requested sputum specimen not obtained.\n\nGU: Nephrology consulted re: elevated BUN/CR. Rec IVF changed to D5W1/2 w/ 75meq NaHCO3 currently up at 75cc/hr.\n\nGlucogon drip at 1mg/hr. Insulin drip trending upward at 3u/hr FSG 120-180.\n\nSkin with scattered ecchymotic areas form mulitiple injections/IV attempts.\n" }, { "category": "Nursing/other", "chartdate": "2188-12-07 00:00:00.000", "description": "Report", "row_id": 1601917, "text": "NURSING PROGRESS NOTES 1900-0700\nNEURO: PERL 4MM SLUGGISH, BEG OF SHIFT PT AT TIMES BUT WAS DIFFICULT TO INTERPRET BY GRANDDAUGHTER. PT WOULD NOT FOLLOW ANY COMMMANDS. HOWEVER WOULD ONLY MOVE TO NOXIOUS STIMULI TO NAIL BEDS AND SHE WOULD LOCALIZE W/ FLEXION W/DRAWAL. @ 0000 PT WAS ABLE TO OPEN HER EYES AND THIS RN, SHE ALSO IS ORIENTED X1 TO HERSELF, GRANDAUGHTER ASKED QUESTIONS D/T PT IS RUSSIAN SPEAKING ONLY. PT WAS ABLE TO SAY YES /NO TO A FEW SIMPLE QUESTIONS. PT CONTINUES NOT TO FOLLOW COMMANDS IE: SQUEEQE MY HANDS, WIGGLE YOUR TOES. AT PRESENT PT IS SLEEPING.\n\nRESP: PT IS ON O2 2LNC SATS 97%, LS CLEAR W/ DIMINISHED BASES. RR 18-20. PT HAS +GAG W/ NO COUGH NOTED THIS SHIFT.\n\nCV: TELE: SB-SR 58-65, W/ OCCASIONAL PVC, SBP >90 THROUGHOUT SHIFT. HRT SOUNDS S1S2\nPEDAL PULSES +2 W/ +1 EDEMA.\n\nGI: NGT TO LCWS 300CC OF PINK W/ SMALL CLOTS NOTED IN GASTRIC RETURN. GUIAC SLIGHT + USING HEMACULT GREEN TEAM RESIDENT AWARE. HCT CHECKED AT 2300 29.5 FROM 33. CBC SENT AT 0400 RESULTS PENDING.\nABD OBESE BS+, NO STOOL THIS SHIFT. PT STARTED ON NEPRO TF AT 10CC/HR @0300. ADVANCE Q8HR BY 10CC TO GOAL OF 70CC/HR. FLUSHES Q8HRS OF 50ML H2O. RESIDUAL CHECK Q4HR HOLD IF RESIDUAL >=100CC\n\nGU: PT FOLEY CATH DRAINING YELLOW URINE IN ADEQUATE AMOUNTS\n\nSKIN: INTACT, EXCEPT FOR ECCYMOTIC AREAS ON ARMS FROM MULTYPLE ALINE ATTEMPTS.\n\nENDO: PT ON GLUCAGON GTT @ 1MG/HR (2CC/HR), INSULIN GTT CONT @ 3UNITS/HR, FINGERSTICKS CHECKED Q1HR AND REMAIN 130S-140S,\n\nID: WBC DOWN TO 15 FROM 25 @2300, SPUTUM C/S AND STOOL CULTURE UNABLE TO BE OBTAINED\n\nACCESS: SL X2 WNL AND ALINE LEFT RADIAL WNL.\n\nFLUIDS: PT CONT ON D51/2 NS W/ 75MEQ OF NABICARB X2LITERS 1ST LITER CONT.\n\nCODE: FULL\n\nSOCIAL: FAMILY VERY SUPPORTIVE AND INVOLVED. GRANDAUGHTER STAYED THROUGHOUT EVENING AND SON NOW IN AT PT BEDSIDE.\n\nPLAN:\nCONT NEURO CHECKS\nCONT TO CHECK FINGER STICKS Q1HR AND TITRATE INSULIN GTT\nCHECK RESIDUALS Q4HRS AND INCREASE TF Q8HRS\nCONT TO KEEP FAMILY INVOLVED AND UPDATED W/ PLAN OF CARE\nREPLACE LYTES AND BLD IF HCT DROPS, LABS FROM THIS AM PENDING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2188-12-07 00:00:00.000", "description": "Report", "row_id": 1601918, "text": "ADDENDUM 1900-0700\nK3.1 BEING REPLACED W/ 40MEQ KCL IN 500CC NS. DR AWARE OF ALL LABS. INSULIN GTT INCREASED TO 3.5UNITS/HR FOR BS OF 153. CONT TO MONITOR CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2188-12-06 00:00:00.000", "description": "Report", "row_id": 1601915, "text": "Admission Note\nRussian speaking 83y/o lady w/ hx/o HTN, EF 55% in , CHF, chronic dyspnea w/ baseline sats 90%, nephrolithiasis, dyskinesis, atrial septal defect, spinal disk dz, pulmnary HTN, L kidney cyst and diverticulosis. Presented to ER with AMS progressively worsening last two days, BP 80/50's junctional rhythm thought to be with betablocker toxicity, given atropine, CA gluconate and glucogon with improvement. CT scan negative. Admitted to MICUa stable w/ labile SBP 80-150 unresponsive except to aggressive physical stimulation leading to hyper agitation. Nonpurposeful movement and equal bilateral strength. PERL 6mm, R pupil sluggish to react. Glucogon drip on hold pending refill from pharmacy. FSG 234 covered w/ RSSI. Foley with clear yellow urine. LS w/ I/E wheezes bilaterally and diminished bibasiler.\n" }, { "category": "Radiology", "chartdate": "2188-12-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 852358, "text": " 11:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk SAT 5:42 AM\n limited by motion, but no bleed seen\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT. Multiple attempts were made to limit patient\n motion.\n\n FINDINGS: There is no intra or extraaxial hemorrhage, midline shift, or mass\n effect. The ventricles and sulci appear normal. The -white matter\n differentiation appears intact. Evaluation of the cerebellum and temporal\n lobes particularly is limited by motion. There are no acute fractures. The\n paranasal sinuses appear well aerated.\n\n IMPRESSION: Study limited by motion, but no intracranial hemorrhage or mass\n effect is seen. If clinically indicated and patient can tolerate, an MR is\n more sensitive to detect acute ischemia.\n\n" }, { "category": "Radiology", "chartdate": "2188-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852592, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: WEAKNESS-BRADYCARDIA-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with SOB, wheeze\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest compared .\n\n CLINICAL INDICATION: Shortness of breath and wheezing.\n\n The heart is enlarged, and the aorta is tortuous. There has been interval\n development of perihilar haziness, peribronchial coughing, and septal\n thickening. There is also a new small right pleural effusion extending into\n the minor fissure. There is also a possible new small left pleural effusion.\n\n IMPRESSION:\n\n Interval development of congestive heart failure with interstitial pulmonary\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852362, "text": " 1:54 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with bradycardia,altered mental status\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bradycardia, altered mental status.\n\n AP PORTABLE CHEST: Compared with 1.5 hours prior.\n\n The cardiac and mediastinal contours are stable. There is respiratory motion.\n No definite infiltrates, but there are low lung volumes. No pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2188-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852359, "text": " 12:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with bradycardia,altered mental status\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bradycardia and altered mental status.\n\n PORTABLE CHEST: Compared with . There is cardiomegaly,\n but no pleural effusions. Stable unfolding and calcification of the\n descending aorta. There is low inspiratory effort, but no definite\n infiltrates or pulmonary edema.\n\n IMPRESSION: Low lung volumes, but no definite acute process.\n\n" }, { "category": "ECG", "chartdate": "2188-12-11 00:00:00.000", "description": "Report", "row_id": 272098, "text": "Baseline artifact\nSinus rhythm with atrial premature complexes\nRight bundle branch block\nLeft anterior fascicular block\nDiffuse ST-T wave changes - may b e in part primary\nclinical correlation is suggested\nSince previous tracing of , atrial fibrillation absent\n\n" }, { "category": "ECG", "chartdate": "2188-12-08 00:00:00.000", "description": "Report", "row_id": 272099, "text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock and left axis deviation. Poissible prior inferior myocardial infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nthe ventricular response to atrial fibrillation is faster. Clinical correlation\nis suggested.\nTRACING #8\n\n" }, { "category": "ECG", "chartdate": "2188-12-08 00:00:00.000", "description": "Report", "row_id": 272100, "text": "Atrial fibrillation with a moderate to intermittently rapid ventricular\nresponse. Intermittent complete right bundle-branch block with left axis\ndeviation. Non-specific ST-T wave changes. Compared to the previous tracing\nof atrial fibrillation is now present with resolution of the extremely\nmarked Q-T(U) interval prolongation. Clinical correlation is suggested.\nTRACING #7\n\n" }, { "category": "ECG", "chartdate": "2188-12-07 00:00:00.000", "description": "Report", "row_id": 272101, "text": "Sinus rhythm with atrial ectopy including a blocked atrial premature beat.\nCompared to the previous tracing of multiple abnormalities are as\nnoted, with persistent marked Q-T(U) interval prolongation at about 0.56\nseconbds, along with left atrial abnormality, bifascicular block and other\nfindings as noted. Clinical correlation is suggested.\nTRACING #6\n\n" }, { "category": "ECG", "chartdate": "2188-12-06 00:00:00.000", "description": "Report", "row_id": 272102, "text": "Borderline sinus bradycardia. Compared to the previous tracing of \nmultiple abnormalities are as reported. There is now even more marked\nQ-T(U) interval prolongation at about 0.6 seconds consistent with marked drug\neffect/toxicity versus hypokalemia, etc. Incomplete, not complete, right\nbundle-branch block is now seen. Clinical correlation is indicated for marked\nrepolarization prolongation.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2188-12-06 00:00:00.000", "description": "Report", "row_id": 272103, "text": "Possible sinus versus ectopic atrial mechanism with ventricular premature\nbeats. Borderline left axis deviation. Non-specific ST-T wave changes which\ncould be due to ischemia, etc. Minor right ventricular conduction delay.\nCompared to the previous tracing of or the rhythm now appears\nto be sinus. Repeat tracing suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2188-12-06 00:00:00.000", "description": "Report", "row_id": 272332, "text": "Sinus rhythm with borderline P-R interval prolongation. Left axis deviation\nconsistent with left anterior fascicular block with right bundle-branch block\nconsistent with bifascicular block. Q-T interval prolongation raising\nconsideration of drug effect, hypokalemia, etc. Left atrial abnormality.\nCompared to the previous tracing of ventricular ectopy is not seen.\nQTc interval prolongation is now present with complete right bundle-branch\nblock and more leftward axis. Clinical correlation is suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2188-12-06 00:00:00.000", "description": "Report", "row_id": 272333, "text": "Tracing is not of diagnostic quality. Compared to the previous tracing\nof , which showed junctional bradycardia, the rate is not as slow.\nAtrial mechanism cannot be determined with any certainty. Prolonged\nrepolarization is again noted. Repeat tracing suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2188-12-05 00:00:00.000", "description": "Report", "row_id": 272334, "text": "A-V junctional bradycardia with prolonged R-P interval. Left axis deviation.\nLeft ventricular hypertrophy. Non-specific ST-T wave change with prominent\nQTc interval prolongation which may be related in part to the bradycardia.\nExclude drug effect/toxicity, hypokalemia, etc. Minor right ventricular\nconduction delay. Delayed precordial transition. Possible prior inferior\nmyocardial infarction. Compared to the previous tracing of \nA-V junctional bradycardia is now present. Complete right bundle-branch block\nis not seen. Clinical correlation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2201-04-20 00:00:00.000", "description": "Report", "row_id": 178520, "text": "Sinus rhythm\nModest nonspecific low amplitude precordial lead T waves\nSince previous tracing of , precordial lead T wave amplitude lower\n\n" }, { "category": "ECG", "chartdate": "2201-04-14 00:00:00.000", "description": "Report", "row_id": 178521, "text": "Sinus rhythm. Since the previous tracing of ventricular ectopy is no\nlonger seen. Non-specific ST-T wave abnormalities persist.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910995, "text": " 11:56 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o PTX, interval change. please perform ~11am.\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagectomy. CT now to water seal.\n REASON FOR THIS EXAMINATION:\n r/o PTX, interval change. please perform ~11am.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of esophagectomy.\n\n Status post CABG and esophagectomy. Chest tube is present in right medial\n hemithorax. There is a small right apical pneumothorax and slight gaseous\n distention of the intrathoracic stomach. Subclavian CV line remains with tip\n located poorly on this film but in the region of the lower right atrium. NG\n tube in stomach and its tip located at level just inferior to the diaphragm.\n There is bibasilar linear atelectasis and residual small amount of\n pneumoperitoneum. Chest tube is present at the left lung base.\n\n IMPRESSION: Tiny right apical pneumothorax. Left subclavian CV line remains\n in lower right atrium. Bibasilar linear atelectasis and small amount of\n residual pneumoperitoneum.\n (Discussed by telephone with Dr )\n\n" }, { "category": "Radiology", "chartdate": "2201-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911118, "text": " 4:37 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: r/o CHF, eval stomach conduit in chest\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy \n\n REASON FOR THIS EXAMINATION:\n r/o CHF, eval stomach conduit in chest\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of esophagogastrectomy.\n\n Status post esophagectomy. There is a residual small, unchanged right\n pneumothorax. Chest tubes are present in both lower hemithoraces. NG tube is\n in stomach at the level just inferior to the diaphragms. There is minimal\n residual pneumoperitoneum. Linear atelectases are present at both lung bases.\n Tip of left subclavian CV line remains in lower right atrium. Surgical drain\n is present in left supraclavicular region.\n\n IMPRESSION: Residual small unchanged right pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911053, "text": " 9:03 AM\n CHEST (PA & LAT) Clip # \n Reason: EVALUATE LUNG FIELD R/UO EFFUSION/PTX\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: Followup right effusion and pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: There is slight improvement in the right middle lobe and lower lobe\n atelectasis. A small right apical pneumothorax is slightly larger than\n yesterday. There is also a small right hydropneumothorax. A very small left\n apical pneumothorax is unchanged from yesterday. Chest tubes are unchanged as\n well as a left subclavian central venous catheter. Nasogastric tube is in\n place. There is small residual subcutaneous gas. In addition, there is\n residual free air under the diaphragm secondary to surgery.\n\n IMPRESSION:\n 1. Slightly enlarging right apical pneumothorax with stable slight left\n apical pneumothorax and right basilar hydropneumothorax.\n 2. Slight improvement in right middle lobe and lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910832, "text": " 5:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for PTX and hemothorax\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy \n REASON FOR THIS EXAMINATION:\n Eval for PTX and hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man status post esophagogastrectomy now evaluate for\n pneumothorax and hemothorax.\n\n COMPARISON: .\n\n SEMI-UPRIGHT CHEST RADIOGRAPH: Endotracheal tube and nasogastric tube are\n unchanged position. There is no change in the position of a dual-chamber\n left-sided subclavian central venous catheter with tip in the IVC. Recommend\n withdrawal 8 cm. There is prominence of the mediastinum with rightward\n deviation of the trachea which may be secondary to a mediastinal hematoma in\n this patient status post surgery. A small right apical pneumothorax was not\n seen on the prior examination. There has been interval reduction in right-\n sided subcutaneous emphysema. Linear atelectases at both lung bases.\n\n IMPRESSION:\n 1. Small right apical pneumothorax.\n 2. Rightward deviation of the trachea in this patient status post surgery may\n be secondary to post-surgical changes and mediastinal hematoma.\n 3. Dual-chamber central venous catheter tip remains in the IVC. Recommend\n withdrawal by 8 cm.\n 4. Right-sided subcutaneous emphysema.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-23 00:00:00.000", "description": "ESOPHAGUS", "row_id": 911511, "text": " 1:06 PM\n ESOPHAGUS Clip # \n Reason: eval s/p esophagectomy -anastomosis and check gastric emptyi\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with esophagectomy\n REASON FOR THIS EXAMINATION:\n eval s/p esophagectomy -anastomosis and check gastric emptying. Please use\n barium for study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post esophagectomy, evaluate for extravasation in transit.\n\n FINDINGS: Scout images demonstrated surgical staples in the upper chest as\n well as the gastric pull up. Images were taken in the AP, right\n anterior oblique and left anterior oblique projections while the patient\n swallowed thin barium. There was no evidence of anastomotic leak. Barium flows\n freely through the intrathoracic stomach, and exits into the small bowel,\n albeit slightly slowly. There were no immediate post- procedure\n complications.\n\n IMPRESSION: No evidence of anastomotic leak status post esophagectomy.\n Slightly slow transit into the small bowel.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911685, "text": " 2:30 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval for interval change, ptx, s/p left CT d/c\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy , right chest tube\n d/c,Cervical JP d/c pm, now s/p left Ct d/c\n REASON FOR THIS EXAMINATION:\n please eval for interval change, ptx, s/p left CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS\n\n INDICATION: 75-year-old man status post laparoscopic esophagogastrectomy in\n , right chest tube discontinued on , now status post left catheter\n discontinued. Please evaluate for interval change.\n\n CHEST, TWO VIEWS: Comparison is made to a prior study of . The\n heart is normal in size. There is widening of the mediastinum to the right,\n consistent with post-surgical changes following an esophagogastrectomy. There\n is atelectasis at the lung basis bilaterally. The left-sided chest tube has\n been removed. Again noted are small bilateral apical pneumothoraces. These\n are unchanged in size.\n\n IMPRESSION: Unchanged size of the small apical bilateral pneumothoraces\n following removal of the left chest tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911322, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate lung field for effusion/ptx progression\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy , chest tubes BL to water seal.\n REASON FOR THIS EXAMINATION:\n evaluate lung field for effusion/ptx progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old post-esophagogastrectomy, assess for pneumothorax.\n\n Portable semi-upright frontal radiograph compared to .\n\n FINDINGS: The right apical pneumothorax has decreased slightly in size. There\n is also a small left apical pneumothorax, which is essentially unchanged.\n Bilateral chest tubes remain in place. Right basilar and left retrocardiac\n atelectasis appear slightly increased. There is no CHF.\n\n IMPRESSION: Persistent tiny left apical pneumothorax; reduction in size of\n the small right apical pneumothorax. Increased bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911504, "text": " 12:38 PM\n CHEST (PA & LAT) Clip # \n Reason: inetrval chnage\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy , chest tubes BL to water seal.\n\n REASON FOR THIS EXAMINATION:\n inetrval chnage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post laparoscopic esophagectomy with bilateral chest tubes\n to waterseal.\n\n COMPARISON: .\n\n FINDINGS: A small right apical pneumothorax is enlarged in the interval with\n the pleural reflection overlying at the bottom of the fourth rib. There is\n also a very small left apical pneumothorax that is unchanged. Bilateral chest\n tubes are in place and unchanged. The cardiac and mediastinal silhouettes are\n stable. Linear right upper lobe opacity likely represents atelectasis. Right\n lower and middle lobe atelectasis has also increased in the interval.\n\n IMPRESSION: Enlarging small right apical pneumothorax with stable left apical\n pneumothorax. These findings were discussed with Dr. at 3:45 p.m. on\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910818, "text": " 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: INCORRECT NEEDLE COUNT\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Incorrect needle count.\n\n COMPARISON: .\n\n Endotracheal tube tip is approximately 2 cm from the carina. Recommend\n pulling back approximately 2 cm. Left subclavian central line tip at the base\n of the right atrium. Recommend pulling back approximately 8 cm. Nasogastric\n tube tip seen at the gastroesophageal junction. Recommend advancing several\n cm. Chest tube seen overlying the right/middle hemithorax and another chest\n tube overlying the left base. Cardiomediastinal silhouette consistent with\n postoperative changes. Lung volumes are low. No focal opacities. Left\n costophrenic angle excluded. No large pleural effusions.\n\n IMPRESSION:\n\n 1. Lines and tubes requiring readjustment as described above.\n 2. No definite radiopaque opacities. Very tiny vague thin linear opacities\n seen in several locations on film, likely artifactual.\n\n Findings discussed with referring team at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-17 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 910819, "text": " 3:51 PM\n PORTABLE ABDOMEN Clip # \n Reason: INCORRECT NEEDLE COUNT\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Incorrect needle count.\n\n COMPARISON: .\n\n SUPINE ABDOMINAL RADIOGRAPH: Multiple staples are seen overlying the abdomen.\n There is no evidence of radiopaque foreign body. Drain is seen overlying the\n mid abdomen. Nonspecific bowel gas pattern.\n\n IMPRESSION: No evidence of radiopaque foreign body concerning for needle.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911571, "text": " 6:50 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for interval change, ptx s/p right CT d/c. thank\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy , right chest tube d/c, left\n CT remains, Cervical JP d/c.\n REASON FOR THIS EXAMINATION:\n please eval for interval change, ptx s/p right CT d/c. thanks\n ______________________________________________________________________________\n FINAL REPORT\n This is a two-view chest of , with indication of status post\n esophagectomy procedure.\n\n COMPARISON: , at 12:33 p.m.\n\n Since the recent study, a right chest tube has been removed. A right apical\n pneumothorax is unchanged in size. Small left apical pneumothorax is also\n stable in size with a left chest tube remaining in place. With the exception\n of right chest tube removal, there has not been a change from the prior study\n performed earlier the same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911216, "text": " 10:07 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate lung field r/uo effusion/ptx\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagectomy. CT now to water seal.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field r/uo effusion/ptx\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n HISTORY: Esophagectomy. Chest tube to waterseal. Evaluate lungs.\n\n IMPRESSION: PA and lateral chest compared to and 8:\n\n Small right pneumothorax with apical anterior and basal components unchanged\n since , right pleural tube unchanged in position traversing the base to\n the lower mediastinal surfaces. Left basal pleural tube also unchanged. No\n appreciable pleural effusion. Heart size normal. Normal postoperative\n mediastinal contours. New esophagus contains a nasogastric tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910879, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n Admitting Diagnosis: ESOPHAGEAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p lap esophagopastrectomy \n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of esophagogastrectomy.\n\n Chest tubes are present in the right mid hemithorax and in the left lower\n hemithorax. Tip of NG tube is a short distance inferior to the diaphragm\n within the intrathoracic stomach, which is mildly distended. No definite\n residual pneumothorax. There is subcutaneous emphysema in the right chest\n wall. A surgical drain is present in the left paratracheal region in a\n supraclavicular location.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-04-17 00:00:00.000", "description": "Report", "row_id": 1481124, "text": "Minimally Invasive Lap Esophagectomy\nNSR with hypertention throughout stay tonight. Discussed htn with DR. and Dr. . More concern expressed over avoiding hypotention and subsequent pressor use with limited blood supply to stomach. Blood pressure improved after extubation and LR hydration.\n\nExtubated abut 1900 without incident. Deep breathing instructions given. Pt initially denied having any pain and now answers that his back, abd and chest ache. Morphine IV given till Morphine PCA pump available. Pt demonstrated proper use of PCA pump. Weaned from 50% OFM to room air. Current SPo2 95% on RA. Bilateral CT draining dark bloody drainage. No air leak in either CT.\n\nL NGT draining minimal thick bloody secretions on low continuous suction. J tube ordered to gravity. Unable to pass any saline through J tube. J tube removed and replaced by Dr. . Patient denied feeling tube being moved. Pt stated that this was his \"4th J tube since \". Plan to watch patency closely with NS flush. No gravity drainage from tube as yet. Pt appears of normal weight. No skin breakdown. Pt denies having every used his J tube for feeding.\n\nSeveral small dsd on abd and r flank. All d & i. Dr. reported that \"central line may be in too far\". Only patient cl is a portacath. Portacath not in use tonight.\n\n^glucose. ssri sc given @ 22/hr.\n\nUrine output ~ 30cc. Needs to be watched closely. need additional IV volume. H/O drainage around meatus. Foley care done, no drainage.\n\nPleasant, oriented, MAE. Possible transfer to 2 tomorrow. Pt lives by himself (widow). He identified his next of as , his son. His son to bring in the glasses tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-04-18 00:00:00.000", "description": "Report", "row_id": 1481125, "text": "11pm to 7am\ns/p esophagogastrectomy completed at 1600.\nNeuro:\nPt oriented x3. Pt able to mae and follow commands. Perrl.\nResp:\nRecieved pt extubated on RA maintaining Sats 94-95%. Pt guarding when taking deep breath or coughing. Lungs CTA. Sats drop when pt sleeps to 90%. pao2 via ABG 63. 2L o2 via nc applied. Initiated IS with max of 750. Encouraged pt to do while he is awake.\ncv:\nNS rhythm noted with no ectopy in the 70's. Left radial a-line with sbp in 140's. call team if pressure goes above s160. Lopressor given with good results. HR 60's and sbp in the one teens. Bilat ct to suction draining sm-mod amt of serosang drainage (less than 50cc/hr). JP in left side of neck draining approx 10cc/hr of sang fluid. dressing dry and intact. Pt has unaccessed left subclavian port-a-cath with questionable drifting into right atrium. Do not use.\nGI:\nNPO! NG via left nare to suction- DO NOT MANIPULATE TUBE! Flushed with 10cc every four hours as ordered. Remained patent. Draining sm amts of serosang drainage to lcws. Jejunostomy tube to gravity bag. no drainage noted. Flushed with 10cc NS every eight hours as ordered. Multiple laproscopic insertion sites noted on abd and right thoracic region. Dressings dry and intact. Abd soft and distended. No bs present.\nGU:\nAmber clear urine to foley with minimal output. Team aware. LR increase to 200cc/hr continous. Pt recieved additonal LR 500cc Bolus x3. With adequate results. See carevue for amounts.\nId: Afebrile this shift. Flagyl and Cefazolin continued.\nlabs:\ndrop in crit from 31 to 24.6 Dr notified. No actions at present, probably secondary to iv fluids. Will continue to access for bleeding. Baseline Mg low. from 1.3 to 1.1 Dr notified. Mag 4gm iv given. Will repeat Mg level. Cal repleted as ordered.\nPain:\nPt on PCA pump. 1.5mg every 6 minutes as needed. Max 15mg/hr. See carevue for Attempts/actual.\nPlan:\nWean O2 when pt awakes. Encourage IS, coughing, and deep breathing. Monitor Crit and s/s bleeding. Monitor MG and lytes and replete as needed. Pain control.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2123-05-23 00:00:00.000", "description": "Report", "row_id": 1572249, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: mild resp distress--compromised resp effort d/t Mult Sclerosis;\nhypotensive in ER;\n\nneuro:\nhs meds include methadone, ativan, lorazapam, baclofen, melatonin;\npt very groggy overnight after having received hs meds per pt request--pt incontinent urine a couple times (likely d/t grogginess)'\n\nc-v:\nvss; on coumadin for hx PE;\ncxr neg PE this admission;\npt states she takes 3.75 mg coumadin at has, instead of 3.5.;\n\nresp:\ncontinues to have conjested cough and nasal conjestion; O2 sat hi 90's with 2.0 nc O2;\n\ng-i:\ntaking po food/fluids per self;\n\ng-u:\nvoiding via bedpan, incont discussed in neuro note;\n\naccess:\nrt EJ; left c.w. portacath accessed and patent;\n\nPLAN:\n1) likely c/o for floor today;\n2) follow pt complaints/requests\n3) abx as ordered\n4) assist w/ cares, meals PRN\n" }, { "category": "Nursing/other", "chartdate": "2123-05-23 00:00:00.000", "description": "Report", "row_id": 1572250, "text": "pmicu nursing progress and transfer note\nplease see nurses admission note and transfer note.\n\nresp: presently on 2l nasal prongs with o2 sats of 95-99% and a resp rate of . pt does become slightly sob with speaking and activity. cxr dated showed no evidence of infiltrate or pneumonia. cta showed no evidence of pulmonary embolis. pt has a strong, essentially, unproductive cough, but pt does sound congested. lung sounds are coarse, slightly deminished in the base. ? whether pt has a bronchitis.\n\ncardiac: bp 85-104/ 52-70 pulse 64-84 nsr, with no ectopy noted. k+ today is 3.7, mag 1.9, calcium 8.2. yesterday when pt turned with the elft side down her bp dropped to 73/ but upon putting her back on her back her bp improved. corgard and dyazide, which pt takes at home, has been held. rec'd a 500cc normal saline fluid bolus yesterday. pt receives coumadin for a hx of pulmonary embolis---tonight pt ordered for 5mg--last night pt rec'd 3.5mg and inr was 1.8.\n\nid: on contact precautions. pt is neg for influenza a and b. wbc was 3.6. on azithromycin---today dosage was changed to 500mg daily x 5 days. temps of 95 ax, and 95.4 ax. ??sinusitis.\n\ngi: abdomin soft, + bowel sounds. given a fleets enema yesterday, , with positive results. tolerating regular house diet and liquids without difficulty.\n\ngi: pt voids---uses either the bedpan or can, with help, use the commode. bun 7 and creat .5. urine is clear yellow, pt denies any burning or pain with urination.\n\nneuro: pt has a history of white matter seizures and takes depakote. pt is alert and oriented---wonderfully pleasant. from a family of nurses---pt's mother and 2 sisters and pt's 2 children are all nurses.\n\naccess: removed the ej line. pt has single lumen portacath accessed\n" }, { "category": "Nursing/other", "chartdate": "2123-05-22 00:00:00.000", "description": "Report", "row_id": 1572247, "text": "MICU NPN\nPT. IS A 53Y/0 FEMALE WITH COMPLICATED PAST MEDICAL HISTORY, SEE FHP FOR DETAILS. CAME INTO ER LAST NIGHT WITH A FEVER OF 102.5 PO AND C/O COUGHING UP YELOOW/GREEN SPUTUM, WAS ALSO FOUND TO BE HYPOTENSIVE WITH BP AS LOW AS 70/30'S WAS GIVEN 4-5 LITERS OF NS AND RESPONDED WELL TO THAT. CXR AND CT SCAN WERE BOTH NEGATIVE.\n\nNEURO: HAS MS AND STATES SHE USES AND WHEELCHAIR AT HOME TO GET AROUND.\n\nRESP: ON DROPLET PRECAUTIONS TO R/O FLU, OTHERWISE IN O2 AT 2L VIA N/C SATS 95-99%. HAS NOT HAD A PRODUCTIVE COUGH SINCE ARRIVAL TO MICU. ALSO ? MRSA FROM A THROAT CULTURE BACK IN /.\n\n\nCV: HR AND BP HAVE BEEN STABLE SINCE ARRIVAL TO THE MICU SEE CAREVUE FOR MOST UP TO DATE INFO.\n\nGI: ABD. SOFT, +BS.\n\nGU: VOIDING USING BEDPAN DOES HAVE A HX. OF URINARY RETENTION.\n\nID: T-MAX 100.7, STARTED ON PO ZITHROMYCIN.\n\nSOCIAL: MARRIED LIVES WITH HUSBAND DAUGHTER AND SON IN LAW.\n\nPLAN: CONTINUE WITH PRESENT CARE IF CONTINUES TO BE STABLE GO TO FLOOR TODAY.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-05-22 00:00:00.000", "description": "Report", "row_id": 1572248, "text": "Pmicu nursing progress note\nresp: presently on 2L nasal prongs with o2 sats of 90-98% and resp rate of 18-26. on room air o2 sats are 92-94% but while sleeping, on room air, pt drops her o2 sats to 88%. pt has a strong non-productive cough---??? whether pt has bronchitis. lung sounds in the lll was deminished, other wise lobes varied between clear and coarse.\n\ncardiac: bp of 92-110/48-56 with pulse of 74-88sr, no ectopy noted. k+ 3.5--pt usually takes K+ dur daily. when pt had left side down, her bp noticeably to 79/41 with a pulse from 79 to 68---when placed back on back bp was 93/50 and pulse 80. notified team. at 1P pt rec'd a 500cc normal saline fluid bolus. pt rec'd a liter of normal saline at 100cc/hr x1 liter, at present kvo.\n\nid: temps of 99.5po, 99.8po, and 100.2po. pt is now off droplet precautions as pt neg for the flu--remains on contact precautions. ??bacterial bronchitis--on azithromycin.\n\ngi: abdomin soft with + bowel sounds. given a fleets enema with + results this am. stool was ob neg. tolerating house diet without any difficulty. takes prilosec, not protonix.\n\ngu: voids on the bedpan. output for 12hrs has been 1500cc. bun 10 and creat .7. urine appears clear.\n\npain: pt rec'd fentanyl patch. complains of pain in left hip as well as lower back---prn use of lido patch.\n\nskin: buttocks slightly red.\n\nheme: inr 2.5, pt 25.1 and ptt 37.1.\n" }, { "category": "ECG", "chartdate": "2123-05-21 00:00:00.000", "description": "Report", "row_id": 162563, "text": "Sinus rhythm\nLateral ST changes are nonspecific\nNo change from previous\n\n" }, { "category": "Radiology", "chartdate": "2123-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910895, "text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please r/o infiltrate\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with MS, h/o PE admitted with URI sx.\n REASON FOR THIS EXAMINATION:\n please r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM.\n\n History of pulmonary embolism with upper respiratory symptoms.\n\n The jugular CV line is in region of cavoatrial junction. No pneumothorax.\n Heart size is within normal limits and the lungs are clear.\n\n IMPRESSION: No evidence for pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-05-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910840, "text": " 7:01 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with chest pain, SOB, productive cough, and fever 102.5\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with chest pain, productive cough and fever.\n Evaluate for pneumonia.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPH: Left-sided internal jugular central venous\n catheter tip lies within the right atrium in unchanged position compared to\n the prior examination. The cardiomediastinal silhouette is within normal\n limits. Pulmonary vasculature is normal. Lungs are grossly clear with no\n evidence of focal consolidation, pleural effusion, or pneumothorax. There is\n persistent elevation of the right hemidiaphragm. The osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. No evidence of acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2123-05-21 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 910844, "text": " 8:06 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: H/O OF PE,FEVER,CHEST TIGHTNESS,R/O PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with h/o PE in the past, +anticardiolipin Ab, with fever,\n chest tightness\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 10:14 PM\n no evidence of pulmonary embolism, however, subsegmental arteries not fully\n evaluated secondary to poor bolus (secondary to infusion via port)\n\n\n WET READ VERSION #1 KCLd FRI 9:03 PM\n no evidence of pulmonary embolism\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of PE, anticardiolipin antibody, fever, chest tightness,\n evaluate for pulmonary embolism.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired axial images of the chest were obtained with and\n without IV contrast. Multiplanar reformatted images were also displayed.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: No evidence of pulmonary\n embolism is seen. Subsegmental pulmonary arteries are not fully assessed\n secondary to suboptimal contrast bolus, secondary to patient's ports. No\n focal consolidations are seen within the lungs. There is no evidence of\n pleural effusion. Several mediastinal lymph nodes are seen, however, none\n appear to meet CT criteria for pathologic enlargement. Heart and great\n vessels are unremarkable.\n\n Limited views of the upper abdomen demonstrated small rounded hypodensity\n within the left lobe of the liver, too small to characterize by CT, not\n significantly changed from prior study. Focal densities seen within the\n bowel, likely represent ingested pills. Otherwise, limited views of the upper\n abdomen are unremarkable.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n Multiplanar reformatted images confirm the axial findings.\n\n IMPRESSION: No evidence of pulmonary embolism. Subsegmental pulmonary\n arteries not fully evaluated secondary to contrast bolus.\n\n (Over)\n\n 8:06 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: H/O OF PE,FEVER,CHEST TIGHTNESS,R/O PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2106-10-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 807459, "text": " 3:32 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate s/p coiling r PCOM aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement\n REASON FOR THIS EXAMINATION:\n evaluate s/p coiling r PCOM aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Status post V-COM aneurysm coil with subarachnoid hemorrhage and\n increasing intracranial pressures.\n\n COMPARISON: at 8:28 pm.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: In the interval, there is a right frontal craniotomy defect with\n pneumocephalus tracking in an apparent position of an attempted right frontal\n ventricular catheter brain tract. However no catheter is identified. In the\n interval, there is interval worsening of hemorrhage in the lateral\n ventricles, the right lateral ventricle is completely filled with blood, and\n the occipital of the left ventricle is filled with blood. There is a\n matallic density/ coil in the region of known aneurysm at the origin of the\n right posterior communicating artery creating significant artifact in this\n region. There is blood seen in the cerebellopontine cistern the fourth\n ventricle, the basilar and quadrigeminal cisterns again. There is also blood\n surrounding the visualized portions of the brain stem. There is slight shift\n of midline structures to the left.\n\n These findings were communicated immediately to the neurosurgical resident\n upon completion of the examination.\n\n IMPRESSION:\n\n Interval development of slight shift of midline structures to the left and\n development of massive hemorrhage into the ventricles. Extensive\n subarachnoid hemorrhage, is again seen in the sulci and in the various\n cisterns and surrounding the brain stem as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807477, "text": " 7:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for position of ET tube\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n Please assess for position of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78 y/o woman status post intubation, to assess position of ET\n tube.\n\n FINDINGS: Chest AP portable supine done at 8:40 hours. No priors for\n comparison. The tip of the ET tube seems to be in the right main bronchus.\n There is left basal and retrocardiac opacity with blunting of the left CP\n angle suggesting underlying collapse consolidation with effusion.\n\n IMPRESSION:\n 1) Left retrocardiac opacity.\n 2) ET tube in the right main bronchus.\n\n Findings were communicated to nurse on the floor.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808230, "text": " 10:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o interval changes: pt with worsening MS\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement - no longer draining\n REASON FOR THIS EXAMINATION:\n r/o interval changes: pt with worsening MS\n contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n CT HEAD W/O CONTRAST:\n\n INDICATION: Arachnoid hemorrhage. Right PCOM aneurysm. Rising intracranial\n pressures.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast CT of head.\n\n FINDINGS: There has been interval placement of a right frontal approach\n drainage catheter whose tip does not appear to be within the right frontal\n . The left frontal approach drainage catheter is in stable position\n within the left frontal . Since the prior exam, there is newly identified\n high density hemorrhage within the ventricles, with only a mild increase in\n size of the right lateral ventricle. Also noted towards the vertex of the\n brain parenchyma is a slight increase in effacement of sulci, which may be\n related to minimal new or evolving subarachnoid hemorrhage. There is no\n shift of the normally midline structures.\n\n Mucosal thickening of the paranasal sinuses and partial opacification of the\n mastoid air cells is stable in appearance.\n\n IMPRESSION;\n 1) Newly identified hemorrhage within the ventricles, with slight interval\n increase in size of the right lateral ventricle. No shift of the normally\n midline structures or evidence of brain herniation.\n\n 2) Newly identified right frontal approach drainage catheter, the tip of\n which does not appear to be within the right frontal .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2106-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 807967, "text": " 9:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for any interval change\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement\n REASON FOR THIS EXAMINATION:\n Please assess for any interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subarachnoid hemorrhage. S/P coiling of the right posterior\n communicating artery aneurysm.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Comparison is made to the prior head CT of . The\n previously described extensive subarachnoid hemorrhage and the right frontal\n hemorrhage are unchanged in size and density. However, there is an increase in\n the amount of surrounding edema, with more prominent sulcal effacement. The\n lateral ventricles are slightly more narrowed than on the prior study. There\n is no shift of normally midline structures. The left frontal drainage catheter\n remains in place. The catheter-associated pneumocephalus has resolved. The\n osseous structures are unchanged.\n\n IMPRESSION: Stable appearance of hemorrhagic areas without evidence of re-\n bleeding. Diffuse increase in edema surrounding the hemorrhagic areas, with\n slight increase in mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-22 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 807454, "text": " 10:14 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 261\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATH EMBO THERAPY *\n * CAROTID/CEREBRAL UNILAT CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: High-grade subarachnoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: Same, status post coil embolization of the ruptured\n right posterior communicating artery aneurysm using GDC coils.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Ms. is a 78-year-old woman who intially presented to an\n outside hospital after having suffered a headache. Upon transfer while in the\n ambulance she deteriorated and required intubation. Upon arrival she was noted\n to have a high-grade subarachnoid hemorrhage with scale and Hunt-\n scale. She was effectively in coma. She underwent placement of\n intraventricular drain for decompression and it was taken to cerebral\n angiography for treatment of what appeared to be a ruptured right posterior\n communicating artery aneurysm.\n\n CONSENT: The patient's son and her family were given a full and complete\n explanation of the procedure. Specifically, the indications, risks, benefits,\n and alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death, were outlined. The\n patient's son and her family understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area(s) was/were\n prepped and draped in the usual sterile fashion. A 19-gauge single- wall\n needle was then used to puncture the right common femoral artery/arteries, and\n upon the return of brisk arterial blood, a 5 Fr vascular sheath was inserted\n over a guidewire and kept on a heparinized saline drip. Next, a diagnostic\n catheter was used to selectively catheterize the following vessels: right\n common carotid artery, right internal carotid artery, right intracranial\n internal carotid artery, right posterior communicating artery aneurysm.\n\n RESULTS: Injection of the right common carotid artery in the cervical region\n reveals no evidence of atherosclerosis at the bifurcation. The course of the\n right common carotid artery in the cervical region is within normal limits.\n The right external carotid artery from the common injection is within normal\n limits with no abnormal shunting. Intracranially injection of the right\n internal carotid artery revealed the presence of a large and irregular 9 x 10\n (Over)\n\n 10:14 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 261\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n mm aneurysm of the right posterior communicating artery with the neck\n measuring approximately 5-1/2 to 6 mm. Given the patient's high-grade\n hemorrhage and poor neurological condition the decision was made to proceed\n with endovascular coil embolization. To that end the catheter which\n had been used in order to catheterize the right common carotid artery because\n of the tortuosity of the arch was exchanged over a wire for a 5 Fr MPC\n guidecatheter which was placed to the right internal carotid artery. With the\n catheter in this position an SL-10 microcatheter was used in combination with\n an Agility 14 microwire to catheterize the aneurysm. With the microcatheter in\n the aneurysm a series of GDC coils were deployed starting with a GDC 10 mm 3D\n which provided a good basket. In addition a series of smaller GDC coils were\n deployed and the aneurysm was recatheterized approximately three times until a\n good dense packing was obtained in the distal inferior and posterior margins\n of the aneurysm which were felt to have been the rupture site. The\n anterior/superior portion of the aneurysm dome close to the origin of the\n right posterior communicating artery was noted to be more loosely packed and\n was left as such. The patient received a low dose of heparinization during the\n procedure with 1000 units of heparin. At the end of the procedure the\n activated clotting time was found to be greater than 200 and accordingly she\n was received 15 mg Protamine. She was then transferred back to intensive care\n unit in stable condition.\n\n IMPRESSION: Right posterior communicating ruptured high-grade aneurysm status\n post GDC coil embolization.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808094, "text": " 10:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate size of bleed, r/o sinusitis **** please do Head C\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement - no longer draining\n REASON FOR THIS EXAMINATION:\n evaluate size of bleed, r/o sinusitis **** please do Head CT including sinus\n cuts to evaluate sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage with elevated ICP.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: In the 12 hours since the prior study, there has been no appreciable\n change in the appearance of the brain, subarachnoid hemorrhage, or left\n frontal approach intraventricular drainage catheter. The ventricles are not\n appreciably changed in size or configuration. Mucosal thickening within the\n paranasal sinuses and small air-fluid level within the right maxillary sinus\n is again noted, unchanged.\n\n IMPRESSION: Stable appearance of the brain in 12 hours' time.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-29 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 808095, "text": " 10:52 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: r/o sinusitis\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement - no longer draining\n REASON FOR THIS EXAMINATION:\n r/o sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Sinusitis.\n\n CT SINUSES: Comparison is made to previous films from earlier same day.\n\n TECHNIQUE: Noncontrast axially acquired sinus CT.\n\n FINDINGS: The patient remains intubated, and there is trace amount of\n fluid layering within the right maxillary sinus. There is mucosal thickening\n within the sphenoid, ethmoid, frontal and left maxillary sinuses as well.\n There is a small amount of fluid layering within both middle ear cavities\n bilaterally, and there is is fluid within the mastoid air cells bilaterally as\n well.\n\n IMPRESSION: Mild to moderate mucosal thickening within the paranasal\n sinuses. Trace fluid in the right maxillary sinus. Fluid within the middle ear\n cavities and mastoid air cells bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807495, "text": " 2:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: moved ETT back approx 2.5 cm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p intubation\n\n REASON FOR THIS EXAMINATION:\n moved ETT back approx 2.5 cm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old woman status post intubation; ET tube moved back\n approximately 2.5 cm.\n\n AP PORTABLE CHEST ON AT 3:00 P.M.:\n\n Compared to prior study earlier this same date, the tip of the ET tube is just\n at the level of the carina. There is no other change. Left subclavian\n central venous catheter tip is in the superior vena cava. No acute\n cardiopulmonary disease.\n\n A second portable chest x-ray was obtained under this clip number, taken at\n 4:11 p.m. It is an unspecified portable chest. It shows the endotracheal\n tube pulled back about 2 cm above the carina. There is no other change.\n\n IMPRESSION: ET tube now in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 807654, "text": " 11:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: reevaluate s/p coiling\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement\n REASON FOR THIS EXAMINATION:\n reevaluate s/p coiling\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up study for subarachnoid hemorrhage with coiling of a\n right posterior communicating artery aneurysm.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Since the prior CT scan of , there has been some\n diminished density of the extensive subarachnoid hemorrhage, presumably\n reflecting minimal resorption of the formed elements of the blood.\n Additionally, there is a right frontal lobe hemorrhage, which may represent\n the effects of a prior drainage catheter insertion. At the present time, a\n left frontal drainage catheter is seen with its tip in the left frontal .\n Along the tract and within the left frontal are small bubbles of gas.\n There is no hydrocephalus or shift of normally midline structures at this\n time. There is a moderate amount of intraventricular hemorrhage.\n\n CONCLUSION: No hydrocephalus at this time. Other findings as noted above.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807795, "text": " 4:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: L subclavian central line changed over guidewire, eval for p\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p intubation with h/o CVA\n REASON FOR THIS EXAMINATION:\n L subclavian central line changed over guidewire, eval for position and r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Left subclavian line change over guide wire.\n\n AP CHEST: Comparison is made to the study from . The\n endotracheal tube has been retracted. The tip is now several cm above the\n carina. The left subclavian central venous line tip is likely within the\n proximal SVC near the confluence of the brachiocephalic veins, but is still\n directed laterally to the right instead of down towards the right atrium. No\n pneumothorax is seen. The NG tube tip and side port remain below the\n diaphragm. Cardiac size and pulmonary vasculature are stable in appearance.\n There is a left pleural effusion which is also not significantly changed.\n\n IMPRESSION: Left subclavian line tip in proximal SVC. No pneumothorax. Small\n left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808045, "text": " 10:52 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess position of intraventricular drain\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh, coiled R PCOM aneurysm, rising ICP's s/p EVD\n placement - no longer draining\n REASON FOR THIS EXAMINATION:\n Please assess position of intraventricular drain\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rising intracranial pressure in patient with subarachnoid\n hemorrhage status post coiling of right posterior communicating artery\n aneurysm.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: , approximately 14 hours prior to the present\n study.\n\n FINDINGS: In the interval since the prior study, there is marked increase in\n the amount of blood surrounding the ventricular shunt as it passes through the\n left frontal lobe. The bleed measures approximately 2.5 x 3.0 cm and there\n are multiple air bubbles within this bleed which are new. There is associated\n mass effect with effacement of adjacent sulci and rightward bowing of the falx\n cerebri. There is no uncal herniation. There is also increase in the amount\n of blood within the left lateral ventricle. There is no interval change in\n extensive subarachnoid hemorrhage and right frontal parenchymal hemorrhage.\n There is poor -white matter differentiation in the superior frontal and\n parietal lobes, indicating cerebral edema.\n\n IMPRESSION: Interval increase in the size of the right frontal hemorrhage\n with increase in associated edema and mass effect. No evidence of herniation.\n Air bubbles within this hemorrhage may relate to reports of attempts to flush\n the catheter. There is also increase in blood within the left lateral\n ventricle.\n\n The neurosurgical resident, Dr. , was immediately informed of\n this finding at approximately 11:55 PM on .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2106-10-22 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 807445, "text": " 8:30 PM\n CT HEAD W/ & W/O CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n LAB RECONSTRUCTIONS\n Reason: evaluate s/p SAH\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with SAh\n REASON FOR THIS EXAMINATION:\n evaluate s/p SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe FRI 9:33 PM\n Large SAH with uncal herniation. Blood extending from sulci to fourth\n ventricle.\n CTA shows R MCA and ACA aneurysm.\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: 78 year old woman with subarachnoid hemorrhage. Transferred from\n an outside hospital.\n\n TECHNIQUE: Multiple axial images were obtained both prior to and following the\n administration of 100 cc of Visipaque. In addition, reformatted images were\n obtained in the coronal and axial planes.\n\n FINDINGS: There is extensive subarachnoid hemorrhage involving the basal\n cisterns, sylvian fissures bilaterally, and the lateral ventricles and 4 th\n ventricle.\n\n CT angiogram demonstrates a large partially thrombosed aneurysm (atleast 8 mm)\n at the origin of the right posterior communicating artery.\n\n There is opacification of the anterior and middle and posterior cerebral a\n rteries bilaterally. There is mucosal thickening in the maxillary sinuses\n bilaterally.\n\n These findings were immediately communicated to the Emergency Room physician\n taking care of the patient.\n\n IMPRESSION: Extensive subarachnoid hemorrhage ad described above. Large\n aneurysm at the origin of the right posterior communicating artery.\n Temporal horns are prominent, raising a suspicion of early hydrocephalus.\n\n" }, { "category": "Radiology", "chartdate": "2106-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807485, "text": " 10:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new left subclavian central line\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p intubation\n\n REASON FOR THIS EXAMINATION:\n new left subclavian central line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old woman S/P intubation. Check position of new left\n subclavian central line.\n\n FINDINGS: AP portable chest x-ray done on at 10:30 hours.\n Comparison is made to prior film done on the same day at 8:40 hours.\n Tip of the catheter placed through the left subclavian vein is seen to be\n lying at the SVC. The tip of the ET tube is unchanged and lying in the right\n main stem bronchus. Nurse on the floor informed of the findings. The left\n retrocardiac opacity is unchanged compared to a prior film.\n\n IMPRESSION:-1. Subclavian catheter tip lying in the SVC.\n 2. Tip of ET in R main stem bronchus.\n\n" }, { "category": "Nursing/other", "chartdate": "2106-10-23 00:00:00.000", "description": "Report", "row_id": 1436195, "text": "CONDITION UPDATE:\nD/A: T MAX 99.1\n\nNEURO: PT . PUPILS SMALL, RIGHT SLIGHTLY BIGGER THAN LEFT, SLUGGISH. PT NOW BRISKLY WITHDRAWING LE'S TO NAIL BED PRESSURE. LUE SLIGHT ABNORMAL FLEXION WITH STERNAL RUB, RUE AT TIMES EXTENDS, AT TIMES FLEXES WITH STERNAL RUB. + COUGH WITH SUCTIONING. NO SPONTANEOUS MOVEMENT WITHOUT PAINFUL / SUCTION STIMULI. VENT DRAIN 10 CM ^ TRAGUS, DRAINING BLOODY DRAINAGE. ICP'S , CPP 60-90 (GOAL CPP 60-70).\n\nCV: HR 60'S NSR, NO ECTOPY NOTED. TLCL PLACED, CONFIRMED PLACEMENT BY CHEST XRAY. ABP GOAL 100-140 MET WITH HELP OF NEO AT TIMES. PT'S BP ELEVATED WITH SUCTIONING AND STIMULATION. + PPP BILAT, NO PEDAL EDEMA. FEMORAL SITE C+D. CVP ~ 10.\n\nRESP: LS CLEAR, SUCTIONED FOR SMALL AMOUNTS OF TAN SECRETIONS. PER X-RAY ETT IN TOO FAR DESPITE BILAT BREATHSOUNDS. REPEAT CHEST X-RAY ETT STILL IN TOO FAR, REPOSITIONED AGAIN WITH REPEAT CHEST X-RAY SHOWING ETT IN GOOD POSITION PER DR. @ 22 @ LIP. PT ON AC 50%, 12X500. NO SPONTANEOUS BREATHS OVER VENT SETTINGS.\n\nGI: OGT-LCWS WITH SMALL AMOUNT BILIOUS DRG. NPO.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: PT HAS 8 CHILDREN (4 DAUGHTERS/4 SONS). ALL ARE ARRIVING TODAY. AT THERE REQUEST, THE PRIEST WAS CALLED AND VISITED WITH PT AND FAMILY. PT HAD X3 RINGS ON, ONE SILVER COLOR BAND, ONE WITH 5 CLEAR STONES, AND ONE WITH ONE CLEAR STONE. RINGS REMOVED AND PT'S DAUGHTER TOOK THEM HOME WITH HER. DR. SPOKE WITH PT'S SON IN AM AND UPDATED HIM.\n\nR: VSS ON/OFF NEO, NEURO STATUS SLIGHTLY IMPROVED HOWEVER REMAINS POOR.\n\nP: CONTINUE WITH FREQUENT NEURO EVALUATIONS, MONITORING OF ICP/CPP AND ALL VS/HEMODYNAMICS. CONTINUE TO TITRATE NEO FOR GOAL SBP 100-140 WITH GOAL CPP 60-70. CONTINUE WITH PT AND FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-23 00:00:00.000", "description": "Report", "row_id": 1436194, "text": "admission note\nD: pt admitted from angio s/p coiling of aneurysm. pt intubated on on ac at a rate of 10. ventricular drain leveled at 5cm above the tragus.\nupon admission ventricular drain not draining csf and no fluid movement. icp 21-25. dr. aware and drain examined and flushed. still no drainage. pt unresonsive and not following commands. pupils 2 and sluggish reaction. no withdrawel to pain to nail bed pressure. dr. aware and spoke with dr. . mannitol 50 gms given iv x one. ventricular drain changed by Dr. . initally functioning but stopped draining after 5 minutes. flushed by dr. and still not draining. heac ct done stat and ventricular drain placed on left side. opening icp was and draining cherry colored csf. icp remains . neuro exam. rt pupil 2 left pupil 1.5 and both sluggishly react. arms and legs withdraw to painful stimuli. no spontaneous movement. nipride weaned off. sbp downt to 78 after nimodipine 60mg dose. Dr. aware and 1 liter of ns fluid bolus given. sbp up to 106. urine output remains adequate. falmily updated by dr. and rn.\nA: continue with neuro checks q1. titrate medication for blood pressure. ?need for central line placement. vent changes made per abgs. dilatin load given.\nr: pt withdrawing to pain after ventricular drain placement. pt currently off nipride. sbp responded well to fluid bolus.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-23 00:00:00.000", "description": "Report", "row_id": 1436196, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per Resp. flowsheet. No vent changes made so far this shift. ETT repositioned from 24cm to 22cm at lip. BS equal bilat. Sxn for small amount tannish secretions. cont vent support.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-25 00:00:00.000", "description": "Report", "row_id": 1436204, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT TO STIM. ATTEMPTS TO OPEN EYES (SWOLLEN). PERRL AT 3-4MM. DOES NOT FOLLOW CO0MMANDS. LOCALIZES TO STERNAL RUB WITH R HAND ONLY. WITHDRAWS LEFT ARM TO NAIL BED PRESSURE. WITHDRAWS BILAT TOES TO LIGHT TOUCH. ICP UP TO 28 THIS AM. NP INFORMED, DOWN TO 18 NEXT HOUR, BUT NO DRG. NP IN TO FLUSH, PRESSURE TUBING CHANGED, STILL NO DRG. PT TO HEAD CT. SEEN BY NP ON RETURN. VENT DRAIN CONTINUES WITH NO DRG, ICP'S .\nRESP: LS COARSE AT UPPER AIRWAY AT TIMES. CLEARED AFTER ET SUCTIONED FOR MOD AMTS THICK SPUTUM. VENT CHANGED TO CPAP 5/5. ABG STABLE.\nCV: TMAX 100.1 THIS SHIFT. PT IN RAPID AF AT CHANGE OF SHIFT THIS AM, UP TO 140S. IV LOPRESSOR ORDERED AND GIVEN, AND STANDING DOSE LATER STARTED. AF CONVERTED TO NSR AT APPROX 0900. PT REMAINS IN NSR THROUGHT REST OF SHIFT 70S-80S. NIPRIDE GTT CONTINUES AND TITRATED UP TO MAINTAIN SBP <140. K REPLETED X1 AS ORDERED.\nGI: TF'S INCREASED TO GOAL WITH MIN RESIDUALS. ABD SOFT. POS BOWEL SOUNDS. NO BM.\nGU: ADEQUATE U/O VIA FOLEY.\nENDO: FSBG COVERED PER RISS.\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY. CONT TO MONITOR ICP'S AND ASSESS FOR DRG. CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-26 00:00:00.000", "description": "Report", "row_id": 1436205, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN CPAP/PS MODE, NO CHANGES MADE THIS SHIFT. PT WELL IN SYNCH W/VENT. BS GROSSLY CLEAR, SXN FOR SM AMT THICK TAN SEC. AM ABG REFLECTS SLIGHT METABOLIC ALKALOSIS W/HYPEROXIA. RSBI 46. NO SBT PER TEAM PENDING FURTHER ORDERS. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-26 00:00:00.000", "description": "Report", "row_id": 1436206, "text": "CONDITION UPDATE\nD: NEURO: AROUSABLE TO STIMULI ONLY. ? ATTEMPTS TO OPENS EYES WHEN NAME CALLED BUT PT HAS SIGNIFICANT PERIORBITAL EDEMA AND IS UNABLE TO OPEN THEM. PUPILS 2-3MM WITH BRISK REACTION. MOVES ALL EXTREMITIES ON BED BUT NOT TO COMMAND. VENT DRAIN AT 10CM ABOVE TRAGUS. DRAIN IRRIGATED BY PA. VENT DRAIN HAS PUT OUT A TOTAL OF 45 CC FOR THE LAST 12 HRS. ICP 8-21.\nCV: T MAX 100.8. OTHER VSS- SEE CAREVUE FOR SPECIFICS. REMAINS ON SNP TO MAINTAIN SBP <140.\nRESP: NO VENT CHANGES LAST NIGHT. BS DIMININISHED IN BASES OTHERWISE CLEAR. SX FOR THICK TAN SECRETIONS\nGI: ABD SOFT AND NON-TENDER. +BS. TOL TF AT GOAL.\nGU: CLEAR YELLOW IN GOOD AMTS\nA: NEURO STATUS MONITORED, LABS REPLETED AS INDICATED, ATTEMPT TO WEAN SNP WHILE MAINTAINING SBP<140\nR: UNCHANGED, ? INCREASE LOPRESSOR\n" }, { "category": "Nursing/other", "chartdate": "2106-10-31 00:00:00.000", "description": "Report", "row_id": 1436226, "text": "Focus-Condition Update\nData-At 20:00 pt sl opens eyes, did not follow commands. at 4mm\n Pt on Neo gtt earlier in the evening. SBP at 160's/. Vent drain at\n 10cm above the tragus-no further drainage noted from drain, no ICP\n tracing noted. Pt on CPAP 5/5, spon resp 20-24, gag reflex present.\n Pt on 3% NS gtt at 10cc/hr.\nAction-Dr. notified of vent drain being clotted off. Nipride gtt restarted to keep SBP 130-160.\nData-21:30, pt noted to have decreased resp (7), Pupils 5mm bilat-non-\n reactive. SBP dropped to 70/. No response to stimuli.\nAction-Dr. and Dr. notified. Neo gtt restarted-titrated\n up to 5mcg/kg/min. Dr. in to see pt. 2nd additional ventri-\n cular drain inserted at bedside. 1st vent drain flushed by Dr. . STAT Ct scan done. Family updated of patients change in condition. Mannitol 25Gm IV x2 given. Pt placed on A/C, rate 12. 3% NS rate increased to 20cc/hr per Dr. .\nResponse-Pt remains . Pt made DNR per family. Family\n awaiting other family members from . Pt remains on Neo\n gtt to maintain SBP. Small amt bloody drainage noted from 1st vent\n drain. Repeat Na 137.\nPlan-Continue with current care.\n Support to family.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-24 00:00:00.000", "description": "Report", "row_id": 1436197, "text": "condition update\nD: pt moving rt arm spontaneously. no movement of any other extremities. withdraws extremities to pain. rt pupil 2mm and reacts briskly. left pupil 1.5 and reacts briskly. pt with positive gag and cough.icp 6-9 and vent draisn continues to drain bloody csf. bs clear to coarse. suctioned for thick tan sputum. neo titrated for sbp 100-140. currently neo is off. pt briefly on nipride for sbp greater than 100. urine output28, 32 and 25. dr. aware and ns bolus of 250cc ordered. monitor urine output for effectiveness. ngt patent and draining bilous fluid. abd soft and no bowel sounds. no areas of breakdown noted. pt tolerating turning and multipodis splints.\na: continue with neuro checks. ns fluid bolus for low urine output. titrate neo and nipride for sbp 100-140. ? start nimodipine today.\nr: slight improvement in neuro status as seen with spontaneous movement of rt arm. currently off neo and nipride\n" }, { "category": "Nursing/other", "chartdate": "2106-10-24 00:00:00.000", "description": "Report", "row_id": 1436198, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 500, A/C 12, Fio2 50%, and Peep 5. Spont effort . Bs clear bilaterally. Sx'd for sm amount of thick blood tinged sputum. No further changes made. Plan: Continue with mechanical support and wean to Psv as tolerated. Will do RSBI later in am.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-24 00:00:00.000", "description": "Report", "row_id": 1436199, "text": "CONDITION UPDATE:\nD/A: T MAX 99.3\n\nNEURO: PT MORE EASILY AROUSABLE TODAY, AT TIMES OPENING EYES TO FAMILY MEMBERS VOICES. , BRISK. RUE WITH SPONTANEOUS PURPOSEFUL MOVEMENT, LUE WITH SLIGHT WITHDRAW TO PAIN, BILAT LE'S BRISK WITHDRAW TO PAIN. VENT DRAIN 10 CM ^ TRAGUS INTACT WITH ICP ~ 9, DRAINING BLOOD TINGED FLUID. PT ATTEMPTING TO BITE ETT AND OGT.\n\nCV: HR 90'S NSR WITH OCC PAC'S. ELECTROLYTES CHECKED AND TREATED. GOAL SBP 100-140 MET WITH NIPRIDE GTT. PT BP ELEVATES WHEN STIMULATED AND NORMALIZES WITH LOW STIMULATION. CVP ~ 8. FLUID BALANCE MN-1600 + CC'S. X2 FLUID BOLUS'S GIVEN FOR LOW U/O.\n\nRESP: VENT CHANGED TO CPAP 40 % 5 PEEP, 10 PS WITH RR ~ 20, TV ~ 400. ABG: 7.43, 38, 156, 26, 1. LS CLEAR.\n\nGI: TUBE FEEDS STARTED VIA OGT.\n\nGU: FOLEY-BSD WITH LOW U/O IN 20'S Q HOUR. X2 FLUID BOLUS GIVEN WITH POOR EFFECT.\n\nSX: FAMILY VISITING OFTEN.\n\nR: IMPROVED NEURO STATUS, IMPROVED RESPIRATORY STATUS.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT. CONTINUE TO MONIOR NEURO STATUS CLOSELY AND ICP PRESSURES. CONTINUE TO TITRATE NIPRIDE FOR GOAL SBP 100-140. ? START LOPRESSOR AS PT WAS ON TOPROL XL PRIOR TO ADMISSION AND HAS HX OF AFIB. CONTINUE WITH PT AND FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-24 00:00:00.000", "description": "Report", "row_id": 1436200, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp. flowsheet. Pt changed from SIMV to PSV today with good ABG's. Pt more responsive today. Good cough effort with sxn, impaired gag. Cont current support.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-29 00:00:00.000", "description": "Report", "row_id": 1436221, "text": "NURSING PROGRESS NOTE 0700-1500\nNEURO--DOWN FOR CT OF HEAD. SMALL NEW BLEED ON OPPOSITE SIDE. PT OPENS EYES SPONT. DOES NOT FOLLOW COMMANDS. RUE WILL MOVE ON BED. ALL EXTREMITIES WILL WITHDRAW TO NOXIOUS STIMULI. PEARL AT 2-3MM. BOTH FEET HAVE +BABINSKI. ICP <13.\n\nCARDIAC--STARTED ON SNP PRESENTLY ON 1.0 MCG.KG/MIN. WITH GOAL TO KEEP SBP <140. HR CONVERTED TO NSR WITH 1ST DEGREE A-V BLOCK WHICH APPEARS TO HAVE SUBSIDED. (PR 2.04) CVP 16-20. NA+ 132. REMAINS ON 3% SALINE AT 10CCHR. NEW ART LINE PLACED.\n\nRESP---SX Q2 HRS FOR THICK COPIOUS AMTS OF YELLOW SPUTUM REQUIRING NS INSTILLATION. LUNGS COARSE BILATERALLY IN ALL FIELDS.\nSAO2 >98%.\n\nGI--TOL TF OF IMPACT AT 55 CC HR. MIN RESIDUALS. SMALL STOOL. RECTUM IS FULL OF STOOL. +FLATUS.\n\nGU--UO ~30 CCHR OF YELLOW URINE.\n\nENDO--INSULIN GTT STARTED NOW AT 5U HR FOR BS 172. (WHILE ON 3U HR). Q1HR FS.\n\nSKIN--GROSSLY INTACT. HEAD INCISION DSD INTACT.\n\nID--FEBRILE TO 100.1. REMAINS ON ABX.\n\nPAIN--UNABLE TO ASSESS BUT PT'S VS DO NOT APPEAR TO REVEAL PAIN AT THIS TIME.\n\nCOPING--SON AND DAUGHTER IN TO VISIT. THEY HAVE BEEN UPDATED AND ARE AWAITING RESULTS OF NEWEST CT SCAN.\n\nA--ICP AND BP CONTROLLED AT THIS TIME. REMAINS .\n\nP--CON'T NEURO CHECKS. STOP HYPERTONIC SALINE WHEN NA TO 135. CON'T Q1HR BS CHECKS. OFFER SUPORT TO FAMILY .\n" }, { "category": "Nursing/other", "chartdate": "2106-10-29 00:00:00.000", "description": "Report", "row_id": 1436222, "text": "Resp Care: Pt remains intubated via #7 ETT secured 22cm at lip. BS I wheezes and wet E wheezes. MDI given w/ gd effect. Transported to and from CT scan w/o incident. Pt remains on PSV 5/5P/.40. Vt's=400, RR 19-22. Sx'd for tenacious tan sputum, requiring lavaging. ABG reveals metabolic alkalosis, normoxia. No vent changes made this shift. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-30 00:00:00.000", "description": "Report", "row_id": 1436223, "text": "CONDITION UPDATE\nNEURO: PT OPENS EYES WHEN SPOKEN TO, NAME CALLED. DOES NOT FOLLOW COMMANDS, DOES NOT MOVE EXTREMITIES SPONTANEOUSLY. WITHDRAWS ALL EXTREMITIES TO NAILBED PRESSURE. HAS WEAK COUGH WHEN SUCTIONED, NO GAG NOTED. VENT DRAIN OPEN AT 10 CM ABOVE TRAGUS. DRAINING BLOODY CSF. ICP 1-9.\nFEVER: TEMP TO 101. NEURO IN TO ACCESS VENT DRAIN FOR CSF FOR CX. SPUTUM SENT. TYLENOL GIVEN.\nCV: BP LABILE. DR WANTS BP 13-160 SYSTOLIC. NEO STARTED BRIEFLY, THEN OFF AND ON. NIPRIDE RESTARTED TO MAINTAIN SBP LESS THAN 160.\nGI: TF AT GOAL OF 55/HR. BOWEL SOUND PRESENT. PASSING FLATUS WHEN COUGHING. MOD AMOUNT SOFT FORMED STOOL, HEM NEG.\nGU: U/O LOW AT 15-20 CC/HR FOR 3 HRS. NS BOLUS 250 CC GIVEN WITH U/O IMPROVING.\nLABS: NA 134-135, NACL 3% STOPPED. K REPLETED. INSULIN DRIP TITRATED FOR BS CONTROL. SEE FLOW SHEET FOR DETAILS.\nSOCIAL: SEVERAL FAMILY MEMBERS VISITING TONIGHT. DAUGHTER IN LAW AT BEDSIDE MOST OF NIGHT.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-30 00:00:00.000", "description": "Report", "row_id": 1436224, "text": "Resp care\nPt remains intubated & supported in CPAP/PS mode\nB/S course w/ wheezes, treated w/ Alb/Atro mdi's\nSx mod. amount of thin tan secretions, Sample sent to lab.\nABG reveals a mixed Resp/Met. Alkalosis w/ good oxygenation\nThere is no current CXR. = 50, Then returned\nPEEP to 5cm/h2o. Plan: continue support\n\n" }, { "category": "Nursing/other", "chartdate": "2106-10-28 00:00:00.000", "description": "Report", "row_id": 1436217, "text": "CONDITION UPDATE:\nD/A:\n\nNEURO: RELATIVELY UNCHANGED. VENT DRAIN CONTINUES @ 10 ^ TRAGUS WITH BLOOD TINGED OUTPUT. , WITHDRAWS ALL EXTREMITIES TO PAIN, SPONT. MOVES RUE, OPENS EYES TO VOICE, OCCASIONALY TRACKS PEOPLE IN ROOM. NOT FOLLOWING COMMANDS. ICP 6-10. HEAD CT DONE, PENDING RESULTS.\n\nCV: HR 80'S NSR WITH PAC'S. GOAL ABP 150-170 MET WITH NIPRIDE. CVP 7-15. FLUID BALANCE MN-1600 - 600CC'S. + PPP BILAT. + GENERALIZED EDEMA THROUGHOUT.\n\nRESP: LS COARSE, CLEARING WITH SUCTIONING FOR TAN THICK SPUTUM. CONTINUES ON CPAP 40%, WITH TV'S ~ 400. ABG: 7.51, 40, 138, 33, 8.\n\nGI: TOLERATING TUBE FEEDS, ABD SOFT, + BS.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nID: T MAX 99.6. PERIPHERAL BLOOD CULTURE SENT.\n\nENDO: SODIUM REMAINS LOW, SALT TABS ADDED TO MEDICATIONS. PT ON .\n\nSX: FAMILY AT BEDSIDE MOST OF DAY.\n\nR: NEURO STATUS UNCHANGED, METABOLIC ALKALOSIS CONTINUES, HYPONATREMIC.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT. CONTINUE TO TREAT ELECTROLYTE IMBALANCES. DILANTIN LOADED AND MAINT. DOSES ORDERED. CONTINUE WITH PT AND FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-28 00:00:00.000", "description": "Report", "row_id": 1436218, "text": "Respiratory Care:\n\nPt. remains on mech. vent as per CareVue, there have been no changes or extubation due to poor cough reflex. T. has been elevated to ~100 today.we went to CT for head scan which was w/no changes....\n" }, { "category": "Nursing/other", "chartdate": "2106-10-29 00:00:00.000", "description": "Report", "row_id": 1436219, "text": "Neuro:Pt remains unchanged, Pupils 3mm brisk. Occasionally moved RUE, otherwise extremities withdraw to nailbed pressure. + cough reflex,poor gag reflex. Vent drain not transducing since 5pm last eve. Pt noted to be increasing SBP, Vent draing flushed by Neurosurg team. Continues to be clotted. DR. flushed with TPA. Vent drain began draining bloody drg. Traveled to CT of head. This am ICP 5-8 with moderate amounts of bloody drg.\nCV: tmax 102.7, HR initially 80's NSR with occasional PAC's, This am pt converted to rapid afib. Med with extra 5mg lopressor with little effect. Rate slightly more controlled but continues in Afib. SBP goal changed to 100-150 since CT scan. lytes repleated. extremities warm with palpable periferal pulses. Sodium continues to be 30 despite hypertonic saline last noc. repeated for another 6 hrs starting at 7am.\nRESP: no vent changes. Lungs clear to coarse at bases. requiring occasional suctioning of thick tan sputum. O2 sats >95% all noc.\nGI: tolerating tube feed at goal no stool tonoc.\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars >200 covered with with no effect.\nPLAN: repeat head CT today. continue to monitor neuro status. Insulin gtt to start this am for blood sugar control.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-29 00:00:00.000", "description": "Report", "row_id": 1436220, "text": "Resp care\nPt remains intubated & supported in CPAP/PS mode\nB/S clear-course, Sx for small amount of thick tan\nsecretions. = 62. No changes made this shift\nPlan: continue support\n" }, { "category": "Nursing/other", "chartdate": "2106-11-01 00:00:00.000", "description": "Report", "row_id": 1436232, "text": "SICU NSG PROG NOTE:\nPt met brain death criteria approx 24hrs ago. She is being sustained until final members of family arrive tonight from . Key family members have verbalized understanding that despite maximum ventilatory and pressure support she may not survive until the family members arrive. THe son has said that they all agree that heroics (CPR/SHOCK) will not be done and that she will be allowed to die without further intervention. The son also said that he does not want additional pressure support added, just \"leave things as they are\".\nAll family is here, some are making burial plans.\n\nPt continues with ventilatory support, maximum neo and levofed support and assessment is consistent w/ brain death. Hr 112-170AF, b/p map 43-50, ICP drains are not draining (they have been clotted prior to this shift).\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-11-01 00:00:00.000", "description": "Report", "row_id": 1436233, "text": "Patient remains on mechanical ventilation,poor prognosis status unchanged,still DNR. Had periods of A-Fib,labile BP family at bed side for support. will continue to monitor patient.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-26 00:00:00.000", "description": "Report", "row_id": 1436207, "text": "Social Work Note\nPt's sons referred by RN today for supportive intervention. Met with them at pt's bedside-one son from NJ who is a crit care MD and reflected on how difficlut it is to be on \"the other side\" as a family member. describes pt a s very \"stubborn,\" and active; she travels frequently, spending time with her 8 kids who are scattered all over the US. husband died emergently 7 yrs ago after a brain bleed. son remains optimistic that pt will show gradual improvement and ultimately survive her injuries, yet seems aware of her critical status. Provided son with my contact info; will remain available for cont support as needed.\n\n LICSW #\n" }, { "category": "Nursing/other", "chartdate": "2106-10-27 00:00:00.000", "description": "Report", "row_id": 1436213, "text": "Social Work Note\nMet with pt's son who continues to be respond well to SW support. Discussed how difficult it is to cope with slow progress and \"rollercoaster\" of emotions experienced. Per son, pt and their whole family immigrated from 20 yrs ago, and pt adjusted well to more active, independent lifestyle- they initially lived in before relocating to Mass. Discussed self care, coping methods during long hospital visits. Will remain avail for cont support. Will follow\n\n LICSW #\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-10-27 00:00:00.000", "description": "Report", "row_id": 1436214, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SL MORE ALERT TODAY. OPENING EYES SPONTANEOUSLY AT TIMES, BUT USUALLY OPENS EYES ONLY TO STIMULATION. PERRL. MINIMAL SPONTANEOUS MOVEMENT OF R FINGERS. LOCALIZES TO TRAPEZIUS SQUEEZE WITH BUE. SLIGHTLY WITHDRAWS BLE TO TOUCH. VENT DRAIN REMAINS OPEN TO DRAINAGE AT 10CM ABOVE TRAGUS. LG AMTS DRG, BLOODY TO BLOOD TINGED. ICP <10.\nRESP: LS CLEAR. MIN SECRETIONS. REMAINS INTUBATED D/T GAG IMPAIRED. REMAINS ON CPAP 5/5.\nCV: FEBRILE TO 103. SICU TEAM AND NSURG INFORMED. CULTURES FROM PENDING. T DOWN TO 99.5 WITH TYLENOL AND COOLING BLANKET. UP TO 101.6 THIS EVE. COOLING BLANKET REAPPLIED. SBP PARAMETERS INCREASED PER NSURG TO 150-170, OFF AND ON NIPRIDE GTT TO MAINTAIN. NSR, PAC'S. NO AFIB. NA DOWN TO 131, REPEAT 136. NO HYPERTONIC SALINE PER SICU TEAM.\nGI: TF RATE CHANGED TOP 55 AS ORDERED. NO BM. ABD SOFTLY DISTENDED.\nGU: CLEAR YELLOW U/O VIA FOLEY.\nENDO: FSBG COVERED PER RISS.\nPLAN: CONT TO MONITOR CLOSELY. TITRATE GTT ACCORDINGLY TO MAINTAIN SBP WITHIN ORDERED PARAMETERS. CONT PER CURRENT MGMT. EMOTIONAL SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-28 00:00:00.000", "description": "Report", "row_id": 1436215, "text": "Neuro: opens eyes to stimuli, pupils 3mm brisk. +cough reflex but poor gag. RUE occasionally will have weak squeeze to command. other extremities withdraws to nailbed pressure. Vent drain remains at 10cm abover tragus draining moderate amounts of blood tinged CSF.\nCV: Tmax 102.7, SICU team aware. HR 80's NSR with occasional PAC's. SBP goal 150-170. nipride titrated to goal. presently nipride off for SBP 140's following 4am lopressor. extremities warm with palpable periferal pulses. lytes replaced. CVP7-10 but very positional.\nRESP: no vent changes. Unable to draw ABG this am. Lungs coarse to clear following suctioning. O2 sats >97%.\nGI: tolerating tube feed at goal with minimal to no residual. No stool tonight. abd soft with + BS,\nGU:foley draining adequate amounts of clear yellow.\nEndocrine: blood sugars slightly elevated requiring coverage per RISS.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-28 00:00:00.000", "description": "Report", "row_id": 1436216, "text": "Respiratory Care\nPt remain intubated and on vent support, novent changes.good am , Pt has no gage Ref, SBT disc.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-26 00:00:00.000", "description": "Report", "row_id": 1436208, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SL MORE ALERT TODAY, OPENING EYES SPONTANEOUSLY THIS EVE (ALTHOUGH ONLY SLIGHTLY). DOES NOT FOLLOW COMMANDS. PERRL. WITHDRAWS ALL EXTREMITIES. INTERMITTENTLY LOCALIZES TO STERNAL RUB WITH R ARM. VENT DRAIN INACT AND REMAINS AT 10CM ABOVE TRAGUS WITH BLOOD TINGED DRG. ICP REMAINS <20.\nRESP: LS CLEAR. ET SUCTIONED FOR AM AMTS THICK SPUTUM. VENT SETTINGS UNCHANGED.\nCV: TMAX 101.0 THIS SHIFT. SICU RES INFORMED. CONTINUES ON NIPRIDE GTT. SBP GOAL CURRENTLY 130-150 MD . PT IN NSR, NO AFIB, BUT O0CCASIONAL PAC'S.\nGI: TOL TF'S. NO BM. ABD SOFTLY DISTENED.\nGU: CLEAR YELLOW U/O VIA FOLEY.\nENDO: FSBG COVERED PER RISS.\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY. CONT PER CURRENT MGMT. EMOTIONAL SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-26 00:00:00.000", "description": "Report", "row_id": 1436209, "text": "Respiratory Care:\nPt still on vent per CareVue with no changes. ICP = 9,wnl. Plan: ??\n" }, { "category": "Nursing/other", "chartdate": "2106-10-26 00:00:00.000", "description": "Report", "row_id": 1436210, "text": "ADDENDUM\nPT TEMP UP TO 101.6 PO. PAN CULTURED (CSF BY NSURG), CVL CHANGED OVER WIRE. CVL CLEARED FOR USE BY CXR MD . TYLENOL GIVEN. PT BP LABILE AFTER LINE CHANGE. NIPRIDE GTT TITRATED ACCORDINGLY.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-27 00:00:00.000", "description": "Report", "row_id": 1436211, "text": "CONDITION UPDATE:\nD/A: T MAX 100.1\n\nNEURO: MORE ALERT IN EVENING, SMILING AT FAMILY MEMEBERS, TRACKING THEM AROUND THE BED WITH HER EYES. SQUEEZING HER SON'S HAND TO COMMAND (HOWEVER NOT FOLLOWING ANY OTHER COMMANDS). REST OF NEURO EXAM RELATIVELY UNCHANGED. VENT DRAIN @ 10 CM ABOVE TRAGUS, DRG BLOOD TINGED FLUID. SITE INTACK.\n\nRESP: LS CLEAR. PT 52, CURRENTLY HAVING A SPONTANEOUS BREATHING TRIAL, WILL CHECK ABG ~ 7AM. RR ~ 20, TV ~ 400. ABG PRIOR TO TRIAL: 7.51, 37, 123, 31, 6 ON CPAP 5/5.\n\nCV: HR 70'S-90'S NSR WITH FREQUENT PAC'S. NO AFIB NOTED. GOAL SBP 130-150 DIFFICULT TO MEET WITH NIPRIDE GTT. PT VERY LABILE TO THE SMALLEST CHANGES IN NIPRIDE GTT IN EVENING, AND THEN IN AM PT REQUIRING MORE NIPRIDE TO KEEP WITHIN PARAMETER.\n\nGI: TF @ GOAL, NO TF RESIDUAL.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nR: METABOLIC ALKALOSIS WITH IMPROVED NEURO EVAL, LABILE BP.\n\nP: CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT, PT AND FAMILY SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2106-10-27 00:00:00.000", "description": "Report", "row_id": 1436212, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN CPAP/PS MODE. NO SEDATION, PT MORE RESPONSIVE THIS SHIFT. BS W/SL CRACKLES NOTED, SXN SCANT AMT THIN CLEAR SEC. AM ABG REFLECTS UNCOMPENSATED METABOLIC ALKALOSIS W/NORMOXIA. 52, SBT STARTED @ 0450. PLAN TO ASSESS FOR POSS EXTUBATION ON DAYS.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-31 00:00:00.000", "description": "Report", "row_id": 1436227, "text": "Resp care\nPt remains intubated & supported. Pt resp. dropped to 7\nVt 100ml, on CPAP/PS 5/5, Pt placed on 100% in A/C mode.\nSx Pt for small amount of thick white secretions\nPt had no gag reflex, which is a change.\nB/S clear-course, Pt treated w/ Alb/Atro mdi's\nABG reveals good oxygenation & ventilation.\nNo = per Dr. . Plan: continue support\n" }, { "category": "Nursing/other", "chartdate": "2106-10-31 00:00:00.000", "description": "Report", "row_id": 1436228, "text": "condition update\nD: FAMILY AT BEDSIDE MOST OF SHIFT. BRAIN DEATH CRITERIA MET. DR SPOKE WITH CHILDREN ABOUT WHAT THIS MEANS. FAMILY PLANS ON WITHDRAWING TX AFTER HER OTHER CHILDREN ARRIVE FROM . NEOB NOTIFIED BUT FAMILY STATES THAT SHE WOULD NOT WANT TO BE A DONOR. PRESENTLY ON NEO AT 9 MCG/KG/MIN TO MAINTAIN SBP 80-90. FLUID BOLUSES X 2. FEBRILE TO 102.7 DESPITE TYLENOL. TF D/C'D SECONDARY TO HIGH RESIDUALS THIS AM.\nA: EMOTIONAL SUPPORT GIVEN FAMILY, SUPPORT PT AND FAMILY UNTIL FAMILY IS READY TO WITHDRAW TX.\nR: CONDITION GRAVE, DNR, COMFORT MEASURES AS INDICATED\n" }, { "category": "Nursing/other", "chartdate": "2106-11-01 00:00:00.000", "description": "Report", "row_id": 1436229, "text": "Resp care\nPt remains intubated & supported in A/C mode\nB/S clear-course, Sx moderate amount of thick\nyellow secretions. No changes made this shift.\nPlan: continue suppport\n" }, { "category": "Nursing/other", "chartdate": "2106-11-01 00:00:00.000", "description": "Report", "row_id": 1436230, "text": "condition update\nneo drip increased gradually to 12 mcg/kg/min, to maintain sbp > 90. ns bolus 500 cc x 2. levophed drip added, started at .01, incr gradually to .06 mcg/kg/in. bp continued to drop, 2 more ns boluses given. no evidence of resp effort, no movement, pupils fixed and dilated. febrile, tx with tylenol.\nSocial: family at bedside all night. request from family to continue treatment of pt until remaining family members arrive from out of state. Dr notified by Dr of pt status.\n" }, { "category": "Nursing/other", "chartdate": "2106-11-01 00:00:00.000", "description": "Report", "row_id": 1436231, "text": "Social Work Note\nMet with pt's family at bedside for cont emotional support-pt's son, dtr, dtr in law and 2 gchildren (13,18) all present. Family discussed change in pt's status over the weekend as she progressed to brain death. They are awaiting the arrival of several other siblings from CA tonight;they are aware that pt may pass before their arrival and seem comfortable with this.\n\nFamily reminisced about pt and her love of , close relationships with her gchildren etc. Education and resources provided re: kids' developmental understanding of death/dying, funerals etc. They paln to have a service at a fuenral home in and then have pt transported to , to be buried with her late husband.\n\nFamily is aware of my cont availability, throughout the day. Will follow\n\n LICSW #\n" }, { "category": "Nursing/other", "chartdate": "2106-10-25 00:00:00.000", "description": "Report", "row_id": 1436201, "text": "Respiratory Care:\n\nPatient remains intubated on Psv. Tolerating well. Spont vols 380-400's with RR high teens to low 20's. Bs slighlty coarse bilaterally. Sx'd for sm amount of thick tan sputum. O2 sats 100%. No further changes made. Plan: Continue with Psv and wean as tolerated. Re assess for gag/cough effort.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-25 00:00:00.000", "description": "Report", "row_id": 1436202, "text": "cardiac status\npt in afib at rate of 130 -150. tx with lopressor 5 mg iv x 1, with conversion to nsr. repeat episode this am at 0730, tx with lopressor 5 mg iv x 1. remians in a fib at this time, with some sporadic slowing of rate, but continuing in nsr\n" }, { "category": "Nursing/other", "chartdate": "2106-10-25 00:00:00.000", "description": "Report", "row_id": 1436203, "text": "resp. care\npatient remains intubated/vented. transported to head ct without incident. ct unchanged. vent weaned to with good abg/vols/rr.\ncontinue current support. see rt flowsheet for more.\n" }, { "category": "Nursing/other", "chartdate": "2106-10-30 00:00:00.000", "description": "Report", "row_id": 1436225, "text": "CONDITION UPDATE\nD: NEURO: OPENS EYES SPONT BUT DOES NOT TRACK. PUPILS 3MM WITH BRISK REACTION. MOVES EXTREMITIES TO NAILBED PRESSURE ONLY (WITHDRAWS). ICP DRAINING LARGE AMTS CHERRY RED FLUID. ICP 6-10.\nCV: T MAX 102- NO CX PER DR , TYLENOL GIVEN. PT ON SNP GTT THIS AM- LOPRESSOR INCREASED TO 10MG Q4HRS AND HYDRALAZINE PRN ADDED. SNP WEANED TO OFF BY 1300 BUT PT THEN SPONT DROPPED SBP TO 90'S. NEO RESTARTED AND IS PRESENTLY WEANING. 1600 DOSE LOPRESSOR HELD. SEE CAREVUE FOR SPECIFICS.\nRESP: REMAINS ON CPAP WITH 5IPS. BS CLEAR BUT DIMINISHED IN BASES. SX FOR THICK WHITE SECRETIONS.\nGI/GU: TOL TF AT GOAL. SM BM THIS MORNING. HUO ADEQUATE\nENDO: STARTED ON 20 UNITS NPH , INSULIN GTT TITRATED TO MAINTAIN BS 80-130.\nA: HEMODYNAMICS MONITORED, DIAMOX X 2 DOSES GIVEN, NEURO STATUS MONITORED\nR: UNCHANGED NEURO STATUS, CONTINUE TO MONITOR CLOSELY, WEAN NEO TO OFF AND MAINTAIN SBP IN RANGE OF 130-160\n" } ]

[ { "category": "Radiology", "chartdate": "2167-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1138087, "text": " 8:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? acute process\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ?seizure\n REASON FOR THIS EXAMINATION:\n ? acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHfd SAT 9:33 AM\n No ICH. If concerned for acute infarction an MRI can be obtained.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Seizure.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage, mass effect,\n or -white matter differentiation abnormality. The ventricles and\n extra-axial spaces are appropriate for age. Bilateral basal ganglia\n calcifications are seen. There is no osseous lesion to suggest malignancy or\n infection.\n\n IMPRESSION: No evidence of acute intracranial abnormality. In case of\n clinical concern for acute infarction/ etiology of seizure, an MRI can be\n obtained if not contra-indicated.\n\n" }, { "category": "Radiology", "chartdate": "2167-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1138286, "text": " 9:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman s/p distal pancreatectomy w/fever\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:28 P.M. ON \n\n HISTORY: Postop distal pancreatectomy. Fever.\n\n IMPRESSION: AP chest compared to .\n\n Normal heart, lungs, hila, mediastinum and pleural surfaces. Right internal\n jugular line tip projects over the mid SVC. No free subdiaphragmatic gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1138076, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o consolidation\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n r/o consolidation\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Altered mental status\n\n Cardiomediastinal contours are normal. Aside from linear atelectasis in the\n left retrocardiac area, the lungs are clear. There is no pneumothorax or\n pleural effusion. NG tube tip is out of view below the diaphragm. Right IJ\n catheter tip is in the upper to mid SVC.\n\n" }, { "category": "Radiology", "chartdate": "2167-05-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1137819, "text": " 6:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? PTX\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cvl intraop\n REASON FOR THIS EXAMINATION:\n ? PTX\n ______________________________________________________________________________\n WET READ: 10:00 PM\n RIJ line extends to mid SVC, with no evidence of pneumothorax. ETT 6 cm from\n carina. NG to stomach. no focal consolidation or effusion, though in\n comparison to prior study, there is new elevation of the right hemidiaphragm\n and new post-operative changes in the upper abdomen. CCY clips are old.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right IJ catheter tip is in the mid SVC. There is no evidence of\n pneumothorax. ET tube tip is 6 cm from the carina. NG tube tip is in the\n stomach. The lungs are clear. There is no pleural effusion. Mild elevation\n of the right hemidiaphragm is new. Multiple surgical clips project in the\n abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2167-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1138166, "text": " 6:15 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: eval bleed\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with hx AMS, depressed MS\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa SAT 8:31 PM\n PFI: No acute intracranial hemorrhage. If concern for ischemia is present,\n MRI is recommended.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: .\n\n HISTORY: Altered mental status. Evaluate for bleed.\n\n TECHNIQUE: MDCT axially acquired images through the brain were obtained. No\n IV contrast was administered.\n\n FINDINGS: There is normal -white matter differentiation. There is no\n evidence of acute hemorrhage, shift of normally midline structures or major\n vascular territorial infarct. The basilar cisterns are preserved. The\n ventricles and sulci are unremarkable. There is no evidence of acute\n hydrocephalus. Calcifications of the bilateral internal carotid arteries are\n noted. The visualized paranasal sinuses are clear.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage. Please note that if concern for acute\n ischemia/parenchymal changes exists, MRI is recommended if not\n contra-indicated.\n Minimala symmetry in the sulci is noted at the vertex- liekly developmental\n rather than due to focal parenchymal changes.\n\n" }, { "category": "Radiology", "chartdate": "2167-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1138167, "text": ", M. SICU-A 6:15 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: eval bleed\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with hx AMS, depressed MS\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No acute intracranial hemorrhage. If concern for ischemia is present,\n MRI is recommended.\n\n" }, { "category": "ECG", "chartdate": "2167-05-23 00:00:00.000", "description": "Report", "row_id": 229253, "text": "Sinus tachycardia, rate 111. Otherwise, normal tracing. Compared to the\nprevious tracing of normal sinus rhythm has given way to sinus\ntachycardia.\n\n" } ]

[ { "category": "Echo", "chartdate": "2179-09-16 00:00:00.000", "description": "Report", "row_id": 80019, "text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary hypertension. Shortness of breath\nHeight: (in) 72\nWeight (lb): 247\nBSA (m2): 2.33 m2\nBP (mm Hg): 111/54\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 12:07\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Hyperdynamic\nLVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. Stranding is visualized within the\npericardial space c/w organization. No echocardiographic signs of tamponade.\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. Left ventricular systolic\nfunction is hyperdynamic (EF 70-80%). Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. The estimated pulmonary artery systolic pressure is\nnormal. There is a small pericardial effusion. The effusion is echo dense,\nconsistent with blood, inflammation or other cellular elements. Stranding is\nvisualized within the pericardial space c/w organization. There are no\nechocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (images reviewed) of , an organizing pericardial effusion is now present.\n\n\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475627, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n LS diminished throughout.RR 18-26.No c/o SOB.CP with deepbreathing and\n coughing.\n Action:\n Pt is on 100% NRB, Morphine 2mg IV given.\n Response:\n Pt is sating 100%.No c/o SOB, Pain score after morphine.\n Plan:\n Pt is due to go down for CXR AP and lateral.\n Thrombocytopenia, chronic\n Assessment:\n Plt count 47.This am plt 38.No s/s of bleeding.Hct down from 32.5 to\n 31.3.\n Action:\n No action, cont to monitor.Repeat hct sent.Type and screen sent.\n Response:\n Pts baseline plt count in 40\ns.Repeat hct 30.\n Plan:\n Monitor plt count.\n Pleural effusion, acute\n Assessment:\n Pt has got B/L pleural effusion .L>R.\n Action:\n Cont ot monitor, Pt is on 100%NRB.\n Response:\n Sating 100%, no c/o SOB.\n Plan:\n For ?tap today.\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475517, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n LS diminished throughout.RR 18-26.No c/o SOB.CP with deepbreathing and\n coughing.\n Action:\n Pt is on 100% NRB, Morphine 2mg IV given.\n Response:\n Pt is sating 100%.No c/o SOB, Pain score after morphine.\n Plan:\n Thrombocytopenia, chronic\n Assessment:\n Plt count 47.No s/s of bleeding.\n Action:\n No action, cont to monitor.\n Response:\n Pts baseline plt count in 40\n Plan:\n Monitor plt count.\n" }, { "category": "Physician ", "chartdate": "2179-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 475603, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:37 PM\n admit overnight. stable, with f/u portable CXR that showed no worsening\n of PTX.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 66 (63 - 76) bpm\n BP: 114/51(67) {99/44(59) - 114/61(71)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 1,790 mL\n 410 mL\n Urine:\n 340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,790 mL\n -410 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Gen- AOx3, NAD\n HEENT- NCAT, no JVD, +scleral icterus\n Pulm- B/L posterior rales, equal BS b/l. Prolonged inspiratory phase,\n with short expiratory phase\n CV- S1/S2 no MGR\n Abd- soft, NTND\n Ext- 1+ LE edema b/l\n Skin -jaundiced\n Labs / Radiology\n 38 K/uL\n 11.1 g/dL\n 93 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 99 mEq/L\n 133 mEq/L\n 30.0 %\n 4.8 K/uL\n [image002.jpg]\n 10:01 PM\n 04:12 AM\n 05:56 AM\n WBC\n 5.2\n 4.8\n Hct\n 32.5\n 31.3\n 30.0\n Plt\n 47\n 38\n Cr\n 1.3\n 1.2\n TropT\n <0.01\n <0.01\n Glucose\n 94\n 93\n Other labs: PT / PTT / INR:20.1/39.2/1.9, CK / CKMB /\n Troponin-T:48//<0.01, ALT / AST:26/52, Alk Phos / T Bili:72/7.2,\n Differential-Neuts:70.4 %, Lymph:14.0 %, Mono:9.5 %, Eos:5.5 %, Lactic\n Acid:1.7 mmol/L, Albumin:2.8 g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL,\n Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Imaging: CXR:small apical PTX b/l, L pleural effusion unchanged from\n prior.\n Microbiology: Bcx : pending\n Assessment and Plan\n PNEUMOTHORAX, OTHER (NOT HOSPITAL ACQUIRED OR TRAUMATIC)\n PLEURAL EFFUSION, ACUTE\n CIRRHOSIS OF LIVER, OTHER\n THROMBOCYTOPENIA, CHRONIC\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n Assessment and Plan: This is a 56M with Hep C cirrhosis admitted with\n B/L PTX and new left effusion\n .\n # B/L PTX: Unclear etiology for new onset bilateral PTX given he has\n had no recent pressure changes that would precipitate PTX and no known\n risk factors for secondary PTX such as COPD, CF, TB, ankylosing\n spondylitis, asthma, histiocytosis X, idiopathic pulmonary fibrosis,\n lymphangioleiomyomatosis, lung cancer, Marfan syndrome, necrotizing\n pneumonia, rheumatoid arthritis, or sarcoidosis. Primary spontaneous\n PTX also possibility but he is not of typical stature, or epidemiology.\n He has no previous known underlying lung disease although likely had\n ruputure of subpleural bleb given mild bullous disease on chest CT\n which is out of proportion to smoking history. He has been on new\n medication which stimulates megakaryocytes for thrombocytopenia but PTX\n or cystic lung disease not obvious side effect.\n - Continue 100% NRB to enhance resorption of PTX\n - Call IP this AM\n - serial exams, repeat PA and lateral CXR\n - monitor for any signs of hemodynamic compromise such as tachycardia,\n hypotension\n - Hold Eltrombopag study medication since unclear if this is underlying\n cause (Dr. \n .\n # Pleural effusion: Pt has chronic small right effusion likely from\n known liver disease but has new moderate to large left pleural effusion\n which has developed since 6/. unclear if related to new PTX but\n Differential includes hemothorax related to , empyema and parapneumonic\n effusion, transudative effusion. Given no infectious symptoms such as\n fever, chills, leukocytosis will not continue abx started in ED but\n would pursue further workup with thoracentesis for determination of\n transudate vs exudate with cytology, cell counts, cx and gram stain.\n Unlikely new heart failure or related to cirrhosis since assymmetric\n and left>right.\n - Thoracentesis today with cx, gram stain, cytology,\n - serial exams\n - TTE to eval for portopulmonary HTN\n - f/u blood cx\n - FFP ordered, check coags in am, has active type and screen\n # Anemia: drop in Hct from 36 to 30 today, INR 1.9. Unclear etiology,\n possible bleeding vs DIC\n -guaiac stool\n -CT scan show hundsfield units of pleural fluid not consistent with\n blood\n -check DIC labs\n - FFP ordered, follow coags, has active type and screen and 1 unit on\n hold\n # CP: Dyspnea and CP likely secondary to PTX but will also ROMI with\n serial enzymes. No ECG changes to suggest ischemia, cardiac enzymes\n negative x 2 and no PE on CTA\n - ROMI, CE's this AM\n - repeat ECG in am\n - controlled with PRN morphine\n # Cirrhosis: hep C acquired from blood transfusion. Stable. No\n active issues\n - continue nadolol for history of varices, cipro for SBP ppx,\n lactulose, rifaximin, lasix, and aldactone\n - appreciate liver following while in house (call c/s)\n # Thrombocytopenia: Stable at baseline. Transfused platelets yesterday,\n plt #back to pre-txf level.\n - CBC at noon\n - continue to monitor\n # HTN: Currently well controlled on home meds of lasix and aldactone,\n nadolol\n # R>L LE edema: per patient is at baseline but much more significant on\n exam since previously documented\n - check LE duplex\n ICU Care\n Nutrition:\n Comments: Low Na diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:25 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: patient and wife\n status: Full code\n Disposition:Transfer to floor in PM\n" }, { "category": "Physician ", "chartdate": "2179-09-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 475582, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:37 PM\n admit overnight. stable, with f/u portable CXR that showed no worsening\n of PTX.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 66 (63 - 76) bpm\n BP: 114/51(67) {99/44(59) - 114/61(71)} mmHg\n RR: 12 (12 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 1,790 mL\n 410 mL\n Urine:\n 340 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,790 mL\n -410 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 38 K/uL\n 11.1 g/dL\n 93 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 99 mEq/L\n 133 mEq/L\n 30.0 %\n 4.8 K/uL\n [image002.jpg]\n 10:01 PM\n 04:12 AM\n 05:56 AM\n WBC\n 5.2\n 4.8\n Hct\n 32.5\n 31.3\n 30.0\n Plt\n 47\n 38\n Cr\n 1.3\n 1.2\n TropT\n <0.01\n <0.01\n Glucose\n 94\n 93\n Other labs: PT / PTT / INR:20.1/39.2/1.9, CK / CKMB /\n Troponin-T:48//<0.01, ALT / AST:26/52, Alk Phos / T Bili:72/7.2,\n Differential-Neuts:70.4 %, Lymph:14.0 %, Mono:9.5 %, Eos:5.5 %, Lactic\n Acid:1.7 mmol/L, Albumin:2.8 g/dL, LDH:262 IU/L, Ca++:8.3 mg/dL,\n Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Imaging: CXR:small apical PTX b/l, L pleural effusion unchanged from\n prior.\n Microbiology: Bcx : pending\n Assessment and Plan\n PNEUMOTHORAX, OTHER (NOT HOSPITAL ACQUIRED OR TRAUMATIC)\n PLEURAL EFFUSION, ACUTE\n CIRRHOSIS OF LIVER, OTHER\n THROMBOCYTOPENIA, CHRONIC\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n Assessment and Plan: This is a 56M with Hep C cirrhosis admitted with\n B/L PTX and new left effusion\n .\n # B/L PTX: Unclear etiology for new onset bilateral PTX given he has\n had no recent pressure changes that would precipitate PTX and no known\n risk factors for secondary PTX such as COPD, CF, TB, ankylosing\n spondylitis, asthma, histiocytosis X, idiopathic pulmonary fibrosis,\n lymphangioleiomyomatosis, lung cancer, Marfan syndrome, necrotizing\n pneumonia, rheumatoid arthritis, or sarcoidosis. Primary spontaneous\n PTX also possibility but he is not of typical stature, or epidemiology.\n He has no previous known underlying lung disease although likely had\n ruputure of subpleural bleb given mild bullous disease on chest CT\n which is out of proportion to smoking history. He has been on new\n medication which stimulates megakaryocytes for thrombocytopenia but PTX\n or cystic lung disease not obvious side effect.\n - Continue 100% NRB to enhance resorption of PTX\n - Call IP this AM\n - serial exams, repeat PA and lateral CXR\n - monitor for any signs of hemodynamic compromise such as tachycardia,\n hypotension\n - Hold Eltrombopag study medication since unclear if this is underlying\n cause (Dr. \n .\n # Pleural effusion: Pt has chronic small right effusion likely from\n known liver disease but has new moderate to large left pleural effusion\n which has developed since 6/. unclear if related to new PTX but\n Differential includes hemothorax related to , empyema and parapneumonic\n effusion, transudative effusion. Given no infectious symptoms such as\n fever, chills, leukocytosis will not continue abx started in ED but\n would pursue further workup with thoracentesis for determination of\n transudate vs exudate with cytology, cell counts, cx and gram stain.\n Unlikely new heart failure or related to cirrhosis since assymmetric\n and left>right.\n - Thoracentesis today with cx, gram stain, cytology,\n - serial exams\n - TTE to eval for portopulmonary HTN\n - f/u blood cx\n - FFP ordered, check coags in am, has active type and screen\n # Anemia: drop in Hct from 36 to 30 today, INR 1.9. Unclear etiology,\n possible bleeding vs DIC\n -guaiac stool\n -CT scan show hundsfield units of pleural fluid not consistent with\n blood\n -check DIC labs\n - FFP ordered, follow coags, has active type and screen and 1 unit on\n hold\n # CP: Dyspnea and CP likely secondary to PTX but will also ROMI with\n serial enzymes. No ECG changes to suggest ischemia, cardiac enzymes\n negative x 2 and no PE on CTA\n - ROMI, CE's this AM\n - repeat ECG in am\n - controlled with PRN morphine\n # Cirrhosis: hep C acquired from blood transfusion. Stable. No\n active issues\n - continue nadolol for history of varices, cipro for SBP ppx,\n lactulose, rifaximin, lasix, and aldactone\n - appreciate liver following while in house (call c/s)\n # Thrombocytopenia: Stable at baseline. Transfused platelets yesterday,\n plt #back to pre-txf level.\n - CBC at noon\n - continue to monitor\n # HTN: Currently well controlled on home meds of lasix and aldactone,\n nadolol\n # R>L LE edema: per patient is at baseline but much more significant on\n exam since previously documented\n - check LE duplex\n ICU Care\n Nutrition:\n Comments: Low Na diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: patient and wife\n status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475559, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n LS diminished throughout.RR 18-26.No c/o SOB.CP with deepbreathing and\n coughing.\n Action:\n Pt is on 100% NRB, Morphine 2mg IV given.\n Response:\n Pt is sating 100%.No c/o SOB, Pain score after morphine.\n Plan:\n Pt is due to go down for CXR AP and lateral.\n Thrombocytopenia, chronic\n Assessment:\n Plt count 47.No s/s of bleeding.Hct down from 37 to 31.\n Action:\n No action, cont to monitor.Repeat hct sent.Type and screen sent.\n Response:\n Pts baseline plt count in 40\n Plan:\n Monitor plt count.\n Pleural effusion, acute\n Assessment:\n Pt has got B/L pleural effusion .L>R.\n Action:\n Cont ot monitor, Pt is on 100%NRB.\n Response:\n Sating 100%, no c/o SOB.\n Plan:\n For ?tap today.\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475672, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS clear to diminish on his\n left side. Sats 100% . No c/o SOB.Cont have Chest pain\n Action:\n Pt had Lateral and anterior done X ray showed large pleural effusion on\n his left lung and small to moderate pneumothorax. Given Morphine for\n pain.\n Response:\n Waiting for IP to come and evaluate for tap. Kept him NPO for\n procedure. Cont non rebreather as a treatment for pneumothorax\n Plan:\n Closely monitor resp status. Follow up with IP and Tap?. PRN Morphine\n for pain.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was47. And Hct was 30.1.\n Action:\n Pt has active clots in the blood bank. Hct this afternoon 29.8 and Plt\n 47\n Response:\n Pt has one unit plt ordered, holding for now until IP come and\n evaluate him for possible tap.\n Plan:\n Monitor closely his plt count as well as Hct.\n" }, { "category": "Physician ", "chartdate": "2179-09-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 475506, "text": "Chief Complaint: Dyspnea, Pleuritic chest pain, B/L PTX\n HPI:\n 56M with cirrhosis Hepatitis C acquired from blood transfusion,\n chronic thrombocytopenia on trial medication x 3 weeks, HTN admitted\n from ED with concerning findings on CXR of B/L PTX and new left pleural\n effusion. Symptoms started 2 days prior to admission with progressively\n worsening shortness of breath followed by central/right sided pleuritic\n chest pain associated with dry cough which started day PTA. CP\n constant, non radiating and not associated with exertion or\n dipahoresis. He called his hepatologist day prior who recommended\n increasing the dose of his lasix. He denies associated fever, chills,\n sputum production. +orthopnea. LE edema at baseline per wife and\n patient. Has had no recent air travel, diving, or other changes in\n altitude or travel. No recent emesis or procedures such as paracentesis\n or surgery. Denies trauma.\n Pt had scheduled flex sig today as outpatient. He reported history as\n above and had CXR which showed B/L PTX and L>R pleural effusion which\n was concerning for bronchopleural fistula. He was then sent to the ED\n for further evaluation.\n .\n In the ED, initial vs were: 98.6 66 100/52 26 95. Chest CTA showed\n small bilateral pneumothorax, no evidence for bronchopleural fistula,\n and bilateral pleural effusions, stable on right new on left. Negative\n for PE. Blood cx x 2 drawn and he was given vanco/zosyn for ?\n infectious etiology. He also received his home doses of Spironolactone\n and lasix and morphine IV with marked improvement in chest pain.\n Thoracics and Surgery were both contact and will see in am\n assuming pt is stable. If unstable, thoracics is aware overnight.\n .\n On the floor, he reports recurrence of chest pain since he received\n morphine several hours prior and persistent SOB which is unchanged from\n earlier.\n Review of systems:\n (+) Per HPI. Has occasional nausea at baseline for which he takes\n compazine.\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n vomiting, diarrhea, constipation or abdominal pain. No recent change in\n bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.\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 Morphine Sulfate - 10:00 PM\n Other medications:\n Ciprofloxacin 250mg daily\n Folic acid 1 mg daily\n lasix 120mg daily\n Lactulose 30mg TID prn\n Nadolol 20mg daily\n compazine 5mg prn\n Rifaximin 600mg PO BID\n Spironolactone 250mg PO daily\n Calcium carbonate 1 tab PO daily\n Omeprazole 20mg PO daily\n MVI daily\n Eltrombopag 75mg/placebo 0mg once a day x last 21 days\n Past medical history:\n Family history:\n Social History:\n 1. Cirrhosis:\n - Secondary to hepatitis C (from blood txn)\n - Listed for liver transplant, MELD previously 17\n - AFP 4.9 ()\n - grade II varices ()\n - ascites formerly requiring paracenteses q2-4 weeks previously but\n well controlled now, last para>1 year prior\n - h/o hepatic encephalopathy\n - h/o SBP on cipro prophylaxis\n 2. Hepatitis C:\n - Genotype 1, Viral load 412,000 IU/mL ()\n - failed interferon tx (thrombocytopenia)\n 3. History of CVA, w/ mild residual R sided weakness\n 4. Heterozygus for H63D for hemochromatosis\n 5. Hypertension\n 6. Osteoporosis\n PSH\n Umbilical hernia repair \n Married and lives with his wife. Formerly worked as a custodian.\n History of smoking but quit 10 years ago. Smoked 1ppd x 7-8 years.\n Denies alcohol or drug use.\n Family History:\n Significant for Alzheimer disease in mother and an unspecified\n cancer in father and brother.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married and lives with his wife. Formerly worked as a custodian.\n History of smoking but quit 10 years ago. Smoked 1ppd x 7-8 years.\n Denies alcohol or drug use.\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: 37.2\nC (98.9\n Tcurrent: 36.8\nC (98.2\n HR: 64 (64 - 76) bpm\n BP: 103/51(64) {101/51(64) - 106/55(67)} mmHg\n RR: 15 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 1,790 mL\n 220 mL\n Urine:\n 340 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,790 mL\n -220 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Neck: supple, JVP 8cm, no LAD\n Lungs: Trachea midline. Decreased BL left base with crackles way\n up, dullness to percussion, crackles rigth base, No wheezes or rhonchi\n CV: Distant heart sounds. Regular. Normal S1 + S2, no murmurs, rubs,\n gallops appreciated\n Abdomen: soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, spleen tip palpated 2-3 cm below\n costal margin\n Ext: 3+ edema RLE 2+ edema LLE, warm, well perfused, 2+ pulses, no\n clubbing, cyanosis\n Skin:No SC emphysema\n Labs / Radiology\n 47 K/uL\n 11.5 g/dL\n 94 mg/dL\n 1.3 mg/dL\n 21 mg/dL\n 25 mEq/L\n 99 mEq/L\n 3.9 mEq/L\n 134 mEq/L\n 32.5 %\n 5.2 K/uL\n [image002.jpg]\n \n 2:33 A8/5/ 10:01 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 5.2\n Hct\n 32.5\n Plt\n 47\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 94\n Other labs: PT / PTT / INR:19.1/39.5/1.7, CK / CKMB /\n Troponin-T:61//<0.01, Differential-Neuts:75.7 %, Lymph:11.4 %, Mono:9.3\n %, Eos:3.3 %, Lactic Acid:1.7 mmol/L, Ca++:8.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.0 mg/dL\n Imaging: CTA: small bilateral pneumothorax. no evidence for\n bronchopleural fistula.\n bilateral pleural effusions, stable on right new on left. coronary\n artery\n calcificiation. no PE. cirrhotic liver. gynecomastia.\n CXR: Moderate left sided effusion, Small r effusion. Small PTX apices\n B/L\n Microbiology: Blood cx x 2\n ECG: nsr. PR prolonged 210msec. poor r wave progression. normal axis.\n no st or t wave changes. qtc 470. unchanged from prior\n Assessment and Plan\n 56M with Hep C cirrhosis admitted with B/L PTX and new left pleural\n effusion\n # B/L PTX: Unclear etiology for new onset bilateral PTX given he has\n had no recent pressure changes that would precipitate PTX and no known\n risk factors for secondary PTX such as COPD, CF, TB, ankylosing\n spondylitis, asthma, histiocytosis X, idiopathic pulmonary fibrosis,\n lymphangioleiomyomatosis, lung cancer, Marfan syndrome, necrotizing\n pneumonia, rheumatoid arthritis, or sarcoidosis. Primary spontaneous\n PTX also possibility but he is not of typical stature, or epidemiology.\n He has no previous known underlying lung disease although likely had\n ruputure of subpleural bleb given mild bullous disease on chest CT\n which is out of proportion to smoking history. He has been on new\n medication which stimulates megakaryocytes for thrombocytopenia but PTX\n or cystic lung disease not obvious side effect.\n - Continue 100% NRB to enhance resorption of PTX\n - Thoracics consulted in ED, appreciate recs\n - serial exams, repeat PA and lateral CXR in am\n - monitor for any signs of hemodynamic compromise such as tachycardia,\n hypotension\n - Appreciate IP following who will see in am for consideration fo tube\n thoracostomy but currently no indication since hemodynamically stable\n and PTX small\n - Hold Eltrombopag study medication since unclear if this is underlying\n precipitant\n # Pleural effusion: Pt has chronic small right effusion likely from\n known liver disease but has new moderate to large left pleural effusion\n which has developed since 6/. Unclear if related to new PTX but\n differential includes hemothorax related to , empyema and parapneumonic\n effusion, transudative effusion. Hemothorax concerning given HCT drop\n from 36 to 32 with pm labs. Given no infectious symptoms such as fever,\n chills, leukocytosis will not continue abx started in ED but would\n pursue further workup with thoracentesis for determination of\n transudate vs exudate with cytology, cell counts, cx and gram stain.\n Unlikely new heart failure or related to cirrhosis since assymmetric\n and left>right.\n - Thoracentesis tomorrow with cx, gram stain, cytology,\n - serial exams\n - TTE to eval for portopulmonary HTN\n - f/u blood cx\n - FFP ordered, check coags in am, has active type and screen\n - monitor HCT q6\n # CP: Dyspnea and CP likely secondary to PTX but will also ROMI with\n serial enzymes. No ECG changes to suggest ischemia, cardiac enzymes\n negative x 2 and no PE on CTA\n - ROMI\n - repeat ECG in am\n # Cirrhosis: hep C acquired from blood transfusion. Stable. No\n active issues\n - continue nadolol for history of varices, cipro for SBP ppx,\n lactulose, rifaximin, lasix, and aldactone\n - appreciate liver following while in house\n # Thrombocytopenia: Stable at baseline. Transfused platelets today in\n clinic.\n - continue to monitor\n # ARF:Cr 1.3 slightly up from baseline 1.0-1.2.\n - continue to monitor, check urine lytes in am if still elevated\n - IVF prn\n - avoid nephrotoxic agents\n .\n # HTN: Currently well controlled on home meds of lasix and aldactone,\n nadolol\n # R>L LE edema: per patient is at baseline but much more significant on\n exam since previously documented\n - check LE duplex\n # FEN: No IVF, replete electrolytes, low na diet\n # Prophylaxis: No subcutaneous heparin given thrombocytopenia, home PPI\n # Access: peripheral\n # Code: Full\n # Communication: Patient and wife\n # Disposition: pending above, likely floor in am if stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:25 PM\n Prophylaxis:\n DVT: (Thrombocytopenia)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475564, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n LS diminished throughout.RR 18-26.No c/o SOB.CP with deepbreathing and\n coughing.\n Action:\n Pt is on 100% NRB, Morphine 2mg IV given.\n Response:\n Pt is sating 100%.No c/o SOB, Pain score after morphine.\n Plan:\n Pt is due to go down for CXR AP and lateral.\n Thrombocytopenia, chronic\n Assessment:\n Plt count 47.This am plt 38.No s/s of bleeding.Hct down from 32.5 to\n 31.3.\n Action:\n No action, cont to monitor.Repeat hct sent.Type and screen sent.\n Response:\n Pts baseline plt count in 40\ns.Repeat hct 30.\n Plan:\n Monitor plt count.\n Pleural effusion, acute\n Assessment:\n Pt has got B/L pleural effusion .L>R.\n Action:\n Cont ot monitor, Pt is on 100%NRB.\n Response:\n Sating 100%, no c/o SOB.\n Plan:\n For ?tap today.\n Pt is also due for USG at 8:15 to be done in the department.Please\n coordinate CXR and USG.\n" }, { "category": "Physician ", "chartdate": "2179-09-16 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 475553, "text": "Chief Complaint: Dyspnea, Pleuritic chest pain, B/L PTX\n HPI:\n 56M with cirrhosis Hepatitis C acquired from blood transfusion,\n chronic thrombocytopenia on trial medication x 3 weeks, HTN admitted\n from ED with concerning findings on CXR of B/L PTX and new left pleural\n effusion. Symptoms started 2 days prior to admission with progressively\n worsening shortness of breath followed by central/right sided pleuritic\n chest pain associated with dry cough which started day PTA. CP\n constant, non radiating and not associated with exertion or\n dipahoresis. He called his hepatologist day prior who recommended\n increasing the dose of his lasix. He denies associated fever, chills,\n sputum production. +orthopnea. LE edema at baseline per wife and\n patient. Has had no recent air travel, diving, or other changes in\n altitude or travel. No recent emesis or procedures such as paracentesis\n or surgery. Denies trauma.\n Pt had scheduled flex sig today as outpatient. He reported history as\n above and had CXR which showed B/L PTX and L>R pleural effusion which\n was concerning for bronchopleural fistula. He was then sent to the ED\n for further evaluation.\n .\n In the ED, initial vs were: 98.6 66 100/52 26 95. Chest CTA showed\n small bilateral pneumothorax, no evidence for bronchopleural fistula,\n and bilateral pleural effusions, stable on right new on left. Negative\n for PE. Blood cx x 2 drawn and he was given vanco/zosyn for ?\n infectious etiology. He also received his home doses of Spironolactone\n and lasix and morphine IV with marked improvement in chest pain.\n Thoracics and Surgery were both contact and will see in am\n assuming pt is stable. If unstable, thoracics is aware overnight.\n .\n On the floor, he reports recurrence of chest pain since he received\n morphine several hours prior and persistent SOB which is unchanged from\n earlier.\n Review of systems:\n (+) Per HPI. Has occasional nausea at baseline for which he takes\n compazine.\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n vomiting, diarrhea, constipation or abdominal pain. No recent change in\n bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.\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 Morphine Sulfate - 10:00 PM\n Other medications:\n Ciprofloxacin 250mg daily\n Folic acid 1 mg daily\n lasix 120mg daily\n Lactulose 30mg TID prn\n Nadolol 20mg daily\n compazine 5mg prn\n Rifaximin 600mg PO BID\n Spironolactone 250mg PO daily\n Calcium carbonate 1 tab PO daily\n Omeprazole 20mg PO daily\n MVI daily\n Eltrombopag 75mg/placebo 0mg once a day x last 21 days\n Past medical history:\n Family history:\n Social History:\n 1. Cirrhosis:\n - Secondary to hepatitis C (from blood txn)\n - Listed for liver transplant, MELD previously 17\n - AFP 4.9 ()\n - grade II varices ()\n - ascites formerly requiring paracenteses q2-4 weeks previously but\n well controlled now, last para>1 year prior\n - h/o hepatic encephalopathy\n - h/o SBP on cipro prophylaxis\n 2. Hepatitis C:\n - Genotype 1, Viral load 412,000 IU/mL ()\n - failed interferon tx (thrombocytopenia)\n 3. History of CVA, w/ mild residual R sided weakness\n 4. Heterozygus for H63D for hemochromatosis\n 5. Hypertension\n 6. Osteoporosis\n PSH\n Umbilical hernia repair \n Married and lives with his wife. Formerly worked as a custodian.\n History of smoking but quit 10 years ago. Smoked 1ppd x 7-8 years.\n Denies alcohol or drug use.\n Family History:\n Significant for Alzheimer disease in mother and an unspecified\n cancer in father and brother.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married and lives with his wife. Formerly worked as a custodian.\n History of smoking but quit 10 years ago. Smoked 1ppd x 7-8 years.\n Denies alcohol or drug use.\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: 37.2\nC (98.9\n Tcurrent: 36.8\nC (98.2\n HR: 64 (64 - 76) bpm\n BP: 103/51(64) {101/51(64) - 106/55(67)} mmHg\n RR: 15 (14 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 1,790 mL\n 220 mL\n Urine:\n 340 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,790 mL\n -220 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Neck: supple, JVP 8cm, no LAD\n Lungs: Trachea midline. Decreased BL left base with crackles way\n up, dullness to percussion, crackles rigth base, No wheezes or rhonchi\n CV: Distant heart sounds. Regular. Normal S1 + S2, no murmurs, rubs,\n gallops appreciated\n Abdomen: soft, obese, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, spleen tip palpated 2-3 cm below\n costal margin\n Ext: 3+ edema RLE 2+ edema LLE, warm, well perfused, 2+ pulses, no\n clubbing, cyanosis\n Skin:No SC emphysema\n Labs / Radiology\n 47 K/uL\n 11.5 g/dL\n 94 mg/dL\n 1.3 mg/dL\n 21 mg/dL\n 25 mEq/L\n 99 mEq/L\n 3.9 mEq/L\n 134 mEq/L\n 32.5 %\n 5.2 K/uL\n [image002.jpg]\n \n 2:33 A8/5/ 10:01 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 5.2\n Hct\n 32.5\n Plt\n 47\n Cr\n 1.3\n TropT\n <0.01\n Glucose\n 94\n Other labs: PT / PTT / INR:19.1/39.5/1.7, CK / CKMB /\n Troponin-T:61//<0.01, Differential-Neuts:75.7 %, Lymph:11.4 %, Mono:9.3\n %, Eos:3.3 %, Lactic Acid:1.7 mmol/L, Ca++:8.3 mg/dL, Mg++:1.7 mg/dL,\n PO4:4.0 mg/dL\n Imaging: CTA: small bilateral pneumothorax. no evidence for\n bronchopleural fistula.\n bilateral pleural effusions, stable on right new on left. coronary\n artery\n calcificiation. no PE. cirrhotic liver. gynecomastia.\n CXR: Moderate left sided effusion, Small r effusion. Small PTX apices\n B/L\n Microbiology: Blood cx x 2\n ECG: nsr. PR prolonged 210msec. poor r wave progression. normal axis.\n no st or t wave changes. qtc 470. unchanged from prior\n Assessment and Plan\n 56M with Hep C cirrhosis admitted with B/L PTX and new left pleural\n effusion\n # B/L PTX: Unclear etiology for new onset bilateral PTX given he has\n had no recent pressure changes that would precipitate PTX and no known\n risk factors for secondary PTX such as COPD, CF, TB, ankylosing\n spondylitis, asthma, histiocytosis X, idiopathic pulmonary fibrosis,\n lymphangioleiomyomatosis, lung cancer, Marfan syndrome, necrotizing\n pneumonia, rheumatoid arthritis, or sarcoidosis. Primary spontaneous\n PTX also possibility but he is not of typical stature, or epidemiology.\n He has no previous known underlying lung disease although likely had\n ruputure of subpleural bleb given mild bullous disease on chest CT\n which is out of proportion to smoking history. He has been on new\n medication which stimulates megakaryocytes for thrombocytopenia but PTX\n or cystic lung disease not obvious side effect.\n - Continue 100% NRB to enhance resorption of PTX\n - Thoracics consulted in ED, appreciate recs\n - serial exams, repeat PA and lateral CXR in am\n - monitor for any signs of hemodynamic compromise such as tachycardia,\n hypotension\n - Appreciate IP following who will see in am for consideration fo tube\n thoracostomy but currently no indication since hemodynamically stable\n and PTX small\n - Hold Eltrombopag study medication since unclear if this is underlying\n precipitant\n # Pleural effusion: Pt has chronic small right effusion likely from\n known liver disease but has new moderate to large left pleural effusion\n which has developed since 6/. Unclear if related to new PTX but\n differential includes hemothorax related to , empyema and parapneumonic\n effusion, transudative effusion. Hemothorax concerning given HCT drop\n from 36 to 32 with pm labs. Given no infectious symptoms such as fever,\n chills, leukocytosis will not continue abx started in ED but would\n pursue further workup with thoracentesis for determination of\n transudate vs exudate with cytology, cell counts, cx and gram stain.\n Unlikely new heart failure or related to cirrhosis since assymmetric\n and left>right.\n - Thoracentesis tomorrow with cx, gram stain, cytology,\n - serial exams\n - TTE to eval for portopulmonary HTN\n - f/u blood cx\n - FFP ordered, check coags in am, has active type and screen\n - monitor HCT q6\n # CP: Dyspnea and CP likely secondary to PTX but will also ROMI with\n serial enzymes. No ECG changes to suggest ischemia, cardiac enzymes\n negative x 2 and no PE on CTA\n - ROMI\n - repeat ECG in am\n # Cirrhosis: hep C acquired from blood transfusion. Stable. No\n active issues\n - continue nadolol for history of varices, cipro for SBP ppx,\n lactulose, rifaximin, lasix, and aldactone\n - appreciate liver following while in house\n # Thrombocytopenia: Stable at baseline. Transfused platelets today in\n clinic.\n - continue to monitor\n # ARF:Cr 1.3 slightly up from baseline 1.0-1.2.\n - continue to monitor, check urine lytes in am if still elevated\n - IVF prn\n - avoid nephrotoxic agents\n .\n # HTN: Currently well controlled on home meds of lasix and aldactone,\n nadolol\n # R>L LE edema: per patient is at baseline but much more significant on\n exam since previously documented\n - check LE duplex\n # FEN: No IVF, replete electrolytes, low na diet\n # Prophylaxis: No subcutaneous heparin given thrombocytopenia, home PPI\n # Access: peripheral\n # Code: Full\n # Communication: Patient and wife\n # Disposition: pending above, likely floor in am if stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:25 PM\n Prophylaxis:\n DVT: (Thrombocytopenia)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held 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: 56M HCV cirrhosis (on transplant list), SBP,\n CVA, HTN p/w CP and DOE. Eval in ED notable for B Pneumothoax on CT.\n Initially noted labored breathing and cough 3d PTA - diuretics\n increased s change in sx. Had outpt flex sig, CXR notable for B PTX.\n Exam notable for Tm 97.9 BP 124/60 HR 73 RR 17 with sat 98 on NRB. WD\n man, mild resp distress. CTA B, at bases. RRR s1s2. Soft +BS. 1+\n edema. Labs notable for WBC 5K, HCT 32, K+ 4.8, Cr 1.3, INR 1.7. CXR\n with B small PTX, effusions.\n Agree with plan to monitor in MICU on 100% NRB with IP/thoracic eval.\n Etiology of B PTX as well as new L>R effusions unclear - no clear signs\n of infection or exposure to intrathoracic pressure swings. He does have\n emphysema / multiple thin walled cysts on CT, likely increasing risk of\n PTX. Effusion, esp on L, should probably be tapped, will also check\n echo to r/o change in RV / LV function. Will continue remainder of home\n regimen. Remainder of plan as outlined above.\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:48 ------\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475667, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS clear to diminish on his\n left side. Sats 100% . No c/o SOB.Cont have Chest pain\n Action:\n Pt had Lateral and anterior done X ray showed large pleural effusion on\n his left lung and small to moderate pneumothorax. Given Morphine for\n pain.\n Response:\n Awaiting for IP to come and evaluate for tap. Kept him NPO for\n procedure. Cont non rebreather as a treatment for pneumothorax\n Plan:\n Closely monitor resp status. Follow up with IP and Tap?. PRN Morphine\n for apin\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was47. And Hct was 30.1.\n Action:\n Pt has actice clots in the blood bank. Hct this afternoon 29.8 and Plt\n 47\n Response:\n Pt has one unit plt ordered, holding for now until IP come and\n evaluate him for possible tap.\n Plan:\n Monitor closely his plt count as well as Hct.\n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 475828, "text": "had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Morphine given for pain. Pt received 2 units of FFP prior to\n thoracentesis,IP done thoracentesis at bedside. Tried 4L NC sats were\n fine.\n Response:\n Plan:\n Closely monitor resp status.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was43. And Hct stable at 29.7.\n Action:\n Pt has active clots in the blood bank.\n Response:\n .\n Plan:\n Monitor closely his plt count as well as Hct\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 107.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Liver failure, Hep C cirrhosis, portal\n hypertension, Recent hernia repair, Ascitis, Rt Pleural effusion,\n Thrombocytopenia with spleenomegaly.\n Sigmoidoscopy on for polp removal.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:47\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 64 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 100% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 522 mL\n 24h total out:\n 660 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 03:27 AM\n Potassium:\n 3.5 mEq/L\n 03:27 AM\n Chloride:\n 100 mEq/L\n 03:27 AM\n CO2:\n 25 mEq/L\n 03:27 AM\n BUN:\n 23 mg/dL\n 03:27 AM\n Creatinine:\n 1.2 mg/dL\n 03:27 AM\n Glucose:\n 124 mg/dL\n 03:27 AM\n Hematocrit:\n 29.7 %\n 03:27 AM\n Finger Stick Glucose:\n 135\n 12:00 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: MICU 683\n Transferred to:\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475743, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Weaned o2 down to 4lit NC.Morphine for pain Mx.\n Response:\n Sating 96% on 4lit NC.Spoke to IP on phone.They will see him in the\n am.They \nt feel he should be seen in ICU.Will see him even if he is\n on the floor regardless if he needs tap or not.Put back on 100% o2 via\n aerosol to resolve the pneumothorax.\n Plan:\n Closely monitor resp status.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was43. And Hct stable at 29.7.\n Action:\n Pt has active clots in the blood bank.\n Response:\n Pt has one unit plt ordered, holding for now until IP come and\n evaluate him for possible tap.\n Plan:\n Monitor closely his plt count as well as Hct.\n" }, { "category": "General", "chartdate": "2179-09-17 00:00:00.000", "description": "Generic Note", "row_id": 475834, "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. Thoracentesis done this morning\n feels much better after procedure\n 97.5 64 105/60\n Alert\n Few crackles L > R dullness L\n w/o m\n Abd\n soft\n WBC 3.8\n Pleural effusion\n likely from communication with peritoneum but we are\n awaiting chems and cell ct. Will need to monitor to see how rapidly he\n reaccumulates. No increase in side of PTXs but continuing to monitor.\n No evidence of GIB.\n Time spent 30 min\n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 475910, "text": "Mr. is a 56 year old male who had Sigmoidoscopy on for\n polyp removal. On the way home pt was called to come to ED because they\n found B/L pneumothorax and Pleural effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Morphine given for pain. Pt received 2 units of FFP prior to\n thoracentesis,IP done thoracentesis at bedside at 1030 this morning and\n took out 1L fluid,sent to lab for culture,cytology etc. Weanned to 4L\n NC sats were fine.\n Response:\n Pt oxygen titrated down to 2l sats are fine. Pt felt comfortable post\n procedure.\n Plan:\n Closely monitor resp status. Follow up with culture result.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was43. And Hct stable at 29.7.\n Action:\n Pt has active clots in the blood bank. Ultrasound on his right leg\n done yesterday, No DVT.\n Response:\n No transfusion this time.\n Plan:\n Monitor closely his plt count as well as Hct\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 107.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Liver failure, Hep C cirrhosis, portal\n hypertension, Recent hernia repair, Ascitis, Rt Pleural effusion,\n Thrombocytopenia with spleenomegaly.\n Sigmoidoscopy on for polp removal.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:53\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 69 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 780 mL\n 24h total out:\n 3,905 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 03:27 AM\n Potassium:\n 3.5 mEq/L\n 03:27 AM\n Chloride:\n 100 mEq/L\n 03:27 AM\n CO2:\n 25 mEq/L\n 03:27 AM\n BUN:\n 23 mg/dL\n 03:27 AM\n Creatinine:\n 1.2 mg/dL\n 03:27 AM\n Glucose:\n 124 mg/dL\n 03:27 AM\n Hematocrit:\n 29.7 %\n 03:27 AM\n Finger Stick Glucose:\n 135\n 12:00 AM\n Valuables / Signature\n Patient valuables: No 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 683\n Transferred to: F1019\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 475842, "text": "had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Morphine given for pain. Pt received 2 units of FFP prior to\n thoracentesis,IP done thoracentesis at bedside at 1030 this morning and\n took out 1L fluid,sent to lab for culture,cytology etc. Tried 4L NC\n sats were fine.\n Response:\n Pt oxygen titrated down to 2l sats are fine. Pt fieel comfortable poet\n procedure.\n Plan:\n Closely monitor resp status. Follow up with culture result.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was43. And Hct stable at 29.7.\n Action:\n Pt has active clots in the blood bank. Ultrasound on his right leg\n done yesterday, No DVT.\n Response:\n No transfusion this time.\n Plan:\n Monitor closely his plt count as well as Hct\n Demographics\n Attending MD:\n \n Admit diagnosis:\n BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 107.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Liver failure, Hep C cirrhosis, portal\n hypertension, Recent hernia repair, Ascitis, Rt Pleural effusion,\n Thrombocytopenia with spleenomegaly.\n Sigmoidoscopy on for polp removal.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:47\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 64 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 100% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 522 mL\n 24h total out:\n 660 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 03:27 AM\n Potassium:\n 3.5 mEq/L\n 03:27 AM\n Chloride:\n 100 mEq/L\n 03:27 AM\n CO2:\n 25 mEq/L\n 03:27 AM\n BUN:\n 23 mg/dL\n 03:27 AM\n Creatinine:\n 1.2 mg/dL\n 03:27 AM\n Glucose:\n 124 mg/dL\n 03:27 AM\n Hematocrit:\n 29.7 %\n 03:27 AM\n Finger Stick Glucose:\n 135\n 12:00 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: MICU 683\n Transferred to: 201\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475826, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Morphine given for pain. Pt received 2 units of FFP prior to\n thoracentesis,IP done thoracentesis at bedside. Tried 4L NC sats were\n fine.\n Response:\n Plan:\n Closely monitor resp status.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was43. And Hct stable at 29.7.\n Action:\n Pt has active clots in the blood bank.\n Response:\n .\n Plan:\n Monitor closely his plt count as well as Hct\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475545, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n LS diminished throughout.RR 18-26.No c/o SOB.CP with deepbreathing and\n coughing.\n Action:\n Pt is on 100% NRB, Morphine 2mg IV given.\n Response:\n Pt is sating 100%.No c/o SOB, Pain score after morphine.\n Plan:\n Thrombocytopenia, chronic\n Assessment:\n Plt count 47.No s/s of bleeding.\n Action:\n No action, cont to monitor.\n Response:\n Pts baseline plt count in 40\n Plan:\n Monitor plt count.\n Pleural effusion, acute\n Assessment:\n Pt has got B/L pleural effusion .L>R.\n Action:\n Cont ot monitor, Pt is on 100%NRB.\n Response:\n Sating 100%, no c/o SOB.\n Plan:\n For ?tap today.\n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475907, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Morphine given for pain. Pt received 2 units of FFP prior to\n thoracentesis,IP done thoracentesis at bedside at 1030 this morning and\n took out 1L fluid,sent to lab for culture,cytology etc. Tried 4L NC\n sats were fine.\n Response:\n Pt oxygen titrated down to 2l sats are fine. Pt feel comfortable post\n procedure. C/O floor\n Plan:\n Closely monitor resp status. Follow up with culture result. Awaiting\n for orders.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was43. And Hct stable at 29.7.\n Action:\n Pt has active clots in the blood bank. Ultrasound on his right leg\n done yesterday, No DVT.\n Response:\n No transfusion this time.\n Plan:\n Monitor closely his plt count as well as Hct\n" }, { "category": "Nursing", "chartdate": "2179-09-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475710, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n Pneumothorax, Other (not hospital acquired or traumatic)\n Assessment:\n Pt received on Non rebreather sating 100%, LS diminished throughout.\n Sats 100% . No c/o SOB.Cont have Chest pain.\n Action:\n Weaned o2 down to 4lit NC.Morphine for pain Mx.\n Response:\n Sating 96% on 4lit NC.Spoke to IP on phone.They will see him in the\n am.They \nt feel he should be seen in ICU.Will see him even if he is\n on the floor regardless if he needs tap or not.\n Plan:\n Closely monitor resp status.\n Thrombocytopenia, chronic\n Assessment:\n Plt count this morning was47. And Hct was 30.1.\n Action:\n Pt has active clots in the blood bank. Hct this afternoon 29.8 and Plt\n 47\n Response:\n Pt has one unit plt ordered, holding for now until IP come and\n evaluate him for possible tap.\n Plan:\n Monitor closely his plt count as well as Hct.\n" }, { "category": "Physician ", "chartdate": "2179-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 475783, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 08:33 AM\n TRANSTHORACIC ECHO - At 10:34 AM\n IP did not see patient today despite plan with ID and plan with us to\n do so, will see tomorrow morning.\n CXR yesterday showed worsening left lung volume loss which may be\n related to increasing large pleural effusion and small-to-moderate\n pneumothorax. No DVT. RUQ U/S: Patent portal vein. CE negative.\n DIC- fibrinogen 156. Continues on NRB.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:47 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.3\n HR: 69 (62 - 75) bpm\n BP: 98/58(68) {94/45(59) - 121/68(81)} mmHg\n RR: 17 (12 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 2,300 mL\n 360 mL\n Urine:\n 2,300 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,300 mL\n -360 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\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 43 K/uL\n 10.3 g/dL\n 124 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 100 mEq/L\n 133 mEq/L\n 29.7 %\n 3.8 K/uL\n [image002.jpg]\n 10:01 PM\n 04:12 AM\n 05:56 AM\n 12:19 PM\n 03:27 AM\n WBC\n 5.2\n 4.8\n 4.4\n 3.8\n Hct\n 32.5\n 31.3\n 30.0\n 29.8\n 29.7\n Plt\n 47\n 38\n 43\n 43\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n <0.01\n <0.01\n <0.01\n Glucose\n 94\n 93\n 124\n Other labs: PT / PTT / INR:19.8/37.7/1.8, CK / CKMB /\n Troponin-T:30//<0.01, ALT / AST:26/49, Alk Phos / T Bili:73/5.3,\n Differential-Neuts:71.0 %, Lymph:14.3 %, Mono:8.2 %, Eos:6.2 %,\n Fibrinogen:157 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL, LDH:244\n IU/L, Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Imaging: CXR portable: improvement or no change in L PTX and effusion.\n No consolidation.\n Microbiology: Bcx: pending\n Assessment and Plan\n PNEUMOTHORAX, OTHER (NOT HOSPITAL ACQUIRED OR TRAUMATIC)\n PLEURAL EFFUSION, ACUTE\n CIRRHOSIS OF LIVER, OTHER\n THROMBOCYTOPENIA, CHRONIC\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n Assessment and Plan: This is a 56M with Hep C cirrhosis admitted with\n B/L PTX and new left effusion\n .\n # B/L PTX: Unclear etiology for new onset bilateral PTX given he has\n had no recent pressure changes that would precipitate PTX and no known\n risk factors for secondary PTX such as COPD, CF, TB, ankylosing\n spondylitis, asthma, histiocytosis X, idiopathic pulmonary fibrosis,\n lymphangioleiomyomatosis, lung cancer, Marfan syndrome, necrotizing\n pneumonia, rheumatoid arthritis, or sarcoidosis. Primary spontaneous\n PTX also possibility but he is not of typical stature, or epidemiology.\n He has no previous known underlying lung disease although likely had\n ruputure of subpleural bleb given mild bullous disease on chest CT\n which is out of proportion to smoking history. He has been on new\n medication which stimulates megakaryocytes for thrombocytopenia but PTX\n or cystic lung disease not obvious side effect.\n - Continue 100% NRB to enhance resorption of PTX\n - Call IP this AM\n - serial exams, repeat PA and lateral CXR\n - monitor for any signs of hemodynamic compromise such as tachycardia,\n hypotension\n - Hold Eltrombopag study medication since unclear if this is underlying\n cause (Dr. \n # Pleural effusion: Pt has chronic small right effusion likely from\n known liver disease but has new moderate to large left pleural effusion\n which has developed since 6/. unclear if related to new PTX but\n Differential includes hemothorax related to , empyema and parapneumonic\n effusion, transudative effusion. Given no infectious symptoms such as\n fever, chills, leukocytosis will not continue abx started in ED but\n would pursue further workup with thoracentesis for determination of\n transudate vs exudate with cytology, cell counts, cx and gram stain.\n Unlikely new heart failure or related to cirrhosis since assymmetric\n and left>right.\n - call IP this AM\n - Thoracentesis today with cx, gram stain, cytology,\n - serial exams\n - TTE to eval for portopulmonary HTN\n - f/u blood cx\n - FFP ordered, check coags in am, has active type and screen\n # Anemia: Hct stable o/n INR 1.8. Unclear etiology, possible bleeding\n vs DIC. DIC labs WNL.\n -guaiac stool\n -CT scan show hundsfield units of pleural fluid not consistent with\n blood\n - FFP ordered, follow coags, has active type and screen and 1 unit on\n hold\n # CP: Dyspnea and CP likely secondary to PTX. ROMI.\n - repeat ECG in am\n - controlled with PRN morphine\n # Cirrhosis: hep C acquired from blood transfusion. Stable. No\n active issues\n - continue nadolol for history of varices, cipro for SBP ppx,\n lactulose, rifaximin, lasix, and aldactone\n - appreciate liver following while in house (call c/s)\n # Thrombocytopenia: Stable at baseline. Transfused platelets yesterday,\n plt #back to pre-txf level. Plts stable o/n.\n - continue to monitor w/ daily CBC\n # HTN: Currently well controlled on home meds of lasix and aldactone,\n nadolol\n # R>L LE edema: No DVT\n ICU Care\n Nutrition:\n Comments: Low Na diet.\n Glycemic Control:\n Lines:\n 20 Gauge - 09:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: PT and wife\n status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2179-09-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 475870, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 08:33 AM\n TRANSTHORACIC ECHO - At 10:34 AM\n IP did not see patient today despite plan with ID and plan with us to\n do so, will see tomorrow morning.\n CXR yesterday showed worsening left lung volume loss which may be\n related to increasing large pleural effusion and small-to-moderate\n pneumothorax. No DVT. RUQ U/S: Patent portal vein. CE negative.\n DIC- fibrinogen 156. Continues on NRB.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:47 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.3\n HR: 69 (62 - 75) bpm\n BP: 98/58(68) {94/45(59) - 121/68(81)} mmHg\n RR: 17 (12 - 20) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 2,300 mL\n 360 mL\n Urine:\n 2,300 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,300 mL\n -360 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n Gen-AOx3, NAD\n HEENT- scleral icterus, NCAT\n Pulm- crackles on L posterior lung, bilaterally equal lung expansion\n CV- RRR no mgr\n Abd- soft, NTND\n Ext- 1+LE edema\n Labs / Radiology\n 43 K/uL\n 10.3 g/dL\n 124 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 100 mEq/L\n 133 mEq/L\n 29.7 %\n 3.8 K/uL\n [image002.jpg]\n 10:01 PM\n 04:12 AM\n 05:56 AM\n 12:19 PM\n 03:27 AM\n WBC\n 5.2\n 4.8\n 4.4\n 3.8\n Hct\n 32.5\n 31.3\n 30.0\n 29.8\n 29.7\n Plt\n 47\n 38\n 43\n 43\n Cr\n 1.3\n 1.2\n 1.2\n TropT\n <0.01\n <0.01\n <0.01\n Glucose\n 94\n 93\n 124\n Other labs: PT / PTT / INR:19.8/37.7/1.8, CK / CKMB /\n Troponin-T:30//<0.01, ALT / AST:26/49, Alk Phos / T Bili:73/5.3,\n Differential-Neuts:71.0 %, Lymph:14.3 %, Mono:8.2 %, Eos:6.2 %,\n Fibrinogen:157 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL, LDH:244\n IU/L, Ca++:8.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Imaging: CXR portable: improvement or no change in L PTX and effusion.\n No consolidation.\n Microbiology: Bcx: pending\n Assessment and Plan\n PNEUMOTHORAX, OTHER (NOT HOSPITAL ACQUIRED OR TRAUMATIC)\n PLEURAL EFFUSION, ACUTE\n CIRRHOSIS OF LIVER, OTHER\n THROMBOCYTOPENIA, CHRONIC\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n Assessment and Plan: This is a 56M with Hep C cirrhosis admitted with\n B/L PTX and new left effusion\n .\n # B/L PTX: Unclear etiology for new onset bilateral PTX given he has\n had no recent pressure changes that would precipitate PTX and no known\n risk factors for secondary PTX such as COPD, CF, TB, ankylosing\n spondylitis, asthma, histiocytosis X, idiopathic pulmonary fibrosis,\n lymphangioleiomyomatosis, lung cancer, Marfan syndrome, necrotizing\n pneumonia, rheumatoid arthritis, or sarcoidosis. Primary spontaneous\n PTX also possibility but he is not of typical stature, or epidemiology.\n He has no previous known underlying lung disease although likely had\n ruputure of subpleural bleb given mild bullous disease on chest CT\n which is out of proportion to smoking history. He has been on new\n medication which stimulates megakaryocytes for thrombocytopenia but PTX\n or cystic lung disease not obvious side effect.\n - Continue 100% NRB to enhance resorption of PTX\n - Call IP this AM\n - serial exams, repeat PA and lateral CXR\n - monitor for any signs of hemodynamic compromise such as tachycardia,\n hypotension\n - Hold Eltrombopag study medication since unclear if this is underlying\n cause (Dr. \n # Pleural effusion: Pt has chronic small right effusion likely from\n known liver disease but has new moderate to large left pleural effusion\n which has developed since 6/. unclear if related to new PTX but\n Differential includes hemothorax related to , empyema and parapneumonic\n effusion, transudative effusion. Given no infectious symptoms such as\n fever, chills, leukocytosis will not continue abx started in ED but\n would pursue further workup with thoracentesis for determination of\n transudate vs exudate with cytology, cell counts, cx and gram stain.\n Unlikely new heart failure or related to cirrhosis since assymmetric\n and left>right.\n - call IP this AM\n - Thoracentesis today with cx, gram stain, cytology,\n - serial exams\n - TTE to eval for portopulmonary HTN\n - f/u blood cx\n - FFP ordered, check coags in am, has active type and screen\n # Anemia: Hct stable o/n INR 1.8. Unclear etiology, possible bleeding\n vs DIC. DIC labs WNL.\n -guaiac stool\n -CT scan show hundsfield units of pleural fluid not consistent with\n blood\n - FFP ordered, follow coags, has active type and screen and 1 unit on\n hold\n # CP: Dyspnea and CP likely secondary to PTX. ROMI.\n - repeat ECG in am\n - controlled with PRN morphine\n # Cirrhosis: hep C acquired from blood transfusion. Stable. No\n active issues\n - continue nadolol for history of varices, cipro for SBP ppx,\n lactulose, rifaximin, lasix, and aldactone\n - appreciate liver following while in house (call c/s)\n # Thrombocytopenia: Stable at baseline. Transfused platelets yesterday,\n plt #back to pre-txf level. Plts stable o/n.\n - continue to monitor w/ daily CBC\n # HTN: Currently well controlled on home meds of lasix and aldactone,\n nadolol\n # R>L LE edema: No DVT\n ICU Care\n Nutrition:\n Comments: Low Na diet.\n Glycemic Control:\n Lines:\n 20 Gauge - 09:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: PT and wife\n status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2179-09-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 475516, "text": "Pt had Sigmoidoscopy on for polyp removal. On the way home pt was\n called to come to ED bcoz they found B/L pneumothorax and Pleural\n effusions on his xray.\n Pt has been having progressive worsening SOB x2days.Pt is in liver\n failure and is on transplant list.\n In pt was put on 100%NRB, recieved 120 lasix and 250\n spirinolactone.Had vanco and zosyn.2mg morphine for CP.Pt was\n transfered to MICU for close monitoring.\n" }, { "category": "ECG", "chartdate": "2179-09-17 00:00:00.000", "description": "Report", "row_id": 203650, "text": "Sinus rhythm. Poor R wave progression, probably a normal variant. Consider\nprior anteroseptal myocardial infarction. Low QRS voltage in the precordial\nleads. Compared to the previous tracing of the findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2179-09-16 00:00:00.000", "description": "Report", "row_id": 203651, "text": "Sinus rhythm. Compared to tracing #1 similar findings are apparent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-09-15 00:00:00.000", "description": "Report", "row_id": 203652, "text": "Sinus rhythm. QTc interval prolongation. First degree A-V delay. Delayed\nR wave transition which may be a normal variant. Low precordial QRS voltage.\nCompared to the previous tracing of the findings are similar.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2179-09-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1092252, "text": " 11:00 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ptx\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with L effusion s/ \n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Left effusion, S/P thoracentesis.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Tiny left apical pneumothorax is not seen in the current study. There is no\n change in left pleural effusion, adjacent left lung consolidation, and\n cardiomediastinal silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1092534, "text": " 10:02 AM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for resolution of PTX and improvement of effusis\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with HCV cirrhosis presented w/ bilateral pleural PTX and L\n pleural effusion s/p thoracentesis. Please eval for resolution of PTX and\n improvement of effusison.\n REASON FOR THIS EXAMINATION:\n Please eval for resolution of PTX and improvement of effusison\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hepatitis C cirrhosis, status post thoracentesis for left\n pleural effusion.\n\n CHEST:\n\n The left pleural effusion is smaller following the thoracocentesis. No\n evidence of a pneumothorax is present. The right lung remains clear.\n\n IMPRESSION: No pneumothorax, reduction in size of left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1092188, "text": " 3:39 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with pneumothorax, hydrothorax\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest, portable AP.\n\n REASON FOR EXAM: 56-year-old man with pneumothorax and hydrothorax, followup\n imaging.\n\n Findings:Since the previous study of , the large left pleural\n effusion has decreased in size, and the lung has re-expanded with a tiny\n remaining apical pneumothorax. The right lung is unchanged.\n\n IMPRESSION: Interval improvement with reduction in size of the left large\n pleural effusion which is now moderate sized and near complete resolution of\n the left apical pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2179-09-16 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 1092113, "text": ", MED MICU 2:13 PM\n US ABD LIMIT, SINGLE ORGAN PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: please do liver u/s with doppler to r/o portal vein thrombos\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with liver disease, elevated bili.\n REASON FOR THIS EXAMINATION:\n please do liver u/s with doppler to r/o portal vein thrombosis\n ______________________________________________________________________________\n PFI REPORT\n Patent portal vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1092042, "text": " 9:18 AM\n CHEST (PA & LAT) Clip # \n Reason: eval PTX.\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with known PTX and effusion.\n REASON FOR THIS EXAMINATION:\n eval PTX.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:37 AM\n PFI: Worsening left pleural effusion and pneumothorax. Decreased left lung\n aeration is likely due to partial lobar collapse secondary to effusion. The\n right lung remains well aerated.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 56-year-old male with known pneumothorax and effusion.\n\n Portable AP chest is compared to radiograph and CT from the same date.\n Slight rotational positioning of the patient is evident. Deviation of the\n trachea to the left is most likely a combination of rotation and new left\n upper lobe volume loss. There is worsening left pleural effusion which is now\n large and a probable increase in the amount of pneumothorax which remains\n small. No right pneumothorax is noted, although a small pneumothorax was seen\n on the CT from one day prior. The right lung itself remains clear.\n\n IMPRESSION: Worsening left lung volume loss which may be related to\n increasing large pleural effusion and small-to-moderate pneumothorax.\n\n Findings were discussed with housestaff on the morning of over the\n telephone.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1092043, "text": ", MED MICU 9:18 AM\n CHEST (PA & LAT) Clip # \n Reason: eval PTX.\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with known PTX and effusion.\n REASON FOR THIS EXAMINATION:\n eval PTX.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Worsening left pleural effusion and pneumothorax. Decreased left lung\n aeration is likely due to partial lobar collapse secondary to effusion. The\n right lung remains well aerated.\n\n" }, { "category": "Radiology", "chartdate": "2179-09-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1091982, "text": " 10:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for change in PTX\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with PTX, please assess for change\n REASON FOR THIS EXAMINATION:\n please assess for change in PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pneumothorax.\n\n COMPARISON: , 1:51 p.m.\n\n FINDINGS: As compared to the previous radiograph, there is a minimal decrease\n of the pre-existing pneumothorax. However, at the left apex, the pneumothorax\n still measures around 1 cm. The pre-existing air-fluid level in the lateral\n aspects of the left hemithorax is no longer visible. The extent of the\n left-sided pleural effusion, however, is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-16 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 1092039, "text": " 8:27 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with RLE edema\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:56 PM\n PFI: No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT LOWER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: .\n\n HISTORY: Edema.\n\n FINDINGS: Grayscale and color Doppler son were performed of the right\n common femoral, superficial femoral, and popliteal veins. These demonstrate\n normal flow, compressibility and augmentation.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-16 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 1092040, "text": ", MED MICU 8:27 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with RLE edema\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1092217, "text": " 8:10 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion and ptx evolution\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with effusion/ptx\n REASON FOR THIS EXAMINATION:\n eval effusion and ptx evolution\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest PA and lateral.\n\n REASON FOR EXAM: 56-year-old man with effusion and pneumothorax. Evaluation.\n\n FINDINGS: Since the previous chest radiograph of same date a tiny left apical\n pneumothorax is unchanged. There is a persistent moderately large left-sided\n pleural effusion. This is not associated with any mediastinal shift\n suggesting there is associated left lower lobe atelectasis. The right lung is\n fully expanded and clear.\n\n IMPRESSION: Stable moderately large left pleural effusion which has improved\n since the chest radiograph of the prior day. Persistent tiny left apical\n pneumothorax is unchanged. Left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1091921, "text": " 1:44 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with cough and chest pain\n REASON FOR THIS EXAMINATION:\n please evaluate for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON :\n\n HISTORY: Cough and chest pain.\n\n IMPRESSION: PA and lateral chest compared to :\n\n A moderate sized left hydropneumothorax is new, but the absence of\n contralateral mediastinal shift suggests that it has been developing\n subacutely or that there is coexisting atelectasis in the left lower lobe.\n Small right apical pneumothorax is new and may not be in communication with\n persistent small layering right pleural effusion because there is no fluid\n level. Right hilus is normal. The lower portion of the left hilus is\n obscured. Overall caliber of the mediastinum is stable but it could \n enlarged lymph nodes. Heart size is normal.\n\n Unless the patient has had thoracentesis, the overall findings suggest an\n infectious left bronchopleural fistula with empyema. The cause of the small\n right pneumothorax is not at all clear. Small right pleural effusion is\n chronic and probably unrelated to acute developments.\n\n Dr. and I discussed these findings by telephone at the time of\n dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-15 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1091957, "text": " 5:02 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: PE? bronchopleural fistula? loculations?\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with cirrhosis and L sided pleural effusion which is new.\n REASON FOR THIS EXAMINATION:\n PE? bronchopleural fistula? loculations?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw WED 6:45 PM\n small bilateral pneumothorax. no evidence for bronchopleural fistula.\n bilateral pleural effusions, stable on right new on left. coronary artery\n calcificiation. no PE. cirrhotic liver. gynecomastia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old man with cirrhosis and left-sided pleural effusion which\n is new. Evaluate for pulmonary embolism or bronchopleural fistula.\n\n TECHINIQUE: Helical imaging was performed from the thoracic inlet through the\n upper abdomen without and with 100 cc IV contrast. Right and left oblique\n reformats were prepared.\n\n COMPARISON: CT torso , CT abdomen , CT chest\n .\n\n CTA CHEST: There is no pulmonary embolism or acute aortic pathology. There is\n a stable moderate sized right-sided pleural effusion with compressive\n atelectasis at the right base. There is a new large left pleural effusion.\n There is near complete collapse of the left lower lobe and partial collapse of\n the left upper lobe. There are no obstructing lesions seen within the central\n airways. These findings are new since . There are small\n bilateral pneumothoraces (3:48 and 3:62). Emphysema is noted, predominantly\n in the lung apices. There is a 4-mm right middle lobe pulmonary nodule\n (3:48), and a 5-mm right upper lobe pulmonary nodule (2:22).\n\n Coronary artery vascular calcifications are noted though the heart is not\n enlarged. No pericardial effusion. Fluid density nodularity is again noted\n anterior to the heart (3:73), which are stable.\n\n This study is not evaluated for subdiaphragmatic evaluation given These\n limitations. The spleen is enlarged. The liver is nodular consistent with\n cirrhotic appearance. There are several hypodensities throughout the liver,\n including one in the right lobe (3:74), incompletely evaluated on this study.\n There is a gallstone within the gallbladder (2:52), which appears stable.\n There is stranding of the mesenteric fat, which is unchanged. Limited views\n of the stomach and bowel appear normal.\n\n BONE WINDOWS: There are no suspicious sclerotic or lytic lesions.\n\n IMPRESSION:\n 1. Small bilateral pneumothoraces, may be due to ruptured blebs as patient\n (Over)\n\n 5:02 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: PE? bronchopleural fistula? loculations?\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n has emphysema.\n 2. Bilateral pleural effusions, new and large on the left, compressive\n atelectasis, left > right.\n 3. 5- mm right middle lobe pulmonary nodule which appears stable.\n 4. Stable cirrhosis. Stable gallstone within the gallbladder. Stable\n stranding of the mesenteric fat, incompletely assessed on this study.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-09-16 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 1092112, "text": " 2:13 PM\n US ABD LIMIT, SINGLE ORGAN PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: please do liver u/s with doppler to r/o portal vein thrombos\n Admitting Diagnosis: BILATERAL PLEURAL EFFUSIONS;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with liver disease, elevated bili.\n REASON FOR THIS EXAMINATION:\n please do liver u/s with doppler to r/o portal vein thrombosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:59 PM\n Patent portal vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 56-year-old man with liver disease, elevated bilirubin.\n\n COMPARISON: Doppler ultrasound, .\n\n FINDINGS: The liver has a coarsened echotexture appearance, but no focal\n liver lesion is identified. No biliary dilatation is seen. No ascites is\n seen in the right upper quadrant. A right pleural effusion is noted.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main portal vein, right portal vein and left portal vein are\n patent with hepatopetal flow. Appropriate flow is seen in the IVC, the\n hepatic veins, and the splenic vein. Appropriate arterial waveforms are seen\n in the main hepatic artery.\n\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Cirrhotic-appearing liver with no focal liver lesions identified.\n 3. Right pleural effusion.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464731, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 110) bpm\n BP: 98/49(60) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 850 mL\n PO:\n TF:\n IVF:\n 703 mL\n 850 mL\n Blood products:\n Total out:\n 1,375 mL\n 740 mL\n Urine:\n 1,375 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 110 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 12.5 g/dL\n 183 K/uL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n CXR : ETT in good position, mild interstiial edema\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status\n intubated for airway protection.\n > Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n Notably, LP is negative for bacterial meningitis. Toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. ? anticholinergic symptoms (? Accidental exposure as\n landscaper). QRS is also prolonged. ? seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - f/u Herpes Simplex Virus PCR; neg Cryptococcal Antigen; VDRL; f/u\n Treponema pallidum Antibody, IFA (CSF)\n - appreciate toxicology recs\n - empiric ACV until HSV PCR negative, no additional empiric coverage\n with Abx given neg LP\n > Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n > Respiratory failure: Performed for airway protection.\n - extubate today\n - aspiration precautions\n > HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n Additional issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 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: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 464732, "text": "Chief Complaint:\n 24 Hour Events:\n - admitted overnight\n - vent settings FiO2 40%, PEEP 5 --> now on PS since 5 AM\n - gave 2 amp sodium bicarb for QRS 104 with little effect\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 91 (87 - 110) bpm\n BP: 102/55(66) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 689 mL\n PO:\n TF:\n IVF:\n 703 mL\n 689 mL\n Blood products:\n Total out:\n 1,375 mL\n 540 mL\n Urine:\n 1,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 149 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n GEN: able to squeeze hands on command, NAD, sedated\n HEENT: PERRL, OP - unable to be examined due to ETT, no cervical LAD\n CHEST: CTAB, no w/r/r\n CV: tachy, no m/r/g\n ABD: NDNT, soft, NABS\n EXT: no c/c/e\n NEURO: able to squeeze hands on command and wiggle toes.\n DERM: no rashes, although chest appears flushed, excoriation on R\n antecubital area\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status.\n .\n # Altered mental status:\n -given the history of abnormal movements\n -f/u HSV PCR, crypto, VDRL\n -resend urine tox, f/u tox recs\n -QRS 100ms\n stable, no response to bicarb\n -MS improving- extubate\n -f/u CSF cultures and GS\n - empiric ACV until HSV PCR negative\n .\n # Widened QRS on EKG:\n -no change, QRS 100ms, repeat in p.m.\n .\n # Respiratory failure:\n -for airway protection\n -extubate\n .\n # HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n .\n # H/o polysubstance abuse: ? relapse yesterday\n - SW consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464599, "text": "Chief Complaint: 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 34M found with altered mental status this morning, babbling, warm,\n erythematous - brought to ER via ambulance.\n In ER HR 125, 02 100% - CXR and head CT negative. LP unremarkable. Tox\n involved and concerned about anti-cholinergic toxic - became more\n unresponsive and intubated for airway protection. EKG with borderline\n QRS widening. Tox screen only pos for benzo following ativan for LP.\n Currently following commands.\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n HIV CD4 540\n PSA\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 05:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5 mL\n PO:\n TF:\n IVF:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Not assessed, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Altered mental status\n suspect toxic in origin, no evidence currently\n for infectious or malignant explanations. Seizure is a consideration.\n Some evidence of possible anti-cholinergic symptoms -\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464597, "text": "Chief Complaint: 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 34M found with altered mental status this morning, babbling, warm,\n erythematous - brought to ER via ambulance.\n In ER HR 125, 02 100% - CXR and head CT negative. LP unremarkable. Tox\n involved and concerned about anti-cholinergic toxic - became more\n unresponsive and intubated for airway protection. EKG with borderline\n QRS widening. Tox screen only pos for benzo following ativan for LP.\n Currently following commands.\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n HIV CD4 540\n PSA\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 05:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5 mL\n PO:\n TF:\n IVF:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Not assessed, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2186-06-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 464657, "text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n 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 Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n :\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: pt expected to be\n extubated this am\n" }, { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 464668, "text": "Chief Complaint:\n 24 Hour Events:\n - admitted overnight\n - vent settings FiO2 40%, PEEP 5 --> now on PS since 5 AM\n - gave 2 amp sodium bicarb for QRS 104 with little effect\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 91 (87 - 110) bpm\n BP: 102/55(66) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 689 mL\n PO:\n TF:\n IVF:\n 703 mL\n 689 mL\n Blood products:\n Total out:\n 1,375 mL\n 540 mL\n Urine:\n 1,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 149 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 464669, "text": "Chief Complaint:\n 24 Hour Events:\n - admitted overnight\n - vent settings FiO2 40%, PEEP 5 --> now on PS since 5 AM\n - gave 2 amp sodium bicarb for QRS 104 with little effect\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 91 (87 - 110) bpm\n BP: 102/55(66) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 689 mL\n PO:\n TF:\n IVF:\n 703 mL\n 689 mL\n Blood products:\n Total out:\n 1,375 mL\n 540 mL\n Urine:\n 1,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 149 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status.\n .\n # Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n In regards to infectious process, reassuringly, LP is negative for\n bacterial meningitis. His recent CD4 count of 540 and acute\n presentation of AMS argues against infectious processes like\n toxoplasmosis, neurosyphilis (last RPR 1:2 in ). Also could\n consider CNS lymphoma but usually CD4<50. As for toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. Also, per ED, patient was flushed, warm, and mydriatic and\n with AMS. He also was noted to have trouble urinating in the ED. This\n is c/w anticholinergic toxicity and his QRS is also prolonged. Also\n consider seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - add on viral culture - routine; Herpes Simplex Virus PCR;\n Cryptococcal Antigen; VDRL; Treponema pallidum Antibody, IFA (CSF)\n - check acetaminophen and salicylate levels to r/o coingestion\n - EKG q 3 hours, if QRS widens, would treat with sodium bicarbonate\n - check CK given ? seizures to r/o rhabodmylosis\n - should agitation occur, would use ativan prn in patient\n - per tox, consider physostigmine if patient worsens clinically as it\n can cause cardiac arrhythmias and asystole\n - appreciate toxicology recs\n - check FS now\n - seizure precautions\n - consider EEG in AM\n - empiric ACV until HSV PCR negative\n .\n # Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n - if QRS widens, will start bicarb\n - will attempt to get baseline EKG\n .\n # Respiratory failure: Performed for airway protection in , be in\n setting of 4 L NS.\n - daily RSBI\n - keep on minimal sedation\n - plans to extubate in AM\n - follow O2 sat\n - check ABG\n .\n # HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n .\n # H/o polysubstance abuse: ? relapse yesterday\n - SW consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 464670, "text": "Chief Complaint:\n 24 Hour Events:\n - admitted overnight\n - vent settings FiO2 40%, PEEP 5 --> now on PS since 5 AM\n - gave 2 amp sodium bicarb for QRS 104 with little effect\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 91 (87 - 110) bpm\n BP: 102/55(66) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 689 mL\n PO:\n TF:\n IVF:\n 703 mL\n 689 mL\n Blood products:\n Total out:\n 1,375 mL\n 540 mL\n Urine:\n 1,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 149 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n GEN: able to squeeze hands on command, NAD, sedated\n HEENT: PERRL, OP - unable to be examined due to ETT, no cervical LAD\n CHEST: CTAB, no w/r/r\n CV: tachy, no m/r/g\n ABD: NDNT, soft, NABS\n EXT: no c/c/e\n NEURO: able to squeeze hands on command and wiggle toes.\n DERM: no rashes, although chest appears flushed, excoriation on R\n antecubital area\n Labs / Radiology\n 183 K/uL\n 12.5 g/dL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status.\n .\n # Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n In regards to infectious process, reassuringly, LP is negative for\n bacterial meningitis. His recent CD4 count of 540 and acute\n presentation of AMS argues against infectious processes like\n toxoplasmosis, neurosyphilis (last RPR 1:2 in ). Also could\n consider CNS lymphoma but usually CD4<50. As for toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. Also, per ED, patient was flushed, warm, and mydriatic and\n with AMS. He also was noted to have trouble urinating in the ED. This\n is c/w anticholinergic toxicity and his QRS is also prolonged. Also\n consider seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - add on viral culture - routine; Herpes Simplex Virus PCR;\n Cryptococcal Antigen; VDRL; Treponema pallidum Antibody, IFA (CSF)\n - check acetaminophen and salicylate levels to r/o coingestion\n - EKG q 3 hours, if QRS widens, would treat with sodium bicarbonate\n - check CK given ? seizures to r/o rhabodmylosis\n - should agitation occur, would use ativan prn in patient\n - per tox, consider physostigmine if patient worsens clinically as it\n can cause cardiac arrhythmias and asystole\n - appreciate toxicology recs\n - check FS now\n - seizure precautions\n - consider EEG in AM\n - empiric ACV until HSV PCR negative\n .\n # Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n - if QRS widens, will start bicarb\n - will attempt to get baseline EKG\n .\n # Respiratory failure: Performed for airway protection in , be in\n setting of 4 L NS.\n - daily RSBI\n - keep on minimal sedation\n - plans to extubate in AM\n - follow O2 sat\n - check ABG\n .\n # HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n .\n # H/o polysubstance abuse: ? relapse yesterday\n - SW consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464647, "text": "From MD notes: Mr. is a 34 y.o. M with HIV (last CD4\n 540 in , HIV VL ) and history of polysubstance abuse, who\n presents with altered mental status. Mr. arrived at\n his parents' residence 1 day prior to admission around noon with\n paranoia regarding stressful living situation (he lives with his male\n partner and another roommate who is supposedly a difficult roommate).\n He went to bed at midnight and was isolated until 6 AM. His father, a\n psychiatrist, found him half hanging off the cough, picking at things,\n doing \"stereotactic\" movements, ? VH, babbling. Per father, he\n appeared very dry and could not focus. His father thought maybe he was\n having a bad dream, but couldn't wake him up. He was noted to be more\n rigid with more incoherent babbling. Dad is a psychiatrist and believed\n that this did not look like a seizure or post-ictal state. Dad states\n he does not know of any seizure history. He took the patient by\n ambulance to be evaluated at the ED at 7:30 AM. Of note, the patient\n has been clean and sober for 6-7 months with a history of multiple drug\n use and crystal meth use.\n .\n In the ED, initial VS: 99.1 HR 125 BP 115/77 RR 17 O2 100%\n Labs performed, including serum tox (negative) and urine tox (+ for\n benzo in setting of having received ativan in ED). Head CT prelim\n negative. CXR performed. UA negative. IV ceftriaxone 2 gm x 1 and\n vancomycin 1 gm IV x 1 was given prior to LP. Prior to LP, ativan 2 mg\n IV x 1 given. LP performed. Toxicology was consulted in the ED as\n patient noted to be flushed, warm, but never febrile, tachycardic, and\n mydriatic. Tox believed pt presentation was c/w anticholinergic\n toxicity and recommended supportive management. The patient was given\n 2 mg IV ativan x 1 again. Pt was originally to go to medical floor,\n but on reevaluation by toxicology team, he was noted to be unresponsive\n to sternal rub. He was noted to desat 85% on RA. NRB placed with O2 sat\n 99% then down to 94-96%. He was intubated for airway protection with\n etomidate 20 mg IV x 1 and succ 130 mg IV x 1. Toxicology then\n recommended serial EKGs as QRS widened at 100. Per ED, serial EKG does\n not show widening of QRS. 4 L NS given.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt intubated on 30mcg/kg/min propofol gtt. Opening eyes to\n voice, intermittently following commands. Pupils 4mm/bsk bilaterally.\n + cough/gag. Awakening startled, coughing and gagging, reaching for\n ETT, HR 1-teens ST.\n Action:\n Propofol gtt increased to 40 mcg/kg/min.\n Response:\n Pt appearing more comfortable. MAE. HR currently 89 SR.\n Plan:\n Cont. sedation, plan to wean vent then for daily wake-up/SBT and\n extubation today if tolerates. F/u blood/CSF cultures. On seizure\n precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on vent settings AC 40% 500/12/5 PEEP. Pt is\n overbreathing vent 3-10 bpm. Sating 96-99%. LS clear to diminished.\n Sxned for no secretions. + cough/gag\n Action:\n Placed on PS 5/5\n Response:\n Pt sating 99%, RR 20.\n Plan:\n ? repeat ABG on PS, then daily wake-up/SBT this AM, ? extubation.\n Problem\n Widened QRS on EKG\n Assessment:\n Likely to antocholinergic toxicity. No baseline to compare.\n Action:\n Serial EKGs q3h, given a total of 2 amps bicarb\n Response:\n No response to bicarb ivp seen on EKG\n Plan:\n Cont. to monitor QRS with serial EKG q3h, if cont. to widen will place\n on bicarb gtt per toxicology recs. Per tox/ recs would consider\n physostigimine if patient worsens clinically as it can cause cardiac\n arrhythmias and asystole.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464777, "text": "Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Psych following\n Response:\n Mental status improving, less agitated\n Plan:\n 1:1 observer\n receive Ativan for agitation prn.\n ADDITIONAL INFORMATION:\n Parents very involved. Social work consulted. Called out to medical\n floor.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 464778, "text": "Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Psych following\n Response:\n Mental status improving, less agitated\n Plan:\n 1:1 observer\n receive Ativan for agitation prn.\n ADDITIONAL INFORMATION:\n Parents very involved. Social work consulted. Called out to medical\n floor.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 464779, "text": "From MD notes: Mr. is a 34 y.o. M with HIV (last CD4\n 540 in , HIV VL ) and history of polysubstance abuse, who\n presents with altered mental status. Mr. arrived at\n his parents' residence 1 day prior to admission around noon with\n paranoia regarding stressful living situation (he lives with his male\n partner and another roommate who is supposedly a difficult roommate).\n He went to bed at midnight and was isolated until 6 AM. His father, a\n psychiatrist, found him half hanging off the cough, picking at things,\n doing \"stereotactic\" movements, ? VH, babbling. Per father, he\n appeared very dry and could not focus. His father thought maybe he was\n having a bad dream, but couldn't wake him up. He was noted to be more\n rigid with more incoherent babbling. Dad is a psychiatrist and believed\n that this did not look like a seizure or post-ictal state. Dad states\n he does not know of any seizure history. He took the patient by\n ambulance to be evaluated at the ED at 7:30 AM. Of note, the patient\n has been clean and sober for 6-7 months with a history of multiple drug\n use and crystal meth use.\n Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Psych following\n Response:\n Mental status improving, less agitated\n Plan:\n 1:1 observer\n receive Ativan for agitation prn.\n ADDITIONAL INFORMATION:\n Parents very involved. Social work consulted. Called out to medical\n floor.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464780, "text": "Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Psych following\n Response:\n Mental status improving, less agitated\n Plan:\n 1:1 observer\n receive Ativan for agitation prn.\n ADDITIONAL INFORMATION:\n Parents very involved. Social work consulted. Called out to medical\n floor.\n" }, { "category": "Social Work", "chartdate": "2186-06-15 00:00:00.000", "description": "Social Work Admission Note", "row_id": 464775, "text": "SOCIAL WORK:\n Family Information\n Next of : father at cell OR father\n \n\n at cell \n Health Care Proxy appointed:\n Family Spokesperson designated: either father, see psychiatry note\n Communication or visitation restriction: Unclear how much involvement\n is welcome from mother \n Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions:\n Past psychiatric history: see psych note, h/o childhood trauma\n Past addictions history: h/o polysubstance abuse including crystal\n meth, in recovery for 7 months\n Employment status:\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment:\n PT is a 34M with h/o HIV and PSA who p/w altered mental status of\n unknown origin. SW referred for coping and substance abuse support.\n Interaction was brief today\npt sleepy, interrupted by physician .\n Father away from pt\ns room, talking with psychiatry attending,\n later available briefly while pt\ns mother is visiting.\n Per record, pt has worked as a hairdresser in the past, and does some\n landscaping work. Was in care system before being adopted by\n his fathers at age 16.\n Pt lives with his boyfriend and with another roommate in a\n seven bedroom house in . Pt is tearful, complaining of\n difficult dynamics with his roommate. From discussion with team who\n spoke with father, it appears that it would be too risky to pt\n recovery for him to return to living with , and that pt will\n return to his home only if is not there (otherwise go to fathers\n home).\n Please see psychiatry note for additional history.\n Clergy Contact: none\n Communication with Team: MD, RN\n Plan / Follow up:\n Assess need for family meeting\n Continuing issues to be addressed: coping support, substance abuse\n counseling and resource needs\n Please page me at with any questions/concerns.\n -, LICSW\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464638, "text": "From MD notes: Mr. is a 34 y.o. M with HIV (last CD4\n 540 in , HIV VL ) and history of polysubstance abuse, who\n presents with altered mental status. Mr. arrived at\n his parents' residence 1 day prior to admission around noon with\n paranoia regarding stressful living situation (he lives with his male\n partner and another roommate who is supposedly a difficult roommate).\n He went to bed at midnight and was isolated until 6 AM. His father, a\n psychiatrist, found him half hanging off the cough, picking at things,\n doing \"stereotactic\" movements, ? VH, babbling. Per father, he\n appeared very dry and could not focus. His father thought maybe he was\n having a bad dream, but couldn't wake him up. He was noted to be more\n rigid with more incoherent babbling. Dad is a psychiatrist and believed\n that this did not look like a seizure or post-ictal state. Dad states\n he does not know of any seizure history. He took the patient by\n ambulance to be evaluated at the ED at 7:30 AM. Of note, the patient\n has been clean and sober for 6-7 months with a history of multiple drug\n use and crystal meth use.\n .\n In the ED, initial VS: 99.1 HR 125 BP 115/77 RR 17 O2 100%\n Labs performed, including serum tox (negative) and urine tox (+ for\n benzo in setting of having received ativan in ED). Head CT prelim\n negative. CXR performed. UA negative. IV ceftriaxone 2 gm x 1 and\n vancomycin 1 gm IV x 1 was given prior to LP. Prior to LP, ativan 2 mg\n IV x 1 given. LP performed. Toxicology was consulted in the ED as\n patient noted to be flushed, warm, but never febrile, tachycardic, and\n mydriatic. Tox believed pt presentation was c/w anticholinergic\n toxicity and recommended supportive management. The patient was given\n 2 mg IV ativan x 1 again. Pt was originally to go to medical floor,\n but on reevaluation by toxicology team, he was noted to be unresponsive\n to sternal rub. He was noted to desat 85% on RA. NRB placed with O2 sat\n 99% then down to 94-96%. He was intubated for airway protection with\n etomidate 20 mg IV x 1 and succ 130 mg IV x 1. Toxicology then\n recommended serial EKGs as QRS widened at 100. Per ED, serial EKG does\n not show widening of QRS. 4 L NS given.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt intubated on 30mcg/kg/min propofol gtt. Opening eyes to\n voice, intermittently following commands. Pupils 4mm/bsk bilaterally.\n + cough/gag. Awakening startled, coughing and gagging, reaching for\n ETT, HR 1-teens ST.\n Action:\n Propofol gtt increased to 40 mcg/kg/min.\n Response:\n Pt appearing more comfortable. MAE. HR currently 89 SR.\n Plan:\n Cont. sedation, plan to wean vent then for daily wake-up/SBT and\n extubation today if tolerates.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on vent settings AC 40% 500/12/5 PEEP. Pt is\n overbreathing vent 3-10 bpm. Sating 96-99%. LS clear to diminished.\n Sxned for no secretions. + cough/gag\n Action:\n No vent changes made this shift.\n Response:\n Pt sating 99%, RR 20.\n Plan:\n Plan to switch to PS this AM, then daily wake-up/SBT, ? extubation.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464639, "text": "From MD notes: Mr. is a 34 y.o. M with HIV (last CD4\n 540 in , HIV VL ) and history of polysubstance abuse, who\n presents with altered mental status. Mr. arrived at\n his parents' residence 1 day prior to admission around noon with\n paranoia regarding stressful living situation (he lives with his male\n partner and another roommate who is supposedly a difficult roommate).\n He went to bed at midnight and was isolated until 6 AM. His father, a\n psychiatrist, found him half hanging off the cough, picking at things,\n doing \"stereotactic\" movements, ? VH, babbling. Per father, he\n appeared very dry and could not focus. His father thought maybe he was\n having a bad dream, but couldn't wake him up. He was noted to be more\n rigid with more incoherent babbling. Dad is a psychiatrist and believed\n that this did not look like a seizure or post-ictal state. Dad states\n he does not know of any seizure history. He took the patient by\n ambulance to be evaluated at the ED at 7:30 AM. Of note, the patient\n has been clean and sober for 6-7 months with a history of multiple drug\n use and crystal meth use.\n .\n In the ED, initial VS: 99.1 HR 125 BP 115/77 RR 17 O2 100%\n Labs performed, including serum tox (negative) and urine tox (+ for\n benzo in setting of having received ativan in ED). Head CT prelim\n negative. CXR performed. UA negative. IV ceftriaxone 2 gm x 1 and\n vancomycin 1 gm IV x 1 was given prior to LP. Prior to LP, ativan 2 mg\n IV x 1 given. LP performed. Toxicology was consulted in the ED as\n patient noted to be flushed, warm, but never febrile, tachycardic, and\n mydriatic. Tox believed pt presentation was c/w anticholinergic\n toxicity and recommended supportive management. The patient was given\n 2 mg IV ativan x 1 again. Pt was originally to go to medical floor,\n but on reevaluation by toxicology team, he was noted to be unresponsive\n to sternal rub. He was noted to desat 85% on RA. NRB placed with O2 sat\n 99% then down to 94-96%. He was intubated for airway protection with\n etomidate 20 mg IV x 1 and succ 130 mg IV x 1. Toxicology then\n recommended serial EKGs as QRS widened at 100. Per ED, serial EKG does\n not show widening of QRS. 4 L NS given.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd pt intubated on 30mcg/kg/min propofol gtt. Opening eyes to\n voice, intermittently following commands. Pupils 4mm/bsk bilaterally.\n + cough/gag. Awakening startled, coughing and gagging, reaching for\n ETT, HR 1-teens ST.\n Action:\n Propofol gtt increased to 40 mcg/kg/min.\n Response:\n Pt appearing more comfortable. MAE. HR currently 89 SR.\n Plan:\n Cont. sedation, plan to wean vent then for daily wake-up/SBT and\n extubation today if tolerates. F/u blood/CSF cultures. On seizure\n precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on vent settings AC 40% 500/12/5 PEEP. Pt is\n overbreathing vent 3-10 bpm. Sating 96-99%. LS clear to diminished.\n Sxned for no secretions. + cough/gag\n Action:\n Placed on PS 5/5\n Response:\n Pt sating 99%, RR 20.\n Plan:\n ? repeat ABG on PS, then daily wake-up/SBT this AM, ? extubation.\n Problem\n Widened QRS on EKG\n Assessment:\n Likely to antocholinergic toxicity. No baseline to compare.\n Action:\n Serial EKGs q3h, given a total of 2 amps bicarb\n Response:\n No response to bicarb ivp seen on EKG\n Plan:\n Cont. to monitor QRS with serial EKG q3h, if cont. to widen will place\n on bicarb gtt per toxicology recs. Per tox/ recs would consider\n physostigimine if patient worsens clinically as it can cause cardiac\n arrhythmias and asystole.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464763, "text": "Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464771, "text": "Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Psych following\n Response:\n Mental status improving, less agitated\n Plan:\n 1:1 observer\n receive Ativan for agitation prn.\n ADDITIONAL INFORMATION:\n Parents very involved. Social work consulted. Called out to medical\n floor.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464759, "text": "Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 464616, "text": "Chief Complaint: REASON FOR ICU ADMISSION: Intubation, prolonged QRS\n interval\n CHIEF COMPLAINT: Altered Mental Status\n HPI:\n Mr. is a 34 y.o. M with HIV (last CD4 540 in ,\n HIV VL ) and history of polysubstance abuse, who presents with\n altered mental status. History obtained from ED intern and patient's\n father as well as OSH records.\n .\n Mr. arrived at his parents' residence 1 day prior to\n admission around noon with paranoia regarding stressful living\n situation (he lives with his male partner and another roommate who is\n supposedly a difficult roommate). He went to bed at midnight and was\n isolated until 6 AM. His father, a psychiatrist, found him half\n hanging off the cough, picking at things, doing \"stereotactic\"\n movements, ? VH, babbling. Per father, he appeared very dry and could\n not focus. His father thought maybe he was having a bad dream, but\n couldn't wake him up. He was noted to be more rigid with more\n incoherent babbling. Dad is a psychiatrist and believed that this did\n not look like a seizure or post-ictal state. Dad states he does not\n know of any seizure history. He took the patient by ambulance to be\n evaluated at the ED at 7:30 AM. Of note, the patient has been clean and\n sober for 6-7 months with a history of multiple drug use and crystal\n meth use.\n .\n In the ED, initial VS: 99.1 HR 125 BP 115/77 RR 17 O2 100%\n Labs performed, including serum tox (negative) and urine tox (+ for\n benzo in setting of having received ativan in ED). Head CT prelim\n negative. CXR performed. UA negative. IV ceftriaxone 2 gm x 1 and\n vancomycin 1 gm IV x 1 was given prior to LP. Prior to LP, ativan 2 mg\n IV x 1 given. LP performed. Toxicology was consulted in the ED as\n patient noted to be flushed, warm, but never febrile, tachycardic, and\n mydriatic. Tox believed pt presentation was c/w anticholinergic\n toxicity and recommended supportive management. The patient was given\n 2 mg IV ativan x 1 again. Pt was originally to go to medical floor,\n but on reevaluation by toxicology team, he was noted to be unresponsive\n to sternal rub. He was noted to desat 85% on RA. NRB placed with O2 sat\n 99% then down to 94-96%. He was intubated for airway protection with\n etomidate 20 mg IV x 1 and succ 130 mg IV x 1. Toxicology then\n recommended serial EKGs as QRS widened at 100. Per ED, serial EKG does\n not show widening of QRS. 4 L NS given.\n .\n Review of systems: unable to ascertain as pt intubated\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HIV infection (was on Atripla in past but was actively using crystal\n meth)\n History of polysubstance abuse (cocaine, EtOH, ecstasy)\n History of MSRA pneumonia \n Crystal meth abuse, currently sober\n History of MRSA skin infections\n History of depression\n History of syphilis (treated)\n History of abnormal anal pap with low grade lesion (HPV)\n Unknown as pt was adopted.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Abused emotional and sexually as child. Was in care.\n Adopted at age of 16 by two male partners, one of which is a\n psychiatrist. Single MSM. Has a male partner currently. Smokes\n approximately ppd, not currently employed, but was a hairdresser.\n History of crystal meth use in past and clean for 7 months per father.\n Used to live in . Did some parttime landscaping now.\n Review of systems:\n Flowsheet Data as of 06:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 29 mL\n PO:\n TF:\n IVF:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -156 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100%\n Ve: 12 L/min\n Physical Examination\n VITAL SIGNS: 99.9 109 108/60 18 100% on FiO2 100% on vent\n GEN: able to squeeze hands on command, NAD, sedated\n HEENT: PERRL, OP - unable to be examined due to ETT, no cervical LAD\n CHEST: CTAB, no w/r/r\n CV: tachy, no m/r/g\n ABD: NDNT, soft, NABS\n EXT: no c/c/e\n NEURO: able to squeeze hands on command and wiggle toes.\n DERM: no rashes, although chest appears flushed, excoriation on R\n antecubital area\n Labs / Radiology\n 219 K/uL\n 12.9 g/dL\n 38.3 %\n 10.8 K/uL\n [image002.jpg]\n \n 2:33 A6/10/ 05:47 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.8\n Hct\n 38.3\n Plt\n 219\n Fluid analysis / Other labs:\n WBC 10.0 Hct 42.5 Plt 246 MCV 95\n N 77 L 18 M 3.0 E 0.3 Bas 0.2\n .\n Na 139 Cl 105 BUN 16\n K 4.3 Bicarb 24 Cr 1.1\n Gluc 100 Agap 10\n .\n Lactate 2.0\n .\n Serum tox negative for ASA, EtOH, acetaminophen, Benzo, Barb, TCA\n Urine tox positive for benzos\n Imaging:\n CT HEAD \n FINDINGS: No acute extra- or intra-axial hemorrhage, large acute\n territorial infarction, or large masses are seen. There is no shift of\n normally midline structures. The ventricles and sulci are normal in\n size and configuration. The visualized portion of the paranasal\n sinuses and mastoid air cells appear normal. Bony structures appear\n within normal limits. Tiny lucency in the skull, on the left, 2:26,\n likely venous .\n IMPRESSION: No acute intracranial process.\n NOTE ADDED IN ATTENDING REVIEW: Incidentally noted are relative\n low-lying cerebellar tonsils with abundant surrounding CSF at the\n foramen magnum level, likely representing slight tonsillar ectopia, a\n normal variant.\n .\n PORTABLE CXR (WET READ)\n No e/o failure of consolidation. Mild septal thickening and\n peribronchial thickening could indicate bronchitis or intersitial\n pneumonia.\n .\n PORTABLE CXR (my read)\n perihilar fullness, ETT 6-7 cm above carina\n Microbiology: Blood Cultures x 2: pending\n .\n UA negative\n .\n CSF:\n CSF tube 1 - WBC 1, RBC 58, Poly 2, Lymph 89, Mono 9\n CSF tube 2 - Protein 58 Glucose 59\n CSF tube 4 - WBC 1, RBC 25, Poly 0, Lymph 96, Mono 4\n .\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): pending\n ECG: EKG : tachycardic at low 100s, QRS 100, no acute Q waves, no\n ST changes, no TWI.\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status.\n .\n # Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n In regards to infectious process, reassuringly, LP is negative for\n bacterial meningitis. His recent CD4 count of 540 and acute\n presentation of AMS argues against infectious processes like\n toxoplasmosis, neurosyphilis (last RPR 1:2 in ). Also could\n consider CNS lymphoma but usually CD4<50. As for toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. Also, per ED, patient was flushed, warm, and mydriatic and\n with AMS. He also was noted to have trouble urinating in the ED. This\n is c/w anticholinergic toxicity and his QRS is also prolonged. Also\n consider seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - add on viral culture - routine; Herpes Simplex Virus PCR;\n Cryptococcal Antigen; VDRL; Treponema pallidum Antibody, IFA (CSF)\n - check acetaminophen and salicylate levels to r/o coingestion\n - EKG q 3 hours, if QRS widens, would treat with sodium bicarbonate\n - check CK given ? seizures to r/o rhabodmylosis\n - should agitation occur, would use ativan prn in patient\n - per tox, consider physostigmine if patient worsens clinically as it\n can cause cardiac arrhythmias and asystole\n - appreciate toxicology recs\n - check FS now\n - seizure precautions\n - consider EEG in AM\n .\n # Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n - if QRS widens, will start bicarb\n - will attempt to get baseline EKG\n .\n # Respiratory failure: Performed for airway protection in , be in\n setting of 4 L NS.\n - daily RSBI\n - keep on minimal sedation\n - plans to extubate in AM\n - follow O2 sat\n - check ABG\n .\n # HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n .\n # H/o polysubstance abuse: ? relapse yesterday\n - SW consult\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 464617, "text": "Chief Complaint: REASON FOR ICU ADMISSION: Intubation, prolonged QRS\n interval\n CHIEF COMPLAINT: Altered Mental Status\n HPI:\n Mr. is a 34 y.o. M with HIV (last CD4 540 in ,\n HIV VL ) and history of polysubstance abuse, who presents with\n altered mental status. History obtained from ED intern and patient's\n father as well as OSH records.\n .\n Mr. arrived at his parents' residence 1 day prior to\n admission around noon with paranoia regarding stressful living\n situation (he lives with his male partner and another roommate who is\n supposedly a difficult roommate). He went to bed at midnight and was\n isolated until 6 AM. His father, a psychiatrist, found him half\n hanging off the cough, picking at things, doing \"stereotactic\"\n movements, ? VH, babbling. Per father, he appeared very dry and could\n not focus. His father thought maybe he was having a bad dream, but\n couldn't wake him up. He was noted to be more rigid with more\n incoherent babbling. Dad is a psychiatrist and believed that this did\n not look like a seizure or post-ictal state. Dad states he does not\n know of any seizure history. He took the patient by ambulance to be\n evaluated at the ED at 7:30 AM. Of note, the patient has been clean and\n sober for 6-7 months with a history of multiple drug use and crystal\n meth use.\n .\n In the ED, initial VS: 99.1 HR 125 BP 115/77 RR 17 O2 100%\n Labs performed, including serum tox (negative) and urine tox (+ for\n benzo in setting of having received ativan in ED). Head CT prelim\n negative. CXR performed. UA negative. IV ceftriaxone 2 gm x 1 and\n vancomycin 1 gm IV x 1 was given prior to LP. Prior to LP, ativan 2 mg\n IV x 1 given. LP performed. Toxicology was consulted in the ED as\n patient noted to be flushed, warm, but never febrile, tachycardic, and\n mydriatic. Tox believed pt presentation was c/w anticholinergic\n toxicity and recommended supportive management. The patient was given\n 2 mg IV ativan x 1 again. Pt was originally to go to medical floor,\n but on reevaluation by toxicology team, he was noted to be unresponsive\n to sternal rub. He was noted to desat 85% on RA. NRB placed with O2 sat\n 99% then down to 94-96%. He was intubated for airway protection with\n etomidate 20 mg IV x 1 and succ 130 mg IV x 1. Toxicology then\n recommended serial EKGs as QRS widened at 100. Per ED, serial EKG does\n not show widening of QRS. 4 L NS given.\n .\n Review of systems: unable to ascertain as pt intubated\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HIV infection (was on Atripla in past but was actively using crystal\n meth)\n History of polysubstance abuse (cocaine, EtOH, ecstasy)\n History of MSRA pneumonia \n Crystal meth abuse, currently sober\n History of MRSA skin infections\n History of depression\n History of syphilis (treated)\n History of abnormal anal pap with low grade lesion (HPV)\n Unknown as pt was adopted.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Abused emotional and sexually as child. Was in care.\n Adopted at age of 16 by two male partners, one of which is a\n psychiatrist. Single MSM. Has a male partner currently. Smokes\n approximately ppd, not currently employed, but was a hairdresser.\n History of crystal meth use in past and clean for 7 months per father.\n Used to live in . Did some parttime landscaping now.\n Review of systems:\n Flowsheet Data as of 06:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 29 mL\n PO:\n TF:\n IVF:\n 29 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -156 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100%\n Ve: 12 L/min\n Physical Examination\n VITAL SIGNS: 99.9 109 108/60 18 100% on FiO2 100% on vent\n GEN: able to squeeze hands on command, NAD, sedated\n HEENT: PERRL, OP - unable to be examined due to ETT, no cervical LAD\n CHEST: CTAB, no w/r/r\n CV: tachy, no m/r/g\n ABD: NDNT, soft, NABS\n EXT: no c/c/e\n NEURO: able to squeeze hands on command and wiggle toes.\n DERM: no rashes, although chest appears flushed, excoriation on R\n antecubital area\n Labs / Radiology\n 219 K/uL\n 12.9 g/dL\n 38.3 %\n 10.8 K/uL\n [image002.jpg]\n \n 2:33 A6/10/ 05:47 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 10.8\n Hct\n 38.3\n Plt\n 219\n Fluid analysis / Other labs:\n WBC 10.0 Hct 42.5 Plt 246 MCV 95\n N 77 L 18 M 3.0 E 0.3 Bas 0.2\n .\n Na 139 Cl 105 BUN 16\n K 4.3 Bicarb 24 Cr 1.1\n Gluc 100 Agap 10\n .\n Lactate 2.0\n .\n Serum tox negative for ASA, EtOH, acetaminophen, Benzo, Barb, TCA\n Urine tox positive for benzos\n Imaging:\n CT HEAD \n FINDINGS: No acute extra- or intra-axial hemorrhage, large acute\n territorial infarction, or large masses are seen. There is no shift of\n normally midline structures. The ventricles and sulci are normal in\n size and configuration. The visualized portion of the paranasal\n sinuses and mastoid air cells appear normal. Bony structures appear\n within normal limits. Tiny lucency in the skull, on the left, 2:26,\n likely venous .\n IMPRESSION: No acute intracranial process.\n NOTE ADDED IN ATTENDING REVIEW: Incidentally noted are relative\n low-lying cerebellar tonsils with abundant surrounding CSF at the\n foramen magnum level, likely representing slight tonsillar ectopia, a\n normal variant.\n .\n PORTABLE CXR (WET READ)\n No e/o failure of consolidation. Mild septal thickening and\n peribronchial thickening could indicate bronchitis or intersitial\n pneumonia.\n .\n PORTABLE CXR (my read)\n perihilar fullness, ETT 6-7 cm above carina\n Microbiology: Blood Cultures x 2: pending\n .\n UA negative\n .\n CSF:\n CSF tube 1 - WBC 1, RBC 58, Poly 2, Lymph 89, Mono 9\n CSF tube 2 - Protein 58 Glucose 59\n CSF tube 4 - WBC 1, RBC 25, Poly 0, Lymph 96, Mono 4\n .\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary): pending\n ECG: EKG : tachycardic at low 100s, QRS 100, no acute Q waves, no\n ST changes, no TWI.\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status.\n .\n # Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n In regards to infectious process, reassuringly, LP is negative for\n bacterial meningitis. His recent CD4 count of 540 and acute\n presentation of AMS argues against infectious processes like\n toxoplasmosis, neurosyphilis (last RPR 1:2 in ). Also could\n consider CNS lymphoma but usually CD4<50. As for toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. Also, per ED, patient was flushed, warm, and mydriatic and\n with AMS. He also was noted to have trouble urinating in the ED. This\n is c/w anticholinergic toxicity and his QRS is also prolonged. Also\n consider seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - add on viral culture - routine; Herpes Simplex Virus PCR;\n Cryptococcal Antigen; VDRL; Treponema pallidum Antibody, IFA (CSF)\n - check acetaminophen and salicylate levels to r/o coingestion\n - EKG q 3 hours, if QRS widens, would treat with sodium bicarbonate\n - check CK given ? seizures to r/o rhabodmylosis\n - should agitation occur, would use ativan prn in patient\n - per tox, consider physostigmine if patient worsens clinically as it\n can cause cardiac arrhythmias and asystole\n - appreciate toxicology recs\n - check FS now\n - seizure precautions\n - consider EEG in AM\n .\n # Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n - if QRS widens, will start bicarb\n - will attempt to get baseline EKG\n .\n # Respiratory failure: Performed for airway protection in , be in\n setting of 4 L NS.\n - daily RSBI\n - keep on minimal sedation\n - plans to extubate in AM\n - follow O2 sat\n - check ABG\n .\n # HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n .\n # H/o polysubstance abuse: ? relapse yesterday\n - SW consult\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Will start empiric ACV until HSV PCR negative from CSF.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:50 ------\n" }, { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464743, "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 24 Hour Events:\n Stable overnight\n Will Extubate this morning\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 110) bpm\n BP: 98/49(60) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 850 mL\n PO:\n TF:\n IVF:\n 703 mL\n 850 mL\n Blood products:\n Total out:\n 1,375 mL\n 740 mL\n Urine:\n 1,375 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 110 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 12.5 g/dL\n 183 K/uL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n CXR : ETT in good position, mild interstiial edema\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status\n intubated for airway protection.\n > Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n Notably, LP is negative for bacterial meningitis. Toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. ? anticholinergic symptoms (? Accidental exposure as\n landscaper). QRS is also prolonged. ? seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - f/u Herpes Simplex Virus PCR; neg Cryptococcal Antigen; VDRL; f/u\n Treponema pallidum Antibody, IFA (CSF)\n - appreciate toxicology recs\n - empiric ACV until HSV PCR negative, no additional empiric coverage\n with Abx given neg LP\n > Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n > Respiratory failure: Performed for airway protection.\n - extubate today\n - aspiration precautions\n > HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n Additional issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 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: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464603, "text": "Chief Complaint: 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 34M found with altered mental status this morning, babbling, warm,\n erythematous - brought to ER via ambulance.\n In ER HR 125, 02 100% - CXR and head CT negative. LP unremarkable. Tox\n involved and concerned about anti-cholinergic toxic - became more\n unresponsive and intubated for airway protection. EKG with borderline\n QRS widening. Tox screen only pos for benzo following ativan for LP.\n Currently following commands.\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n HIV CD4 540\n PSA\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 05:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5 mL\n PO:\n TF:\n IVF:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Not assessed, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Altered mental status\n suspect toxic in origin, no evidence currently\n for infectious or malignant explanations. Seizure is a consideration.\n Some evidence of possible anti-cholinergic symptoms though unclear\n exposure. Will continue to provide supportive care. Will empirically\n treat with acyclovir. Follow EKG and QRS duration\n bicarb if needed.\n Respiratory failure\n continue vent support, follow CXR and start\n antibiotics for aspiration if worsens or fever.\n HIV\n recent CD4 540\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: elevated HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464605, "text": "Chief Complaint: 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 34M found with altered mental status this morning, babbling, warm,\n erythematous - brought to ER via ambulance.\n In ER\n delirious, HR 125, 02 100% - CXR and head CT negative. LP\n unremarkable. Tox involved and concerned about anti-cholinergic\n toxicity - became more unresponsive and intubated for airway\n protection. EKG with borderline QRS widening. Tox screen only pos for\n benzo following ativan for LP.\n Currently following commands.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n HIV CD4 540\n PSA\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 05:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5 mL\n PO:\n TF:\n IVF:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: unremarkable, No Rash\n Neurologic: Follows simple commands, Responds to name; Tone: normal\n Labs / Radiology\n Labs drawn in ER reviewed\n EKG sinus tach, QRS 100msec\n CXR\n ETT elevated\n will advance, new widespread interstitial\n infiltrates\n Assessment and Plan\n Altered mental status\n suspect toxic in origin, no evidence currently\n for infectious or malignant explanations. Seizure is a consideration.\n Some evidence of possible anti-cholinergic symptoms though unclear\n exposure. Will continue to provide supportive care. Will empirically\n treat with acyclovir. Follow EKG and QRS duration\n bicarb if needed.\n Respiratory failure\n continue vent support, follow CXR and start\n antibiotics for aspiration if worsens or fever.\n HIV\n recent CD4 540\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: elevated HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 37\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-06-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464703, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 05:37 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 11:55 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 92 (87 - 110) bpm\n BP: 98/49(60) {92/43(57) - 118/71(82)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 803 mL\n 850 mL\n PO:\n TF:\n IVF:\n 703 mL\n 850 mL\n Blood products:\n Total out:\n 1,375 mL\n 740 mL\n Urine:\n 1,375 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n -572 mL\n 110 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): 558 (558 - 558) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 33\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.38/40/207/24/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 518\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 12.5 g/dL\n 183 K/uL\n 88 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 110 mEq/L\n 143 mEq/L\n 36.3 %\n 8.8 K/uL\n [image002.jpg]\n 05:47 PM\n 06:47 PM\n 03:53 AM\n WBC\n 10.8\n 8.8\n Hct\n 38.3\n 36.3\n Plt\n 219\n 183\n Cr\n 1.0\n 0.9\n TCO2\n 25\n Glucose\n 91\n 88\n Other labs: CK / CKMB / Troponin-T:93//, ALT / AST:36/25, Alk Phos / T\n Bili:49/0.5, Lactic Acid:2.2 mmol/L, Albumin:4.0 g/dL, LDH:168 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 34 y.o. M with HIV (last CD4 540 in , HIV VL ) and history\n of polysubstance abuse, who presents with altered mental status.\n > Altered mental status: Differential diagnosis is wide in this patient\n with immunosuppression (CD4 540) and history of polysubstance abuse.\n In regards to infectious process, reassuringly, LP is negative for\n bacterial meningitis. His recent CD4 count of 540 and acute\n presentation of AMS argues against infectious processes like\n toxoplasmosis, neurosyphilis (last RPR 1:2 in ). Also could\n consider CNS lymphoma but usually CD4<50. As for toxicology, serum tox\n negative, urine tox + for benzos but in setting of having received\n ativan. Also, per ED, patient was flushed, warm, and mydriatic and\n with AMS. He also was noted to have trouble urinating in the ED. This\n is c/w anticholinergic toxicity and his QRS is also prolonged. Also\n consider seizures and post-ictal state.\n - f/u blood cultures and CSF cultures\n - add on viral culture - routine; Herpes Simplex Virus PCR;\n Cryptococcal Antigen; VDRL; Treponema pallidum Antibody, IFA (CSF)\n - check acetaminophen and salicylate levels to r/o coingestion\n - EKG q 3 hours, if QRS widens, would treat with sodium bicarbonate\n - check CK given ? seizures to r/o rhabodmylosis\n - should agitation occur, would use ativan prn in patient- per tox,\n consider physostigmine if patient worsens clinically as it can cause\n cardiac arrhythmias and asystole\n - appreciate toxicology recs\n - check FS now\n - seizure precautions\n - consider EEG in AM\n - empiric ACV until HSV PCR negative\n > Widened QRS on EKG: Likely secondary to anticholinergic toxicity. No\n baseline to compare to.\n - monitor QRS with serial EKGs\n - if QRS widens, will start bicarb\n - will attempt to get baseline EKG\n > Respiratory failure: Performed for airway protection in , be in\n setting of 4 L NS.\n - daily RSBI\n - keep on minimal sedation\n - plans to extubate in AM\n - follow O2 sat\n - check ABG\n > HIV: CD4 540, VL in .\n - no need to resend HIV VL and CD4\n - no need for OI ppx\n Additional issues per ICU resident note.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:21 PM\n 20 Gauge - 08:32 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: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2186-06-14 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 464608, "text": "Chief Complaint: 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 34M found with altered mental status this morning, babbling, warm,\n erythematous - brought to ER via ambulance.\n In ER\n delirious, HR 125, 02 100% - CXR and head CT negative. LP\n unremarkable. Tox involved and concerned about anti-cholinergic\n toxicity - became more unresponsive and intubated for airway\n protection. EKG with borderline QRS widening. Tox screen only pos for\n benzo following ativan for LP.\n Currently following commands.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n HIV CD4 540\n PSA\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 05:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 106 (106 - 109) bpm\n BP: 101/52(64) {101/52(64) - 108/60(71)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5 mL\n PO:\n TF:\n IVF:\n 5 mL\n Blood products:\n Total out:\n 0 mL\n 185 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 12 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: unremarkable, No Rash\n Neurologic: Follows simple commands, Responds to name; Tone: normal\n Labs / Radiology\n Labs drawn in ER reviewed\n EKG sinus tach, QRS 100msec\n CXR\n ETT elevated\n will advance, new widespread interstitial\n infiltrates\n Assessment and Plan\n Altered mental status\n suspect toxic in origin, no evidence currently\n for infectious or malignant explanations. Seizure is a consideration.\n Some evidence of possible anti-cholinergic symptoms though unclear\n exposure. Will continue to provide supportive care. Will empirically\n treat with acyclovir. Follow EKG and QRS duration\n bicarb if needed.\n Respiratory failure\n continue vent support, follow CXR and start\n antibiotics for aspiration if worsens or fever.\n HIV\n recent CD4 540\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 20 Gauge - 05:13 PM\n 18 Gauge - 05:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: elevated HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 37\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2186-06-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 464613, "text": "Day of mechanical ventilation: 1\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Comments:\n 34yr male admitted for MS changes. Found thrashing and confused at\n home. Polysubstance abuse history but has reportedly been clean for 6\n months. HIV+. Intubated for airway protection. Head CT clear. Tox\n screen negative. Wean FiO2 as tolerated. Still undetermined cause of\n present condition.\n" }, { "category": "Nursing", "chartdate": "2186-06-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 464799, "text": "From MD notes: Mr. is a 34 y.o. M with HIV (last CD4\n 540 in , HIV VL ) and history of polysubstance abuse, who\n presents with altered mental status. Mr. arrived at\n his parents' residence 1 day prior to admission around noon with\n paranoia regarding stressful living situation (he lives with his male\n partner and another roommate who is supposedly a difficult roommate).\n He went to bed at midnight and was isolated until 6 AM. His father, a\n psychiatrist, found him half hanging off the cough, picking at things,\n doing \"stereotactic\" movements, ? VH, babbling. Per father, he\n appeared very dry and could not focus. His father thought maybe he was\n having a bad dream, but couldn't wake him up. He was noted to be more\n rigid with more incoherent babbling. Dad is a psychiatrist and believed\n that this did not look like a seizure or post-ictal state. Dad states\n he does not know of any seizure history. He took the patient by\n ambulance to be evaluated at the ED at 7:30 AM. Of note, the patient\n has been clean and sober for 6-7 months with a history of multiple drug\n use and crystal meth use.\n Altered mental status (not Delirium)\n Assessment:\n Speaking nonsensically after extubation. Confused with attempts to get\n OOB. Pulled out PIV.\n Initially denied Suicidal Ideation but famly member reported that\n patient did intentionally overdose on Wellbutrin and HIV med.\n Action:\n Frequent redirection with 1:1 observer\n Psych following\n Response:\n Mental status improving, less agitated\n Plan:\n 1:1 observer\n receive Ativan for agitation prn.\n ADDITIONAL INFORMATION:\n Parents very involved. Social work consulted. Called out to medical\n floor.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n ANTICHOLINERGIC SYNDROME\n Code status:\n Height:\n Admission weight:\n 104.7 kg\n Daily weight:\n Allergies/Reactions:\n Erythromycin Base\n laryngeal spasm\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Rash;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: polysubstance abuse, HIV +, hx MRSA pna ,\n crystal meth abuse (currently sober), depression, syphillis, MRSA skin\n infection, abnormal anal pap with HPV,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:71\n Temperature:\n 99.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 110 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 40% %\n 24h total in:\n 1,474 mL\n 24h total out:\n 3,220 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:53 AM\n Potassium:\n 3.8 mEq/L\n 03:53 AM\n Chloride:\n 110 mEq/L\n 03:53 AM\n CO2:\n 24 mEq/L\n 03:53 AM\n BUN:\n 9 mg/dL\n 03:53 AM\n Creatinine:\n 0.9 mg/dL\n 03:53 AM\n Glucose:\n 88 mg/dL\n 03:53 AM\n Hematocrit:\n 36.3 %\n 03:53 AM\n Finger Stick Glucose:\n 108\n 06:47 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: sent home with family\n Transferred from: MICU 7\n Transferred to: CC7\n Date & time of Transfer: \n" }, { "category": "ECG", "chartdate": "2186-06-16 00:00:00.000", "description": "Report", "row_id": 113842, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2186-06-16 00:00:00.000", "description": "Report", "row_id": 113843, "text": "Sinus rhythm. Normal tracing. Proper chest lead positioning. Compared to the\nprevious tracing of the findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-06-15 00:00:00.000", "description": "Report", "row_id": 113844, "text": "Leads V1-V2 are probably reversed. Taking this into acoount, there is\nborderline sinus tachycardia and tracing is normal. Compared to the previous\ntracing no diagnostic interim changes.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2186-06-15 00:00:00.000", "description": "Report", "row_id": 113845, "text": "Sinus rhythm. Compared to the previous tracing heart rate is reduced.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2186-06-14 00:00:00.000", "description": "Report", "row_id": 113846, "text": "Sinus tachycardia. Compared to the previous tracing no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-06-14 00:00:00.000", "description": "Report", "row_id": 113847, "text": "Sinus tachycardia. Otherwise, within normal limits. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2186-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083134, "text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ett placement\n Admitting Diagnosis: ANTICHOLINERGIC SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man s/p intubation for airway protection\n REASON FOR THIS EXAMINATION:\n evaluate for ett placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient. Comparison is made to prior study\n performed a day earlier.\n\n ET tube tip is 6.3 cm above the carina. Cardiomediastinal contours are\n unchanged. There are low lung volumes. Improved pulmonary edema somehow\n asymmetric, greater on the left lung. There are no enlarging pleural\n effusions or pneumothorax. Of note the right lateral CP angle was not\n included on the film.\n\n" }, { "category": "Radiology", "chartdate": "2186-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083072, "text": " 2:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate tube placement\n Admitting Diagnosis: ANTICHOLINERGIC SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with decreased mental status and airway obstruction intubated\n REASON FOR THIS EXAMINATION:\n evaluate tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Decreased mental status, airway obstruction, evaluation of tube\n placement.\n\n COMPARISON: Portable chest radiograph from , 9:59.\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the tube is projecting 6.6 cm above the carina. The\n tube could be advanced by 1-2 cm. The lung volumes are relatively low.\n Moderate signs of overhydration. Mild cardiomegaly, no evidence of pleural\n effusions. No focal parenchymal opacities suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-06-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1082997, "text": " 9:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for mass, edema, ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man HIV+ with acute mental status change\n REASON FOR THIS EXAMINATION:\n assess for mass, edema, ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf WED 10:16 AM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 34-year-old man with HIV and acute mental status change. Assess for\n mass, edema, or intracerebral hemorrhage.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: No images for comparison at the time of dictation.\n\n FINDINGS: No acute extra- or intra-axial hemorrhage, large acute territorial\n infarction, or large masses are seen. There is no shift of normally midline\n structures. The ventricles and sulci are normal in size and configuration.\n\n The visualized portion of the paranasal sinuses and mastoid air cells appear\n normal. Bony structures appear within normal limits. Tiny lucency in the\n skull, on the left, 2:26, likely venous .\n\n IMPRESSION: No acute intracranial process.\n\n Please note that MRI is more sensitive for subtle lesions, if there is a\n clinical concern.\n\n NOTE ADDED IN ATTENDING REVIEW: Incidentally noted are relative low-lying\n cerebellar tonsils with abundant surrounding CSF at the foramen magnum level,\n likely representing slight tonsillar ectopia, a normal variant.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083005, "text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assses for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with altered mental status, low grade fever\n REASON FOR THIS EXAMINATION:\n assses for infiltrate\n ______________________________________________________________________________\n WET READ: EAGg WED 11:40 AM\n No e/o failure of consolidation. Mild septal thickening and peribronchial\n thickening could indicate bronchitis or intersitial pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old male with altered mental status and low-grade fever.\n Assess for infiltrate.\n\n COMPARISON: No prior study available for comparison.\n\n AP VIEW OF THE CHEST: Allowing for low lung volumes, mild septal thickening\n and peribronchial thickening may indicate early interstitial pneumonia or\n bronchitis. There is no focal opacity or consolidation in the lungs. The\n heart size is top normal, but there is no evidence of pulmonary edema or\n vascular congestion. No appreciable pleural effusion or pneumothorax is\n present.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2130-12-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 430085, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n Hypotension (not Shock)\n Assessment:\n Pt has had a SBP in the 80s and 90s all day, HR low 100s to 160s, 130s\n while sitting in a chair and up to the 160 while standing, she denies\n feeling light headed, afebrile.\n Action:\n Given 2 IVF boluses of 1 liter each, an EKG was done\n no changes were\n seen\n Response:\n Her vitals did not change with the fluid bolses\n Plan:\n A TSH has been added of, cont to follow, increase her TF until they are\n at a goal of 110cc/hr from 6am to 9pm, watch I&Os, to have chest CT\n tonight to r/o PE\n Constipation (Obstipation, FOS)\n Assessment:\n Pt has a hx of constipation, she told the interpreter that she was\n concerned about this, abd has been soft and nontender\n Action:\n Given lactulose and docusate x1\n Response:\n She has had frequent stools today, OB neg\n Plan:\n Follow, give lactulose as needed\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt conts with a trache, coughing up white thick sputum from her trache\n and her mouth, she has had coughing spells with movement, lung sounds\n are clear.\n Action:\n To have speech and swallow come tomorrow to try her with a passymure\n valve\n she did have stidor with her cuff down yesterday so this may be\n an issue with the valve.\n Response:\n Plan:\n Try a passymure valve tomorrow, she will need teaching with the trache\n" }, { "category": "Nursing", "chartdate": "2130-12-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 430156, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Continued with trache collar 35%. Sats 100%. HR 100-110 while on bed\n and upto 150\ns when out of bed .OOB to chair for few hours.\n Action:\n Inner canula clean, suctioned for small white secretions,pt coughing\n out and using yankeur.\n Response:\n Remains stable with RR/Sats..no SOB / stridor noted.\n Plan:\n Continue with trache collar.possible call out to floor if HR stays\n within normal range.\n PEG intact. Tube feed @goal. Feed stopped at 9pm and restarted at\n 6am.\n BP remained 80-90/50-60 mm of hg.MAP > 60.\n Bath given and positioned for comfort. Back care given .redness on\n buttock and inner thigh. Voided good amount urine.\n" }, { "category": "Physician ", "chartdate": "2130-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429243, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n Started on decadron\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Slight shortness of breath, improved, cough\n resolved. Denies abdominal pain\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 102 (102 - 131) bpm\n BP: 94/73(78) {94/59(71) - 110/73(78)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,472 mL\n 755 mL\n PO:\n TF:\n IVF:\n 1,412 mL\n 755 mL\n Blood products:\n Total out:\n 1,500 mL\n 800 mL\n Urine:\n 1,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n -45 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG:\n Physical Examination\n General Appearance: Thin, NAS\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: Expansion: Symmetric, diffuse minimal upper\n airway noises\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Communication with phone translator.\n Labs / Radiology\n 7.9 K/uL\n 633 K/uL\n 9.7 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 98 mEq/L\n 136 mEq/L\n 27.8 %\n [image002.jpg]\n 03:18 AM\n WBC\n 7.9\n Hct\n 27.8\n Plt\n 633\n Cr\n 0.5\n Glucose\n 138\n Other labs: Ca++:10.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n 40 yo woman with a history of esophageal cancer; admitted for stridor\n and airway compromise in the setting of nausea/vomiting.\n 1. Airway obstruction: Now significantly improved. Pt to receive last\n dose of decadron this evening. ENT following and would like thoracic\n surgery evaluation for ? of esophageal perforation.\n - continue IV steroids\n - ENT recs\n - contact surgery\n 2. Malignancy: Patient s/p chemo and radiation. Recent CT with\n concerning lung lesion (? metastatic disease). Will need further\n oncology follow-up.\n - F/u onc recs\n - MRI of neck today for further evaluation of lesion.\n 3. Anemia/Thrombocytosis: currently at baseline, no signs of active\n bleeding\n ICU Care\n Nutrition: J tube, NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to OMED\n" }, { "category": "Physician ", "chartdate": "2130-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429870, "text": "Chief Complaint: stridor\n 24 Hour Events:\n - Appeared lethargic in am; abg did not show hypercarbia 7.48/38/159/29\n - Had trachyostomy; tolerated procedure well. Weaned off vent\n overnight and placed on trach mask.\n - Per Thoracics, would attempt passy miur valve today.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:09 PM\n Metronidazole - 12:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies n/v, cp, sob.\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: 37.2\nC (98.9\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 131) bpm\n BP: 92/60(67) {82/26(57) - 120/90(96)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 4,637 mL\n 150 mL\n PO:\n TF:\n IVF:\n 4,637 mL\n 150 mL\n Blood products:\n Total out:\n 3,000 mL\n 1,350 mL\n Urine:\n 3,000 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,637 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 602 (602 - 721) mL\n PS : 15 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.48/38/159/28/5\n Ve: 6.5 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General Appearance: Thin, NAD\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Neck: Trach mask in place, site c/d/i\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: CTA b\n Abdominal: Soft, Non-tender, J tube in place, non-tender, site c/d/i\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 466 K/uL\n 8.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 5.9 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n Plt\n 633\n 645\n 514\n 466\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement.\n # Airway Obstruction/malignancy- S/p trach placement and without\n stridor. Received 1 dose of dexemethasone yesterday. Now appears in no\n distress. MRI of neck ? esophageal perforation vs abscess vs\n diverticulum. On CPAP o/n and now transitioned to trach mask.\n - Continue broad spectrum antibiotic coverage empirically for esophagel\n perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 3 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx (per thoracics\n plan for 2 weeks broad\n spectrum coverage)\n # Nutrition: restarting tube feeds today pending surgical approval\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429144, "text": "40 yo Portaguese speaking woman w/unresectable esoph cancer dx ,\n trans from 7F w/stridor ? r/t edema from XRT vs disease vs chord edema.\n Here for airway observation overnight and potential trach in a.m.\n Earlier scope by ENT showed narrowing trach. Initially admitted to 11R\n w/ SOB.\n Pt alert on arrival. Shallow slow breaths w/ gd O2sats on RA. Heliox\n at bedside. Non-English speaking. Pt has a PEG and had been on Ensure\n at 110cc/hr RN report but is currently NPO. Her cousin \n speaks English and is her HCP RN report.\n" }, { "category": "Nursing", "chartdate": "2130-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429145, "text": "40 yo Portaguese speaking woman w/unresectable esoph cancer dx ,\n trans from 7F w/stridor ? r/t edema from XRT vs disease vs chord edema.\n Here for airway observation overnight and potential trach in a.m.\n Earlier scope by ENT showed narrowing trach. Initially admitted to 11R\n w/ SOB and N/V. She denies pain and does not appear nausea or had\n any vomiting since admit.\n Pt alert on arrival. Shallow slow breaths w/ gd O2sats on RA. Heliox\n at bedside. Non-English speaking. Pt has a PEG and had been on Ensure\n at 110cc/hr RN report but is currently NPO. Her cousin \n speaks English and is her HCP RN report.\n" }, { "category": "Physician ", "chartdate": "2130-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429234, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Slight shortness of breath, improved, cough\n resolved. Denies abdominal pain\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 102 (102 - 131) bpm\n BP: 94/73(78) {94/59(71) - 110/73(78)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,472 mL\n 755 mL\n PO:\n TF:\n IVF:\n 1,412 mL\n 755 mL\n Blood products:\n Total out:\n 1,500 mL\n 800 mL\n Urine:\n 1,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n -45 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG:\n Physical Examination\n General Appearance: Thin, NAS\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: Expansion: Symmetric, diffuse upper airway noises\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Communication with phone translator.\n Labs / Radiology\n 7.9 K/uL\n 633 K/uL\n 9.7 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 98 mEq/L\n 136 mEq/L\n 27.8 %\n [image002.jpg]\n 03:18 AM\n WBC\n 7.9\n Hct\n 27.8\n Plt\n 633\n Cr\n 0.5\n Glucose\n 138\n Other labs: Ca++:10.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition: J tube\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 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": "2130-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429927, "text": "Chief Complaint: stridor\n 24 Hour Events:\n - Appeared lethargic in am; abg did not show hypercarbia 7.48/38/159/29\n - Had trachyostomy; tolerated procedure well. Weaned off vent\n overnight and placed on trach mask.\n - Per Thoracics, would attempt passy miur valve today.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:09 PM\n Metronidazole - 12:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies n/v, cp, sob.\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: 37.2\nC (98.9\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 131) bpm\n BP: 92/60(67) {82/26(57) - 120/90(96)} mmHg\n RR: 11 (9 - 23) insp/\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 4,637 mL\n 150 mL\n PO:\n TF:\n IVF:\n 4,637 mL\n 150 mL\n Blood products:\n Total out:\n 3,000 mL\n 1,350 mL\n Urine:\n 3,000 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,637 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 602 (602 - 721) mL\n PS : 15 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.48/38/159/28/5\n Ve: 6.5 L/\n PaO2 / FiO2: 318\n Physical Examination\n General Appearance: Thin, NAD\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Neck: Trach mask in place, site c/d/i\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: CTA b\n Abdominal: Soft, Non-tender, J tube in place, non-tender, site c/d/i\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 466 K/uL\n 8.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 5.9 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n Plt\n 633\n 645\n 514\n 466\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement.\n # Airway Obstruction/malignancy- S/p trach placement and without\n stridor. Received 1 dose of dexemethasone yesterday. Now appears in no\n distress. MRI of neck ? esophageal perforation vs abscess vs\n diverticulum. On CPAP o/n and now transitioned to trach mask.\n - Continue broad spectrum antibiotic coverage empirically for esophagel\n perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 3 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx (per thoracics\n plan for 2 weeks broad\n spectrum coverage)\n # Nutrition: restarting tube feeds today pending surgical approval\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU Attending Addendum:\n On this day I examined the patient and was present for the key portion\n of the services provided. I have reviewed the note by Dr and\n agree with the findings and plan of care. I have previously seen this\n unfortunate young woman with a very serious esophageal cancer, who now\n presents with upper airway obstruction needing tracheostomy. I concur\n with antibiotic coverage in case there has been some soiling of\n mediastinum from occult esophageal perf. We will attempt to expedite a\n Passy Muir valve for her use, but the major limiting factor in\n communication is her language barrier. She seems very depressed and I\n would strongly urge a psych consult with the help of interpreter\n services, as I think she may benefit from antidepressant therapy. We\n will call her out to the floor, now that her airway is stable with a\n sutured in trache.\n Time spent in care: 40 \n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 20:17 ------\n" }, { "category": "Physician ", "chartdate": "2130-12-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430055, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n - c/od but no bed\n - ENT s/o\n - CXR shows trach well palced\n - tolerated trach proecedure well\n - no stridor, no n/v\n - restarted tube feeds\n - thoracics - 2 wks antibx but will follow on the floor\n - patient somewhat confused about cancer dx and prognosis - will need\n to have / to explain to patient what to expect for the\n future\n - continues to be tachycardic\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:14 PM\n Vancomycin - 08:26 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history: No changes to medical and family\n history\n Review of systems is unchanged from admission except as noted below\n Review of systems: There are no changes to the medical and family\n history\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 104 (89 - 140) bpm\n BP: 83/58(62) {83/51(59) - 103/69(76)} mmHg\n RR: 16 (11 - 32) insp/\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,689 mL\n 541 mL\n PO:\n TF:\n 239 mL\n 219 mL\n IVF:\n 1,100 mL\n 221 mL\n Blood products:\n Total out:\n 1,500 mL\n 950 mL\n Urine:\n 1,500 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -409 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, trach C/D/I, no surrounding\n erythema or drainiage\n Lymphatic: Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No M/T/R. No S3 or S4.\n Respiratory / Chest: (Expansion: Symmetric), CTA BL/ No R/W\n Abdominal: Soft, Non-tender, N/D\n Labs / Radiology\n 457 K/uL\n 9.1 g/dL\n 116 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 98 mEq/L\n 131 mEq/L\n 26.7 %\n 8.4 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n Plt\n 633\n 645\n 514\n 466\n 457\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement.\n # Airway Obstruction/malignancy- S/p trach placement and without\n stridor. Received 1 dose of dexemethasone two days ago. Now appears in\n no distress. MRI of neck ? esophageal perforation vs abscess vs\n diverticulum. Now transitioned to trach mask.\n - Continue broad spectrum antibiotic coverage empirically for esophagel\n perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 4 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx (per thoracics\n plan for 2 weeks broad\n spectrum coverage)\n # Nutrition: restarting tube feeds today pending surgical approval\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n #Pain: Continue regimen with:\n -Gabapentin 300QAM and 600QPM\n -Methadone 2.5mg \n #Proph: Bowel Regimen with Docusate and Lactulose. Patient is not\n currently on Heparin SQ. Con\nt Pantoprazole.\n ICU Care\n Nutrition:\n Ensure (Full) - 02:58 PM 60 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM:\n On this day I examined the patient and was present for the key portion\n of the services provided. I have reviewed Dr \ns note above and\n agree with the findings and plan of care. We have also discussed the\n patient\ns case and seen the patient with Dr , of GI, who knows her\n well.\n The patient appears to be in little pain and with little nausea on the\n combination of low dose Methadone, Zofran, and Neurontin. Her resp\n status is stable though her upper airway is still narrow as seen by the\n stridor when she breathes around her trache and through her vocal\n cords. Her BP is stable for her, and her mild tachycardia, also not\n new, will be addressed by giving her more liberal IV fluids. She has\n been called out to the floor, to finish her antibiotics for abnormal\n MRI suggestive of a microscopic esophageal perforation. So far she has\n declined to have any Rx of what we think is significant depression.\n Time spent: 30 \n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 12:49 ------\n" }, { "category": "Nursing", "chartdate": "2130-12-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429955, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Pt more sleepy, lethargic, looks like more depressed than yesterday.\n Continued with trache collar ,sats 100% .\n Action:\n Slept till MN and then OOB to chair for 2 hrs. voided in the bedpan.\n Response:\n Remains stable.\n Plan:\n Continue with trache collar. Monitor sats /RR\n Call out to OMED, waiting for bed.\n" }, { "category": "Nursing", "chartdate": "2130-12-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 430081, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n Hypotension (not Shock)\n Assessment:\n Pt has had a SBP in the 80s and 90s all day, HR low 100s to 160s, 130s\n while sitting in a chair and up to the 160 while standing, she denies\n feeling light headed, she has had these vitals since she has been here.\n Action:\n Given 2 IVF boluses, an EKG was done\n no changes were seen\n Response:\n Her vitals did not change with the fluid bolses\n Plan:\n Cont to follow\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Response:\n Plan:\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2130-12-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 430084, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight:\n Ideal tidal volume:\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position:\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure:\n Cuff volume:\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency:\n Sputum source/amount:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: ppm\n Indication:\n Effect of therapy: []\n Nitric Oxide trial:\n Comments:\n HeliOx:\n Additional O[2] by cannula: L/min\n Continuous nebulized bronchodilator:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments:\n Pt continues on trach collar. Small amts of secretions. Coughing most\n likely related to irritation from trach.\n" }, { "category": "Physician ", "chartdate": "2130-12-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429240, "text": "Chief Complaint: Respiratory distress, stridor, esophageal ca,\n laryngeal edema, 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 Patient on decadron through the night. Stridor improving.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n History obtained from Patient\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n protonix, decadron, methadone, nortryptaline, neurontin, heparin sc\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 11:10 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: 35.8\nC (96.5\n HR: 108 (96 - 131) bpm\n BP: 109/57(63) {94/57(63) - 110/73(78)} mmHg\n RR: 18 (14 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,472 mL\n 885 mL\n PO:\n TF:\n IVF:\n 1,412 mL\n 885 mL\n Blood products:\n Total out:\n 1,500 mL\n 800 mL\n Urine:\n 1,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\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\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: Clear : , No(t) Crackles : , No(t) Bronchial: , Wheezes\n : Slight expiratory prolongation, No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): not able to assess with language barrier,\n Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 9.7 g/dL\n 633 K/uL\n 138 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 98 mEq/L\n 136 mEq/L\n 27.8 %\n 7.9 K/uL\n [image002.jpg]\n 03:18 AM\n WBC\n 7.9\n Hct\n 27.8\n Plt\n 633\n Cr\n 0.5\n Glucose\n 138\n Other labs: Ca++:10.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n RESPIRATORY DISTRESS\n LARYNGEAL EDEMA\n Patient no longer using accessory muscles of ventilation. Stridor\n greatly improved. Completing course of decadron.\n Thoracic surgery to assess patient re: possible esophageal stricture.\n Patient to get MRI today.\n Consider PET scan for pulmonary nodule.\n Hct stable. Not at transfusion threshold.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429855, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt has been on trache collar all day, resp did try to deflate the cuff\n so we could help her to talk but she had a lot of and not much\n of a leak around the trache. Her LS are clear, she has been coughing\n up thick sputum into her mouth.\n Action:\n Suctioned from her trache for minimal white secretions, OOB to a chair\n with minimal assist\n Response:\n She has a small trache\n a number 6 and needs the small suction cath to\n suction her trache with (size 10 french)\n Plan:\n She will need valve from speech and swallow, they will\n need to come by and evaluate her for this before it is used.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt with unresectable esophageal CA, she just had a baby prior to being\n diagnosed, her 4 children and husband live in . Her affect\n is very withdrawn, her cousin who is her healthcare proxy states that\n she feels that the patient needs to get counseling.\n Action:\n Appears withdrawn and depressed, to contact psych\n Response:\n Plan:\n Cont to follow, have psych see her with an interpreter. D/C plans need\n to be addressed, if she wants to go back home she will need sevices and\n supplies as well as patient teaching. She currently is living with her\n cousin in .\n" }, { "category": "Nursing", "chartdate": "2130-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429137, "text": "40 yo Portaguese speaking woman w/unresectable esoph cancer dx ,\n trans from 7F w/stridor ? r/t edema from XRT vs disease vs chord edema.\n Here for airway observation overnight and potential trach in a.m.\n Earlier scope by ENT showed narrowing trach.\n Pt alert on arrival. Shallow slow breaths w/ gd O2sats on RA. Heliox\n at bedside. Non-English speaking. Pt has a PEG and had been on Ensure\n at 110cc/hr RN report but is currently NPO. Her cousin \n speaks English and is her HCP RN report.\n" }, { "category": "Nursing", "chartdate": "2130-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429138, "text": "40 yo Portaguese speaking woman w/unresectable esoph cancer dx ,\n trans from 7F w/stridor ? r/t edema from XRT vs disease vs chord edema.\n Here for airway observation overnight and potential trach in a.m.\n Earlier scope by ENT showed narrowing trach. Initially admitted to 11R\n w/ neck and jaw pain.\n Pt alert on arrival. Shallow slow breaths w/ gd O2sats on RA. Heliox\n at bedside. Non-English speaking. Pt has a PEG and had been on Ensure\n at 110cc/hr RN report but is currently NPO. Her cousin \n speaks English and is her HCP RN report.\n" }, { "category": "Physician ", "chartdate": "2130-12-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429212, "text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 102 (102 - 131) bpm\n BP: 94/73(78) {94/59(71) - 110/73(78)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,472 mL\n 755 mL\n PO:\n TF:\n IVF:\n 1,412 mL\n 755 mL\n Blood products:\n Total out:\n 1,500 mL\n 800 mL\n Urine:\n 1,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n -45 mL\n Respiratory support\n O2 Delivery Device: None\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 633 K/uL\n 9.7 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 98 mEq/L\n 136 mEq/L\n 27.8 %\n 7.9 K/uL\n [image002.jpg]\n 03:18 AM\n WBC\n 7.9\n Hct\n 27.8\n Plt\n 633\n Cr\n 0.5\n Glucose\n 138\n Other labs: Ca++:10.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 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": "2130-12-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430012, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n - c/od but no bed\n - ENT s/o\n - CXR shows trach well palced\n - tolerated trach proecedure well\n - no stridor, no n/v\n - restarted tube feeds\n - thoracics - 2 wks antibx but will follow on the floor\n - patient somewhat confused about cancer dx and prognosis - will need\n to have / to explain to patient what to expect for the\n future\n - continues to be tachycardic\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:14 PM\n Vancomycin - 08:26 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history: No changes to medical and family\n history\n Review of systems is unchanged from admission except as noted below\n Review of systems: There are no changes to the medical and family\n history\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 104 (89 - 140) bpm\n BP: 83/58(62) {83/51(59) - 103/69(76)} mmHg\n RR: 16 (11 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,689 mL\n 541 mL\n PO:\n TF:\n 239 mL\n 219 mL\n IVF:\n 1,100 mL\n 221 mL\n Blood products:\n Total out:\n 1,500 mL\n 950 mL\n Urine:\n 1,500 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -409 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, trach C/D/I, no surrounding\n erythema or drainiage\n Lymphatic: Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No M/T/R. No S3 or S4.\n Respiratory / Chest: (Expansion: Symmetric), CTA BL/ No R/W\n Abdominal: Soft, Non-tender, N/D\n Labs / Radiology\n 457 K/uL\n 9.1 g/dL\n 116 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 98 mEq/L\n 131 mEq/L\n 26.7 %\n 8.4 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n Plt\n 633\n 645\n 514\n 466\n 457\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Ensure (Full) - 02:58 PM 60 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430013, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n - c/od but no bed\n - ENT s/o\n - CXR shows trach well palced\n - tolerated trach proecedure well\n - no stridor, no n/v\n - restarted tube feeds\n - thoracics - 2 wks antibx but will follow on the floor\n - patient somewhat confused about cancer dx and prognosis - will need\n to have / to explain to patient what to expect for the\n future\n - continues to be tachycardic\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:14 PM\n Vancomycin - 08:26 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history: No changes to medical and family\n history\n Review of systems is unchanged from admission except as noted below\n Review of systems: There are no changes to the medical and family\n history\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 104 (89 - 140) bpm\n BP: 83/58(62) {83/51(59) - 103/69(76)} mmHg\n RR: 16 (11 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,689 mL\n 541 mL\n PO:\n TF:\n 239 mL\n 219 mL\n IVF:\n 1,100 mL\n 221 mL\n Blood products:\n Total out:\n 1,500 mL\n 950 mL\n Urine:\n 1,500 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 189 mL\n -409 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, trach C/D/I, no surrounding\n erythema or drainiage\n Lymphatic: Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No M/T/R. No S3 or S4.\n Respiratory / Chest: (Expansion: Symmetric), CTA BL/ No R/W\n Abdominal: Soft, Non-tender, N/D\n Labs / Radiology\n 457 K/uL\n 9.1 g/dL\n 116 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 98 mEq/L\n 131 mEq/L\n 26.7 %\n 8.4 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n Plt\n 633\n 645\n 514\n 466\n 457\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:8.9 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement.\n # Airway Obstruction/malignancy- S/p trach placement and without\n stridor. Received 1 dose of dexemethasone two days ago. Now appears in\n no distress. MRI of neck ? esophageal perforation vs abscess vs\n diverticulum. Now transitioned to trach mask.\n - Continue broad spectrum antibiotic coverage empirically for esophagel\n perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 4 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx (per thoracics\n plan for 2 weeks broad\n spectrum coverage)\n # Nutrition: restarting tube feeds today pending surgical approval\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n #Pain: Continue regimen with:\n -Gabapentin 300QAM and 600QPM\n -Methadone 2.5mg \n #Proph: Bowel Regimen with Docusate and Lactulose. Patient is not\n currently on Heparin SQ. Con\nt Pantoprazole.\n ICU Care\n Nutrition:\n Ensure (Full) - 02:58 PM 60 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429189, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting. Here for airway observation overnight and potential\n trach in a.m. Earlier scope by ENT showed narrowing trach. Pt alert on\n arrival. Shallow slow breaths w/ gd O2sats on RA. On decadron for\n inflammation. Heliox at bedside. Pt has a PEG, currently NPO for\n potential trach.. Pt is portugese speaking, understands little English.\n Her cousin is her closest relative in the US and her HCP. She\n is available by phone for translation\nphone # on board in room.\n MRI of head done, still needs MRI of neck.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Initially with stridor, resonating to upper airway, audible without\n stethoscope. RR teens, sats high 90s on RA. Hoarse NP. Speaks in\n hoarse whisper. ST 100s-110s, ^^ 150 with coughing, ^^ 130s with\n activity. Denies pain. Blood sugars elevated d/t decadron.\n Action:\n Decadron. Heliox in room, No O2 as it will dry out airway. MRI of head\n done (ordered )\n Response:\n Lung exam improved, no stridor , Faint exp wheezes in upper lobes only.\n Sats remain > 95% on RA.\n Plan:\n Needs MRI of neck to evaluate laryngeal edema. If needs O2, use\n humidified Heliox only. Decadron. NPO for ? trach today, ENT to\n evaluate MRI of neck when available. Pt and her cousin are aware of\n plan. RISS.\n" }, { "category": "Nursing", "chartdate": "2130-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429291, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Stridor improved. Scope by ENT revealed improved edema in a.m. w/ r\n chord paralysis. Re-scoped in afternoon and edema was worse. This was 7\n hrs after Decadron and she was due for third dose in 1hr. Also c/o more\n pain after 2^nd scope.\n Action:\n Given Tylenol and 10mg IV Decadron.\n Response:\n Throat sl better.\n Plan:\n Morphine via PEG. MRI neck and mediastinum. Thoracic wants to r/o\n esophageal tear. Dispo ICU per ENT attending. Possible trach or\n resection pnd MRI.\n" }, { "category": "Nursing", "chartdate": "2130-12-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 430113, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Continued with trache collar 35%. Sats 100%. HR 100-110 while on bed\n and upto 150\ns when out of bed .OOB to chair for few hours.\n Action:\n Inner canula clean,suctioned for small white secretions,pt coughing\n out and using yankeur.\n Response:\n Remains stable with RR/Sats..no SOB / stridor noted.\n Plan:\n Continue with trache collar.possible call out to floor if HR stays\n within normal range.\n PEG intact. Tube feed @goal. Feed stopped at 9pm and restart at 6am.\n BP remained 80-90/50-60 mm of hg.MAP > 60.\n Bath given and positioned for comfort. Voided good amount urine.\n" }, { "category": "Respiratory ", "chartdate": "2130-12-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 430286, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 6.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Expectorated /\n Comments:\n Respiratory Care Shift Procedures\n :\n Comments:\n Inner cannula changed.\n" }, { "category": "Nursing", "chartdate": "2130-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429664, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt with stidor this am, 02 SATs have been in the high 90s, seen by\n surgery and the interpreter this am to discuss the pending surgery. Pt\n remains NPO. BP has been in the 80s-90s, HR low 100s while in bed but\n goes up to the 140s when out of bed to the commode\n Action:\n Given 1.5 liters of IVF today for her low BP and high HR, went to the\n OR this afternoon for a trache\n Response:\n Her BP has been in the 90s-100s,\n Plan:\n" }, { "category": "Physician ", "chartdate": "2130-12-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 430214, "text": "Chief Complaint: Laryngeal edema, esophageal cancer, respiratory\n distress, esophageal perforation.\n I saw and examined the patient, and was physically present with the ICU\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 has had tachycadia and intermittent hypotension. Patient given\n fluids for orthostatic changes in HR. Patient has hx of low baseline\n blood pressure.\n stim done (4.1 to 25).\n 24 Hour Events:\n CALLED OUT\n History obtained from Medical records\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:00 PM\n Metronidazole - 08:19 AM\n Vancomycin - 09:06 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:50 PM\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: 36.6\nC (97.9\n HR: 125 (99 - 145) bpm\n BP: 70/43(49) {70/39(49) - 92/67(72)} mmHg\n RR: 15 (14 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 4,644 mL\n 2,239 mL\n PO:\n TF:\n 1,243 mL\n 714 mL\n IVF:\n 3,190 mL\n 1,475 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,125 mL\n Urine:\n 2,750 mL\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,894 mL\n 1,114 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///29/\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\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, Trach\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 : , Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ),\n Diffuse coarse rales, probable large airway sounds\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Difficult to assess due to language barrier,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 415 K/uL\n 107 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 102 mEq/L\n 137 mEq/L\n 26.1 %\n 6.9 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n 04:22 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n 6.9\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n 26.1\n Plt\n 633\n 645\n 514\n 466\n 457\n 415\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n 0.5\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n 107\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n LARYNGEAL EDEMA\n O2 sats are good on trach mask, with no increased work of breathing;\n patient has stridor with trach cuff down - may be pulling some air\n over her vocal cords.\n Hypotension today that appears to be responding to fluids. BUN/creat\n ratio normal. Has made over a liter of urine since midnight. The good\n urine output suggests a high output state, which may be more consistent\n with vasodilatation than primary volume depletion, or that this is her\n normal pressure and she is voiding exactly what we put in. WBC normal.\n Continues on antibiotics for esophageal perforation. Obtain echo to\n assess for pericardial involvement with tumor.\n Hct stable. Not at transfusion threshold.\n ICU Care\n Nutrition:\n Ensure (Full) - 06:00 AM 110 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2130-12-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430215, "text": "Chief Complaint: airway obstruction\n 24 Hour Events:\n Tachycardic; hypotensive to SBPs 80s.\n Cortisol level 4.1; increased to 25 with cortsyntropin.\n Given 500cc bolus this AM for tachycardia and MAP 58; HR and BP\n responded but appeared orthostatic and so given another 500cc bolus.\n Seen by speech and swallow. Failed PMV; recommended waiting a few more\n days until patient more comfortable with trach.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:00 PM\n Vancomycin - 08:11 PM\n Metronidazole - 11:11 PM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 PM\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, again complains of cough\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 128 (99 - 145) bpm\n BP: 83/39(51) {80/39(51) - 92/67(72)} mmHg\n RR: 30 (14 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 4,644 mL\n 376 mL\n PO:\n TF:\n 1,243 mL\n 198 mL\n IVF:\n 3,190 mL\n 128 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,125 mL\n Urine:\n 2,750 mL\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,894 mL\n -749 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n Physical Examination\n General Appearance: Thin, NAD\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Neck: Trach mask in place, site c/d/i\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: CTA b\n Abdominal: Soft, Non-tender, J tube in place, non-tender, site c/d/i\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 415 K/uL\n 8.9 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 102 mEq/L\n 137 mEq/L\n 26.1 %\n 6.9 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n 04:22 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n 6.9\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n 26.1\n Plt\n 633\n 645\n 514\n 466\n 457\n 415\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n 0.5\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n 107\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement.\n # Airway/Malignancy: S/P tracheostomy on . Appears in no\n distress but does have persistent cough. Now on trach mask; failed\n passy miur valve.\n - Continue broad spectrum antibiotic coverage empirically for\n esophageal perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n - f/u palliative care recs\n # Hypotension/tachycardia: Pt with low SBPs at baseline. No evidence\n of poor perfusion; good uop. Tachy with movement, cough. EKG shows\n sinus tach. Given location of cancer, hx radiation treatment. ? If\n this may related to cardiac effusion, pericarditis?\n - Echo today.\n # Flat Affect: ? depression. Pt refusing social work/psych input.\n - will continue to monitor\n # Leukocytosis: resolved. Now day 4 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx (per thoracics\n plan for 2 weeks broad\n spectrum coverage)\n # Nutrition: restarting tube feeds today pending surgical approval\n #Pain: Continue regimen with home regimen\n -Gabapentin 300QAM and 600QPM\n -Methadone 2.5mg \n #Proph: Bowel Regimen with Docusate and Lactulose.\n ICU Care\n Nutrition:\n Ensure (Full) - 06:00 AM 110 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 PM\n Prophylaxis:\n DVT: Heparin SQ.\n Stress ulcer: PPI\n Code status: Full code\n Disposition: transfer to floor\n" }, { "category": "Nursing", "chartdate": "2130-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429173, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting. Here for airway observation overnight and potential\n trach in a.m. Earlier scope by ENT showed narrowing trach. Pt alert on\n arrival. Shallow slow breaths w/ gd O2sats on RA. On decadron for\n inflammation. Heliox at bedside. Pt has a PEG, currently NPO for\n potential trach.. Pt is portugese speaking, understands little English.\n Her cousin is her closest relative in the US and her HCP. She\n is available by phone for translation\nphone # on board in room.\n MRI of head done, still needs MRI of neck.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Initial stridor, resonating to upper airway, audible without\n stethoscope. RR teens, sats high 90s on RA. Hoarse NP. Speaks in\n hoarse whisper. ST 100s-110s, ^^ 150 with coughing, ^^ 130s with\n activity. Denies pain.\n Action:\n Decadron. Heliox in room, No O2 as it will dry out airway. MRI of head\n done (ordered )\n Response:\n Lung exam improved, no stridor , Faint exp wheezes in upper lobes only.\n Sats remain > 95% on RA.\n Plan:\n Needs MRI of neck. If needs O2, use humidified only. Decadron. NPO for\n ? trach today, ENT to evaluate MRI. Pt and her cousin are aware of\n plan.\n" }, { "category": "Physician ", "chartdate": "2130-12-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429188, "text": "Chief Complaint: nausea, vomiting, transferred to MICU for stridor\n HPI:\n Pt is a 40 yo F with unresectable esophageal cancer who was recently\n discharged from the hospital secondary to right neck pain. She was\n then discharged on . Since /6 per discussion with the\n PCP/oncologist, the patient has had persistent nausea and vomiting with\n severe wretching over the last 72 hours. The nausea seemed to be\n temporally related to the patient's increase in pain medications and\n d/c of scopalamine patch.\n Per chart and discussion, the patient presented on with the chief\n complaint of \"strange sounding airway\". The patient also reported to\n ENT that her dyspnea has worsened since friday (time of the vomiting)\n but denied change in her dyspnea in the last 4 months when I spoke with\n her.\n The patient was admitted overnight to the hospitalist service and was\n managed with 2-3 L NS and home meds. The patient was then transferred\n to the onc service for further management. CT neck was done and after\n evaluation by radiology was found to have concering air\n paraesophageal. Additionally the patient was found to have stridor and\n was evaluated by ENT. ENT found that the patient had significant edema\n of the glottic structures and restrictied abduction of the vocal cords\n due to the swelling and narrowing fo teh airway.\n .\n On my evaluation prior to transfer the patient denied current pain,\n nausea or recent vomiting. She felt that her symptoms has been\n improved with the hospitalized care.\n Patient admitted from: \n History obtained from Family / Friend, Interpreter\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:01 AM\n Other medications:\n Unable to confirm meds, but as of d/c home meds were:Discharge\n Medications were:\n Acetaminophen (650) MG PO Q6H (every 6 hours).\n Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2\n times a day).\n 3. Morphine 10 mg/5 mL Solution Sig: 4-6 MG PO Q4H (every 4\n hours) as needed for pain.\n 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3\n times a day) as needed for constipation.\n 5. Bisacodyl 10 mg Suppository\n 6. Miconazole Nitrate 2 % Powder\n 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID\n 8. Methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).\n 9. Gabapentin 250 mg/5 mL Solution Sig: 300 mg po qam, 600 mg po\n qpm mg PO twice a day.\n 10. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,\n Rapid Dissolve PO Q8H (every 8 hours)\n 11. Promethazine 6.25 mg/5 mL Syrup Sig: 12.5 mg PO Q8H (every 8\n hours) as needed for nausea.\n 12. Protonix 40 mg Susp,Delayed Release for Recon Sig: Forty\n (40) mg PO once a day.\n 13. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr\n Transdermal Q72H (every 72 hours). (PATIENT ELECTIVELY D/Ced prior to\n admission)\n 14. Tube feeds, with free water boluses\n .\n Meds on transfer:\n Ondansetron ODT 8 mg PO TID\n Gabapentin 300 mg PO QAM .\n Gabapentin 600 mg PO QPM\n Prochlorperazine 25 mg PR Q12H\n Nortriptyline 25 mg NG HS\n Methadone 2.5 mg PO BID\n Ampicillin-Sulbactam 1.5 g IV Q6H\n Lorazepam 0.5-2 mg IV ONCE MR1\n Dexamethasone 10 mg IV Q8H\n Past medical history:\n Family history:\n Social History:\n #. Esophageal Squamous Cell Carcinoma - diagnosed in\n setting of esophageal stricture\n - high cervical esophageal lesion not resectable\n - completed therapy with Cetuximab and radiation therapy\n #Anemia\n #Upper esophageal and pharyngeal stricture\n #Shoulder Pain\n #Lung lesion - NOS\n #Chronic pain from radiation.\n #Nausea and vomiting.\n # PEG tube site candidiasis\n There is no history in her family of heart disease, gastric\n cancer, esophageal cancer or colon cancer or inflammatory bowel\n disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient lives in , MA with her cousin ,\n who is her HCP. THe patient is initially from \n islands, dhe is not currently working.\n Tobacco: None\n ETOH: None\n Illicits: None\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n Constipation\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 06:05 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.9\nC (98.5\n HR: 112 (103 - 131) bpm\n BP: 110/63(74) {96/59(71) - 110/71(78)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,472 mL\n 733 mL\n PO:\n TF:\n IVF:\n 1,412 mL\n 733 mL\n Blood products:\n Total out:\n 1,500 mL\n 800 mL\n Urine:\n 1,500 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n -67 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Able to converse\n somewhat in spanish with me and in Portugese with interpreter\n Labs / Radiology\n 633 K/uL\n 9.7 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 10 mg/dL\n 29 mEq/L\n 98 mEq/L\n 4.2 mEq/L\n 136 mEq/L\n 27.8 %\n 7.9 K/uL\n [image002.jpg]\n \n 2:33 A12/10/ 03:18 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.9\n Hct\n 27.8\n Plt\n 633\n Cr\n 0.5\n Glucose\n 138\n Other labs: Ca++:10.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Imaging: CT neck:FINDINGS: The true and false vocal folds are apposed\n on this study. A small\n amount of air is noted within the left laryngeal saccule which is a\n normal\n finding. A small amount of fluid and air is noted within the esophagus\n at the\n level of the thyroid gland, also noted on prior study from \n . No\n airway lesions are identified to suggest airways compromise secondary\n to mass\n lesion. No external compression is detected. The thyroid gland is\n within\n normal limits. No adenopathy is identified per CT size criteria.\n Cavitary\n lesion is again noted within the left lung apex with slight increase\n since\n prior study currently measuring 1 x 0.9 cm.\n IMPRESSION:\n 1. No mass lesions are detected within the airway to explain stridorous\n breathing.\n 2. Fluid again noted within the esophagus in the region of the thyroid\n gland.\n Also noted on prior study, possibly relating to region of stricture.\n 3. Slight increase in cavitary lesion within the left lung apex.\n NOTE ADDED AT ATTENDING REVIEW: There is a collection of air in the\n right\n neck, apparently just lateral to the esophagus, but possibly within a\n dilated\n esophagus, best seen on images 34-37 of series 2. In this location it\n raises\n the possibility of an esophageal perforation. Since it is difficult to\n determine the location of the lateral margin of the esophagus, it is\n difficult\n to distinguish an extraluminal collection from dilatation of the organ.\n An MR\n examination may be helpful.\n There is induration of the adjacent tissues, which could be a\n consequence of\n local infection, but also could arise as a result of prior radiation.\n CT chest:\n IMPRESSION:\n 1. Small pharyngeal or paralaryngeal abscess, phlegmon or malignancy\n has\n grown over two weeks. If the lesion is inflammatory it suggests\n ulceration in\n the hypopharynx/upper esohagus. Please see report of today's neck CT.\n 2. Slow growth of small left upper lobe lung cavity and a tiny right\n lower\n lobe lesion as well as a new left lower lobe lesion are concerning for\n multifocal metastases, or slow spread of an indolent infection. Small\n growing\n left pleural mass is more characteristic of metastasis.\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n 1. Airway obstruction: Patient with know squamous cell cancer of the\n esophagus that is not significantly changed per CT report. However, the\n patient does have esophageal strictures that are likely secondary to\n radiation changes and cancer complications. Recent worsening though,\n is likely due to the siginificantly increase wretching that the\n patient has been experiencing. Thus will continue with IV steroids\n (significant improvement after initial dose). The patient does need\n MRI neck that was incorrectly ordered initially. The MRI will be done\n today to evaluate for laryngeal edema.\n - continue IV steroids\n - MRI neck\n - ENT recs\n - Rad onc consult\n 2. Malignancy: Patient s/p chemo and radiation. Concern that new lung\n lesion is secondary to metastatic disease. will need tissue dx at some\n point. Await onc recs regarding final path.\n - F/u onc recs\n 3. Anemia: currently at baseline, no signs of active bleeding\n ICU Care\n Nutrition:\n Comments: NPo for now\n Glycemic Control: Regular insulin sliding scale, Comments: for steroids\n Lines:\n 20 Gauge - 06:03 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": "2130-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429449, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n No tests or procedures. No noted stridor. Gd O2sats on RA.\n Action:\n Monitored airway. OOB to commode. Tol well.\n Response:\n Napping on and off all day.\n Plan:\n ICU for airway monitoring per ENT.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n No c/o neck/shoulder pain. Esophageal perf per MRI.\n Action:\n Antibiotics.\n Response:\n Afebrile.\n Plan:\n Cont antibiotics. Follow temps.\n TFs resumes at 10cc/hr. Advance slowly asl tol. Goal: Ensure at\n 110cc/hr.\n No stool since ICU admit. Please give prn Colace ATC.\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429834, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt with stidor this am, 02 SATs have been in the high 90s, seen by\n surgery and the interpreter this am to discuss the pending surgery. Pt\n remains NPO. BP has been in the 80s-90s, HR low 100s while in bed but\n goes up to the 140s when out of bed to the commode.\n Action:\n Given 1.5 liters of IVF today for her low BP and high HR, went to the\n OR this afternoon for a trache, given paralytics and fent/versed for\n this.\n Response:\n Her BP has been in the 90s-100s, returned from the OR, tolerated the\n procedure well she now has a # 6 trache in. She has a large amount of\n oral secretions and some secretions from her trache, her 02 SAT has\n been 100% on A/C, she was changed to PSV and tolerating this well as\n well.\n Plan:\n Put her on a trache collar when she wakes up, follow SATs, restart TF,\n follow n/v with the pain meds.\n" }, { "category": "Nursing", "chartdate": "2130-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429166, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting. Here for airway observation overnight and potential\n trach in a.m. Earlier scope by ENT showed narrowing trach. Pt alert on\n arrival. Shallow slow breaths w/ gd O2sats on RA. On decadron for\n inflammation. Heliox at bedside. Pt has a PEG, currently NPO for\n potential trach.. Pt is portugese speaking, understands little English.\n Her cousin is her closest relative in the US and her HCP. She\n is available by phone for translation\nphone # on board in room.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Initial stridor, resonating to upper airway, audible without\n stethoscope. RR teens, sats high 90s on RA. Hoarse NP. Speaks in\n hoarse whisper.\n Action:\n Decadron. Heliox in room, No O2 as it will dry out airway. MRI of head\n done (ordered )\n Response:\n Lung exam improved, no stridor when awake, Faint exp wheezes in upper\n lobes only. Sats remain > 95% on RA.\n Plan:\n Needs MRI of neck. If needs O2, use humidified only. Decadron. NPO for\n ? trach today, ENT to evaluate MRI. Pt and her cousin are aware of\n plan.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2130-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429527, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to XRT. Has PEG @\n home. NPO @ home. MRI done shows esophageal perforation @ level\n of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Patient had no stridor early this evening while awake. Developed\n stridor while sleeping. No c/o SOB or respiratory distress.\n Maintained O2 sats: 97-100% on room air. HR: 90\ns SR - no\n ectopy. HR up to 120\ns w/exertion (walking to toilet).\n Action:\n Placed humidified O2 @ 35% via tent mask, overnight, near face as\n patient wouldn\nt wear it as it was uncomfortable. Neb was set up\n w/racemic epi (unopened). Helio-oxygen tank in back room.\n Response:\n Preop checklist started. NPO since Mn.\n Plan:\n Meeting w/PCP, , GI (& thoracics) in am to discuss trach\n placement. If agreed on, patient to have trach placed later today.\n" }, { "category": "Nursing", "chartdate": "2130-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429531, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Patient had no stridor early this evening while awake. Developed\n stridor while sleeping. No c/o SOB or respiratory distress.\n Maintained O2 sats: 97-100% on room air. HR: 90\ns SR - no\n ectopy. HR up to 120\ns w/exertion (walking to toilet).\n Action:\n Placed humidified O2 @ 35% via tent mask, overnight, near face as\n patient wouldn\nt wear it as it was uncomfortable. Neb was set up\n w/racemic epi (unopened). Helio-oxygen tank in back room.\n Response:\n Preop checklist started. NPO since Mn.\n Plan:\n Meeting w/PCP, , GI (& thoracics) in am to discuss trach\n placement. If agreed on, patient to have trach placed later today.\n Constipation (Obstipation, FOS)\n Assessment:\n Patient told GI MD that she had no BM since Sun (). Abdomen soft.\n +Bowel sounds. Had N/V before admission.\n Action:\n Patient placed back on lactulose 30cc tid prn. Received 1^st dose last\n evening. Now NPO for possible trach placement.\n Response:\n No BM yet.\n Plan:\n Continue to give lactulose when patient can receive tube feedings.\n" }, { "category": "Nursing", "chartdate": "2130-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429328, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting. Here for airway observation overnight and potential\n trach in a.m. Earlier scope by ENT showed narrowing trach. Pt alert on\n arrival. Shallow slow breaths w/ gd O2sats on RA. On decadron for\n inflammation. Heliox at bedside. Pt has a PEG, currently NPO for\n potential trach.. Pt is portugese speaking, understands little English.\n Her cousin is her closest relative in the US and her HCP. She\n is available by phone for translation\nphone # on board in room.\n MRI of head / neck/mediastinum is pending. Tube feeds restarted last\n night.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Initially lungs are clear, diminished at bases. Later in night noted to\n have upper airway stridor but less so than yesterday. No respiratory\n distress, Sats 99-100% on RA. This AM pt vomited very small amt green\n bile, spitting it out into yankeur and tissues, c/o nausea. Coughing\n afterwards, stridor increased after episode of vomiting.. HR ^^ 120s\n with N/V. Sats 99-100%\n Action:\n HOB^^ 90. HO in to evaluate pt. Changed zofran from PO->>IV, dose given\n with episode N/V. Tube feeds off although no residuals.\n Response:\n Mild upper airway stridor, increased after N/V but no respiratory\n distress. Zofran effective for nausea.\n Plan:\n Continue to monitor airway. Would give another dose of decadron if\n stridor worsens. Awaiting MRI results, input from thoracics and ENT re:\n trach. NPO. d/t dysphagia, esophageal stricture.\n" }, { "category": "Physician ", "chartdate": "2130-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429415, "text": "Chief Complaint: Stridor\n 24 Hour Events:\n - ENT - advised continued MICU care, trachea 3 mm at narrowest point\n and supraglottic edema, R vocal cord paralysis\n - Thoracics consult- likely not a tear; advised barium swallow and\n broad spectrum coverage, ddx perforation vs TE fistula;\n - Pt did not tolerate barium swallow\n - Added Vanco/Levo/Flagyl/Fluconazole\n - MR Neck - read PENDING (wet read by surgery - no ET fistula, no\n extaluminal air)\n - TFs - restart Ensure\n - Evaluated for worsening stridor at 0400; Inspiratory stridor noted on\n exam in all lung fields, but pt saturating well. Denies worsening pain.\n Thoracics informed.\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 09:05 PM\n Metronidazole - 12:19 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: ROS limited due to language barrier. Continues to\n complain of cough, breathing ok, no abdominal pain, slight neck\n tenderness\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.3\nC (97.3\n HR: 90 (90 - 111) bpm\n BP: 104/60(70) {95/57(63) - 113/92(98)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,565 mL\n 531 mL\n PO:\n TF:\n 145 mL\n 239 mL\n IVF:\n 1,315 mL\n 172 mL\n Blood products:\n Total out:\n 1,550 mL\n 700 mL\n Urine:\n 1,550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, NAS\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: Expansion: Symmetric, diffuse minimal upper\n airway noises\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 645 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 15 mg/dL\n 97 mEq/L\n 133 mEq/L\n 30.3 %\n 12.8 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n WBC\n 7.9\n 12.8\n Hct\n 27.8\n 30.3\n Plt\n 633\n 645\n Cr\n 0.5\n 0.6\n Glucose\n 138\n 142\n Other labs: Ca++:9.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n 1) Airway Obstruction/malignancy\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 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": "2130-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429334, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting. Here for airway observation overnight and potential\n trach in a.m. Earlier scope by ENT showed narrowing trach. Pt alert on\n arrival. Shallow slow breaths w/ gd O2sats on RA. On decadron for\n inflammation. Heliox at bedside. Pt has a PEG, currently NPO for\n potential trach.. Pt is portugese speaking, understands little English.\n Her cousin is her closest relative in the US and her HCP. She\n is available by phone for translation\nphone # on board in room.\n MRI of head / neck/mediastinum is pending. Tube feeds restarted last\n night.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Initially lungs are clear, diminished at bases. Later in night noted to\n have upper airway stridor but less so than yesterday. No respiratory\n distress, Sats 99-100% on RA. This AM pt vomited very small amt green\n bile, spitting it out into yankeur and tissues, c/o nausea. Coughing\n afterwards, stridor increased after episode of vomiting. HR ^^ 120s\n with N/V. Sats 99-100%\n Action:\n HOB^^ 90. HO in to evaluate pt. Changed zofran from PO->>IV, dose given\n with episode N/V. Tube feeds off although no residuals.\n Response:\n Mild upper airway stridor, increased after N/V but no respiratory\n distress. Zofran effective for nausea.\n Plan:\n Continue to monitor airway. Would give another dose of decadron if\n stridor worsens. Awaiting MRI results, input from thoracics and ENT re:\n trach. NPO. d/t dysphagia, esophageal stricture. Tube feeds off for\n now, ? plan.\n" }, { "category": "Nursing", "chartdate": "2130-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429165, "text": "CT Scan reviewed. LUL lesion noted. Mild narrowing of trachea at region\n of vocal cords. Subglottic esophageal mass seen. No focal lung\n infiltrates.\n IMP: Patient with acute laryngeal edema, likely due to acid from\n vomiting. Patient receiving decadron to reduce swelling. Will keep\n heliox at bedside; if work of breathing increases or oxygen saturation\n decreases, would begin heliox. Hope to avoid intubation.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Action:\n Response:\n Plan:\n .H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2130-12-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 429408, "text": "Pertinent medications: NS, IV abx, protonix, heparin, RISS, flagyl,\n others noted\n Labs:\n Value\n Date\n Glucose\n 142 mg/dL\n 03:47 AM\n Glucose Finger Stick\n 133\n 12:00 PM\n BUN\n 15 mg/dL\n 03:47 AM\n Creatinine\n 0.6 mg/dL\n 03:47 AM\n Sodium\n 133 mEq/L\n 03:47 AM\n Potassium\n 4.5 mEq/L\n 03:47 AM\n Chloride\n 97 mEq/L\n 03:47 AM\n TCO2\n 29 mEq/L\n 03:47 AM\n Calcium non-ionized\n 9.8 mg/dL\n 03:47 AM\n Phosphorus\n 3.1 mg/dL\n 03:47 AM\n Magnesium\n 2.0 mg/dL\n 03:47 AM\n WBC\n 12.8 K/uL\n 03:47 AM\n Hgb\n 10.4 g/dL\n 03:47 AM\n Hematocrit\n 30.3 %\n 03:47 AM\n Current diet order / nutrition support: Ensure @ 110 ml/hr (2798 kcals/\n 97 g pro) on hold\n GI: +BS, soft, NT, ND, PEG\n Specifics: 40 year old femfale with esophageal mass and neck pain. Pt\n TF restarted last night and was running at 60 ml/hr but currently on\n hold as pt vomited this morning. RN plan is to restart TF. Current\n TF overfeeds pt, recommend changing TF to Ensure @ 110 ml/hr x15hrs to\n provide 1749 kcals/ 60 g pro.\n Medical Nutrition Therapy Plan - Recommend the Following\n Restart TF when able\n Change TF goal to Ensure @ 110 ml/hr x 15 hrs (1749 kcals/60g pro)\n If ATC TF is needed recommend Ensure @ 70 ml/hr (1781 kcasl/62 g pro)\n Will continue to follow pls page with questions \n" }, { "category": "Physician ", "chartdate": "2130-12-07 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429410, "text": "Chief Complaint: Laryngeal edema, respiratory distress, esophageal\n rupture\n I saw and examined the patient, and was physically present with the ICU\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 comfortable throughout the day. O2 sats good without\n supplemental oxygen. MRI suggests there is esophageal perfoation.\n 24 Hour Events:\n History obtained from Patient\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 07:24 AM\n Metronidazole - 08:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Pantoprazole (Protonix) - 08:42 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:31 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.8\nC (96.5\n HR: 85 (85 - 111) bpm\n BP: 95/59(67) {93/57(66) - 113/92(98)} mmHg\n RR: 15 (13 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,565 mL\n 952 mL\n PO:\n TF:\n 145 mL\n 239 mL\n IVF:\n 1,315 mL\n 533 mL\n Blood products:\n Total out:\n 1,550 mL\n 1,300 mL\n Urine:\n 1,550 mL\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n -348 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///29/\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\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: 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 Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n Wheezes : Expiratory wheeze localized over neck; I/E=, No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Not able to assess given language barrier,\n Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 10.4 g/dL\n 645 K/uL\n 142 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 15 mg/dL\n 97 mEq/L\n 133 mEq/L\n 30.3 %\n 12.8 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n WBC\n 7.9\n 12.8\n Hct\n 27.8\n 30.3\n Plt\n 633\n 645\n Cr\n 0.5\n 0.6\n Glucose\n 138\n 142\n Other labs: Ca++:9.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n Patient's voice continues to improve. Oxygenation remains excellent\n without supplemental oxygen. On antibiotics for esophageal perforation.\n Hct stable. No evidence of acute bleeding. Not at transfusion threshold\n now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 25\n" }, { "category": "Physician ", "chartdate": "2130-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429422, "text": "Chief Complaint: Stridor\n 24 Hour Events:\n - ENT - advised continued MICU care, trachea 3 mm at narrowest point\n and supraglottic edema, R vocal cord paralysis\n - Thoracics consult- likely not a tear; advised barium swallow and\n broad spectrum coverage, ddx perforation vs TE fistula;\n - Pt did not tolerate barium swallow\n - Added Vanco/Levo/Flagyl/Fluconazole\n - MR Neck - read PENDING (wet read by surgery - no ET fistula, no\n extaluminal air)\n - TFs - restart Ensure\n - Evaluated for worsening stridor at 0400; Inspiratory stridor noted on\n exam in all lung fields, but pt saturating well. Denies worsening pain.\n Thoracics informed.\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 09:05 PM\n Metronidazole - 12:19 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: ROS limited due to language barrier. Continues to\n complain of cough, breathing ok, no abdominal pain, slight neck\n tenderness\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.3\nC (97.3\n HR: 90 (90 - 111) bpm\n BP: 104/60(70) {95/57(63) - 113/92(98)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,565 mL\n 531 mL\n PO:\n TF:\n 145 mL\n 239 mL\n IVF:\n 1,315 mL\n 172 mL\n Blood products:\n Total out:\n 1,550 mL\n 700 mL\n Urine:\n 1,550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, NAS\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: Expansion: Symmetric, diffuse minimal upper\n airway noises\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 645 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 15 mg/dL\n 97 mEq/L\n 133 mEq/L\n 30.3 %\n 12.8 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n WBC\n 7.9\n 12.8\n Hct\n 27.8\n 30.3\n Plt\n 633\n 645\n Cr\n 0.5\n 0.6\n Glucose\n 138\n 142\n Other labs: Ca++:9.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n # Airway Obstruction/malignancy- pt with ? episode of stridor\n overnight. Now appears in no distress. MRI of neck yesterday, read\n pending but there is question of a possible esophageal perforation. Pt\n is stable currently but unclear of risks of continued edema or risk of\n complications from current state.\n - f/u MRI read\n - dicuss need/plans for trach with ENT\n - f/u thoracics recs\n - f/u with oncology service\n # Leukocytosis: WBC to 12.8. Started on\n Vanco/Levo/Flagyl/Fluconazole () for risk of esophageal\n perforation/infection. - - Will continue with abx- need to determine\n course\n - f/u MRI\n # Nutrition: NPO. J-tube feedings\n ICU Care\n Nutrition: J-tubes\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 06:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: ppi\n Code status: Full code\n Disposition: ICU\n floor transfer/surgery\n" }, { "category": "Physician ", "chartdate": "2130-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429423, "text": "Chief Complaint: Stridor\n 24 Hour Events:\n - ENT - advised continued MICU care, trachea 3 mm at narrowest point\n and supraglottic edema, R vocal cord paralysis\n - Thoracics consult- likely not a tear; advised barium swallow and\n broad spectrum coverage, ddx perforation vs TE fistula;\n - Pt did not tolerate barium swallow\n - Added Vanco/Levo/Flagyl/Fluconazole\n - MR Neck - read PENDING (wet read by surgery - no ET fistula, no\n extaluminal air)\n - TFs - restart Ensure\n - Evaluated for worsening stridor at 0400; Inspiratory stridor noted on\n exam in all lung fields, but pt saturating well. Denies worsening pain.\n Thoracics informed.\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 09:05 PM\n Metronidazole - 12:19 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: ROS limited due to language barrier. Continues to\n complain of cough, breathing ok, no abdominal pain, slight neck\n tenderness\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.3\nC (97.3\n HR: 90 (90 - 111) bpm\n BP: 104/60(70) {95/57(63) - 113/92(98)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,565 mL\n 531 mL\n PO:\n TF:\n 145 mL\n 239 mL\n IVF:\n 1,315 mL\n 172 mL\n Blood products:\n Total out:\n 1,550 mL\n 700 mL\n Urine:\n 1,550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, NAS\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: Expansion: Symmetric, diffuse minimal upper\n airway noises\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 645 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 15 mg/dL\n 97 mEq/L\n 133 mEq/L\n 30.3 %\n 12.8 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n WBC\n 7.9\n 12.8\n Hct\n 27.8\n 30.3\n Plt\n 633\n 645\n Cr\n 0.5\n 0.6\n Glucose\n 138\n 142\n Other labs: Ca++:9.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n # Airway Obstruction/malignancy- pt with ? episode of stridor\n overnight. Now appears in no distress. MRI of neck yesterday, read\n pending but there is question of a possible esophageal perforation. Pt\n is stable currently but unclear of risks of continued edema or risk of\n complications from current state.\n - f/u MRI read\n - dicuss need/plans for trach with ENT\n - f/u thoracics recs\n - f/u with oncology service\n # Leukocytosis: WBC to 12.8. Started on\n Vanco/Levo/Flagyl/Fluconazole () for risk of esophageal\n perforation/infection. - - Will continue with abx- need to determine\n course\n - f/u MRI\n # Nutrition: NPO. J-tube feedings\n ICU Care\n Nutrition: J-tubes\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 06:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: ppi\n Code status: Full code\n Disposition: ICU\n floor transfer/surgery\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429722, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting.open tracheostomy done on with no:6.0 portex\n tube.\n .H/O airway obstruction, Central / Upper\n Assessment:\n s/p open tracheostomy on with no:6 portex tube. Sutures\n intact. Initially pt was on CPAP + PS ,peep5/ PS 10/ fio2 50%.\n Mentating well. portugese speaking, sats 100% RR 18-24\ns. No Resp\n distress or noted.\n Action:\n Put trache collar 50% at 2am. Sats 100% . RR 18-22. Pt looks\n comfortable.suctioned for white thick secretions. Pt cough well and\n bringining out white secretions.\n Response:\n VS stable. No resp distress noted.\n Plan:\n Continue with trache collar. Monitor VS and sats. Suctione PRN.\n Hypotension (not Shock)\n Assessment:\n Pt received with BP 80-90/50-60 mm of hg. But MAP > 60 all the time. ?\n secondary to methadone. HR > 120\ns mostly when more awake.\n Action:\n Fluid bolus N/S 1litre x once given with improvement in Sys BP 90-100\n for sometime.again after sometime sys 80-90 mm of hg. ICU team aware.\n Pt awake and comfortable.\n Response:\n Per Dr. , monitor MAP ,mainatain > 60. HR 90-100\n Plan:\n Continue to monitor MAP.\n Pt alert, gesturing. Able to follow gestures. Voided good amount yellow\n clear urine in the bedpan.\n PEG intact.plan to restart with feed today. NPO now. No PM po meds\n given.\n 22 g Piv x 2, both slight redness after iv levaquin, redness subsided\n later on. started new 20g PIV on lt hand.\n Pt refused for bath. Back care given and positioned .\n" }, { "category": "Physician ", "chartdate": "2130-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429800, "text": "Chief Complaint: stridor\n 24 Hour Events:\n - Had trachyostomy; tolerated procedure well. Weaned off vent\n overnight and placed on trach mask.\n - Per Thoracics, would attempt passy miur valve today.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:09 PM\n Metronidazole - 12:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\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: 37.2\nC (98.9\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 131) bpm\n BP: 92/60(67) {82/26(57) - 120/90(96)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 4,637 mL\n 150 mL\n PO:\n TF:\n IVF:\n 4,637 mL\n 150 mL\n Blood products:\n Total out:\n 3,000 mL\n 1,350 mL\n Urine:\n 3,000 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,637 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 602 (602 - 721) mL\n PS : 15 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.48/38/159/28/5\n Ve: 6.5 L/min\n PaO2 / FiO2: 318\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 466 K/uL\n 8.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 5.9 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n Plt\n 633\n 645\n 514\n 466\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429801, "text": "Chief Complaint: stridor\n 24 Hour Events:\n - Had trachyostomy; tolerated procedure well. Weaned off vent\n overnight and placed on trach mask.\n - Per Thoracics, would attempt passy miur valve today.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:09 PM\n Metronidazole - 12:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\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: 37.2\nC (98.9\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 131) bpm\n BP: 92/60(67) {82/26(57) - 120/90(96)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 4,637 mL\n 150 mL\n PO:\n TF:\n IVF:\n 4,637 mL\n 150 mL\n Blood products:\n Total out:\n 3,000 mL\n 1,350 mL\n Urine:\n 3,000 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,637 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 602 (602 - 721) mL\n PS : 15 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.48/38/159/28/5\n Ve: 6.5 L/min\n PaO2 / FiO2: 318\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 466 K/uL\n 8.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 5.9 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n Plt\n 633\n 645\n 514\n 466\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n # Airway Obstruction/malignancy- pt with ? episode of stridor\n overnight. Now appears in no distress. MRI of neck yesterday, read\n pending but there is question of a possible esophageal perforation. Pt\n is stable currently but unclear of risks of continued edema or risk of\n complications from current state.\n - 1x dose dexamethasone; will discuss with ENT\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 2 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx\n # Nutrition: NPO for possible surgery. J-tube feedings on hold.\n - give 1L NS\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429806, "text": "Chief Complaint: stridor\n 24 Hour Events:\n - Appeared lethargic in am; abg did not show hypercarbia 7.48/38/159/29\n - Had trachyostomy; tolerated procedure well. Weaned off vent\n overnight and placed on trach mask.\n - Per Thoracics, would attempt passy miur valve today.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:09 PM\n Metronidazole - 12:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\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: 37.2\nC (98.9\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 131) bpm\n BP: 92/60(67) {82/26(57) - 120/90(96)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 4,637 mL\n 150 mL\n PO:\n TF:\n IVF:\n 4,637 mL\n 150 mL\n Blood products:\n Total out:\n 3,000 mL\n 1,350 mL\n Urine:\n 3,000 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,637 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 602 (602 - 721) mL\n PS : 15 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.48/38/159/28/5\n Ve: 6.5 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General Appearance: Thin, NAD\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Neck: Trach mask in place, site c/d/i\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: CTA b\n Abdominal: Soft, Non-tender, J tube in place, non-tender, site c/d/i\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 466 K/uL\n 8.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 5.9 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n Plt\n 633\n 645\n 514\n 466\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement\n # Airway Obstruction/malignancy- S/p trach placement and without\n stridor. Received 1 dose of dexemethasone yesterday. Now appears in no\n distress. MRI of neck ? esophageal perforation vs abscess vs\n diverticulum. On CPAP o/n and now transitioned to trach mask.\n - Continue broad spectrum antibiotic coverage empirically for esophagel\n perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 3 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx\n # Nutrition: NPO for possible surgery. J-tube feedings on hold.\n - restarting tube feeds today pending surgical approval\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429504, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to XRT. Has PEG @\n home. NPO @ home. MRI done shows esophageal perforation @ level\n of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Patient had no stridor early this evening while awake. Developed\n stridor while sleeping. No c/o SOB or respiratory distress.\n Maintained O2 sats: 97-100% on room air\n Action:\n Placed humidified O2 @ 35% via tent mask near face as patient wouldn\n wear it as it was uncomfortable. Neb was set up w/racemic epi\n (unopened). Helio-oxygen tank in back room.\n Response:\n Preop checklist started. NPO since Mn.\n Plan:\n Meeting w/PCP, , GI (& thoracics) in am to discuss trach\n placement. If agreed on, patient to have trach placed later today.\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429710, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429711, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting\n" }, { "category": "Physician ", "chartdate": "2130-12-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430194, "text": "Chief Complaint: airway obstruction\n 24 Hour Events:\n Tachycardic; hypotensive to SBPs 80s.\n Cortisol level 17; increased to 25 with cortsyntropin.\n Given 500cc bolus this AM for tachycardia and MAP 58; HR and BP\n responded but appeared orthostatic and so given another 500cc bolus.\n Seen by speech and swallow. Failed PMV; recommended waiting a few more\n days until patient more comfortable with trach.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:00 PM\n Vancomycin - 08:11 PM\n Metronidazole - 11:11 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies pain, again complains of cough\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 128 (99 - 145) bpm\n BP: 83/39(51) {80/39(51) - 92/67(72)} mmHg\n RR: 30 (14 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 4,644 mL\n 376 mL\n PO:\n TF:\n 1,243 mL\n 198 mL\n IVF:\n 3,190 mL\n 128 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,125 mL\n Urine:\n 2,750 mL\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,894 mL\n -749 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, NAD\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Neck: Trach mask in place, site c/d/i\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: CTA b\n Abdominal: Soft, Non-tender, J tube in place, non-tender, site c/d/i\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 415 K/uL\n 8.9 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 102 mEq/L\n 137 mEq/L\n 26.1 %\n 6.9 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n 04:22 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n 6.9\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n 26.1\n Plt\n 633\n 645\n 514\n 466\n 457\n 415\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n 0.5\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n 107\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n40yF with terminal esophageal CA with hx of recent stridor,n/v/retching and ? ev\nidence on MRI for esophageal perforation now s/p trach placement.\n # Airway Obstruction/malignancy- S/p trach placement and without\n stridor. Received 1 dose of dexemethasone two days ago. Now appears in\n no distress. MRI of neck ? esophageal perforation vs abscess vs\n diverticulum. Now transitioned to trach mask.\n - Continue broad spectrum antibiotic coverage empirically for esophagel\n perforation (see below)\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 4 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx (per thoracics\n plan for 2 weeks broad\n spectrum coverage)\n # Nutrition: restarting tube feeds today pending surgical approval\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n #Pain: Continue regimen with:\n -Gabapentin 300QAM and 600QPM\n -Methadone 2.5mg \n #Proph: Bowel Regimen with Docusate and Lactulose. Patient is not\n currently on Heparin SQ. Con\nt Pantoprazole.\n ICU Care\n Nutrition:\n Ensure (Full) - 06:00 AM 110 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429262, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Stridor improved. Scope by ENT revealed improved edema in a.m. w/ r\n chord paralysis. Re-scoped in afternoon and edema was worse. This was 7\n hrs after Decadron and she was due for third dose in 1hr. Also c/o pain\n after 2^nd scope.\n Action:\n Given Tylenol and 10mg IV Decadron.\n Response:\n Throat better per pt.\n Plan:\n MRI neck and ?mediastinum. Dispo ICU per ENT attending. Possible trach\n or resection pnd MRI.\n" }, { "category": "Nursing", "chartdate": "2130-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429313, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting. Here for airway observation overnight and potential\n trach in a.m. Earlier scope by ENT showed narrowing trach. Pt alert on\n arrival. Shallow slow breaths w/ gd O2sats on RA. On decadron for\n inflammation. Heliox at bedside. Pt has a PEG, currently NPO for\n potential trach.. Pt is portugese speaking, understands little English.\n Her cousin is her closest relative in the US and her HCP. She\n is available by phone for translation\nphone # on board in room.\n MRI of head / neck/mediastinum is pending. Tube feeds restarted last\n night.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Lungs are clear, diminished at bases. Later in night noted to have\n upper airway stridor but less so than yesterday. No respiratory\n distress, Sats 99-100% on RA. No coughing spells. HR NSR 90s-100s.\n Action:\n HOB^^ 30. HO aware and in to evaluate pt.\n Response:\n Mild upper airway stridor, no respiratory distress.\n Plan:\n Continue to monitor airway. Would give another dose of decadron if\n stridor worsens. Awaiting MRI results, input from thoracics and ENT re:\n trach. NPO. d/t dysphagis, esophageal stricture. Advance tube feeds.\n" }, { "category": "Nursing", "chartdate": "2130-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429501, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to XRT. Has PEG @\n home. NPO @ home. MRI done shows esophageal perforation @ level\n of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Patient had no stridor early this evening while awake. Developed\n stridor while sleeping. No c/o SOB or respiratory distress.\n Maintained O2 sats: 97-100% on room air\n Action:\n Placed humidified O2 @ 35% via tent mask near face as patient wouldn\n wear it as it was uncomfortable. Neb was set up w/racemic epi\n (unopened). Helio-oxygen tank in back room. Patient remained NPO p\n Mn.\n Response:\n Plan:\n Meeting w/PCP, , GI (& thoracics) in am to discuss trach\n placement. If agreed on, patient to have trach placed today.\n" }, { "category": "Physician ", "chartdate": "2130-12-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429610, "text": "Chief Complaint: Airway compromise, strior\n 24 Hour Events:\n Patient had no stridor while awake but developed stridor while\n sleeping. Pt denied feeling SOB or respiratory distress and Maintained\n O2 sats.\n HR up to 120\ns w/exertion (walking to toilet).\n ENT and thoracics discussing the need for tracheostomy.\n Pt constipated (no BM since ), given lactulose.\n Now NPO for possible trach placement\n SBPs in the low 90\ns this AM; given 500cc bolus.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:30 PM\n Metronidazole - 11:59 PM\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Review of systems is unchanged from admission except as noted below\n Review of systems: continues to have throat discomfort. Otherwise\n feels ok\n Flowsheet Data as of 07:55 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: 96 (76 - 105) bpm\n BP: 99/61(68) {92/51(62) - 107/69(76)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,860 mL\n 710 mL\n PO:\n TF:\n 390 mL\n IVF:\n 2,060 mL\n 710 mL\n Blood products:\n Total out:\n 1,900 mL\n 700 mL\n Urine:\n 1,900 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 960 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\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 514 K/uL\n 9.0 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 99 mEq/L\n 135 mEq/L\n 26.8 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n WBC\n 7.9\n 12.8\n 7.0\n Hct\n 27.8\n 30.3\n 26.8\n Plt\n 633\n 645\n 514\n Cr\n 0.5\n 0.6\n 0.7\n Glucose\n 138\n 142\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.1 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.2 mg/dL\n MRI Neck:\n 12 x 8 mm collection of air with small amount of fluid just anterior to\n the right aspect of the esophagus at the level of the thyroid\n gland which likely represents esophageal perforation and/or abscess.\n Additional considerations include esophageal diverticulum, although\n less likely.\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:20 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": "2130-12-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 429627, "text": "Chief Complaint: Laryneal edema, perforated esophagus, respiratory\n distress, 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 Patient noted to have some stridor when sleeping last night; resolved\n when awake. O2 sats stable. Tachycardia with exertion.\n Received fliuds for drop in BP. Tolerating tube feeds.\n Afebrile\n 24 Hour Events:\n History obtained from Medical records\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:40 AM\n Metronidazole - 09:44 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Other medications:\n protonix, methadone, nortryptaline, compazine, heparin, insulin,\n levoflox, flagyl, vanco, lactulose\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:00 PM\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: 98 (76 - 105) bpm\n BP: 94/48(58) {88/48(57) - 107/69(76)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,860 mL\n 1,548 mL\n PO:\n TF:\n 390 mL\n IVF:\n 2,060 mL\n 1,548 mL\n Blood products:\n Total out:\n 1,900 mL\n 950 mL\n Urine:\n 1,900 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 960 mL\n 598 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///30/\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\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), (Breath\n Sounds: Clear : , Wheezes : Prolonged expiratory phase), Soft\n inspiratory stridor present\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, PEG\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Unable to assess due to language barrier,\n Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 9.0 g/dL\n 514 K/uL\n 97 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 99 mEq/L\n 135 mEq/L\n 26.8 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n WBC\n 7.9\n 12.8\n 7.0\n Hct\n 27.8\n 30.3\n 26.8\n Plt\n 633\n 645\n 514\n Cr\n 0.5\n 0.6\n 0.7\n Glucose\n 138\n 142\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.1 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n LARYNGEAL EDEMA\n ESOPHAGEAL PERFORATION\n Ongoing concern about patient's airway; stridor persists. Will place\n back on decadron. Plan was for a tracheostomy to be done today; the\n family and patient are resistant. Attempts being made to contact her\n Primary care physician.\n and WBC improving on antibiotics for esophageal perforation.\n Hct stable. No evidence of bleeding. Not at transfusion threshold.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 22 Gauge - 03:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2130-12-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429630, "text": "Chief Complaint: Airway compromise, strior\n 24 Hour Events:\n Patient had no stridor while awake but developed stridor while\n sleeping. Pt denied feeling SOB or respiratory distress and Maintained\n O2 sats.\n HR up to 120\ns w/exertion (walking to toilet).\n ENT and thoracics discussing the need for tracheostomy.\n Pt constipated (no BM since ), given lactulose.\n Now NPO for possible trach placement\n SBPs in the low 90\ns this AM; given 500cc bolus.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:30 PM\n Metronidazole - 11:59 PM\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Review of systems is unchanged from admission except as noted below\n Review of systems: continues to have throat discomfort. Otherwise\n feels ok\n Flowsheet Data as of 07:55 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: 96 (76 - 105) bpm\n BP: 99/61(68) {92/51(62) - 107/69(76)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,860 mL\n 710 mL\n PO:\n TF:\n 390 mL\n IVF:\n 2,060 mL\n 710 mL\n Blood products:\n Total out:\n 1,900 mL\n 700 mL\n Urine:\n 1,900 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 960 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\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 514 K/uL\n 9.0 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 99 mEq/L\n 135 mEq/L\n 26.8 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n WBC\n 7.9\n 12.8\n 7.0\n Hct\n 27.8\n 30.3\n 26.8\n Plt\n 633\n 645\n 514\n Cr\n 0.5\n 0.6\n 0.7\n Glucose\n 138\n 142\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.1 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.2 mg/dL\n MRI Neck:\n 12 x 8 mm collection of air with small amount of fluid just anterior to\n the right aspect of the esophagus at the level of the thyroid\n gland which likely represents esophageal perforation and/or abscess.\n Additional considerations include esophageal diverticulum, although\n less likely.\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n # Airway Obstruction/malignancy- pt with ? episode of stridor\n overnight. Now appears in no distress. MRI of neck yesterday, read\n pending but there is question of a possible esophageal perforation. Pt\n is stable currently but unclear of risks of continued edema or risk of\n complications from current state.\n - 1x dose dexamethasone; will discuss with ENT\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 2 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx\n # Nutrition: NPO for possible surgery. J-tube feedings on hold.\n - give 1L NS\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n ICU Care\n Nutrition: NPO, J-tube\n Glycemic Control: ISS\n Lines:\n 22 Gauge - 03:20 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n Communication:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429713, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting.open tracheostomy done on with no:6.0 portex\n tube.\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429716, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting.open tracheostomy done on with no:6.0 portex\n tube.\n .H/O airway obstruction, Central / Upper\n Assessment:\n s/p open tracheostomy on with no:6 portex tube. Sutures\n intact. Initially pt was on CPAP + PS ,peep5/ PS 10/ fio2 50%.\n Mentating well. portugese speaking, sats 100% RR 18-24\ns. No Resp\n distress or noted.\n Action:\n Put trache collar 50% at 2am. Sats 100% . RR 18-22. Pt looks\n comfortable.suctioned for white thick secretions. Pt cough well and\n bringining out white secretions.\n Response:\n VS stable. No resp distress noted.\n Plan:\n Continue with trache collar. Monitor VS and sats. Suctione PRN.\n" }, { "category": "Physician ", "chartdate": "2130-12-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430170, "text": "Chief Complaint: airway obstruction\n 24 Hour Events:\n Tachycardic; hypotensive to SBPs 80s.\n Cortisol level 17; increased to 25 with cortsyntropin.\n Givem 500cc bolus this AM for tachycardia and MAP 58\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 06:00 PM\n Vancomycin - 08:11 PM\n Metronidazole - 11:11 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:12 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 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 128 (99 - 145) bpm\n BP: 83/39(51) {80/39(51) - 92/67(72)} mmHg\n RR: 30 (14 - 30) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 4,644 mL\n 376 mL\n PO:\n TF:\n 1,243 mL\n 198 mL\n IVF:\n 3,190 mL\n 128 mL\n Blood products:\n Total out:\n 2,750 mL\n 1,125 mL\n Urine:\n 2,750 mL\n 1,125 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,894 mL\n -749 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\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 415 K/uL\n 8.9 g/dL\n 107 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 102 mEq/L\n 137 mEq/L\n 26.1 %\n 6.9 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n 04:26 AM\n 04:22 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n 8.4\n 6.9\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n 26.7\n 26.1\n Plt\n 633\n 645\n 514\n 466\n 457\n 415\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n 0.6\n 0.5\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n 116\n 107\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Ensure (Full) - 06:00 AM 110 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429369, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Stridor improved. Scope by ENT revealed improved edema in a.m. w/ r\n chord paralysis. Re-scoped in afternoon and edema was worse. This was 7\n hrs after Decadron and she was due for third dose in 1hr. Also c/o more\n pain after 2^nd scope.\n Action:\n Given Tylenol and 10mg IV Decadron.\n Response:\n Throat sl better.\n Plan:\n Morphine via PEG. MRI neck and mediastinum. Thoracic wants to r/o\n esophageal tear. Dispo ICU per ENT attending. Possible trach or\n resection pnd MRI.\n" }, { "category": "Physician ", "chartdate": "2130-12-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429372, "text": "Chief Complaint: Stridor\n 24 Hour Events:\n - ENT - advised continued MICU care, trachea 3 mm at narrowest point\n and supraglottic edema, R vocal cord paralysis\n - Thoracics consult- likely not a tear; advised barium swallow and\n broad spectrum coverage, ddx perforation vs TE fistula;\n - Pt did not tolerate barium swallow\n - Added Vanco/Levo/Flagyl/Fluconazole\n - MR Neck - read PENDING (wet read by surgery - no ET fistula, no\n extaluminal air)\n - TFs - restart Ensure\n - Evaluated for worsening stridor at 0400; Inspiratory stridor noted on\n exam in all lung fields, but pt saturating well. Denies worsening pain.\n Thoracics informed.\n Patient unable to provide history: Language barrier\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 09:05 PM\n Metronidazole - 12:19 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.3\nC (97.3\n HR: 90 (90 - 111) bpm\n BP: 104/60(70) {95/57(63) - 113/92(98)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,565 mL\n 531 mL\n PO:\n TF:\n 145 mL\n 239 mL\n IVF:\n 1,315 mL\n 172 mL\n Blood products:\n Total out:\n 1,550 mL\n 700 mL\n Urine:\n 1,550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 15 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\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 645 K/uL\n 10.4 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 15 mg/dL\n 97 mEq/L\n 133 mEq/L\n 30.3 %\n 12.8 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n WBC\n 7.9\n 12.8\n Hct\n 27.8\n 30.3\n Plt\n 633\n 645\n Cr\n 0.5\n 0.6\n Glucose\n 138\n 142\n Other labs: Ca++:9.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:03 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": "2130-12-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 429880, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt has been on trache collar all day, resp did try to deflate the cuff\n so we could help her to talk but she had a lot of and not much\n of a leak around the trache. Her LS are clear, she has been coughing\n up thick sputum into her mouth.\n Action:\n Suctioned from her trache for minimal white secretions, OOB to a chair\n with minimal assist\n Response:\n She has a small trache\n a number 6 and needs the small suction cath to\n suction her trache with (size 10 french)\n Plan:\n She will need valve from speech and swallow, they will\n need to come by and evaluate her for this before it is used.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt with unresectable esophageal CA, she just had a baby prior to being\n diagnosed, her 4 children and husband live in . Her affect\n is very withdrawn, her cousin who is her healthcare proxy states that\n she feels that the patient needs to get counseling.\n Action:\n Appears withdrawn and depressed, to contact psych\n Response:\n Plan:\n Cont to follow, have psych see her with an interpreter. D/C plans need\n to be addressed, if she wants to go back home she will need sevices and\n supplies as well as patient teaching. She currently is living with her\n cousin in .\n After talking with the translator who has been translating for her\n since her initial treatment, he feels that the patient thinks that the\n cancer is all gone and that we will be able to fix her airway in the\n future. Her oncologist will be emailed this info, this will need to be\n followed up on so she has a full picture of her cancer and any\n treatment options and her long term out look and if it is possible to\n get her back home to to her family.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n ESOPHAGEAL MASS, NECK PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 54.4 kg\n Daily weight:\n Allergies/Reactions:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:91\n D:57\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 622 mL\n 24h total out:\n 1,500 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 04:54 AM\n Potassium:\n 3.3 mEq/L\n 08:38 AM\n Chloride:\n 98 mEq/L\n 04:54 AM\n CO2:\n 28 mEq/L\n 04:54 AM\n BUN:\n 8 mg/dL\n 04:54 AM\n Creatinine:\n 0.6 mg/dL\n 04:54 AM\n Glucose:\n 97 mg/dL\n 04:54 AM\n Hematocrit:\n 25.0 %\n 04:54 AM\n Finger Stick Glucose:\n 124\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2130-12-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430318, "text": "Hypotension (not Shock)\n Assessment:\n Pt w/ baseline hypotension which can go down into high 70\ns systolic\n and maps of 50\ns but will continue to remain asymptomatic\n Action:\n Fluid challenged w/ 2 liters NS during day. 1L NS @ midnight.. Had\n cardiac echo.\n Response:\n Min response to fluid challenge no change in hemodynamics, echo n WNL\n Plan\n Plan call out to floor\n .H/O airway obstruction, Central / Upper\n Assessment:\n pt on trach mask @ 40% for moisture\n Action:\n Speech and swallow attempted pass\n muir valve\n Response:\n Pt did not tolerate valve\n Plan:\n Will try again tommorow\n 40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema. Patient had esophageal\n strictures likely due to radiation changes & cancer complications.\n Unable to dilate due to s/p XRT. Has PEG @ home for TF\ns. MRI done\n shows esophageal perforation @ level of thyroid. Trach done\n" }, { "category": "Nursing", "chartdate": "2130-12-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429495, "text": "40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease swelling.\n" }, { "category": "Nursing", "chartdate": "2130-12-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429765, "text": "40 yo Portuguese speaking woman with /unresectable esoph cancer dx\n , trans from 7F w/stridor r/t acute laryngeal edema, likely from\n acid d/t vomiting.open tracheostomy done on with no:6.0 portex\n tube.\n .H/O airway obstruction, Central / Upper\n Assessment:\n s/p open tracheostomy on with no:6 portex tube. Sutures\n intact. Initially pt was on CPAP + PS ,peep5/ PS 10/ fio2 50%.\n Mentating well. portugese speaking, sats 100% RR 18-24\ns. No Resp\n distress or noted.\n Action:\n Put trache collar 50% at 2am. Sats 100% . RR 18-22. Pt looks\n comfortable.suctioned for white thick secretions. Pt cough well and\n bringining out white secretions.\n Response:\n VS stable. No resp distress noted.\n Plan:\n Continue with trache collar. Monitor VS and sats. Suctione PRN.\n Hypotension (not Shock)\n Assessment:\n Pt received with BP 80-90/50-60 mm of hg. But MAP > 60 all the time. ?\n secondary to methadone. HR > 120\ns mostly when more awake.\n Action:\n Fluid bolus N/S 1litre x once given with improvement in Sys BP 90-100\n for sometime.again after sometime sys 80-90 mm of hg. ICU team aware.\n Pt awake and comfortable.\n Response:\n Per Dr. , monitor MAP ,mainatain > 60. HR 90-100\n Plan:\n Continue to monitor MAP.\n Pt alert, oriented, gesturing. Able to follow gestures. Voided good\n amount yellow clear urine in the bedpan.\n PEG intact.plan to restart with feed today. NPO now. No PM po meds\n given.\n 22 g Piv x 2, both slight redness after iv levaquin, redness subsided\n later on. started new 20g PIV on lt hand.\n Bath,trache care given .PEG dressing changed. Repositioned.remains\n stable.\n" }, { "category": "Respiratory ", "chartdate": "2130-12-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429774, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 6.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Patient switched to trache mask with 40% aerosol.\n Ventilator d/c\n" }, { "category": "Respiratory ", "chartdate": "2130-12-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429859, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 6.0mm\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Attempted to deflated cuff and have pt speak. Not tolerated well. Pt\n with stridor and a forced exhaletion. Us if related to edema from\n surgury of obstruction from tumor.\n" }, { "category": "Physician ", "chartdate": "2130-12-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429565, "text": "Chief Complaint:\n 24 Hour Events:\n Had stridor ~6am.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:30 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 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: 96 (76 - 105) bpm\n BP: 99/61(68) {92/51(62) - 107/69(76)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,860 mL\n 710 mL\n PO:\n TF:\n 390 mL\n IVF:\n 2,060 mL\n 710 mL\n Blood products:\n Total out:\n 1,900 mL\n 700 mL\n Urine:\n 1,900 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 960 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///30/\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 514 K/uL\n 9.0 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 99 mEq/L\n 135 mEq/L\n 26.8 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n WBC\n 7.9\n 12.8\n 7.0\n Hct\n 27.8\n 30.3\n 26.8\n Plt\n 633\n 645\n 514\n Cr\n 0.5\n 0.6\n 0.7\n Glucose\n 138\n 142\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.1 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.2 mg/dL\n MRI Neck:\n 12 x 8 mm collection of air with small amount of fluid just\n anterior to the right aspect of the esophagus at the level of the\n thyroid\n gland which likely represents esophageal perforation and/or abscess.\n Additional considerations include esophageal diverticulum, although\n less\n likely.\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:20 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": "2130-12-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 430675, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n No tests or procedures. No noted stridor. Gd O2sats on RA.\n Action:\n Monitored airway. OOB to commode. Tol well.\n Response:\n Napping on and off all day.\n Plan:\n ICU for airway monitoring per ENT.\n Cancer (Malignant Neoplasm), Esophageal\n Assessment:\n No c/o neck/shoulder pain. Esophageal perf per MRI.\n Action:\n Antibiotics.\n Response:\n Afebrile.\n Plan:\n Cont antibiotics. Follow temps.\n TFs resumes at 10cc/hr. Advance slowly asl tol. Goal: Ensure at\n 110cc/hr.\n No stool since ICU admit. Please give prn Colace ATC.\n" }, { "category": "Respiratory ", "chartdate": "2130-12-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429674, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: 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: Stridor\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Stridor\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: 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:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt trached in or this shift.\n" }, { "category": "Nursing", "chartdate": "2130-12-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 430001, "text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Pt more sleepy, lethargic, looks like more depressed than yesterday.\n Continued with trache collar ,sats 100% .\n Action:\n Slept till MN and then OOB to chair for 2 hrs. voided in the bedpan.\n Response:\n Remains stable.\n Plan:\n Continue with trache collar. Monitor sats /RR\n BP sys 80-90.monitoring with MAP,to maintain MAP > 60mm of hg\n Call out to OMED, waiting for bed.\n" }, { "category": "Nutrition", "chartdate": "2130-12-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 430198, "text": "Subjective\n Patient with trach\n Objective\n Pertinent medications: pantoprazole, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 107 mg/dL\n 04:22 AM\n Glucose Finger Stick\n 135\n 06:00 AM\n BUN\n 6 mg/dL\n 04:22 AM\n Creatinine\n 0.5 mg/dL\n 04:22 AM\n Sodium\n 137 mEq/L\n 04:22 AM\n Potassium\n 4.0 mEq/L\n 04:22 AM\n Chloride\n 102 mEq/L\n 04:22 AM\n TCO2\n 29 mEq/L\n 04:22 AM\n Calcium non-ionized\n 9.0 mg/dL\n 04:22 AM\n Phosphorus\n 2.7 mg/dL\n 04:22 AM\n Magnesium\n 1.8 mg/dL\n 04:22 AM\n Current diet order / nutrition support: Ensure at 110ml/hr x 15 hours -\n provides 1749kcal and 60g protein\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 40yF with terminal esophageal CA with hx of recent stridor,n/v/retching\n and ?esophageal perforation now s/p trach placement. Patient continues\n on home tube feeding regimen and is tolerating fairly well. Noted\n patient s/p trach placement on , but failed PMV evaluation today.\n Will follow.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue with Ensure at 110ml/hr x 15 hours\n 2. Monitor tolerance of tube feeding via abdominal exam\n 3. Will follow for plan of care\n 10:42 AM\n" }, { "category": "Nursing", "chartdate": "2130-12-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430266, "text": "Hypotension (not Shock)\n Assessment:\n Pt w/ baseline hypotension which can go down into high 70\ns systolic\n and maps of 50\ns but will continue to remain asymptomatic\n Action:\n Fluid challenged w/ 2 liters nss , bedside echo\n Response:\n Min response to fluid challenge no change in hemodynamics, echo n WNL\n Plan\n Plan call out to floor\n .H/O airway obstruction, Central / Upper\n Assessment:\n pt on trach mask @ 40% for moisture\n Action:\n Speech and swallow attempted pass\n muir valve\n Response:\n Pt did not tolerate valve\n Plan:\n Will try again tommorow\n 40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema, likely from acid d/t vomiting.\n Here for airway observation. Treated w/decadron to decrease\n swelling. Patient has esophageal strictures likely due to radiation\n changes & cancer complications. Unable to dilate due to s/p XRT. Has\n PEG @ home for TF\ns. Takes only swabs/toothbrush in mouth. MRI done\n shows esophageal perforation @ level of thyroid.\n" }, { "category": "Nursing", "chartdate": "2130-12-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430319, "text": "Hypotension (not Shock)\n Assessment:\n Pt w/ baseline hypotension which can go down into high 70\ns systolic\n and maps of 50\ns but will continue to remain asymptomatic\n Action:\n Fluid challenged w/ 2 liters NS during day. 1L NS @ midnight.. Had\n cardiac echo.\n Response:\n Min response to fluid challenge no change in hemodynamics, echo n WNL\n Plan\n Plan call out to floor\n .H/O airway obstruction, Central / Upper\n Assessment:\n pt on trach mask @ 40% for moisture\n Action:\n Speech and swallow attempted pass\n muir valve\n Response:\n Pt did not tolerate valve\n Plan:\n Will try again tommorow\n 40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema. Patient had esophageal\n strictures likely due to radiation changes & cancer complications.\n Unable to dilate due to s/p XRT. Has PEG @ home for TF\ns. MRI done\n shows esophageal perforation @ level of thyroid. Tracheostomy\n placed (#6 portex). Covered w/flagyl & vanco IV for esophageal\n perf.\n" }, { "category": "Nursing", "chartdate": "2130-12-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430320, "text": "Hypotension (not Shock)\n Assessment:\n Pt w/ baseline hypotension which can go down into high 70\ns systolic\n and maps of 50\ns but will continue to remain asymptomatic\n Action:\n Fluid challenged w/ 2 liters NS during day. 1L NS @ midnight.. Had\n cardiac echo.\n Response:\n Min response to fluid challenge no change in hemodynamics, echo n WNL\n Plan\n Plan call out to floor\n .H/O airway obstruction, Central / Upper\n Assessment:\n pt on trach mask @ 40% for moisture\n Action:\n Speech and swallow attempted pass\n muir valve\n Response:\n Pt did not tolerate valve\n Plan:\n Will try again tommorow\n 40 yo Portuguese speaking woman with /unresectable esophogeal cancer dx\n . Admitted to 7F & transferred to MICU on \n w/stridor r/t acute laryngeal edema. Patient had esophageal\n strictures likely due to radiation changes & cancer complications.\n Unable to dilate due to s/p XRT. Has PEG @ home for TF\ns. MRI done\n shows esophageal perforation @ level of thyroid. Tracheostomy\n placed (#6 portex). Covered w/flagyl & vanco IV for esophageal\n perf.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n ESOPHAGEAL MASS, NECK PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 54.4 kg\n Daily weight:\n Allergies/Reactions:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history:\n Surgery / Procedure and date: tracheostomy placed\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:78\n D:48\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 119 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,118 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 04:22 AM\n Potassium:\n 4.0 mEq/L\n 04:22 AM\n Chloride:\n 102 mEq/L\n 04:22 AM\n CO2:\n 29 mEq/L\n 04:22 AM\n BUN:\n 6 mg/dL\n 04:22 AM\n Creatinine:\n 0.5 mg/dL\n 04:22 AM\n Glucose:\n 107 mg/dL\n 04:22 AM\n Hematocrit:\n 26.1 %\n 04:22 AM\n Finger Stick Glucose:\n 181\n 10:00 PM\n Valuables / Signature\n Patient valuables: sent to floor w/her\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: 7 South\n Date & time of Transfer: @ 0100\n" }, { "category": "General", "chartdate": "2130-12-05 00:00:00.000", "description": "ICU Event Note", "row_id": 429149, "text": "Clinician: Attending\n Patient admitted to for respiratory distress and stridor. Patient\n with hx of esophageal ca treated with XRT. Has had chest pain and found\n to have mediastional/esophageal mass. Patient came to hospital with\n recurrent vomiting. Developed stridor with evidence on laryngoscopy of\n vocal cord edema and reduced vocal cord motin, and transferred to \n for further care. Patient has also been found to have a LUL nodular\n lesion. Underwent bronchoscopy recently with negative BAL.\n On exam, patient is a thin woman using accessory muscles of\n inspiration. O2 sats are 96% without supplemental oxygen. There is\n stridor and expiratory wheeze over the neck. Chest is resonant to\n percussion and symmetrical on expansion. Good air movement bilaterally\n without wheezes and rhonchi. PMI is not displaced. S1 and S2 are\n normal. No gallop or murmur. Abdomen with PEG. Active bowel sounds. No\n tenderness. Extremities warm and well perfused. No edema. Patient\n awake and alert. Communication hampered by language barriers.\n CT Scan reviewed. LUL lesion noted. Mild narrowing of trachea at region\n of vocal cords. Subglottic esophageal mass seen. No focal lung\n infiltrates.\n IMP: Patient with acute laryngeal edema, likely due to acid from\n vomiting. Patient receiving decadron to reduce swelling. Will keep\n heliox at bedside; if work of breathing increases or oxygen saturation\n decreases, would begin heliox. Hope to avoid intubation.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2130-12-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429802, "text": "Chief Complaint: stridor\n 24 Hour Events:\n - Appeared lethargic in am; abg did not show hypercarbia 7.48/38/159/29\n - Had trachyostomy; tolerated procedure well. Weaned off vent\n overnight and placed on trach mask.\n - Per Thoracics, would attempt passy miur valve today.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:09 PM\n Metronidazole - 12:10 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\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: 37.2\nC (98.9\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 131) bpm\n BP: 92/60(67) {82/26(57) - 120/90(96)} mmHg\n RR: 11 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 4,637 mL\n 150 mL\n PO:\n TF:\n IVF:\n 4,637 mL\n 150 mL\n Blood products:\n Total out:\n 3,000 mL\n 1,350 mL\n Urine:\n 3,000 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,637 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 602 (602 - 721) mL\n PS : 15 cmH2O\n RR (Set): 20\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n SpO2: 100%\n ABG: 7.48/38/159/28/5\n Ve: 6.5 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General Appearance: Thin, NAS\n HEENT: PERRL, MMM, neck mildly tenderness to palpation.\n Neck: Trach mask in place\n Cardiovascular: RRR, s1/s2, no appreciable murmur\n Peripheral Vascular: 2+ distal pulses\n Respiratory / Chest: Expansion: Symmetric, diffuse minimal upper\n airway noises\n Abdominal: Soft, Non-tender, J tube in place, non-tender\n Extremities: no clubbing, cyanosis, edema\n Neurologic: Attentive, Follows simple commands, Responds,\n Labs / Radiology\n 466 K/uL\n 8.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 5.9 mEq/L\n 8 mg/dL\n 98 mEq/L\n 132 mEq/L\n 25.0 %\n 9.1 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n 12:33 PM\n 04:54 AM\n WBC\n 7.9\n 12.8\n 7.0\n 9.1\n Hct\n 27.8\n 30.3\n 26.8\n 25.0\n Plt\n 633\n 645\n 514\n 466\n Cr\n 0.5\n 0.6\n 0.7\n 0.6\n TCO2\n 29\n Glucose\n 138\n 142\n 97\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n # Airway Obstruction/malignancy- pt with ? episode of stridor\n overnight. Now appears in no distress. MRI of neck yesterday, read\n pending but there is question of a possible esophageal perforation. Pt\n is stable currently but unclear of risks of continued edema or risk of\n complications from current state.\n - 1x dose dexamethasone; will discuss with ENT\n - f/u thoracics/ENT recs\n - f/u with oncology service\n # Leukocytosis: resolved. Now day 2 Vanco/Levo/Flagyl/Fluconazole\n () for possible esophageal perforation/abcess.\n - Will continue with abx\n # Nutrition: NPO for possible surgery. J-tube feedings on hold.\n - give 1L NS\n # Hypotension: SBP\ns consistently low but patient in no distress. \n be due to hypovolemia.\n - fluids as above.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 02:16 PM\n 20 Gauge - 07:20 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": "2130-12-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429568, "text": "Chief Complaint:\n 24 Hour Events:\n Had stridor ~6am.\n H/O airway obstruction, Central / Upper\n Assessment:\n Patient had no stridor early this evening while awake. Developed\n stridor while sleeping. No c/o SOB or respiratory distress.\n Maintained O2 sats: 97-100% on room air. HR: 90\ns SR - no\n ectopy. HR up to 120\ns w/exertion (walking to toilet).\n Action:\n Placed humidified O2 @ 35% via tent mask, overnight, near face as\n patient wouldn\nt wear it as it was uncomfortable. Neb was set up\n w/racemic epi (unopened). Helio-oxygen tank in back room.\n Response:\n Preop checklist started. NPO since Mn.\n Plan:\n Meeting w/PCP, , GI (& thoracics) in am to discuss trach\n placement. If agreed on, patient to have trach placed later today.\n Constipation (Obstipation, FOS)\n Assessment:\n Patient told GI MD that she had no BM since Sun (). Abdomen\n soft. +Bowel sounds. Had N/V before admission.\n Action:\n Patient placed back on lactulose 30cc tid prn. Received 1st dose last\n evening. Now NPO for possible trach placement.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:53 PM\n Vancomycin - 08:30 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Other medications:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 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: 96 (76 - 105) bpm\n BP: 99/61(68) {92/51(62) - 107/69(76)} mmHg\n RR: 13 (12 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,860 mL\n 710 mL\n PO:\n TF:\n 390 mL\n IVF:\n 2,060 mL\n 710 mL\n Blood products:\n Total out:\n 1,900 mL\n 700 mL\n Urine:\n 1,900 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 960 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///30/\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 514 K/uL\n 9.0 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 13 mg/dL\n 99 mEq/L\n 135 mEq/L\n 26.8 %\n 7.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:47 AM\n 04:25 AM\n 06:10 AM\n WBC\n 7.9\n 12.8\n 7.0\n Hct\n 27.8\n 30.3\n 26.8\n Plt\n 633\n 645\n 514\n Cr\n 0.5\n 0.6\n 0.7\n Glucose\n 138\n 142\n 97\n Other labs: PT / PTT / INR:17.0/29.6/1.5, Differential-Neuts:84.1 %,\n Lymph:9.3 %, Mono:5.7 %, Eos:0.7 %, Ca++:9.1 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.2 mg/dL\n MRI Neck:\n 12 x 8 mm collection of air with small amount of fluid just\n anterior to the right aspect of the esophagus at the level of the\n thyroid\n gland which likely represents esophageal perforation and/or abscess.\n Additional considerations include esophageal diverticulum, although\n less\n likely.\n Assessment and Plan\n CONSTIPATION (OBSTIPATION, FOS)\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL\n ANEMIA, CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436699, "text": "TITLE:\n 40 y/o non-smoker w/esophageal SCC x/p chemo/XRT, s/p trach \n for upper airway compromise w/parapharyngeal abcess. Reconsulted\n recently for cavitary lung lesions inc. in size from to . No\n hemopytsis from trach or night sweats. No TB hx.\n : Metastatic esophageal cancer s/p L VATS, upper lobe wedge\n resection, pleural biopsy and talc pleurodesis. In PACU unable to wean\n Neo and tachycardic to 120s with low grade temp of 100.2 PO >> to SICU.\n .H/O cancer (Malignant Neoplasm), Lung\n Assessment:\n Lungs clear. Diminished in bases. Oxygen saturation >98% on\n 35% FiO2 trach mask.\n Moderate amounts of thick tan secretions.\n CT at 20cm suction.\n Action:\n S/p vats wedge resection and chest tube placement.\n Encouraging C/DB. Receiving nebs as needed.\n Response:\n Lungs remain clear and diminished in bases. 02 sat\ns 99-100%\n on 35% FiO2 trach mask.\n Continues coughing up moderate amounts of thick tan\n secretions. Using yankeur appropriately.\n No fluctuation or leak noted in CT. Draining small amounts\n of serous fluid.\n Plan:\n Continue to monitor resp status.\n Monitor CT output.\n Hypotension (not Shock)\n Assessment:\n Pt on Neo with SBP 95-120. MAP >65.\n Action:\n Started on 5% Albumin x24 hours.\n Continues receiving maintenance fluids at 60cc/hr and\n titrating Neo to goal MAP >65.\n Response:\n Pt continues requiring Neo drip however titrating down since\n starting Albumin.\n Plan:\n Continue IVF and Albumin.\n Titrate Neo to MAP >65.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt primarily Portuguese speaking however with c/o\n generalized pain. Unable to properly rate pain due to language barrier.\n On Morphine PCA.\n Action:\n Continues on PCA and receiving Methadone twice daily.\n Applying hot packs to sore areas as requested.\n Response:\n Using PCA appropriately.\n Slept in 1.5 hr intervals comfortably.\n Plan:\n Continue to monitor pain/comfort.\n" }, { "category": "Nursing", "chartdate": "2131-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436840, "text": "TITLE:\n .H/O cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt Portuguese speaking. Oriented x3. MAE assisting as\n tolerates. States having Right arm pain along with generalized\n soreness.\n On 35% FiO2 trach mask. Lungs clear to diminished in bases.\n No c/o SOB or inc WOB. Expectorated small amounts of thick white\n secretions.\n TF at goal. 30-120cc light clear yellow urine hourly.\n Awaiting second CXR PICC confirmation.\n Action:\n Morphine PCA continues.\n -muir and other valuables obtained from .\n CXR for PICC read.\n Receiving NeutraPhos twice daily.\n Response:\n Adequate pain relief with PCA.\n Unable to tolerate -muir valve this am as pt became\n hypertensive with mild bronchospasms.\n PICC pulled out further to total 7cm out.\n Urine output remains >50cc/hr. Phosphate level increased to\n 1.9 from 1.3. K and Mag 3.6 and 1.8 respectively. BMx1 for loose brown\n stool.\n Plan:\n Continue with current pain medication regime.\n -muir as tolerates and translator as needed.\n Continue w/trach mask.\n Continue w/TF at goal. Repleting electrolytes. Cont with\n Neutra Phos x1 more day.\n Transfer to today.\n Tachycardia, Other\n Assessment:\n Sinus tachycardia HR 100-135.\n SBP 90-110. MAP >70.\n Tmax 100.5\n Action:\n Received 250cc NS fluid bolus and 650mg PO Tylenol x1.\n Response:\n HR remains 100-130. SBP >90 and MAP >70.\n Plan:\n Continue to monitor hemodynamics maintaining SBP >90.\n Monitor temp. F/u cultures from .\n" }, { "category": "Physician ", "chartdate": "2131-01-13 00:00:00.000", "description": "Intensivist Note", "row_id": 436567, "text": "SICU\n HPI:\n HPI: 40 F non-smoker w/ upper esophageal SCC x/p\n chemo/XRT, s/p tracheostomy () for upper airway compromise\n with parapharyngeal abscess/contained perf (now resolved s/p 28 day\n course of Unasyn/Clindamycin).\n Intraop finding of malignant pleural studding\n s/p L VATS, pleural bx, LUL wedge resection, talc pleurodesis \n PMH: Esophageal SCC (s/p Chemo XRT done ); anemia; upper esophageal\n stricture; lung mass; PEG candidiasis\n PSH: PEG, trach\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - START 06:40 AM\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.8\nC (100\n HR: 137 (137 - 137) bpm\n BP: 102/59(75) {102/59(75) - 102/59(75)} mmHg\n RR: 25 (25 - 25) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,483 mL\n PO:\n Tube feeding:\n IV Fluid:\n 983 mL\n Blood products:\n 500 mL\n Total out:\n 0 mL\n 5,190 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -3,707 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular, tachy)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: HPI: 40 F non-smoker w/ upper esophageal SCC x/p\n chemo/XRT, s/p tracheostomy () for upper airway compromise\n with parapharyngeal abscess/contained perf (now resolved s/p 28 day\n course of Unasyn/Clindamycin).\n Intraop finding of malignant pleural studding\n s/p L VATS, pleural bx, LUL wedge resection, talc pleurodesis \n PMH: Esophageal SCC (s/p Chemo XRT done ); anemia; upper esophageal\n stricture; lung mass; PEG candidiasis\n PSH: PEG, trach\n Neurologic: Morphine PCA, Methadone 2.5 mg PO BID, lorazepam for\n anxiety\n Cardiovascular: wean neo as tolerated, albumin for tachycardia\n Pulmonary: Trach, nebs prn\n Gastrointestinal / Abdomen: strictly NPO, restart TF\n Nutrition: Tube feeding\n Renal: f/u u/o\n Hematology: Hct 23 no transfusion\n Endocrine: RISS\n Infectious Disease: no abx\n Lines / Tubes / Drains: lt CT, foley, PIV, rt aline, trach\n Wounds:\n Imaging: CXR today\n Fluids: LR at 200 ml/hr\n Consults: CT surgery\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:40 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2131-01-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 436835, "text": "Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 6.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff volume: 2 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Pt unable to tol capping with PMV this am. Became bronchospastic,\n coughing continuously. Placed 2cc air back in cuff. Will attempt\n capping later today.\n" }, { "category": "Physician ", "chartdate": "2131-01-14 00:00:00.000", "description": "Intensivist Note", "row_id": 436705, "text": "SICU\n HPI:\n 40 F non-smoker w/ upper esophageal SCC x/p chemo/XRT, s/p\n tracheostomy () for upper airway compromise\n with parapharyngeal abscess/contained perf (now resolved s/p 28 day\n course of Unasyn/Clindamycin).\n Intraop finding of malignant pleural studding s/p L VATS, pleural bx,\n LUL wedge resection, talc pleurodesis \n PMHx:\n Esophageal SCC (s/p Chemo XRT done ); anemia; upper esophageal\n stricture; lung mass; PEG candidiasis\n Current medications:\n Acetaminophen (Liquid), Acetylcysteine 20%, Aluminum-Magnesium\n Hydrox.-Simethicone, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral\n Rinse, DiphenhydrAMINE, Docusate Sodium (Liquid), Fluticasone\n Propionate 110mcg, Guaifenesin, Heparin, Hydrocerin, Ipratropium\n Bromide Neb, Lactulose, Lansoprazole Oral Disintegrating Tab,\n Lorazepam, Magnesium Oxide, Methadone, Metoprolol Tartrate, Morphine\n Sulfate, Nortriptyline, Phenylephrine, Potassium Chloride, Sarna\n Lotion, Senna\n 24 Hour Events:\n BAL FLUID CULTURE - At 05:41 PM\n EKG - At 10:45 PM\n ordered for continued tachycardia.\n : still on neo, received 2 units of PRBC and albumin.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:10 AM\n Flowsheet Data as of 05:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.3\n HR: 105 (93 - 137) bpm\n BP: 97/61(76) {84/45(60) - 122/72(92)} mmHg\n RR: 32 (19 - 39) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,449 mL\n 1,460 mL\n PO:\n Tube feeding:\n 599 mL\n 377 mL\n IV Fluid:\n 2,770 mL\n 353 mL\n Blood products:\n 1,045 mL\n 500 mL\n Total out:\n 9,240 mL\n 1,340 mL\n Urine:\n 4,010 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,791 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands\n Labs / Radiology\n 358 K/uL\n 10.2 g/dL\n 192 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 5 mg/dL\n 100 mEq/L\n 135 mEq/L\n 27.7 %\n 7.8 K/uL\n [image002.jpg]\n 10:21 PM\n 04:41 AM\n WBC\n 10.6\n 7.8\n Hct\n 29.0\n 27.7\n Plt\n 425\n 358\n Creatinine\n 0.4\n Troponin T\n <0.01\n Glucose\n 192\n Other labs: CK / CK-MB / Troponin T:217/2/<0.01, Ca:8.6 mg/dL, Mg:1.7\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O CANCER (MALIGNANT\n NEOPLASM), ESOPHAGEAL, .H/O CANCER (MALIGNANT NEOPLASM), LUNG,\n HYPOTENSION (NOT SHOCK)\n Assessment and Plan:\n Neurologic: Morphine PCA, Methadone 2.5 mg PO BID, lorazepam for\n anxiety\n Cardiovascular: wean neo as tolerated, recieved 2 units of PRBC and\n albumin, consider placeing central line for both access and CVP\n Pulmonary: Trach, nebs prn\n Gastrointestinal / Abdomen: TF\n Nutrition: Tube feeding\n Renal: 5L UOP, FENA 0.7%, urine OSM 172, serum 277\n Hematology: Serial Hct, Hct 23 two unit PRBC and albumin\n Endocrine: RISS, RISS, stem test 21->31\n Infectious Disease: no Abx\n Lines / Tubes / Drains: CONSIDER CVL, Lt CT to wall suction, foley,\n PIV, rt aline, trach\n Wounds: c/d/i\n Imaging: CXR today\n Fluids: NS, 60ml/hr\n Consults: CT surgery, ID dept\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Ensure Plus (Full) - 12:00 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:40 AM\n 20 Gauge - 01:06 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2131-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436677, "text": "TITLE:\n .H/O cancer (Malignant Neoplasm), Lung\n Assessment:\n Lungs clear. Diminished in bases. Oxygen saturation >98% on\n 35% FiO2 trach mask.\n Moderate amounts of thick tan secretions.\n CT at 20cm suction.\n Action:\n S/p vats wedge resection and chest tube placement.\n Encouraging C/DB. Receiving nebs as needed.\n Response:\n Lungs remain clear and diminished in bases. 02 sat\ns 99-100%\n on 35% FiO2 trach mask.\n Continues coughing up moderate amounts of thick tan\n secretions. Using yankeur appropriately.\n No fluctuation or leak noted in CT. Draining small amounts\n of serous fluid.\n Plan:\n Continue to monitor resp status.\n Monitor CT output.\n Hypotension (not Shock)\n Assessment:\n Pt on Neo with SBP 95-120. MAP >65.\n Action:\n Started pt on 5% Albumin x24 hours.\n Continues receiving maintenance fluids at 60cc/hr and\n titrating Neo to goal MAP >65.\n Response:\n Pt continues requiring Neo drip however titrating down since\n starting Neo.\n Plan:\n Continue IVF and Albumin.\n Titrate Neo to MAP >65.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt primarily Portuguese speaking however with c/o\n generalized pain. Unable to properly rate pain due to language barrier.\n On Morphine PCA.\n Action:\n Continues on PCA and receiving Methadone twice daily.\n Applying hot packs to sore areas as requested.\n Response:\n Using PCA appropriately.\n Slept in 1.5 hr intervals comfortably.\n Plan:\n Continue to monitor pain/comfort.\n" }, { "category": "Physician ", "chartdate": "2131-01-15 00:00:00.000", "description": "Intensivist Note", "row_id": 436850, "text": "SICU\n HPI:\n 40 F non-smoker w/ upper esophageal SCC x/p chemo/XRT, s/p\n tracheostomy () for upper airway compromise with parapharyngeal\n abscess/contained perf (now resolved s/p 28 day course of\n Unasyn/Clindamycin).Intraop finding of malignant pleural studding\n s/p L VATS, pleural bx, LUL wedge resection, talc pleurodesis \n Chief complaint:\n upper esophageal SCC\n PMHx:\n Esophageal SCC (s/p Chemo XRT done ); anemia; upper esophageal\n stricture; lung mass; PEG candidiasis\n Current medications:\n Acetaminophen (Liquid) 5. Acetylcysteine 20% 6. Aluminum-Magnesium\n Hydrox.-Simethicone\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. DiphenhydrAMINE\n 11. Docusate Sodium (Liquid) 12. Fluticasone Propionate 110mcg 13.\n Guaifenesin 14. Heparin 15. Hydrocerin\n 16. 17. Insulin 18. Ipratropium Bromide Neb 19. Lactulose 20.\n Lansoprazole Oral Disintegrating Tab\n 21. Lorazepam 22. Magnesium Oxide 23. Methadone 24. Morphine Sulfate\n 25. Neutra-Phos 26. Nortriptyline\n 27. Phenylephrine 28. Potassium Chloride 29. Sarna Lotion 30. Senna\n 24 Hour Events:\n PICC LINE - START 12:21 PM\n CHEST TUBE REMOVED - At 04:38 PM\n PAN CULTURE - At 05:54 PM\n FEVER - 101.1\nF - 04:00 PM\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 38.1\nC (100.5\n HR: 112 (103 - 134) bpm\n BP: 100/61(76) {90/56(68) - 121/75(89)} mmHg\n RR: 22 (20 - 41) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 57.5 kg (admission): 48 kg\n Total In:\n 5,363 mL\n 1,064 mL\n PO:\n Tube feeding:\n 1,682 mL\n 441 mL\n IV Fluid:\n 1,401 mL\n 433 mL\n Blood products:\n 1,500 mL\n Total out:\n 3,560 mL\n 680 mL\n Urine:\n 3,540 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,803 mL\n 384 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 352 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 105 mEq/L\n 138 mEq/L\n 26.8 %\n 5.0 K/uL\n [image002.jpg]\n 10:21 PM\n 04:41 AM\n 02:04 AM\n WBC\n 10.6\n 7.8\n 5.0\n Hct\n 29.0\n 27.7\n 26.8\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.4\n Troponin T\n <0.01\n <0.01\n Glucose\n 192\n 160\n 129\n Other labs: CK / CK-MB / Troponin T:172/2/<0.01, Ca:8.2 mg/dL, Mg:1.8\n mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL, .H/O CANCER (MALIGNANT\n NEOPLASM), LUNG, HYPOTENSION (NOT SHOCK)\n Assessment and Plan:\n Neurologic: Morphine PCA, Methadone 2.5 mg PO BID, lorazepam for\n anxiety\n Cardiovascular: stable tachycardic wean neo as tolerated, recieved\n albumin, PICC placed,\n Pulmonary: trach'd nebs prn, chest tube dc'd\n Gastrointestinal / Abdomen: TF\n Nutrition: TF\n Renal: High UOP, follow FENA, follow urine OSM , follow serum osmol\n per renal not DI, stoped albumin,\n Hematology: Hct 27 stable\n Endocrine: RISS\n Infectious Disease: no Abx\n Lines / Tubes / Drains: PICC, Lt CT to wall suction, foley, PIV, rt\n aline, trach\n Wounds: c/d/i\n Imaging:\n Fluids:\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Ensure Plus (Full) - 07:56 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:40 AM\n PICC Line - 12:21 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:\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2131-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436825, "text": "TITLE:\n .H/O cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt Portuguese speaking. Oriented x3. MAE assisting as\n tolerates. States having Right arm pain along with generalized\n soreness.\n On 35% FiO2 trach mask. Lungs clear to diminished in bases.\n No c/o SOB or inc WOB. Expectorated small amounts of thick white\n secretions.\n TF at goal. 30-120cc light clear yellow urine hourly.\n Awaiting second CXR PICC confirmation.\n Action:\n Morphine PCA continues.\n -muir and other valuables obtained from .\n CXR for PICC read.\n Receiving NeutraPhos twice daily.\n Response:\n Adequate pain relief with PCA.\n PICC pulled out further to total 7cm out.\n Urine output remains >50cc/hr. Phosphate level increased to\n 1.9 from 1.3. K and Mag 3.6 and 1.8 respectively.\n Plan:\n -muir as tolerates and translator as needed.\n Continue current pain medication regime.\n Continue w/trach mask.\n Continue w/TF at goal. Repleting electrolytes. Cont with\n Neutra Phos x1 more day.\n Transfer to today.\n Tachycardia, Other\n Assessment:\n Sinus tachycardia HR 100-135.\n SBP 90-110. MAP >70.\n Tmax 100.5\n Action:\n Received 250cc NS fluid bolus and 650mg PO Tylenol x1.\n Response:\n HR remains 100-130. SBP >90 and MAP >70.\n Temp\n Plan:\n Continue to monitor hemodynamics maintaining SBP >90.\n Monitor temp. F/u cultures from .\n" }, { "category": "Nursing", "chartdate": "2131-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436668, "text": ".H/O cancer (Malignant Neoplasm), Lung\n Assessment:\n LS clear, diminished at the bases. Pt w/ moderate amts of tan\n secretions. 02 sats 99-100% on 50% fi02.\n Action:\n s/p vats wedge resection, chest tube placement. Sputum sample collected\n this eve.\n Response:\n 02 sats 99-100% on 50% fi02\n Plan:\n continue to closely monitor resp status.\n Hypotension (not Shock)\n Assessment:\n SBP 80\ns-90\n Action:\n bld infusing, IVF infusing, neo gtt being titrated to maintain map >\n 65.\n Response:\n Pt remains hypotensive.\n Plan:\n continue IVF, bld transfusion, titrate neo gtt.\n" }, { "category": "Physician ", "chartdate": "2131-01-14 00:00:00.000", "description": "Intensivist Note", "row_id": 436738, "text": "SICU\n HPI:\n 40 F non-smoker w/ upper esophageal SCC x/p chemo/XRT, s/p\n tracheostomy () for upper airway compromise\n with parapharyngeal abscess/contained perf (now resolved s/p 28 day\n course of Unasyn/Clindamycin).\n Intraop finding of malignant pleural studding s/p L VATS, pleural bx,\n LUL wedge resection, talc pleurodesis \n PMHx:\n Esophageal SCC (s/p Chemo XRT done ); anemia; upper esophageal\n stricture; lung mass; PEG candidiasis\n Current medications:\n Acetaminophen (Liquid), Acetylcysteine 20%, Aluminum-Magnesium\n Hydrox.-Simethicone, Bisacodyl, Chlorhexidine Gluconate 0.12% Oral\n Rinse, DiphenhydrAMINE, Docusate Sodium (Liquid), Fluticasone\n Propionate 110mcg, Guaifenesin, Heparin, Hydrocerin, Ipratropium\n Bromide Neb, Lactulose, Lansoprazole Oral Disintegrating Tab,\n Lorazepam, Magnesium Oxide, Methadone, Metoprolol Tartrate, Morphine\n Sulfate, Nortriptyline, Phenylephrine, Potassium Chloride, Sarna\n Lotion, Senna\n 24 Hour Events:\n BAL FLUID CULTURE - At 05:41 PM\n EKG - At 10:45 PM\n ordered for continued tachycardia.\n : still on neo, received 2 units of PRBC and albumin.\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:10 AM\n Flowsheet Data as of 05:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.9\nC (100.3\n HR: 105 (93 - 137) bpm\n BP: 97/61(76) {84/45(60) - 122/72(92)} mmHg\n RR: 32 (19 - 39) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,449 mL\n 1,460 mL\n PO:\n Tube feeding:\n 599 mL\n 377 mL\n IV Fluid:\n 2,770 mL\n 353 mL\n Blood products:\n 1,045 mL\n 500 mL\n Total out:\n 9,240 mL\n 1,340 mL\n Urine:\n 4,010 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,791 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands\n Labs / Radiology\n 358 K/uL\n 10.2 g/dL\n 192 mg/dL\n 0.4 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 5 mg/dL\n 100 mEq/L\n 135 mEq/L\n 27.7 %\n 7.8 K/uL\n [image002.jpg]\n 10:21 PM\n 04:41 AM\n WBC\n 10.6\n 7.8\n Hct\n 29.0\n 27.7\n Plt\n 425\n 358\n Creatinine\n 0.4\n Troponin T\n <0.01\n Glucose\n 192\n Other labs: CK / CK-MB / Troponin T:217/2/<0.01, Ca:8.6 mg/dL, Mg:1.7\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O CANCER (MALIGNANT\n NEOPLASM), ESOPHAGEAL, .H/O CANCER (MALIGNANT NEOPLASM), LUNG,\n HYPOTENSION (NOT SHOCK)\n Assessment and Plan:\n Neurologic: Morphine PCA, Methadone 2.5 mg PO BID, lorazepam for\n anxiety\n Cardiovascular: wean neo as tolerated, recieved 2 units of PRBC and\n albumin, consider placeing central line for both access and CVP\n Pulmonary: Trach collar, nebs prn\n Gastrointestinal / Abdomen: TF\n Nutrition: Tube feeding\n Renal: 5L UOP, FENA 0.7%, urine OSM 172, serum 277\n Hematology: Serial Hct, Hct 23 two unit PRBC and cont albumin\n Endocrine: RISS, RISS, stem test 21->31\n Infectious Disease: no Abx\n Lines / Tubes / Drains: CONSIDER CVL, Lt CT to wall suction, foley,\n PIV, rt aline, trach\n Wounds: c/d/i\n Imaging: CXR today\n Fluids: NS, 60ml/hr\n Consults: CT surgery, ID dept\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Ensure Plus (Full) - 12:00 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:40 AM\n 20 Gauge - 01:06 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2131-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436822, "text": "TITLE:\n .H/O cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt Portuguese speaking. Oriented x3. MAE assisting as\n tolerates. States having Right arm pain along with generalized\n soreness.\n On 35% FiO2 trach mask. Lungs clear to diminished in bases.\n No c/o SOB or inc WOB. Expectorated small amounts of thick white\n secretions.\n SBP >90. Tmax 98.9.\n TF at goal.\n Awaiting second CXR PICC confirmation.\n Action:\n Morphine PCA continues.\n -muir and other valuables obtained from .\n CXR for PICC read.\n Response:\n Adequate pain relief with PCA.\n PICC pulled out further to total 7cm out.\n Plan:\n -muir as tolerates and translator as needed.\n Continue current pain medication regime.\n Continue w/trach mask.\n Maintain SBP >90.\n Transfer to today.\n" }, { "category": "Nursing", "chartdate": "2131-01-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436888, "text": "40 year old female history of proximal esophageal squamous cell\n carcinoma, chronic pain from radiation, reflux, anxiety, csection ,\n tubal ligation, j tube placement , multiple egd, trach for\n upper airway compromise with parapharyngeal abscess\n left lung nodule and left pleural effusion s/p flex bronch vats\n left upper lobe wedge resection, pleural biopsy, talc pleurodesis,\n chest tube placement, hypotensive post op, on neo\n neo weaned off, picc line placed, febrile, pan cultured, chest\n tube dc\n transfer back to 7 \n .H/O cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt alert and oriented x 3\n Portugese speaking\n Trach mask to 35%\n Sinus tach at baseline\n Sbp 90-100 (pts baseline)\n Afebrile\n Tube feeds at goal of 70cc/hr via peg\n Large loose bm\n Foley with adequate urine output\n Skin intact\n Dsd to peg and old chest tube site\n Morphine pca for pain control\n Picc line right upper arm\n Action:\n Translator obtained\n Suction via trach prn\n Monitor hemodynamics and pulmonary status\n Comfort measures provided\n Response:\n Pt resting comfortably in bed\n Vital signs stable\n Report called to 7 \n Plan:\n Awaiting ambulance to transfer patient to \n" }, { "category": "Nursing", "chartdate": "2131-01-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436889, "text": "40 year old female history of proximal esophageal squamous cell\n carcinoma, chronic pain from radiation, reflux, anxiety, csection ,\n tubal ligation, j tube placement , multiple egd, trach for\n upper airway compromise with parapharyngeal abscess\n left lung nodule and left pleural effusion s/p flex bronch vats\n left upper lobe wedge resection, pleural biopsy, talc pleurodesis,\n chest tube placement, hypotensive post op, on neo\n neo weaned off, picc line placed, febrile, pan cultured, chest\n tube dc\n transfer back to 7 \n .H/O cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Pt alert and oriented x 3\n Portugese speaking\n Trach mask to 35%\n Sinus tach at baseline\n Sbp 90-100 (pts baseline)\n Afebrile\n Tube feeds at goal of 70cc/hr via peg\n Large loose bm\n Foley with adequate urine output\n Skin intact\n Dsd to peg and old chest tube site\n Morphine pca for pain control\n Picc line right upper arm\n Action:\n Translator obtained\n Suction via trach prn\n Monitor hemodynamics and pulmonary status\n Comfort measures provided\n Response:\n Pt resting comfortably in bed\n Vital signs stable\n Report called to 7 \n Plan:\n Awaiting ambulance to transfer patient to \n ------ Protected Section ------\n Demographics\n Attending MD:\n BUSS K.\n Admit diagnosis:\n ESOPHAGEAL MASS, NECK PAIN\n Code status:\n Full code\n Height:\n Admission weight:\n 48 kg\n Daily weight:\n 57.5 kg\n Allergies/Reactions:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history: Potuguese speaking. chronic pain from radiation\n Reflux, anxiety, C-section , tubal ligation, J tube placement '\n Multiple EGD.\n Surgery / Procedure and date: s/p tracheostomy for upper airway\n compromise with parapharyngeal abscess.\n left lung nodule and left pleural effusion. s/p Flexible\n bronchoscopy, VATS, Left upper lobe wedge resection, pleural biopsy and\n talc pleurodesis. chest tube placement.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:60\n Temperature:\n 99.3\n Arterial BP:\n S:104\n D:72\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 118 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 99% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,481 mL\n 24h total out:\n 1,020 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:04 AM\n Potassium:\n 3.6 mEq/L\n 02:04 AM\n Chloride:\n 105 mEq/L\n 02:04 AM\n CO2:\n 26 mEq/L\n 02:04 AM\n BUN:\n 7 mg/dL\n 02:04 AM\n Creatinine:\n 0.4 mg/dL\n 02:04 AM\n Glucose:\n 129 mg/dL\n 02:04 AM\n Hematocrit:\n 26.8 %\n 02:04 AM\n Finger Stick Glucose:\n 131\n 10:00 AM\n Additional pertinent labs:\n calcium, kcl, mag, phos repleted this am\n Lines / Tubes / Drains:\n trach, peg, foley, picc\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 7\n Date & time of Transfer: 12:00 AM\n ------ Protected Section Addendum Entered By: , RN\n on: 10:10 ------\n" }, { "category": "Nursing", "chartdate": "2131-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 436815, "text": "TITLE:\n .H/O cancer (Malignant Neoplasm), Esophageal\n Assessment:\n Alert and oriented x 3\n Portugese speaking only\n Chest tube dc\nd by thoracid after being placed to waterseal\n Temp 101.1\n Pt received with neo infusing\n Ivf dc\n Pt with limited iv access and need for long term access for\n chemo\n Tube feeds at goal\n Pt complained of right arm pain x 6 days\n Glucoses elevated\n Phosphorus low this am\n Action:\n Translator obtained\n Cxr post chest tube removal\n Pan cultured\n Neo weaned off per sicu team\n Two doses albumin given as ordered\n Picc line placed at bedside by iv rn\n Renal consult obtained\n Right arm pain assessed by md\n Regular sliding scale insulin added\n Neutral phos ordered and given\n Response:\n Pt able to make needs known\n Pt with o2 sat\ns 97% on 35% trach mask\n Cultures pending\n Pt sbp 90-100\ns off neo\n Picc in too far per radiology, line pulled back by iv rn,\n repeat cxr done\n Pt re-educated regarding pca use\n Glucose improved\n Repeat phos in am\n Plan:\n Translator as needed\n Continue with trach mask\n Follow culture results\n Maintain sbp >90\n Awaiting read on repeat cxr for picc line placement\n Continue with current tube feeds\n Continue with morphine pca\n Continue with sliding scale insulin\n Transfer to tomorrow\n" }, { "category": "Physician ", "chartdate": "2131-01-15 00:00:00.000", "description": "Intensivist Note", "row_id": 436870, "text": "SICU\n HPI:\n 40 F non-smoker w/ upper esophageal SCC x/p chemo/XRT, s/p\n tracheostomy () for upper airway compromise with parapharyngeal\n abscess/contained perf (now resolved s/p 28 day course of\n Unasyn/Clindamycin).Intraop finding of malignant pleural studding\n s/p L VATS, pleural bx, LUL wedge resection, talc pleurodesis \n Chief complaint:\n upper esophageal SCC\n PMHx:\n Esophageal SCC (s/p Chemo XRT done ); anemia; upper esophageal\n stricture; lung mass; PEG candidiasis\n Current medications:\n Acetaminophen (Liquid) 5. Acetylcysteine 20% 6. Aluminum-Magnesium\n Hydrox.-Simethicone\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. DiphenhydrAMINE\n 11. Docusate Sodium (Liquid) 12. Fluticasone Propionate 110mcg 13.\n Guaifenesin 14. Heparin 15. Hydrocerin\n 16. 17. Insulin 18. Ipratropium Bromide Neb 19. Lactulose 20.\n Lansoprazole Oral Disintegrating Tab\n 21. Lorazepam 22. Magnesium Oxide 23. Methadone 24. Morphine Sulfate\n 25. Neutra-Phos 26. Nortriptyline\n 27. Phenylephrine 28. Potassium Chloride 29. Sarna Lotion 30. Senna\n 24 Hour Events:\n PICC LINE - START 12:21 PM\n CHEST TUBE REMOVED - At 04:38 PM\n PAN CULTURE - At 05:54 PM\n FEVER - 101.1\nF - 04:00 PM\n Allergies:\n Roxicet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 38.1\nC (100.5\n HR: 112 (103 - 134) bpm\n BP: 100/61(76) {90/56(68) - 121/75(89)} mmHg\n RR: 22 (20 - 41) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 57.5 kg (admission): 48 kg\n Total In:\n 5,363 mL\n 1,064 mL\n PO:\n Tube feeding:\n 1,682 mL\n 441 mL\n IV Fluid:\n 1,401 mL\n 433 mL\n Blood products:\n 1,500 mL\n Total out:\n 3,560 mL\n 680 mL\n Urine:\n 3,540 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,803 mL\n 384 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 352 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 105 mEq/L\n 138 mEq/L\n 26.8 %\n 5.0 K/uL\n [image002.jpg]\n 10:21 PM\n 04:41 AM\n 02:04 AM\n WBC\n 10.6\n 7.8\n 5.0\n Hct\n 29.0\n 27.7\n 26.8\n Plt\n \n Creatinine\n 0.4\n 0.5\n 0.4\n Troponin T\n <0.01\n <0.01\n Glucose\n 192\n 160\n 129\n Other labs: CK / CK-MB / Troponin T:172/2/<0.01, Ca:8.2 mg/dL, Mg:1.8\n mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O\n CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL, .H/O CANCER (MALIGNANT\n NEOPLASM), LUNG, HYPOTENSION (NOT SHOCK)\n Assessment and Plan:\n Neurologic: Morphine PCA, Methadone 2.5 mg PO BID, lorazepam for\n anxiety\n Cardiovascular: stable tachycardic weaned neo as tolerated, recieved\n albumin, PICC placed,\n Pulmonary: trach'd nebs prn, chest tube dc'd\n Gastrointestinal / Abdomen: TF\n Nutrition: TF\n Renal: High UOP, follow FENA, follow urine OSM , follow serum osmol\n per renal not DI, stoped albumin,\n Hematology: Hct 27 stable\n Endocrine: RISS\n Infectious Disease: no Abx\n Lines / Tubes / Drains: PICC, Lt CT to wall suction, foley, PIV, rt\n aline, trach\n Wounds: c/d/i\n Imaging:\n Fluids:\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Ensure Plus (Full) - 07:56 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:40 AM\n PICC Line - 12:21 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:\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Echo", "chartdate": "2131-01-14 00:00:00.000", "description": "Report", "row_id": 82440, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p Left VATS, LUL wedge resection for metastatic esophageal CA now with post op hypotension on pressors.\nHeight: (in) 65\nWeight (lb): 120\nBSA (m2): 1.59 m2\nBP (mm Hg): 94/56\nHR (bpm): 133\nStatus: Inpatient\nDate/Time: at 10:35\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\n Billing and site error corrected. No changes made in the findings. WJM\nRIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. Normal IVC diameter\n(<2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Indeterminate LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Three aortic valve leaflets.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe estimated right atrial pressure is 0-10mmHg. There is mild symmetric left\nventricular hypertrophy. Left ventricular cavity size could not be determined.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere are three aortic valve leaflets. The mitral valve leaflets are not well\nseen. There is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2130-12-11 00:00:00.000", "description": "Report", "row_id": 82441, "text": "PATIENT/TEST INFORMATION:\nIndication: Tachycardia.\nHeight: (in) 60\nWeight (lb): 105\nBSA (m2): 1.42 m2\nBP (mm Hg): 86/48\nHR (bpm): 110\nStatus: Outpatient\nDate/Time: at 14:38\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. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease\nduring respiration (estimated RA pressure (0-5mmHg).\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.\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\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 0-5 mmHg. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%). There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-02 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1055215, "text": ", M.F. MED 7S 3:57 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal CA s/p esophageal abscess treated & trach.\n REASON FOR THIS EXAMINATION:\n please eval for change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Retropharyngeal and retrotracheal swelling and soft tissue density\n encompassing the esophagus, which may represent a combination of\n post-radiation changes and phlegmon. No drainable fluid collection.\n\n Interval enlargement of a cavitary lesion at the left lung apex. New pleural\n fluid in the upper left hemithorax. Please refer to the concurrent chest CT\n report for further detail.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2131-01-02 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1055216, "text": " 3:57 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal CA s/p esophageal abscess treated & trach.\n REASON FOR THIS EXAMINATION:\n please eval for change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc 7:32 PM\n CT CHEST WITH CONTRAST: Significant increase in left pleural effusion, now\n moderate with basilar atelectasis. Increase in size of left upper lobe\n cavitary lesion and increase in size of smaller noncavitary lesions. New\n right lower lobe cavitary lesion, could be septic emboli, multifocal infection\n such as fungal infection or esophageal cancer metastases. Left pleural\n nodule, worrisome for esophageal metastases.\n\n Esophageal abscess not imaged and this study will be better characterized by\n CT of the neck.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITH CONTRAST\n\n REASON FOR EXAM: 40-year-old woman with esophageal cancer status post\n esophageal abscess treated, tracheostomy, please evaluate for change.\n\n TECHNIQUE: Chest MDCT was performed following 75 cc of intravenous Optiray\n using 5-mm and 1.25-mm axial slice thickness. Coronal and sagittal\n reformations were also obtained.\n\n FINDINGS: Since , the previously described esophageal\n abscess is not imaged, will be evaluated by neck CT. A tracheostomy is in\n expected position. Minimal tracheal secretions are present.\n\n Left upper lobe cavitary lesion increased from 12 x 12 mm to 16 x 18 mm. There\n is no adjacent bone erosion. Left posterior enhancing pleural nodule also\n increased from 6 x 12 mm to 9 x 15 mm (102:120). Right upper lobe tiny nodule\n increased from 2.5 to 3.1 mm (102:74). Right upper lobe 7-mm cavitary lesion\n is at the site of previous 1-mm tiny opacity (102:105) and right basilar\n nodule increased from 4.5 x 7 mm to 6 x 9 mm. Left pleural effusion\n significantly increased, now moderate, with left basilar and lingular\n atelectasis.\n\n Scattered lymph nodes are not enlarged using CT criteria. Hilar lymph nodes\n decreased, not enlarged using CT criteria. There is no pericardial effusion.\n Airways are patent to the subsegmental level.\n\n This study was not tailored for subdiaphragmatic evaluation but the upper\n abdomen is unremarkable. There is no bone lesion suspicious for malignancy.\n\n (Over)\n\n 3:57 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Increase in size of left upper lobe cavitary lesion, new right lower lobe\n cavitary lesion and increase in size of noncavitary smaller nodules. These\n findings could be due to septic emboli, granulomatous (e.g. fungal) infection,\n or cavitary lung metastases.\n 2. Left pleural enhancing nodularity, worriesome for pleural metastasis. New\n moderate left pleural effusion with adjacent atelectasis.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-02 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1055217, "text": ", M.F. MED 7S 3:57 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal CA s/p esophageal abscess treated & trach.\n REASON FOR THIS EXAMINATION:\n please eval for change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n CT CHEST WITH CONTRAST: Significant increase in left pleural effusion, now\n moderate with basilar atelectasis. Increase in size of left upper lobe\n cavitary lesion and increase in size of smaller noncavitary lesions. New\n right lower lobe cavitary lesion, could be septic emboli, multifocal infection\n such as fungal infection or esophageal cancer metastases. Left pleural\n nodule, worrisome for esophageal metastases.\n\n Esophageal abscess not imaged and this study will be better characterized by\n CT of the neck.\n\n" }, { "category": "Radiology", "chartdate": "2130-12-17 00:00:00.000", "description": "G/GJ/GI TUBE CHECK", "row_id": 1052523, "text": " 6:43 PM\n G/GJ/GI TUBE CHECK Clip # \n Reason: check J-tube placement\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal CA s/p j-tube replacement today\n REASON FOR THIS EXAMINATION:\n check J-tube placement\n ______________________________________________________________________________\n WET READ: ARHb SUN 7:47 PM\n J- tube appears well positioned with injected contrast entering small bowel\n loops. Unremarkable bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Query J-tube obstruction.\n\n A small amount of injected Conray contrast material is seen entering the\n jejunum and passing anterograde with no evidence of obstruction, stricture or\n contrast leak. Bowel gas pattern is nonobstructive. A moderate amount of\n retained fecal material is seen within the colon. There is no free gas or\n pneumatosis. Visualized osseous structures are unremarkable.\n\n IMPRESSION: Grossly normal jejunostomy tube study.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-02 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1055214, "text": " 3:57 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal CA s/p esophageal abscess treated & trach.\n REASON FOR THIS EXAMINATION:\n please eval for change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DFDkq 7:44 PM\n Retropharyngeal and retrotracheal swelling and soft tissue density\n encompassing the esophagus, which may represent a combination of\n post-radiation changes and phlegmon. No drainable fluid collection.\n\n Interval enlargement of a cavitary lesion at the left lung apex. New pleural\n fluid in the upper left hemithorax. Please refer to the concurrent chest CT\n report for further detail.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal cancer status post esophageal abscess and status post\n tracheostomy on .\n\n COMPARISON: Neck CT dated , and neck MRI dated .\n\n TECHNIQUE: Axial multidetector CT images of the neck were obtained following\n intravenous contrast administration. Coronal reformatted images were\n generated.\n\n FINDINGS: A new tracheostomy is in place. There is retropharyngeal and\n retrotracheal swelling with soft tissue density from the supraglottic level to\n the lower aspect of the thyroid gland, located in the midline and to the right\n of midline. The esophagus is not distinguishable from this soft tissue\n density. There is no evidence of a drainable fluid collection. These\n findings may represent a combination of post-radiation changes, given the\n history of esophageal cancer, and phlegmon. There is no evidence of an\n exophytic mucosal mass in the pharynx. There is no evidence of cervical\n lymphadenopathy. The salivary glands appear unremarkable.\n\n There is a cavitary lesion in the left lung apex measuring 1.8 cm, larger than\n on . There is a new pleural effusion in the upper left hemithorax\n compared to .\n\n No osseous lesion suspicious for malignancy are identified.\n\n IMPRESSION:\n 1. Retropharyngeal and retrotracheal swelling and soft tissue density\n encompassing the esophagus, which may represent a combination of post-\n radiation changes and phlegmon. No evidence of a drainable fluid collection.\n\n 2. Enlargement of the cavitary lesion in the left lung apex. New pleural\n (Over)\n\n 3:57 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid in the upper left hemithorax. Please refer to the concurrent chest CT\n report for further detail.\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2131-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1055463, "text": " 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with Squamous cell cancer of the esophagus, s/p left sided\n thoracentesis, bubbles aspirated at end of procedure. Please evaluate for\n pneumothorax\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPSc WED 6:39 PM\n Effusion smaller with small amount of gas at the left lung base that could be\n small bubbles of pneumothorax, however, no apical large pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Squamous cell cancer of the esophagus with left-sided\n thoracentesis with some air during procedure. Please assess for pneumothorax.\n\n STUDY: Portable upright frontal chest x-ray.\n\n FINDINGS:\n Compared to the chest CT from , the left pleural effusion has decreased\n in size. There is heterogeneous opacity at the left lung base and there could\n be a small pneumothorax at the left lung base, however, no apical pneumothorax\n is evident. There is left basilar atelectasis, as before. Right lung is\n clear. Heart size and mediastinal contour are normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1055464, "text": ", F. MED 7S 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with Squamous cell cancer of the esophagus, s/p left sided\n thoracentesis, bubbles aspirated at end of procedure. Please evaluate for\n pneumothorax\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax\n ______________________________________________________________________________\n PFI REPORT\n Effusion smaller with small amount of gas at the left lung base that could be\n small bubbles of pneumothorax, however, no apical large pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057336, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with LLL atelectasis\n REASON FOR THIS EXAMINATION:\n reassess\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lower lobe atelectasis, reassess.\n\n FINDINGS: A single frontal chest radiograph is compared to . There is\n a stable small left apical pneumothorax. A left chest tube is in place. There\n is increased left lower lobe consolidation and left pleural effusion. The\n cardiac and mediastinal contours are stable. The osseous structures are\n unchanged. Tracheostomy remains in place.\n\n IMPRESSION: Increased left pleural effusion with increased left lower lobe\n consolidation suspicious for worsening pneumonia. Stable small left\n apical pneumothorax with chest tube in place. Findings discussed with Dr. \n at 10:19am.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057273, "text": " 7:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: change in pneumothorax\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with pneumothorax s/p VATS\n REASON FOR THIS EXAMINATION:\n change in pneumothorax\n ______________________________________________________________________________\n WET READ: RSRc 9:32 PM\n No change in small left apical pneumothorax. -\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax.\n\n FINDINGS: A single frontal chest radiograph demonstrates a stable small left\n apical pneumothorax. A left chest tube is in place. There is increased left\n lower lobe consolidation, suspicious for pneumonia, with left pleural\n effusion. The right lung is clear. The cardiac and mediastinal contours are\n within normal limits. A tracheostomy is in place. The osseous structures are\n unchanged.\n\n IMPRESSION: Increased left lower lobe consolidation, suspicious for worsening\n pneumonia, with increasing left pleural effusion. Stable small left apical\n pneumothorax with left chest tube in place.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1057506, "text": ", F. OMED SICU-A 12:45 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: rb dl picc 40cm\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n rb dl picc 40cm\n ______________________________________________________________________________\n PFI REPORT\n Right PICC is in region of junction of superior vena cava in right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057160, "text": " 11:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess L lung expansion\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with now metastatic esophageal CA, s/p LUL wedge resection,\n talc pleurodesis\n REASON FOR THIS EXAMINATION:\n reassess L lung expansion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc 4:31 PM\n PFI: Left upper lobe wedge resection was performed. Small apical\n pneumothorax is new. Left pleural effusion slightly increased, still small.\n Subcutaneous emphysema is minimal. Left chest tube is in place.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 40-year-old woman with known metastatic esophageal cancer\n status post left upper lobe wedge resection and talc pleurodesis. Reassess\n left lung.\n\n Since , left upper lobe wedge resection was performed. A left\n chest tube was installed projecting over the left retrocardiac region. Small\n left apical pneumothorax is new. Left pleural effusion slightly increased,\n still small. Basilar opacity has also increased, likely atelectasis.\n Subcutaneous emphysema is minimal, new since the prior study.\n\n The tracheostomy tube is midline, in expected position.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057161, "text": ", P. TSURG PACU 11:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess L lung expansion\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with now metastatic esophageal CA, s/p LUL wedge resection,\n talc pleurodesis\n REASON FOR THIS EXAMINATION:\n reassess L lung expansion\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left upper lobe wedge resection was performed. Small apical\n pneumothorax is new. Left pleural effusion slightly increased, still small.\n Subcutaneous emphysema is minimal. Left chest tube is in place.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057462, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: recent VATS,\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with recent VATS\n REASON FOR THIS EXAMINATION:\n recent VATS,\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Recent VATS procedure.\n\n FINDINGS: As compared to the recent radiograph, there has been no substantial\n interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1057505, "text": " 12:45 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: rb dl picc 40cm\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with\n REASON FOR THIS EXAMINATION:\n rb dl picc 40cm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 5:05 PM\n Right PICC is in region of junction of superior vena cava in right atrium.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n Since the recent radiograph of earlier the same date, a right PICC has been\n placed with poor visualization of the tip, not confidently seen beyond\n junction of SVC and right atrium; however, subsequent CXR of the same\n date shows tip deep within the right atrium.\n\n Other indwelling devices are unchanged in position. Left hydropneumothorax\n with loculated apical pneumothorax component appears slightly more prominent\n than on the prior study, but may reflect positional differences of the patient\n (upright versus semi-upright previously). Right pleural effusion has\n apparently decreased in size, but could also reflect positional differences.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057546, "text": " 5:43 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PICC Placement\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with new PICC adjusted\n REASON FOR THIS EXAMINATION:\n PICC Placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: PICC placement.\n\n Right PICC has been withdrawn several centimeters since the recent radiograph\n and now terminates in the body of the right atrium. Otherwise, no substantial\n change since the recent radiograph of less than two hours earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057626, "text": " 2:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with small hydropneumothorax s/p pleurodesis. also\n ?pneumonia\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST.\n\n Comparison to previous study of earlier the same date.\n\n INDICATION: Hydropneumothorax.\n\n Loculated left apical hydropneumothorax is without change as well as a\n moderate multiloculated left pleural effusion. Adjacent increased parenchymal\n opacity in left perihilar and basilar regions has slightly worsened, and there\n is also a new patchy opacity at the right base. Although possibly due to\n atelectasis, coexisting aspiration or pneumonia should be considered in the\n appropriate clinical setting. Small right pleural effusion has developed in\n the interval as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-12-04 00:00:00.000", "description": "CT NECK W/O CONTRAST (EG: PAROTIDS)", "row_id": 1050007, "text": " 10:02 PM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: Please evaluate for airway compromise. Thank you.\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal cancer s/p XRT and chemo presents now with\n heavy weight feeling in her throat and stridor/rhoncherous breath sounds on\n exam.\n REASON FOR THIS EXAMINATION:\n Please evaluate for airway compromise. Thank you.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n STUDY: CT neck without contrast and reconstructions.\n\n INDICATION: Esophageal cancer status post radiation and chemotherapy, now\n with uncomfortable feeling in throat and stridorous breathing.\n\n COMPARISON: CT chest .\n\n TECHNIQUE: MDCT axially acquired images were obtained of the cervical spine\n without contrast.\n\n FINDINGS: The true and false vocal folds are apposed on this study. A small\n amount of air is noted within the left laryngeal saccule which is a normal\n finding. A small amount of fluid and air is noted within the esophagus at the\n level of the thyroid gland, also noted on prior study from . No\n airway lesions are identified to suggest airways compromise secondary to mass\n lesion. No external compression is detected. The thyroid gland is within\n normal limits. No adenopathy is identified per CT size criteria. Cavitary\n lesion is again noted within the left lung apex with slight increase since\n prior study currently measuring 1 x 0.9 cm.\n\n IMPRESSION:\n\n 1. No mass lesions are detected within the airway to explain stridorous\n breathing.\n\n 2. Fluid again noted within the esophagus in the region of the thyroid gland.\n Also noted on prior study, possibly relating to region of stricture.\n\n 3. Slight increase in cavitary lesion within the left lung apex.\n\n NOTE ADDED AT ATTENDING REVIEW: There is a collection of air in the right\n neck, apparently just lateral to the esophagus, but possibly within a dilated\n esophagus, best seen on images 34-37 of series 2. In this location it raises\n the possibility of an esophageal perforation. Since it is difficult to\n determine the location of the lateral margin of the esophagus, it is difficult\n to distinguish an extraluminal collection from dilatation of the organ. An MR\n examination may be helpful.\n\n There is induration of the adjacent tissues, which could be a consequence of\n (Over)\n\n 10:02 PM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: Please evaluate for airway compromise. Thank you.\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n local infection, but also could arise as a result of prior radiation.\n\n These findings were discussed with Dr. at 10:30 am on .\n\n" }, { "category": "Radiology", "chartdate": "2130-12-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1050008, "text": " 10:35 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Please evaluate for intrapulmonary lesion.\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal cancer with stridor.\n REASON FOR THIS EXAMINATION:\n Please evaluate for intrapulmonary lesion.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n CHEST CT \n\n HISTORY: Esophageal cancer. Stridor.\n\n TECHNIQUE: Multidetector helical scanning of the chest was coordinated with\n intravenous infusion of 100 cc Optiray 350 nonionic iodinated contrast \n coordinated with CT scanning of the neck reported separately, reconstructed as\n contiguous 5 and 1.25-mm thick axial and 5 mm thick coronal images compared to\n CT scanning of the chest since , most recently .\n\n FINDINGS: Asymmetry in the false vocal cords with a small bulge on the right\n , 2:11, is new since . To the right of midline posterior to\n the larynx at the level of the cricopharyngeus, a 21 x 12 mm low- density\n region is better defined today, and has small gas bubbles, 2:17, concerning\n for a small abscess or a phlegmon communicating with the irradiated and\n presumably ulcerated hypopharynx/esophagus . This finding will be addressed in\n the report of the neck CT scan. Circumferential thickening of the upper\n esophagus is stable since ; the periesophageal soft tissue\n planes at this level are intact, whereas more superiorly at the level of the\n questionned abscess, they are indistinct. There is no pathologic enlargement\n of central lymph nodes by size criteria and no pleural or pericardial\n effusion.\n\n A small branching nodular opacity with a perimeter of ground glass opacity at\n the posterior right lung base, 3:60, is unchanged since , but new\n or substantially larger compared to . A similar-appearing 8.2\n mm wide lesion in the posterior basal segment of the left lower lobe,\n 4:216-222, is new since . These lesions could be either inflammatory\n or malignant. An elliptical 8 x 10 mm soft tissue lesion along the posterior\n costopleural periphery of the left lower lobe, has grown since and\n is suspicious for a pleural or subpleural metastasis.\n\n The spiculated, cavitary left upper lobe nodule has continued to grow though\n more slowly since than over the preceding eight weeks. At\n comparable levels it is 11 x 13 mm today, compared to 10 x 12 mm on , with a broad base on the anterior costal pleural margin, presumably the\n site of pleural seeding, although given it previous rapid growth between\n (Over)\n\n 10:35 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Please evaluate for intrapulmonary lesion.\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n (Cont)\n and , an infection, including tuberculosis, nocardia and\n fungus should also be entertained as the diagnosis.\n\n This examination is not designed for subdiaphragmatic evaluation except to\n note the absence of adrenal mass.\n\n IMPRESSION:\n\n 1. Small pharyngeal or paralaryngeal abscess, phlegmon or malignancy has\n grown over two weeks. If the lesion is inflammatory it suggests ulceration in\n the hypopharynx/upper esohagus. Please see report of today's neck CT.\n\n 2. Slow growth of small left upper lobe lung cavity and a tiny right lower\n lobe lesion as well as a new left lower lobe lesion are concerning for\n multifocal metastases, or slow spread of an indolent infection. Small growing\n left pleural mass is more characteristic of metastasis.\n\n Dr. and I discussed these findings, at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2130-12-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1050006, "text": " 9:59 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for metastases.\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal cancer presents shortness of breath and\n cough.\n REASON FOR THIS EXAMINATION:\n Please evaluate for metastases.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophageal cancer with shortness of breath and cough, to evaluate\n for metastases.\n\n FINDINGS: In comparison with study of , there is little change. Again the\n heart is within normal limits in size and there is no evidence of vascular\n congestion or pleural effusion. No evidence of acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-12-06 00:00:00.000", "description": "MRI SOFT TISSUE NECK, W/O & W/CONTRAST", "row_id": 1050403, "text": " 4:27 PM\n MRI SOFT TISSUE NECK, W/O & W/CONTRAST Clip # \n Reason: evaluate for esophageal rupture, abscess\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with stridor and laryngeal swelling\n REASON FOR THIS EXAMINATION:\n evaluate for esophageal rupture, abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Laryngeal swelling, stridor. Questionable esophageal rupture on\n prior CT.\n\n COMPARISON: CT of the neck dated .\n\n FINDINGS: There is a collection of gas with small amount of fluid in the\n right anterior neck, just lateral to the esophagus at the level of\n approximately C5, in the region of the thyroid gland. The collection is\n displacing minimally the trachea to the left. No other fluid collections are\n identified.\n\n Views of the lung apices demonstrate a cavitary lesion in the left upper lobe\n measuring approximately 14 x 11 mm, not fully characterized in this MRI.\n\n IMPRESSION: 12 x 8 mm collection of air with small amount of fluid just\n anterior to the right aspect of the esophagus at the level of the thyroid\n gland which likely represents esophageal perforation and/or abscess.\n Additional considerations include esophageal diverticulum, although less\n likely.\n\n The findings were discussed with Dr. at the time of the interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-12-05 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1050231, "text": " 9:08 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: ESOPHAGEAL CANCER,N/V\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal cancer s/p XRT and chemotherapy now with\n persistent nausea and vomiting.\n REASON FOR THIS EXAMINATION:\n Please evaluat e for metastatic disease.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with esophageal cancer status post radiotherapy\n and chemotherapy now with persistent nausea and vomiting, please evaluate for\n metastatic disease.\n\n COMPARISON: None.\n\n TECHNIQUE: Sagittal T1, MP-RAGE post-contrast images, axial FLAIR, fast spin\n echo T2, T1, T2 gradient echo, T1 post-contrast images were obtained.\n Additional diffusion-weighted images with reconstruction of ADC, FA, trace\n mass were generated. Reformations in the coronal and the axial plane after\n gadolinium administration were also obtained.\n\n FINDINGS: There are multiple bilateral punctate foci of hyperintensity on\n FLAIR and T2-weighted images. In the absence of contrast enhancement these\n lesions do not represent metastases. There are no masses, mass effect. The\n ventricles and sulci are normal in size and configuration. There are no areas\n of abnormal diffusivity.\n\n IMPRESSION: No evidence of intracranial metastases or other abnormalities to\n explain patient's symptoms.\n\n" }, { "category": "Radiology", "chartdate": "2130-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052452, "text": " 10:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with esophageal ca s/p trach with copious secretions\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: Esophageal cancer status post trach with copious secretions.\n\n REFERENCE EXAM: .\n\n FINDINGS: Tracheostomy tube is again visualized. There is new left small\n pleural effusion with volume loss in the left lower lobe. An early infiltrate\n in this region cannot be totally excluded. Otherwise, the lungs are clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050951, "text": " 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with new trach placement\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, \n\n CLINICAL INFORMATION: New tracheostomy placement.\n\n FINDINGS:\n\n Comparison is made to the prior study from . A tracheostomy has been\n placed in the midline. The lungs are clear. The cardiomediastinal silhouette\n is unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-12-12 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1051624, "text": " 6:32 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Any pulmonary embolism?\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with unexplained persistent sinus tachycardia and prolonged\n hospitalization.\n REASON FOR THIS EXAMINATION:\n Any pulmonary embolism?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg TUE 8:26 PM\n 1. NO PE.\n 2. LEFT UPPER LOBE LESION WITH CAVITATION IS UNCHANGED. 7MM RIGHT POSTERIOR\n LOWER LOBE LESION IS SLIGHLTY INCREASED IN SIZE AND DENSITY COMPARED TO EXAM\n FROM 8 DAYS PRIOR (3:91), 6MM POSTERIOR LEFT LOWER LOBE NODULAR OPACITY IS\n IMPROVED (3;76). ELLIPTICAL SOFT TISSUE ALONG THE POSTERIOR COSTOPLEURAL\n PERIPHERY OF THE LEFT LOWER LOBE IS UNCHANGED (3:54,64).\n 3. NEW TRACH.\n 4,. THE CAVITY IN THE RIGHT NECK POSTEROLATERAL TO THE TRACHEA NOW CONTAINS\n PREDOMINANTLY AIR (3:3).\n \n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the chest.\n\n HISTORY: 40-year-old female with history of cervical esophageal cancer,\n unresectable, presenting with persistent tachycardia. Assess for pulmonary\n embolism.\n\n COMPARISONS: CT chest , , and .\n\n TECHNIQUE: Following the administration of 100 mL of Optiray intravenous\n contrast, MDCT axial images of the chest were obtained. Coronal, sagittal,\n and oblique reformatted images were then acquired.\n\n CTA OF THE CHEST: A small air collection now replaces the previously seen\n fluid collection with air bubbles posterior to the cricopharyngeus muscle\n (3:2). Mild thickening of the adjacent esophagus at this level is again\n evident. Note is made of a new tracheostomy which appears well positioned. A\n 6-mm right paratracheal lower lymph node is unchanged in size compared to the\n previous exam (3:41). An aortic pulmonary window lymph node measures 7 mm in\n short-axis diameter and may be new compared to the previous exam (3:41). Right\n hilar nonpathologicaly enlarged hilar adenopathy is new (3:46). Small left\n hilar lymph nodes are also present. No pathologically enlarged axillary lymph\n nodes are evident. The heart is normal in size, and the great vessels are\n unremarkable. There are no filling defects within the pulmonary arterial\n vasculature. There is no pericardial effusion.\n\n A cavitary lesion within the left upper lobe measuring 12 x 12 mm has slightly\n increased in size compared to the previous measurements of 9 x 8 mm on the CT\n (Over)\n\n 6:32 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Any pulmonary embolism?\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of (3:22). A pleural based elliptical lesion at the left lung base\n posteriorly measures 12 x 6 mm and has increased in size compared to the CT of\n (previously 7 x 3 mm) (3:63). A nodular area of pleural thickening\n located slightly more superiorly along the left posterior pleural surface is\n slightly more prominent compared to the CT of (3:53). At the left\n lung base, there is new minimal atelectasis with apparent thickening of the\n pleural surface (3:87). A 6-mm pleural-based opacity at the left lung base\n measures 6 mm in greatest diameter and is slightly decreased compared to the\n CT of . This finding is new compared to the CT (3:36). A\n ground glass opacity at the right lung base measures 7 x 4 mm and is slightly\n increased in size compared to the previous measurements of 4 x 3 mm on CT of\n (3:91). No other pulmonary nodules are noted. There is no pleural\n effusion. The airways are patent to the subsegmental level.\n\n Although this examination was not tailored for subdiaphragmatic evaluation,\n the imaged portions of the upper abdomen are unremarkable.\n\n\n IMPRESSION:\n 1. No pulmonary embolism.\n\n 2. New left posterior pleural lesion. Although this would be an atypical\n location for an esophageal carcinoma metastasis, the possibility of malignancy\n cannot be totally excluded and PET CT may provide additional diagnostic\n information.\n\n 3. Increase in right lower lobe and left upper lobe opacities and new left\n lower lobe opacity most likely represent infectios process; from the same or\n different \n\n 4. Resolution of fluid collection in the posterior parapharyngeal space\n compared to the CT of ., now fluid filled\n\n jr\n\n" }, { "category": "ECG", "chartdate": "2130-12-15 00:00:00.000", "description": "Report", "row_id": 206348, "text": "Baseline artifact. Sinus tachycardia. Non-diagnostic inferolateral Q waves.\nConsider left ventricular hypertrophy. Early precordial ST segment elevation\nmay be related to left ventricular hypertrophy. Since the previous tracing\nof S wave in lead V2 is more prominent. ST-T wave abnormalities\nare more prominent.\n\n" }, { "category": "ECG", "chartdate": "2130-12-10 00:00:00.000", "description": "Report", "row_id": 206349, "text": "Technically difficult study\nSinus tachycardia\nSince previous tracing of , heart rate faster\n\n" }, { "category": "ECG", "chartdate": "2130-12-09 00:00:00.000", "description": "Report", "row_id": 206350, "text": "Technically difficult study\nSinus rhythm\nNondiagnostic inferolateral Q waves noted\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-01-13 00:00:00.000", "description": "Report", "row_id": 206347, "text": "Sinus tachycardia. Compared to the previous tracing of the\nrate has slowed. Otherwise, no diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2131-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057568, "text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New infiltrate?\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with s/p pleyrodesis\n REASON FOR THIS EXAMINATION:\n New infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Status post pleurodesis.\n\n FINDINGS: Interval repositioning of right PICC, with tip now at junction of\n superior vena cava and right atrium. Otherwise, no substantial change in the\n appearance of the chest except for slight improved aeration at the left lung\n base adjacent to a loculated left pleural effusion.\n\n IMPRESSION: Small loculated hydropneumothorax at left apex.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057864, "text": " 4:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate interval change\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman s/p trach change\n REASON FOR THIS EXAMINATION:\n evaluate interval change\n ______________________________________________________________________________\n WET READ: KYg 10:09 PM\n Trach in place. Loculated left apical hydropneumothorax as well as a moderate\n loculated left pleural effusion is again noted. The lung volumes are improved\n as is right basilar atelectasis. Left basilar opacity is unchanged. \n \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy change.\n\n FINDINGS: In comparison with study of , tracheostomy is again in place.\n Persistent low lung volumes on the left with elevation of the hemidiaphragm.\n The opacification along the left lateral chest wall has substantially reduced.\n Right lung remains clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057401, "text": " 3:26 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: changes\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with VATS\n REASON FOR THIS EXAMINATION:\n changes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 6:05 PM\n Interval increase in right pleural effusion. Slight decrease in left pleural\n effusion, although still significant amount is present.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after VATS.\n\n Portable AP chest radiograph was compared to obtained at\n 07:39 a.m.\n\n The chest tube is in place, the right pleural effusion has slightly decreased\n in the interim, although still significant amount is present. There is\n worsening of the right pleural effusion with right basal opacity consistent\n with relaxation atelectasis, although infectious process cannot be excluded.\n Small vascular engorgement is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057402, "text": ", F. OMED SICU-A 3:26 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: changes\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with VATS\n REASON FOR THIS EXAMINATION:\n changes\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in right pleural effusion. Slight decrease in left pleural\n effusion, although still significant amount is present.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057530, "text": ", F. OMED SICU-A 3:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chest tube out, reassess\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with LUL wedge resection\n REASON FOR THIS EXAMINATION:\n chest tube out, reassess\n ______________________________________________________________________________\n PFI REPORT\n Left hydropneumothorax with stable apical pneumothorax component and slight\n increase in pleural effusion component following tube removal. Right PICC tip\n low in the right atrium.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057529, "text": " 3:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chest tube out, reassess\n Admitting Diagnosis: ESOPHAGEAL MASS, NECK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with LUL wedge resection\n REASON FOR THIS EXAMINATION:\n chest tube out, reassess\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 5:31 PM\n Left hydropneumothorax with stable apical pneumothorax component and slight\n increase in pleural effusion component following tube removal. Right PICC tip\n low in the right atrium.\n ______________________________________________________________________________\n FINAL REPORT\n Following removal of left chest tube, loculated apical pneumothorax is\n unchanged, but a moderate-sized left pleural effusion has slightly increased\n in size. Right PICC line terminates within the inferior aspect of the right\n atrium, as communicated by phone to Dr. on .\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2148-05-09 00:00:00.000", "description": "Report", "row_id": 1336500, "text": "npn 7p-7a\n\ndx: GIB; liv dz\n\nneuro:\na/o x3; quiet this evening; verbalized \"I wish they could have put the shunt in\".\n\nc-v:\nb/p w/in pt's nl baseline; extremities warm, good perfusion;\n\nresp:\nnl rate and effort of respirations; O2 sat 98% RA;\n\ng-i:\nabd remains soft and distended with ascites; receiving lactulose; received snack of jello, broth, and italian ice at 03:00 per pt request;\n mushroom cath in use, catching much of liquid stool, still leaks stool around at times; stool black/tarry;\n\ng-u:\nvoiding via patent foley;\n\nskin:\nfragile, no new skin tears; assisted with repositioning q 2-3 hrs; hygiene care received to back and peri-area;\n\nsocial:\ndaughter and wife in this evening;\n\nPLAN:\nLikely d/c to floor tomorrow\ncheck a.m. labs ordered\n" }, { "category": "Nursing/other", "chartdate": "2148-05-07 00:00:00.000", "description": "Report", "row_id": 1336497, "text": "FULL CODE Universal precautions\nAllergies: ASA, coumadin\n\n\nNeuro: AAOx3, MAEx4 spont/command. No deficits.\n\nCardiac: HR=70s, NSR, no ectopy. BP=90-100s/50-60s. +periph pulses, no edema in extrems, warm extrems.\n\nResp: on 3L n/p in am, but is now on R/A w/ 02sats 98%. RR=. Lungs clear bilat. No cough.\n\nGI: Abd soft, large L ventral hernia. Rectal bag in place, black tarry liquid stool, large amt in am, less this afternoon. Continues on lactulose tid. Taking po fluids, and full liqs - NPO after midnight for TIPS placement.\n\nGU: foley cath, clear dark yellow urine, marginal output.\n\nIVs: Remains on sandostatin at 49.8 mcg/hr via PIV. No central line.\n\nSkin: Fragile skin w/ multiple bruises and tears.\n\nLabs: HCT at 1400 30.1, dwon from 32.5 at 0400. 2nd set of blood cx sent.\n\nSocial: Wife and daughter very attentive, asking approp questions.\n\nPlan: TIPS placement tomorrow, NPO after midnight. Check labs (HCT). Continue to administer lactulose as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2148-05-08 00:00:00.000", "description": "Report", "row_id": 1336498, "text": "npn 7p-7a\n\ndx: GIB; liver dz\n\nneuro:\na/o x 3, verbalized needs, concerns;\n\nc-v:\nhct 28.8 at 20:00 check; received 1 unit PRBC's overnight, received w/out reaction; b/p stable, systolic low to 90's;\n\nresp:\nO2 sat 100% on RA; no SOB overnight;\n\ng-i:\nreceived liquids only last eve, no emesis or fresh GI bleeding;\nNPO MN for TIPS procedure today;\n\nskin:\nskin very fragile, new skin tear left dorsal antecub area, sterile telfa applied, wrapped with kling;\n\nPLAN:\nTIPS today\ncheck a.m. labs\n" }, { "category": "Nursing/other", "chartdate": "2148-05-08 00:00:00.000", "description": "Report", "row_id": 1336499, "text": "MICU NPN 0700-:\n Pt had a stable day, CT of liver done and portal vein is occluded; therefore, TIPS procedure was not done.\n Neuro: Pt A + O, pleasant, cooperative. Pt able to stand and pivot into chair with supervision only. Lactulose given PR in setting of NPO status. Pt sleeping in short naps.\n CV: Pt afebrile. NSR rate 60-80. No ectopy. BP stable (90/systolic when sleeping, low 100's/systolic when awake). New #18 PIV placed leaving pt with 2 large bore IV's in setting of recent GIB. AM labs sent--HCT bumped appropriately with blood. No further studies ordered until am.\n Pulm: Pt on RA, lungs CTA, able to lie flat for CT scan. No cough.\n GI: Pt NPO for procedure today. CT scan as above. Dr. updated pts wife, and pt on inability to do procedure. Pt with >1L stool out today after lactulose enemas. Mostly old blood (heme +), but no clots. Abd with large hernia and ascites. + BS. Mushroom catheter in place. Pt very thirsty and taking clears for dinner.\n GU: Foley with adequate UOP.\n Skin: Two skin tears covered with telfa and cling. NO TAPE.\n Wife and friend at bedside throughout day.\n" }, { "category": "Nursing/other", "chartdate": "2148-05-06 00:00:00.000", "description": "Report", "row_id": 1336495, "text": "74 year old male admitted to CC7 with SOB and abd pain. Today experienced one episiode of vomiting 150cc's of BRB. No hypotension/SOB/CP. Hct at that time was 32. Repeat CBC and coags\npending. Pt is awake but lethargic-restless in bed. + melena stool-received lactulose enema on CC7 prior to arrival to MICU.\nBP/HR stable. see CareVue for objective data and admission form for PMH. Endoscopy at bedside currently being completed. Received .5 mg versed IV and 25 mg fentanyl IV with excellent sedtaion for procedure.\nTolerated well.\nRectal bag/condom cath placed. NPO. Left abd hernia noted as well. No pain. Ocreotide at 50 mcg initiated at 1800.\n" }, { "category": "Nursing/other", "chartdate": "2148-05-07 00:00:00.000", "description": "Report", "row_id": 1336496, "text": "npn 7p-7a\n\ndx: r/o'd for MI; GIB;\n\nneuro:\npt borderline confused overnight, able to verbalize needs to nurse; assists with turning self in bed, respostions self at times despite weakness;\n\nc-v:\nb/p adequate w/out maintenance IVF's or vasopressor assist, systolic 90's to low 100's;\n\nresp:\nO2 sat 100 % on 3 l nc; respirations nl rate and effort;\n\ng-i:\ncopious amount liquid stool; pt also receiving lactulose for hepatic encephalopathy; rectal bag in use;\n abd w/ soft abdn'l large ventral hernia;\nGIB:Q6 hrs Hct stable overnight; no reaction from blood transfusion of last eve;\n\ng-u:\nat s/p attempt of foley insertion previous shift; pt with uretharal clot at beginning of shift, passed on own; pt successfully cath'd using xylocaine gel squirted into urethra, and #16 coude catheter;\nmoderated amount urine via foley overnight;\n\nskin:\nskin very fragile, scattered bruising noted on arms; old scabbed sites and old phlebotomy sites leaked blood when tourniquet applied for drawing of a.m. bloods;\n\nsocial:\nwife and daughter in at approx 19:00 last eve, both anxious and concerned; called x3 during the night;\n\nPLAN:\n1) follow exam\n2) check a.m. labs\n3) emotional support.\n\n" }, { "category": "ECG", "chartdate": "2148-05-06 00:00:00.000", "description": "Report", "row_id": 295326, "text": "Sinus bradycardia\nLeft atrial abnormality\nConduction defect of RBBB type\nPoor R wave progression - probable normal variant\nLow QRS voltages in precordial leads\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2148-05-06 00:00:00.000", "description": "Report", "row_id": 295327, "text": "Normal sinus rhythm. Right bundle-branch block. Compared to tracing #4, there\nhas been no diagnostic interval change.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2148-05-05 00:00:00.000", "description": "Report", "row_id": 295328, "text": "Normal sinus rhythm. Right bundle-branch block. Compared to tracing #2, there\nhas been no diagnostic interval change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2148-05-05 00:00:00.000", "description": "Report", "row_id": 295329, "text": "Right-sided leads are submitted. Normal sinus rhythm. Right-sided leads show no\nevidence of ischemia.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2148-05-05 00:00:00.000", "description": "Report", "row_id": 295330, "text": "Normal sinus rhythm. Right bundle-branch block. Compared to tracing #1, no\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-05-05 00:00:00.000", "description": "Report", "row_id": 295331, "text": "Normal sinus rhythm. Right bundle-branch block. Compared to the previous\ntracing of no diagnostic interval change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2142-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557866, "text": "transfered here from OSH hospital. Pt went to hospital after a\n night of N/V/D. Pt stated he thought blood was in his stool and this am\n he became dizzy, SOB, pale and he took his home BP and his SBP was 87.\n Pt called EMS, we he was guaic positive at the OSH. Pt was transfered\n for further work up and his liver doctors are here. Pt HCT in \n was 40.9 which was up for a baseline of 35. Pt had a low grade temp in\n the ED of 100.2 and received tylenol. Pt was sent to the MICU for\n further workup of LGIB.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Pt had a brief period of hypotension prior to any admission either \n or OSH. Pt stated he was up vomiting multiple times throughout the\n night and he was having multiple episodes of watery diarrhea. Pt is\n noted to be tachy at this time with a HR in the 120\n Action:\n Pt has received a total of 8 liter of IVF.\n Response:\n Pt HR remains elevated in the 1 teens to 120\ns. ST\n Plan:\n Cont with fluid until pt is less tachy. Monitor uop and resp status.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt has guiac positive diarrhea which he states is not normal despite\n his ulcerative colitis, pt hct was 40 upon admission. Pt denies abd\n pain or tenderness\n Action:\n Pt had an HCT sent from the ICU and HCT dropped to 32 towards his\n baseline of 35. This drop occurred after pt received 7 liters of NS\n Response:\n Pt has not had any sign of bleeding at this time. Cont to monitor\n Plan:\n Pt will need a stool sample with next BM. Q 6 hr HCT\n" }, { "category": "Physician ", "chartdate": "2142-03-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 557867, "text": "Chief Complaint:\n HPI:\n Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he work up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. Tmax in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n Allergies:\n Ciprofloxacin (rash)\n Flagyl (rash)\n Amoxicillin (unknown)\n Iodinated contrast (skin desquamation on soles of feet)\n Last dose of Antibiotics:\n Bactrim (Sunday)\n Infusions:\n Other ICU medications:\n Home medications:\n Prograf 2 mg \n Asacol 2400 mg \n NPH 14 units qAM, 8 units qPM\n Protonix 40 mg daily\n Lisinopril 10 mg daily\n MVI\n Calcium + D\n ASA 81 mg daily\n Prednisone (discontinued Sunday)\n Bactrim (completed 3-day course for tx of UTI on Sunday)\n Past medical history:\n Family history:\n Social History:\n 1) Sclerosing cholangitis with cholangiocarcinoma: s/p living\n unrelated partial liver transplant in at the \n in .\n 2) Cholangiocarcinoma: treatment at the included 30\n radiation treatments as well as chemotherapy with 5FU as part of the\n chemoradiation protocol. The course of chemotherapy was abbreviated\n because it induced a flare of ulcerative colitis for which he was\n started on Asacol.\n 3) Ulcerative colitis: previously quiescent until treatment for his\n cholangiocarcinoma\n 4) h/o VRE bacteremia\n 5) h/o partially occlusive venous thrombosis\n 6) IDDM secondary to chronic steroids\n 7) HTN secondary to chronic steroids\n 8) Osteopenia\n 9) Umbilical wall hernia\n 10) Grade I esophageal varices (EGD )\n Non contributory\n He denies any history of tobacco use. He has not consumed alcohol for\n the past 13 years, since he was diagnosed with PSC. He is married with\n a 9 year-old daughter and a 6 year-old son. previously worked as an\n electrician but is currently on medical disability.\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Heme / Lymph: Anemia\n Flowsheet Data as of 06:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 107 (107 - 112) bpm\n BP: 104/66(74) {104/66(74) - 121/74(85)} mmHg\n RR: 21 (13 - 23) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,000 mL\n PO:\n TF:\n IVF:\n 3,000 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,800 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 92%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 176\n 1\n 11\n 26\n 109\n 4.9\n 142\n 32.1 %\n [image002.jpg]\n \n 2:33 A2/18/ 04:27 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.1\n Hct\n 32.1\n Plt\n 160\n Other labs: PT / PTT / INR:15.2/32.4/1.3, ALT / AST:26/22, Alk Phos / T\n Bili:/1.8, Differential-Neuts:83.7, Band:0, Lymph:7.4, Mono:5.5,\n Eos:2.9, LDH:189\n labs:\n WBC 11.4 (66N,23L,6M,2E)\n Hct 48.8\n Microbiology: UA - negative\n ECG: EKG: sinus tach, HR 120, LAD\n Assessment and Plan\n 1) Diarrhea: Presentation is most consistent with a viral\n gastroenteritis; however, differential is broad in this chronically\n immunosuppressed patient and includes bacterial infection vs. c. diff\n vs. CMV colitis vs. opportunistic infection. Guiac-positive stools\n make salmonella, shigella, and campylobacter possible pathogens.\n - Check stool studies, including c. diff toxin, O&P, salmonella,\n shigella, campylobacter, viral culture\n - Check CMV VL as patient is known to be CMV mismatch with liver donor\n - NPO\n 2) Hypotension/tachycardia: Most likely secondary to profound volume\n depletion in the setting of intractable emesis and diarrhea; however,\n cannot rule out infection vs. bleeding. Patient currently meets SIRS\n criteria with 2 out 4 conditions (T>38, and HR>90), conferring some\n risk that his presentation is consistent with infection.\n - IVF; will continue to bolus\n - pan-culture with blood cx x 2, urine culture\n - antibiotics deferred given clinical suspicion for viral etiology\n - Consider RUQ ultrasound if no improvement given fluid collection\n posterior to right lobe of liver seen on MRI in (as per interval\n history, there was no history of this on recent imaging performed at\n )\n - hold Lisinopril\n 3) Microcytic anemia: Hematocrit has dropped from 48 -> 41 -> 32.6\n since initial presentation to s/p fluid resuscitation. Baseline\n hematocrit is 35-38 (38.2 in at ). Stools now\n guiac-positive.\n - q 6 hour hematocrits\n - 2 peripheral IV's in place\n - active T&C\n - check iron studies given microcytosis\n 4) Ulcerative Colitis: ? flare vs. alternate cause of guaic-positive\n diarrhea, as above.\n - Continue Asacol\n 5) h/o Liver Transplant: Performed in at .\n - Continue immunosuppresion Prograf 2 mg (dose recently reduced)\n - Prograf level in AM\n - Liver team following\n 6) IDDM:\n - Continue NPH at 50% of dose while NPO\n - RISS q6 while NPO, then transition to HISS QACHS when tolerating PO\n 7) PPx: Pneumoboots, PPI\n 8) FEN:\n - NPO overnight; will advance diet when able to tolerate PO.\n - IVF for volume resuscitation.\n 9) Code status: full code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Continue home PPI.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Admit to ICU.\n" }, { "category": "Physician ", "chartdate": "2142-03-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558039, "text": "Chief Complaint: Gastroenteritis\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n BLOOD CULTURED - At 05:14 PM\n CALLED OUT\n Stool and mucusy, then green overnight.\n VSS\n All cell lines down today\n Allergies:\n Ciprofloxacin\n Rash;\n Flagyl (Oral) (Metronidazole)\n Rash;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Hives;\n Morphine\n Nausea/Vomiting\n Penicillins\n Rash;\n Cefpodoxime\n Eczema;\n Iodine; Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 86 (80 - 112) bpm\n BP: 135/84(95) {104/66(74) - 135/85(95)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,539 mL\n 1,406 mL\n PO:\n TF:\n IVF:\n 3,539 mL\n 1,406 mL\n Blood products:\n Total out:\n 1,050 mL\n 300 mL\n Urine:\n 1,050 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 1,106 mL\n Respiratory support\n SpO2: 94%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: PPP, Respiratory / Chest: (Expansion: Symmetric),\n (Breath Sounds: Clear : )\n Extremities: Right: Absent, Left: Absent, Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.6 g/dL\n 105 K/uL\n 100 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 112 mEq/L\n 141 mEq/L\n 30.3 %\n 2.5 K/uL\n [image002.jpg]\n 04:27 PM\n 10:09 PM\n 05:45 AM\n WBC\n 2.5\n Hct\n 32.1\n 31.3\n 30.3\n Plt\n 105\n Cr\n 0.8\n Glucose\n 100\n Other labs: ALT / AST:22/23, Alk Phos / T Bili:65/1.5, Ca++:7.7 mg/dL,\n Mg++:1.2 mg/dL, PO4:2.1 mg/dL\n Fluid analysis / Other labs: FK level 19\n Random cortisol 11.\n Assessment and Plan\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ULCERATIVE COLITIS\n 44-year-old male status post orthopic liver transplant for primary\n sclerosing cholangitis and cholangiocarcinoma p/w fever, emesis and\n frequent waterry/ diarrhea, hypotensio, recent course of Bactrim\n for asymptomatic UTI. Prednisone 5 mg discontinued few days ago\n was\n started for UC flare. Prograf recently reduced. CMV donor mismatch, not\n on ppx.\n Hypotension and tachycardia resolved after fluid resuscitation. + sick\n contact and guiac +. Multiple cxs pend.\n GI: likely viral gastroenteritis, especially given + sick contact. Not\n on CMV prophylaxis, CMV VL pend. Extensive stool cultures/c diff sent.\n Doubt UC flare since symptoms are different, and it shouldnt cause N/V.\n But follow for now.\n Liver tx: check FK level. Keep lower given leukopenia. Liver team recs\n appreciated.\n Heme: all cell lines down\n Anemia: Hct dropped 17 points but stable, likely dilutional from fluid\n resuscitation. Guiac +. Transfuse prn to keep Hct > 25\n Leukocytosis: viral vs immunosuppression induced\n Thrombocytopenia: close to baseline, follow\n Rest per resident note.\n ICU Care\n Glycemic Control: Regular insulin sliding scale, Comments: NPH held\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Code status: Full, Disposition : called out, 35 minutes spent\n" }, { "category": "Nursing", "chartdate": "2142-03-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558040, "text": "Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he woke up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. T-max in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n Patient was transferred here from OSH hospital. Pt went to \n hospital after a night of N/V/D. Pt stated he thought blood was in his\n stool and this am he became dizzy, SOB, pale and he took his home BP\n and his SBP was 87. Pt called EMS, we he was guaic positive at the OSH.\n Pt was transferred for further work up and his liver doctors are here.\n Pt HCT in was 40.9 which was up for a baseline of 35. Pt had a\n low grade temp in the ED of 100.2 and received Tylenol. Pt was sent to\n the MICU for further workup of LGIB.\n Pt. has had an uneventful shift. Pt. remains A/A/O and denies any pain\n or discomfort. Stool is guiac negative this afternoon. Pt remains\n afebrile with all vitals signs WNL. Pt. has had both urine and stool\n sent, and remains on contact precautions to r/o VRE. Pt. has HCT\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n LOWER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 77.7 kg\n Daily weight:\n Allergies/Reactions:\n Ciprofloxacin\n Rash;\n Flagyl (Oral) (Metronidazole)\n Rash;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Hives;\n Morphine\n Nausea/Vomiting\n Penicillins\n Rash;\n Cefpodoxime\n Eczema;\n Iodine; Iodine Containing\n Unknown;\n Precautions: Contact\n PMH: Diabetes - Insulin, GI Bleed, Liver Failure\n CV-PMH:\n Additional history: Liver transplant 6 months ago\n cholenageal ca\n ulcerative colitis\n osteopenia\n umbilical hernia\n recent hx of UTI\n Surgery / Procedure and date: Liver transplant 6 months ago\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:87\n Temperature:\n 97.7\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 None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,486 mL\n 24h total out:\n 400 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:45 AM\n Potassium:\n 3.9 mEq/L\n 05:45 AM\n Chloride:\n 112 mEq/L\n 05:45 AM\n CO2:\n 22 mEq/L\n 05:45 AM\n BUN:\n 6 mg/dL\n 05:45 AM\n Creatinine:\n 0.8 mg/dL\n 05:45 AM\n Glucose:\n 100 mg/dL\n 05:45 AM\n Hematocrit:\n 30.3 %\n 05:45 AM\n Finger Stick Glucose:\n 110\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-785\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2142-03-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 558041, "text": "Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he woke up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. T-max in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n Patient was transferred here from OSH hospital. Pt went to \n hospital after a night of N/V/D. Pt stated he thought blood was in his\n stool and this am he became dizzy, SOB, pale and he took his home BP\n and his SBP was 87. Pt called EMS, we he was guaic positive at the OSH.\n Pt was transferred for further work up and his liver doctors are here.\n Pt HCT in was 40.9 which was up for a baseline of 35. Pt had a\n low grade temp in the ED of 100.2 and received Tylenol. Pt was sent to\n the MICU for further workup of LGIB.\n Pt. has had an uneventful shift. Pt. remains A/A/O and denies any pain\n or discomfort. Stool is guiac negative this afternoon. Pt remains\n afebrile with all vitals signs WNL. Pt. has had both urine and stool\n sent, and remains on contact precautions to r/o VRE. Pt. has HCT\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n LOWER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 77.7 kg\n Daily weight:\n Allergies/Reactions:\n Ciprofloxacin\n Rash;\n Flagyl (Oral) (Metronidazole)\n Rash;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Hives;\n Morphine\n Nausea/Vomiting\n Penicillins\n Rash;\n Cefpodoxime\n Eczema;\n Iodine; Iodine Containing\n Unknown;\n Precautions: Contact\n PMH: Diabetes - Insulin, GI Bleed, Liver Failure\n CV-PMH:\n Additional history: Liver transplant 6 months ago\n cholenageal ca\n ulcerative colitis\n osteopenia\n umbilical hernia\n recent hx of UTI\n Surgery / Procedure and date: Liver transplant 6 months ago\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:87\n Temperature:\n 97.7\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 None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,486 mL\n 24h total out:\n 400 mL\n Lines: #18G L AC, #20G R Hand.\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:45 AM\n Potassium:\n 3.9 mEq/L\n 05:45 AM\n Chloride:\n 112 mEq/L\n 05:45 AM\n CO2:\n 22 mEq/L\n 05:45 AM\n BUN:\n 6 mg/dL\n 05:45 AM\n Creatinine:\n 0.8 mg/dL\n 05:45 AM\n Glucose:\n 100 mg/dL\n 05:45 AM\n Hematocrit:\n 30.3 %\n 05:45 AM\n Finger Stick Glucose:\n 110\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-785\n Transferred to: \n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2142-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 557858, "text": "Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Ulcerative colitis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2142-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558013, "text": "Chief Complaint: Continued diarrhea overnight\n 24 Hour Events:\n BLOOD CULTURED - At 05:14 PM\n Continued diarrhea overnight x 10 episodes of greenish watery stool\n since arrival to ICU\n denies abdominal pain, nausea\n Tachycardia resolved with IVF, HR 80 this AM\n Allergies:\n Ciprofloxacin\n Rash;\n Flagyl (Oral) (Metronidazole)\n Rash;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Hives;\n Morphine\n Nausea/Vomiting\n Penicillins\n Rash;\n Cefpodoxime\n Eczema;\n Iodine; Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n NS @ 150 cc/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Gastrointestinal: Diarrhea\n Endocrine: Hyperglycemia\n Allergy / Immunology: Immunocompromised\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 86 (80 - 112) bpm\n BP: 135/84(95) {104/66(74) - 135/85(95)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,539 mL\n 1,164 mL\n PO:\n TF:\n IVF:\n 3,539 mL\n 1,164 mL\n Blood products:\n Total out:\n 1,050 mL\n 300 mL\n Urine:\n 1,050 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 864 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, non-toxic\n Eyes / Conjunctiva: PERRL, MM\n Head, Ears, Nose, Throat: Normocephalic, Continued diarrhea overnight\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdomen well-healed RUQ & LUQ scars, hyperactive bowel sounds, no\n rebound, no guarding, no abdominal tenderness to deep palpation\n Extremities: Right: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.6 g/dL\n 30.3 %\n 2.5 K/uL\n [image002.jpg]\n 04:27 PM\n 10:09 PM\n 05:45 AM\n WBC\n 2.5\n Hct\n 32.1\n 31.3\n 30.3\n Assessment and Plan\n 1) Diarrhea: Presentation is most consistent with a viral\n gastroenteritis; however, differential is broad in this chronically\n immunosuppressed patient and includes bacterial infection vs. c. diff\n vs. CMV colitis vs. opportunistic infection. Guiac-positive stools\n make salmonella, shigella, and campylobacter possible pathogens. This\n is likely a secretory diarrhea as it has not decreased while NPO.\n - f/u stool studies, including c. diff toxin, O&P, salmonella,\n shigella, campylobacter, viral culture\n - Check CMV VL as patient is known to be CMV mismatch with liver donor\n - NPO until diarrhea improving\n 2) Hypotension/tachycardia: Most likely secondary to profound volume\n depletion in the setting of intractable emesis and diarrhea; however,\n cannot rule out infection vs. bleeding. Patient currently meets SIRS\n criteria with 2 out 4 conditions (T>38, and HR>90), conferring some\n risk that his presentation is consistent with infection. Tachycardia\n improved with IVF.\n - maintenance IVF while diarrhea persists; will continue to bolus PRN\n - f/u blood & urine cultures\n - antibiotics deferred given clinical suspicion for viral etiology\n - Consider RUQ ultrasound if no improvement given fluid collection\n posterior to right lobe of liver seen on MRI in (as per interval\n history, there was no history of this on recent imaging performed at\n )\n - hold Lisinopril in the setting of ongoing volume losses\n 3) Microcytic anemia: Hematocrit has dropped from 48 -> 41 -> 32.6\n since initial presentation to s/p fluid resuscitation. Baseline\n hematocrit is 35-38 (38.2 in at ). Stools now\n guiac-positive.\n - q 12 hour hematocrits\n - 2 peripheral IV's in place\n - active T&C\n - check iron studies given microcytosis\n 4) Leukopenia: Suggests a viral process vs. hemodilution.\n - continue to follow\n - add-on differential\n 5) Ulcerative Colitis: ? flare vs. alternate cause of guaic-positive\n diarrhea, as above.\n - Continue Asacol\n 6) h/o Liver Transplant: Performed in at .\n - Continue immunosuppression Prograf 2 mg (dose recently reduced)\n - f/u Prograf level\n - Liver team following\n 7) IDDM:\n - hold NPH while NPO\n - RISS q6 while NPO, then transition to HISS QACHS when tolerating PO\n 8) PPx: Pneumoboots, PPI\n 9) FEN:\n - NPO while diarrhea persists\n - NS @ 150 cc/hour.\n - Replete Mg\n 9) Code status: full code.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed\n Comments:\n Code status: Full code\n Disposition:Transfer to - service.\n" }, { "category": "Physician ", "chartdate": "2142-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 557970, "text": "Chief Complaint: Continued diarrhea overnight\n 24 Hour Events:\n BLOOD CULTURED - At 05:14 PM\n Continued diarrhea overnight\n Tachycardia resolved with IVF\n Allergies:\n Ciprofloxacin\n Rash;\n Flagyl (Oral) (Metronidazole)\n Rash;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Hives;\n Morphine\n Nausea/Vomiting\n Penicillins\n Rash;\n Cefpodoxime\n Eczema;\n Iodine; Iodine Containing\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 Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Gastrointestinal: Diarrhea\n Endocrine: Hyperglycemia\n Allergy / Immunology: Immunocompromised\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 86 (80 - 112) bpm\n BP: 135/84(95) {104/66(74) - 135/85(95)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,539 mL\n 1,164 mL\n PO:\n TF:\n IVF:\n 3,539 mL\n 1,164 mL\n Blood products:\n Total out:\n 1,050 mL\n 300 mL\n Urine:\n 1,050 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 864 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL, MM\n Head, Ears, Nose, Throat: Normocephalic, Continued diarrhea overnight\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.6 g/dL\n 30.3 %\n 2.5 K/uL\n [image002.jpg]\n 04:27 PM\n 10:09 PM\n 05:45 AM\n WBC\n 2.5\n Hct\n 32.1\n 31.3\n 30.3\n Assessment and Plan\n 1) Diarrhea: Presentation is most consistent with a viral\n gastroenteritis; however, differential is broad in this chronically\n immunosuppressed patient and includes bacterial infection vs. c. diff\n vs. CMV colitis vs. opportunistic infection. Guiac-positive stools\n make salmonella, shigella, and campylobacter possible pathogens.\n - Check stool studies, including c. diff toxin, O&P, salmonella,\n shigella, campylobacter, viral culture\n - Check CMV VL as patient is known to be CMV mismatch with liver donor\n - NPO\n 2) Hypotension/tachycardia: Most likely secondary to profound volume\n depletion in the setting of intractable emesis and diarrhea; however,\n cannot rule out infection vs. bleeding. Patient currently meets SIRS\n criteria with 2 out 4 conditions (T>38, and HR>90), conferring some\n risk that his presentation is consistent with infection. Tachycardia\n improved with IVF.\n - IVF; will continue to bolus PRN\n - pan-culture with blood cx x 2, urine culture\n - antibiotics deferred given clinical suspicion for viral etiology\n - Consider RUQ ultrasound if no improvement given fluid collection\n posterior to right lobe of liver seen on MRI in (as per interval\n history, there was no history of this on recent imaging performed at\n )\n - hold Lisinopril\n 3) Microcytic anemia: Hematocrit has dropped from 48 -> 41 -> 32.6\n since initial presentation to s/p fluid resuscitation. Baseline\n hematocrit is 35-38 (38.2 in at ). Stools now\n guiac-positive.\n - q 6 hour hematocrits\n - 2 peripheral IV's in place\n - active T&C\n - check iron studies given microcytosis\n 4) Ulcerative Colitis: ? flare vs. alternate cause of guaic-positive\n diarrhea, as above.\n - Continue Asacol\n 5) h/o Liver Transplant: Performed in at .\n - Continue immunosuppresion Prograf 2 mg (dose recently reduced)\n - Prograf level in AM\n - Liver team following\n 6) IDDM:\n - Continue NPH at 50% of dose while NPO\n - RISS q6 while NPO, then transition to HISS QACHS when tolerating PO\n 7) PPx: Pneumoboots, PPI\n 8) FEN:\n - NPO overnight; will advance diet when able to tolerate PO.\n - IVF for volume resuscitation.\n 9) Code status: full code.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2142-03-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 557997, "text": "Chief Complaint: Gastroenteritis\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 05:14 PM\n CALLED OUT\n Stool and mucusy, then green overnight.\n VSS\n All cell lines down today\n Allergies:\n Ciprofloxacin\n Rash;\n Flagyl (Oral) (Metronidazole)\n Rash;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Hives;\n Morphine\n Nausea/Vomiting\n Penicillins\n Rash;\n Cefpodoxime\n Eczema;\n Iodine; Iodine Containing\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 Flowsheet Data as of 09:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.7\nC (98\n HR: 86 (80 - 112) bpm\n BP: 135/84(95) {104/66(74) - 135/85(95)} mmHg\n RR: 18 (13 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,539 mL\n 1,406 mL\n PO:\n TF:\n IVF:\n 3,539 mL\n 1,406 mL\n Blood products:\n Total out:\n 1,050 mL\n 300 mL\n Urine:\n 1,050 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 1,106 mL\n Respiratory support\n SpO2: 94%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.6 g/dL\n 105 K/uL\n 100 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 112 mEq/L\n 141 mEq/L\n 30.3 %\n 2.5 K/uL\n [image002.jpg]\n 04:27 PM\n 10:09 PM\n 05:45 AM\n WBC\n 2.5\n Hct\n 32.1\n 31.3\n 30.3\n Plt\n 105\n Cr\n 0.8\n Glucose\n 100\n Other labs: ALT / AST:22/23, Alk Phos / T Bili:65/1.5, Ca++:7.7 mg/dL,\n Mg++:1.2 mg/dL, PO4:2.1 mg/dL\n Fluid analysis / Other labs: FK level pend\n Random cortisol 11.\n Assessment and Plan\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ULCERATIVE COLITIS\n 44-year-old male status post orthopic liver transplant for primary\n sclerosing cholangitis and cholangiocarcinoma p/w fever, emesis and\n frequent waterry/ diarrhea, hypotensio, recent course of Bactrim\n for asymptomatic UTI. Prednisone 5 mg discontinued few days ago\n was\n started for UC flare. Prograf recently reduced. CMV donor mismatch, not\n on ppx.\n Hypotension and tachycardia resolved after fluid resuscitation. + sick\n contact and guiac +. Multiple cxs pend.\n GI: ? viral gastroenteritis, especially given + sick contact. Not on\n CMV prophylaxis, CMV VL pend. Extensive stool cultures/c diff sent.\n Doubt UC flare since symptoms are different, and it shouldnt cause N/V.\n But follow for now.\n Liver tx: check FK level. Keep lower given leukopenia. d/w liver team.\n Heme: all cell lines down\n Anemia: Hct dropped 17 ppoints but stable, likely dilutional from fluid\n resuscitation. Guiac +. Transfuse to keep Hct > 25\n Leukocytosis: viral vs immunesuppression induced, d/x liver reg\n reducing prograf dose\n Thrombocytopenia: close to baseline, follow\n Rest per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: NPH held\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition : called out\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2142-03-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 557943, "text": "Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he work up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. Tmax in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n transfered here from OSH hospital. Pt went to hospital after a\n night of N/V/D. Pt stated he thought blood was in his stool and this am\n he became dizzy, SOB, pale and he took his home BP and his SBP was 87.\n Pt called EMS, we he was guaic positive at the OSH. Pt was transfered\n for further work up and his liver doctors are here. Pt HCT in \n was 40.9 which was up for a baseline of 35. Pt had a low grade temp in\n the ED of 100.2 and received tylenol. Pt was sent to the MICU for\n further workup of LGIB.\n Pt. has had an uneventful shift. Pt. remains A/A/O and denies any pain\n or discomfort . Pt remains afebrile with all vitals signs WNL\ns Pt. has\n had both urine and stool sent , and remains on contact precautions to\n r/o VRE. Pt. will be a c/o to the floor this am.\n" }, { "category": "Nursing", "chartdate": "2142-03-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 557944, "text": "Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he work up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. Tmax in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n transfered here from OSH hospital. Pt went to hospital after a\n night of N/V/D. Pt stated he thought blood was in his stool and this am\n he became dizzy, SOB, pale and he took his home BP and his SBP was 87.\n Pt called EMS, we he was guaic positive at the OSH. Pt was transfered\n for further work up and his liver doctors are here. Pt HCT in \n was 40.9 which was up for a baseline of 35. Pt had a low grade temp in\n the ED of 100.2 and received tylenol. Pt was sent to the MICU for\n further workup of LGIB.\n Pt. has had an uneventful shift. Pt. remains A/A/O and denies any pain\n or discomfort . Pt remains afebrile with all vitals signs WNL\ns Pt. has\n had both urine and stool sent , and remains on contact precautions to\n r/o VRE. Pt. has q6hr HCT\ns, with am labs pending at this time. Pt.\n will be a c/o to the floor this am.\n" }, { "category": "Physician ", "chartdate": "2142-03-14 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 557874, "text": "Chief Complaint:\n HPI:\n Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he work up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. Tmax in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n Allergies:\n Ciprofloxacin (rash)\n Flagyl (rash)\n Amoxicillin (unknown)\n Iodinated contrast (skin desquamation on soles of feet)\n Last dose of Antibiotics:\n Bactrim (Sunday)\n Infusions:\n Other ICU medications:\n Home medications:\n Prograf 2 mg \n Asacol 2400 mg \n NPH 14 units qAM, 8 units qPM\n Protonix 40 mg daily\n Lisinopril 10 mg daily\n MVI\n Calcium + D\n ASA 81 mg daily\n Prednisone (discontinued Sunday)\n Bactrim (completed 3-day course for tx of UTI on Sunday)\n Past medical history:\n Family history:\n Social History:\n 1) Sclerosing cholangitis with cholangiocarcinoma: s/p living\n unrelated partial liver transplant in at the \n in .\n 2) Cholangiocarcinoma: treatment at the included 30\n radiation treatments as well as chemotherapy with 5FU as part of the\n chemoradiation protocol. The course of chemotherapy was abbreviated\n because it induced a flare of ulcerative colitis for which he was\n started on Asacol.\n 3) Ulcerative colitis: previously quiescent until treatment for his\n cholangiocarcinoma\n 4) h/o VRE bacteremia\n 5) h/o partially occlusive venous thrombosis\n 6) IDDM secondary to chronic steroids\n 7) HTN secondary to chronic steroids\n 8) Osteopenia\n 9) Umbilical wall hernia\n 10) Grade I esophageal varices (EGD )\n Non contributory\n He denies any history of tobacco use. He has not consumed alcohol for\n the past 13 years, since he was diagnosed with PSC. He is married with\n a 9 year-old daughter and a 6 year-old son. previously worked as an\n electrician but is currently on medical disability.\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Heme / Lymph: Anemia\n Flowsheet Data as of 06:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 107 (107 - 112) bpm\n BP: 104/66(74) {104/66(74) - 121/74(85)} mmHg\n RR: 21 (13 - 23) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,000 mL\n PO:\n TF:\n IVF:\n 3,000 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,800 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 92%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 176\n 1\n 11\n 26\n 109\n 4.9\n 142\n 32.1 %\n [image002.jpg]\n \n 2:33 A2/18/ 04:27 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.1\n Hct\n 32.1\n Plt\n 160\n Other labs: PT / PTT / INR:15.2/32.4/1.3, ALT / AST:26/22, Alk Phos / T\n Bili:/1.8, Differential-Neuts:83.7, Band:0, Lymph:7.4, Mono:5.5,\n Eos:2.9, LDH:189\n labs:\n WBC 11.4 (66N,23L,6M,2E)\n Hct 48.8\n Microbiology: UA - negative\n ECG: EKG: sinus tach, HR 120, LAD\n Assessment and Plan\n 1) Diarrhea: Presentation is most consistent with a viral\n gastroenteritis; however, differential is broad in this chronically\n immunosuppressed patient and includes bacterial infection vs. c. diff\n vs. CMV colitis vs. opportunistic infection. Guiac-positive stools\n make salmonella, shigella, and campylobacter possible pathogens.\n - Check stool studies, including c. diff toxin, O&P, salmonella,\n shigella, campylobacter, viral culture\n - Check CMV VL as patient is known to be CMV mismatch with liver donor\n - NPO\n 2) Hypotension/tachycardia: Most likely secondary to profound volume\n depletion in the setting of intractable emesis and diarrhea; however,\n cannot rule out infection vs. bleeding. Patient currently meets SIRS\n criteria with 2 out 4 conditions (T>38, and HR>90), conferring some\n risk that his presentation is consistent with infection.\n - IVF; will continue to bolus\n - pan-culture with blood cx x 2, urine culture\n - antibiotics deferred given clinical suspicion for viral etiology\n - Consider RUQ ultrasound if no improvement given fluid collection\n posterior to right lobe of liver seen on MRI in (as per interval\n history, there was no history of this on recent imaging performed at\n )\n - hold Lisinopril\n 3) Microcytic anemia: Hematocrit has dropped from 48 -> 41 -> 32.6\n since initial presentation to s/p fluid resuscitation. Baseline\n hematocrit is 35-38 (38.2 in at ). Stools now\n guiac-positive.\n - q 6 hour hematocrits\n - 2 peripheral IV's in place\n - active T&C\n - check iron studies given microcytosis\n 4) Ulcerative Colitis: ? flare vs. alternate cause of guaic-positive\n diarrhea, as above.\n - Continue Asacol\n 5) h/o Liver Transplant: Performed in at .\n - Continue immunosuppresion Prograf 2 mg (dose recently reduced)\n - Prograf level in AM\n - Liver team following\n 6) IDDM:\n - Continue NPH at 50% of dose while NPO\n - RISS q6 while NPO, then transition to HISS QACHS when tolerating PO\n 7) PPx: Pneumoboots, PPI\n 8) FEN:\n - NPO overnight; will advance diet when able to tolerate PO.\n - IVF for volume resuscitation.\n 9) Code status: full code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Continue home PPI.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Admit to ICU.\n ------ Protected Section ------\n Attending Note: patient was seen and examined with Dr . The\n above note reflects our discussion. I would add the following:\n 44-year-old male status post orthopic liver transplant for primary\n sclerosing cholangitis and cholangiocarcinoma. This AM had emesis and\n frequent waterry/ diarrhea. Home BP was 80/palp associated with\n lightheadedness. Called EMS, brought to with BP>100 systolic, 2\n L IVF infused, initial Hct 48 (baseline 35-38). Transferred to .\n In our ED, temp 100.2, HR ~110. Feels better without nausea or vomiting\n since 5am. Daughter home with lethargy, fever, pain. Recent course\n of Bactrim for asymptomatic UTI. Prednisone 5 mg discontinued 3 days\n ago\n was started for UC flare. Prograf reduced.\n Exam as above. Lungs CTA, S1S2 tacchy, 1/6 SEM, abdomen soft, surgical\n scar well healed, no \ns, nontender, no LE edema, neuro exam\n grossly intact.\n Labs reviewed\n Hct 40.9, wbc 7.1. On repeat Hct was 32. BUN 11, creat\n 1.0, lipase normal\n Impression\n Emesis and diarrhea x 1 day\n guaiac reportedly positive, will need to\n check. Symptoms highly suggestive for viral gastroenteritis, especially\n given daughter\ns probable viral illness. Not on CMV prophylaxis but\n doubt this is active. Extensive stool cultures/c diff sent/\n microsporidia. need to proceed with abd imaging. Liver service has\n seen the patient.\n Hypotension/Tachycardia\n hypotension resolved. tachycardia seems to be\n responding well to IVF. Agree with holding off on Abx for now. Off Pred\n since Sunday but less likely adrenal insufficiency given fluid\n responsiveness. Cortisol pending. Lisinopril on hold.\n Anemia\n will need to verify recent drop, rechcek guaiac (per ED, stool\n and guaiac positive). He will be crossmatched. Received 7 L IVF\n so dilutional component.\n Patient is ill but stable. He will remain in the ICU. Time spent 45\n minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:13 ------\n ------ Protected Section Addendum Entered By: , MD\n on: 19:29 ------\n" }, { "category": "Physician ", "chartdate": "2142-03-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 557872, "text": "Chief Complaint:\n HPI:\n Mr. is a 44 yo male with a history of UC and s/p liver\n transplant for PSC and cholangiocarcinoma who presents with emesis and\n diarrhea x 1 day. He states that he work up at 1:30 AM and felt ill.\n He went to the bathroom and passed a normal stool at that time. He\n then subsequently had multiple episodes of diarrhea, which he describes\n as watery, unformed stool. He had 8 episodes of non-bloody,\n non-bilious emesis and states that he was unable to keep down a small\n amount of Hawaiian Punch. At 5:30 AM he measured his blood pressure at\n 80's systolic. He states that he felt weak and lightheaded at that\n time. On subsequent attempts to measure his blood pressure, the\n machine recorded that it was \"unable to measure.\" He states that his\n symptoms \"felt similar to the time he developed septic shock,\" so he\n decided to call EMS. He endorses a sick contact with his 9 year-old\n daughter who has had fevers, lethargy, and abdominal pain this week;\n she has not had diarrhea or vomiting. He denies any recent exposures\n to uncooked foods, and states that he ate store-cooked chicken for\n dinner last night. His wife also ate the same chicken and has not been\n sick. He reports that he also had a few sips of tap water which tasted\n strange to him. Patient visited the last week for routine\n follow-up care with his Surgeon. He was diagnosed with a UTI and was\n treated with a 3-day course of Bactrim. He also reports that he was\n exposed to someone with C. diff during that visit. He feels that\n symptoms are not consistent with previous UC flares, as he typically\n experiences only diarrhea and no vomiting.\n He was transported by EMS to , where he received 2 L\n NS. He was subsequently transferred to ED. On arrival, T\n 100.2, BP 111/79, HR 132, SpO2 98% on RA. Tmax in the ED was 100.6.\n He received 2 L NS and 1 gram of Tylenol prior to transfer to the ICU\n for further care.\n Allergies:\n Ciprofloxacin (rash)\n Flagyl (rash)\n Amoxicillin (unknown)\n Iodinated contrast (skin desquamation on soles of feet)\n Last dose of Antibiotics:\n Bactrim (Sunday)\n Infusions:\n Other ICU medications:\n Home medications:\n Prograf 2 mg \n Asacol 2400 mg \n NPH 14 units qAM, 8 units qPM\n Protonix 40 mg daily\n Lisinopril 10 mg daily\n MVI\n Calcium + D\n ASA 81 mg daily\n Prednisone (discontinued Sunday)\n Bactrim (completed 3-day course for tx of UTI on Sunday)\n Past medical history:\n Family history:\n Social History:\n 1) Sclerosing cholangitis with cholangiocarcinoma: s/p living\n unrelated partial liver transplant in at the \n in .\n 2) Cholangiocarcinoma: treatment at the included 30\n radiation treatments as well as chemotherapy with 5FU as part of the\n chemoradiation protocol. The course of chemotherapy was abbreviated\n because it induced a flare of ulcerative colitis for which he was\n started on Asacol.\n 3) Ulcerative colitis: previously quiescent until treatment for his\n cholangiocarcinoma\n 4) h/o VRE bacteremia\n 5) h/o partially occlusive venous thrombosis\n 6) IDDM secondary to chronic steroids\n 7) HTN secondary to chronic steroids\n 8) Osteopenia\n 9) Umbilical wall hernia\n 10) Grade I esophageal varices (EGD )\n Non contributory\n He denies any history of tobacco use. He has not consumed alcohol for\n the past 13 years, since he was diagnosed with PSC. He is married with\n a 9 year-old daughter and a 6 year-old son. previously worked as an\n electrician but is currently on medical disability.\n Review of systems:\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Heme / Lymph: Anemia\n Flowsheet Data as of 06:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 107 (107 - 112) bpm\n BP: 104/66(74) {104/66(74) - 121/74(85)} mmHg\n RR: 21 (13 - 23) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 3,000 mL\n PO:\n TF:\n IVF:\n 3,000 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,800 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 92%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 176\n 1\n 11\n 26\n 109\n 4.9\n 142\n 32.1 %\n [image002.jpg]\n \n 2:33 A2/18/ 04:27 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.1\n Hct\n 32.1\n Plt\n 160\n Other labs: PT / PTT / INR:15.2/32.4/1.3, ALT / AST:26/22, Alk Phos / T\n Bili:/1.8, Differential-Neuts:83.7, Band:0, Lymph:7.4, Mono:5.5,\n Eos:2.9, LDH:189\n labs:\n WBC 11.4 (66N,23L,6M,2E)\n Hct 48.8\n Microbiology: UA - negative\n ECG: EKG: sinus tach, HR 120, LAD\n Assessment and Plan\n 1) Diarrhea: Presentation is most consistent with a viral\n gastroenteritis; however, differential is broad in this chronically\n immunosuppressed patient and includes bacterial infection vs. c. diff\n vs. CMV colitis vs. opportunistic infection. Guiac-positive stools\n make salmonella, shigella, and campylobacter possible pathogens.\n - Check stool studies, including c. diff toxin, O&P, salmonella,\n shigella, campylobacter, viral culture\n - Check CMV VL as patient is known to be CMV mismatch with liver donor\n - NPO\n 2) Hypotension/tachycardia: Most likely secondary to profound volume\n depletion in the setting of intractable emesis and diarrhea; however,\n cannot rule out infection vs. bleeding. Patient currently meets SIRS\n criteria with 2 out 4 conditions (T>38, and HR>90), conferring some\n risk that his presentation is consistent with infection.\n - IVF; will continue to bolus\n - pan-culture with blood cx x 2, urine culture\n - antibiotics deferred given clinical suspicion for viral etiology\n - Consider RUQ ultrasound if no improvement given fluid collection\n posterior to right lobe of liver seen on MRI in (as per interval\n history, there was no history of this on recent imaging performed at\n )\n - hold Lisinopril\n 3) Microcytic anemia: Hematocrit has dropped from 48 -> 41 -> 32.6\n since initial presentation to s/p fluid resuscitation. Baseline\n hematocrit is 35-38 (38.2 in at ). Stools now\n guiac-positive.\n - q 6 hour hematocrits\n - 2 peripheral IV's in place\n - active T&C\n - check iron studies given microcytosis\n 4) Ulcerative Colitis: ? flare vs. alternate cause of guaic-positive\n diarrhea, as above.\n - Continue Asacol\n 5) h/o Liver Transplant: Performed in at .\n - Continue immunosuppresion Prograf 2 mg (dose recently reduced)\n - Prograf level in AM\n - Liver team following\n 6) IDDM:\n - Continue NPH at 50% of dose while NPO\n - RISS q6 while NPO, then transition to HISS QACHS when tolerating PO\n 7) PPx: Pneumoboots, PPI\n 8) FEN:\n - NPO overnight; will advance diet when able to tolerate PO.\n - IVF for volume resuscitation.\n 9) Code status: full code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:22 PM\n 20 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Continue home PPI.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Admit to ICU.\n ------ Protected Section ------\n Attending Note: patient was seen and examined with Dr . The\n above note reflects our discussion. I would add the following:\n 44-year-old male status post orthopic liver transplant for primary\n sclerosing cholangitis and cholangiocarcinoma. This AM had emesis and\n frequent waterry/ diarrhea. Home BP was 80/palp associated with\n lightheadedness. Called EMS, brought to with BP>100 systolic, 2\n L IVF infused, initial Hct 48 (baseline 35-38). Transferred to .\n In our ED, temp 100.2, HR ~110. Feels better without nausea or vomiting\n since 5am. Daughter home with lethargy, fever, pain. Recent course\n of Bactrim for asymptomatic UTI. Prednisone 5 mg discontinued 3 days\n ago\n was started for UC flare. Prograf reduced.\n Exam as above. Lungs CTA, S1S2 tacchy, 1/6 SEM, abdomen soft, surgical\n scar well healed, no \ns, nontender, no LE edema, neuro exam\n grossly intact.\n Labs reviewed\n Hct 40.9, wbc 7.1. On repeat Hct was 32. BUN 11, creat\n 1.0, lipase normal\n Impression\n Emesis and diarrhea x 1 day\n guaiac reportedly positive, will need to\n check. Symptoms highly suggestive for viral gastroenteritis, especially\n given daughter\ns probable viral illness. Not on CMV prophylaxis but\n doubt this is active. Extensive stool cultures/c diff sent/\n microsporidia. need to proceed with abd imaging. Liver service has\n seen the patient.\n Hypotension/Tachycardia\n hypotension resolved. tachycardia seems to be\n responding well to IVF. Agree with holding off on Abx for now. Off Pred\n since Sunday but less likely adrenal insufficiency given fluid\n responsiveness. Cortisol pending. Lisinopril on hold.\n Anemia\n will need to verify recent drop, rechcek guaiac (per ED, stool\n and guaiac positive). He will be crossmatched. Received 7 L IVF\n so dilutional component.\n Patient is ill but stable. He will remain in the ICU. Time spent 45\n minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:13 ------\n" }, { "category": "Nursing", "chartdate": "2142-03-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 557928, "text": "transfered here from OSH hospital. Pt went to hospital after a\n night of N/V/D. Pt stated he thought blood was in his stool and this am\n he became dizzy, SOB, pale and he took his home BP and his SBP was 87.\n Pt called EMS, we he was guaic positive at the OSH. Pt was transfered\n for further work up and his liver doctors are here. Pt HCT in \n was 40.9 which was up for a baseline of 35. Pt had a low grade temp in\n the ED of 100.2 and received tylenol. Pt was sent to the MICU for\n further workup of LGIB.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Pt had a brief period of hypotension prior to any admission either \n or OSH. Pt stated he was up vomiting multiple times throughout the\n night and he was having multiple episodes of watery diarrhea. Pt is\n noted to be tachy at this time with a HR in the 120\n Action:\n Pt has received a total of 8 liter of IVF.\n Response:\n Pt HR remains elevated in the 1 teens to 120\ns. ST\n Plan:\n Cont with fluid until pt is less tachy. Monitor uop and resp status.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt has guiac positive diarrhea which he states is not normal despite\n his ulcerative colitis, pt hct was 40 upon admission. Pt denies abd\n pain or tenderness\n Action:\n Pt had an HCT sent from the ICU and HCT dropped to 32 towards his\n baseline of 35. This drop occurred after pt received 7 liters of NS\n Response:\n Pt has not had any sign of bleeding at this time. Cont to monitor\n Plan:\n Pt will need a stool sample with next BM. Q 6 hr HCT\n" }, { "category": "ECG", "chartdate": "2142-03-14 00:00:00.000", "description": "Report", "row_id": 172521, "text": "Sinus tachycardia\nBorderline left axis deviation may be due to left anterior fascicular block\notherwise is nondiagnostic\nLate precordial QRS transition is nonspecific\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Radiology", "chartdate": "2154-03-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1130072, "text": " 5:57 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? pna , check lineVent dependent\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with FEVER, S/P THORACOABD ANEURSYM REPair. Vented\n REASON FOR THIS EXAMINATION:\n ? pna , check lineVent dependent\n ______________________________________________________________________________\n WET READ: JKSd MON 10:03 PM\n right sided CVL in the lower SVC. s/p aortic aneurysm repair. persistent\n retrocardiac density.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aneurysm repair.\n\n FINDINGS: In comparison with study of , the patient has undergone an\n aneurysm repair. Prominence of the superior mediastinum persists.\n\n\n" }, { "category": "Respiratory ", "chartdate": "2154-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 736733, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\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: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / 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 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: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions; Comments: Pt remains\n stable on current vent settings. Pt has siginificant leak at trach\n site, but still recieving good tidal volumes. Pt very agitated in bed,\n causing tachypnea and high Mv alarm to sound off. Plan is for pt to be\n returned to Rehab today and continue current vent support\n" }, { "category": "Respiratory ", "chartdate": "2154-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 736947, "text": "Demographics\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 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: 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: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Pt placed on Trach collar at\n approx 8:00am this morning; has tolerated wean well throughout shift &\n remains on trach collar at this time.\n Assessment of breathing comfort: no complaints of dyspnea\n Plan\n Next 24-48 hours: Continue with Trach Collar weans as tolerated.\n" }, { "category": "Nursing", "chartdate": "2154-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736572, "text": "Pneumonia, other\n Assessment:\n Remains anxious, c/o itchiness all over body.\n Lungs rhoncherous bilaterally, copious thick white secretions.\n Remains on CPAP 40% 5/8. O2 sat 98-100%.\n Action:\n Suctioned via in-line catheter.\n Vancomycin discontinued per ID.\n Turned and repositioned per protocol.\n Response:\n Continues with copious secretions, unable to place on trach collar.\n CXR improved.\n O2 sat remains stable.\n Plan:\n Monitor respiratory status, pulmonary toilet.\n Impaired Skin Integrity\n Assessment:\n Stage III on coccyx covered with mepilex dressing.\n Action:\n Turned and repositioned per protocol.\n Remains on tube feeding at goal via j tube.\n Response:\n Remains unchanged.\n Plan:\n Monitor skin, turn and reposition, support nutrition.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Remains afebrile. WBC 11.8. Ecoli in urine.\n Action:\n Vancomycin discontinued, Cefepime continues.\n Response:\n Catheter remains out, straight cathed for 700 ml.\n Plan:\n Monitor for fever, monitor WBC, continue with cefepime for urine.\n" }, { "category": "Physician ", "chartdate": "2154-03-06 00:00:00.000", "description": "ICU Note - CVI", "row_id": 736141, "text": "CVICU\n HPI:\n HD3\n Ejection Fraction:55%\n Hemoglobin A1c:6\n Pre-Op Weight:250.44 lbs 113.6 kgs\n Baseline Creatinine:1.1\n TLD:RT SCV TLC:Day3\n 59 year old male status post ruptured thoracoabdominal aneurysm repair\n on . Transferred from Rehab with fever of unknown\n origin and new thoracoabdominal drainage.\n Major Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm with a 34-mm Dacron tube graft using deep\n hypothermic circulatory arrest.\n -------------------------------------------------------------\n Medications at Rehab\n 1. Ranitidine 150(1),Aspirin 325 (1),Polyvinyl Alcohol-Povidone 1.4-0.6\n % Dropperette Sig: 1-2Drops Ophthalmic PRN (as needed) as needed for\n dryness, Heparin SC 5K tid,Tramadol 50 1-2q4h for\n pain,Ipratropium-Albuterol 6puffs QID prn,Amiodarone 200 mg Tablet\n daily, Miconazole powder(1) Appl Topical , Sertraline 50 (1),\n Metoprolol Tartrate 37.5(3),Nystatin 100,000 unit/mL Suspension Sig:\n Five (5) ML PO QID,Clonazepam 1 (2),Lorazepam 1 (3)/prn for\n agitation/anxiety,Insulin Glargine 100 unit/mL Solution Sig: Twenty\n (20) units, SSI Subcutaneous once a day, Furosemide 20 (2),Warfarin 1\n mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: 3mg on \n target INR 2-2.5 (received 5mg last 4 days), Insulin Regular Human 100\n unit/mL Solution Sig: sliding\n Events:\n readmit from rehab for fever of unknown origin\n Plan:pan cx,Vanco/cefipime.Prob urinary source(??pulm). ID involved.\n stopping anticoagulation\n Current medications:\n Albuterol-Ipratropium . Amiodarone . Artificial Tears Preserv. Free .\n Aspirin . Bisacodyl CefePIME . Clonazepam . . DiphenhydrAMINE .\n Docusate Sodium (Liquid) . Furosemide Glucagon Hydrocortisone Cream 1%\n . Insulin . Lorazepam . Lorazepam Metoprolol Tartrate Ranitidine\n (Liquid). Sarna Lotion . Sertraline TraMADOL (Ultram)\n Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 12:30 PM\n BLOOD CULTURED - At 03:00 PM 2 sets sent\n URINE CULTURE - At 10:49 PM\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 10:23 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: 36.9\nC (98.4\n HR: 84 (69 - 90) bpm\n BP: 119/56(71) {82/28(48) - 119/58(72)} mmHg\n RR: 32 (15 - 42) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.5 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 2,109 mL\n 732 mL\n PO:\n Tube feeding:\n 1,344 mL\n 593 mL\n IV Fluid:\n 605 mL\n 49 mL\n Blood products:\n Total out:\n 1,160 mL\n 0 mL\n Urine:\n 860 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 949 mL\n 732 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 372 (325 - 641) mL\n PS : 8 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///29/\n Ve: 13.9 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, blind\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), mid wound open area clean\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 405 K/uL\n 8.8 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.3 %\n 11.6 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n WBC\n 18.2\n 13.9\n 11.6\n Hct\n 26.7\n 27.1\n 27.3\n Plt\n \n Creatinine\n 1.1\n 1.1\n 1.0\n Glucose\n 85\n 92\n 106\n Other labs: PT / PTT / INR:16.5/29.6/1.5, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Microbiology: urine-GNR 10,000-100,000\n wound-NG\n BC-pending\n legioniella titre -neg\n Legionella sp-pending\n sputum-mod GNRs\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: afebrile, WBC down. Urine/sp both suggestive of\n infection. Continue antibiotics for now. To a rehab facility once this\n sorted out. Pruritis continues to improve.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: Trach, (Ventilator mode: CPAP + PS, Other), TC trials\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: st cath prn\n Hematology:\n Endocrine: RISS, Lantus (R)\n Infectious Disease:\n Lines / Tubes / Drains: G-tube, J-Tube\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery, P.T., O.T., Nutrition\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:16 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2154-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736783, "text": "Pneumonia, other\n Assessment:\n Alert, anxious, cooperative. Some audible language around\n trach.\n Lungs congested in upper lobes and diminished at bases,\n trached on ventilator\n Pale pink, raised on thighs, full body rash continues to\n itch\n Foley draining clear yellow urine > 30 cc per hour\n Afebrile, vitals within parameters\n Tube feed at goal, PEGJ tube patent\n Action:\n Pulmo toilet, suction for thick white secretions\n Sarna lotion to rash, Benadryl via GT\n Response:\n Oxygen sats 98\n Lungs sounds clearing after suction and MDI\n Tube feed continues\n Becoming very anxious about transfer to rehab tomorrow,\n demanding excess amounts of attention and care from staff, short\n tempered, difficulty sleeping, pulling vent off trach for attention.\n Patient reports reduced need to itch after multiple baths,\n meds, and lotions.\n Plan:\n Probable return to rehab, family meeting with\n rehab staff today to discuss issues with last stay.\n Continue care and monitoring per orders\n Limit setting with emotional support\n" }, { "category": "Nursing", "chartdate": "2154-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736064, "text": "Pneumonia, other\n Assessment:\n Afebrile, vitals stable\n Trached, vented on CPAP.\n Extremely anxious\n Full body raised red rash, itching.\n Thoracotmy dressing CDI.\n Tube feedings at 60 cc per hour\n Straight cathed at per orders.\n Action:\n Suctioned for thick tan to blood tinged secretions.\n Ativan via JT for anxiety\n Benadryl via JT for itching, hydrocortisone and sarna topically to rash\n Continued tube feedings.\n Humalog sliding scale\n Urine 350 cc, sent for culture and legionella\n Response:\n Lung sounds clear after suctioning\n Pt slept, calm, not touching tubes after anxiolytic dose\n Itching discomfort relieved mostly by cream application.\n No further orders for straight cath at this time, no urge to void.\n Plan:\n Continue to medicate for anxiety\n Pulmo hygiene\n Increase activity and OOB\n Possible trach collar trial\n Cdiff specimen if stooling.\n Need further orders for straight cath or Foley.\n" }, { "category": "Nursing", "chartdate": "2154-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736415, "text": "59 y/o M With history significant for HTN, AFIB, Blindness (post op);S/P rupture\nd thoracoabdominal aneurysm repair on . He was transferred today from Rehab with FUO and new L-thoracotomy drainage. On arrival he\ns pan cu\nltured.\nPt also experiencing moderate bleeding from site post RSC- TLC insertion; coag\ns on arrival showing marked elevation PT36.8 PTT 106 INR 3.8.\n - Emergent salvage repair of ruptured thoracoabdominal aortic aneurysm.\n - Chest and abdomen exploration, Removal of packs, Chest closure.\n - Abdomen closure/ PEG placement\n tracheostomy\n Re admit FUO.\n \n Continues with low grade fever overnight. T max 100.1F PO. Alert,\n oriented x2. Following commands. Able to communicate needs using non\n verbal cues and soft speech. PERRLA. LS Clear/ rhonchii bilat. Trach\n intact, sutures intact, Leak. Vented on CPAP 40% 8/5. O2 sats 99-100%\n . Moist creamy copious and blood tinged secretions per inline\n suction. SR per tele HR 70\ns, SBP 100-110mmHg. Easily palpable PP\n bilaterally. Active BS 4Q\ns. TF at goal 50cc/hr tolerating well with\n minimal residual seen on assessment. FSBS Q6hr 100-130mgdL . Turned\n and repositioned per protocol. Stage 3 pressure wound over coccygeal\n area; skin broken. Mepilex DSD intact. Skin rash continues to\n improve. Skin care provided. Removed, cleaned and replaceed\n L-thoracotomy DSD w-D. Straight cath for clear amber urine at 2200hr.\n Lantus +SS coverage for FSBS.\n PLAN\n Cultures pending\n Monitor oxygenation.\n C diff specs with nextg stool\n Monitor FSBS.\n" }, { "category": "General", "chartdate": "2154-03-06 00:00:00.000", "description": "Generic Note", "row_id": 736186, "text": "CVICU\n HPI:\n 59 year old male status post ruptured thoracoabdominal aneurysm repair\n on . Post-op course complicated by strokes and blindness.\n Eventually ransferred to rehab and re-admitted from Rehab\n with fever of unknown origin and new thoracoabdominal drainage.\n Major Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm with a 34-mm Dacron tube graft using deep\n hypothermic circulatory arrest.\n -------------------------------------------------------------\n Medications at Rehab\n 1. Ranitidine 150(1),Aspirin 325 (1),Polyvinyl Alcohol-Povidone 1.4-0.6\n % Dropperette Sig: 1-2Drops Ophthalmic PRN (as needed) as needed for\n dryness, Heparin SC 5K tid,Tramadol 50 1-2q4h for\n pain,Ipratropium-Albuterol 6puffs QID prn,Amiodarone 200 mg Tablet\n daily, Miconazole powder(1) Appl Topical , Sertraline 50 (1),\n Metoprolol Tartrate 37.5(3),Nystatin 100,000 unit/mL Suspension Sig:\n Five (5) ML PO QID,Clonazepam 1 (2),Lorazepam 1 (3)/prn for\n agitation/anxiety,Insulin Glargine 100 unit/mL Solution Sig: Twenty\n (20) units, SSI Subcutaneous once a day, Furosemide 20 (2),Warfarin 1\n mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: 3mg on \n target INR 2-2.5 (received 5mg last 4 days), Insulin Regular Human 100\n unit/mL Solution Sig: sliding\n Events:\n readmit from rehab for fever of unknown origin\n Current medications:\n Albuterol-Ipratropium . Amiodarone . Artificial Tears Preserv. Free .\n Aspirin . Bisacodyl CefePIME . Clonazepam . . DiphenhydrAMINE .\n Docusate Sodium (Liquid) . Furosemide Glucagon Hydrocortisone Cream 1%\n . Insulin . Lorazepam . Lorazepam Metoprolol Tartrate Ranitidine\n (Liquid). Sarna Lotion . Sertraline TraMADOL (Ultram)\n Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 12:30 PM\n BLOOD CULTURED - At 03:00 PM 2 sets sent\n URINE CULTURE - At 10:49 PM\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 10:23 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: 36.9\nC (98.4\n HR: 84 (69 - 90) bpm\n BP: 119/56(71) {82/28(48) - 119/58(72)} mmHg\n RR: 32 (15 - 42) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.5 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 2,109 mL\n 732 mL\n PO:\n Tube feeding:\n 1,344 mL\n 593 mL\n IV Fluid:\n 605 mL\n 49 mL\n Blood products:\n Total out:\n 1,160 mL\n 0 mL\n Urine:\n 860 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 949 mL\n 732 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 372 (325 - 641) mL\n PS : 8 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///29/\n Ve: 13.9 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, blind\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), mid wound open area clean\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 405 K/uL\n 8.8 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.3 %\n 11.6 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n WBC\n 18.2\n 13.9\n 11.6\n Hct\n 26.7\n 27.1\n 27.3\n Plt\n \n Creatinine\n 1.1\n 1.1\n 1.0\n Glucose\n 85\n 92\n 106\n Other labs: PT / PTT / INR:16.5/29.6/1.5, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Microbiology: urine-GNR 10,000-100,000\n wound-NG\n BC-pending\n legioniella titre -neg\n Legionella sp-pending\n sputum-mod GNRs\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: 59 year old male status post ruptured\n thoracoabdominal aneurysm repair on . Post-op course complicated\n by strokes and blindness. Eventually ransferred to rehab and\n re-admitted from Rehab with fever of unknown origin and new\n thoracoabdominal drainage.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled. Ativan low dose for\n anxiety.\n Cardiovascular: Aspirin, Beta-blocker, Statins. HD stable. Amiodarone\n PO.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS, Other), trach mask as\n tolerated\n Gastrointestinal / Abdomen: no issues\n Nutrition: Tube feeding\n Renal: st cath prn\n Hematology: Stable anemia. Monitor for now\n Endocrine: RISS, Lantus (R). BG well controlled. Keep < 150\n Infectious Disease: GNR in sputum. On Vanco/cefepime per ID recs. f/u\n on ID recs. Monitor vanc level.\n Lines / Tubes / Drains: G-tube, J-Tube\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery, P.T., O.T., Nutrition\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:16 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: Will start SQ heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 15 min\n" }, { "category": "Rehab Services", "chartdate": "2154-03-06 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 736284, "text": "Subjective:\n Communicating via mouthing words, very appropriate, responsive and\n interactive. \"I need lotion!\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise (PROM, ), patient\n education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n Total assist c mechanical lift\n\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 78\n 97/52\n 99% CPAP 40% FiO2\n Activity\n 80\n 120/62\n 100% CPAP 40% FiO2\n Recovery\n 82\n 108/60\n 99% CPAP 40% FiO2\n Total distance walked: n/a\n Minutes:\n Gait: N/A\n Balance: Static sitting eob c B knees blocked for safety, Pt c B UE\n support on bed, able to obtain midline c verbal cueing and CG p lateral\n weightbearing on elbows. Sat eob x10 minutes c min A to CG.\n Education / Communication: c RN re: pt status and plan of care\n Pt education re: goal of session, DB and coughing, safety, plan of care\n Other: Pt reports vision getting better L>R however incorrect\n visual recognition/identification questions (how many fingers), unable\n to see color correctly but states he can see shadows/shapes. Mild c/o\n lightheadedness c sup-sit. 2+/5 B dorsiflexion, nothing more proximal.\n Performed PROM to BLEs c attempt at .\n Assessment: 59yoM s/p emergent TAA repair admit from rehab c FUO,\n rash and drainage presents today continuing to particpate fully in PT\n session and making gains c tolerating upright activity. Pt will\n continue to benefit from increased activity c OOB-->chair c nsg and\n continued PT intervention. D/c back to rehab once medically stable.\n Anticipated Discharge: Rehab\n Plan: bed mobility, transfer trainer, PROM/, Pt education, d/c\n planning\n Face Time: 1230-1305\n" }, { "category": "Respiratory ", "chartdate": "2154-03-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 736410, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\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: 20 cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff\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 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 Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Comments: Pt. remains on IPS overnoc. RR ^30\ns. Unable to do RSBI due\n to ^RR. Suctioned thick blood tinged sputum. Audible cuff leak at\n times.\n" }, { "category": "Nursing", "chartdate": "2154-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736640, "text": "Pneumonia, other\n Assessment:\n Remains anxious, c/o itchiness all over body.\n Lungs rhoncherous bilaterally, copious thick white secretions.\n Remains on CPAP 40% 5/8. O2 sat 98-100%.\n Action:\n Suctioned via in-line catheter.\n Vancomycin discontinued per ID.\n Turned and repositioned per protocol.\n Response:\n Continues with copious secretions, unable to place on trach collar.\n CXR improved.\n O2 sat remains stable.\n Plan:\n Monitor respiratory status, pulmonary toilet.\n Impaired Skin Integrity\n Assessment:\n Stage III on coccyx covered with mepilex dressing.\n Action:\n Turned and repositioned per protocol.\n Remains on tube feeding at goal via j tube.\n Response:\n Remains unchanged.\n Plan:\n Monitor skin, turn and reposition, support nutrition.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Remains afebrile. WBC 11.8. Ecoli in urine.\n Action:\n Vancomycin discontinued, Cefepime continues.\n Response:\n Catheter remains out, straight cathed for 700 ml.\n Plan:\n Monitor for fever, monitor WBC, continue with cefepime for urine.\n" }, { "category": "Physician ", "chartdate": "2154-03-06 00:00:00.000", "description": "ICU Note - CVI", "row_id": 736269, "text": "CVICU\n HPI:\n HD3\n Ejection Fraction:55%\n Hemoglobin A1c:6\n Pre-Op Weight:250.44 lbs 113.6 kgs\n Baseline Creatinine:1.1\n TLD:RT SCV TLC:Day3\n 59 year old male status post ruptured thoracoabdominal aneurysm repair\n on . Transferred from Rehab with fever of unknown\n origin and new thoracoabdominal drainage.\n Major Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm with a 34-mm Dacron tube graft using deep\n hypothermic circulatory arrest.\n -------------------------------------------------------------\n Medications at Rehab\n 1. Ranitidine 150(1),Aspirin 325 (1),Polyvinyl Alcohol-Povidone 1.4-0.6\n % Dropperette Sig: 1-2Drops Ophthalmic PRN (as needed) as needed for\n dryness, Heparin SC 5K tid,Tramadol 50 1-2q4h for\n pain,Ipratropium-Albuterol 6puffs QID prn,Amiodarone 200 mg Tablet\n daily, Miconazole powder(1) Appl Topical , Sertraline 50 (1),\n Metoprolol Tartrate 37.5(3),Nystatin 100,000 unit/mL Suspension Sig:\n Five (5) ML PO QID,Clonazepam 1 (2),Lorazepam 1 (3)/prn for\n agitation/anxiety,Insulin Glargine 100 unit/mL Solution Sig: Twenty\n (20) units, SSI Subcutaneous once a day, Furosemide 20 (2),Warfarin 1\n mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: 3mg on \n target INR 2-2.5 (received 5mg last 4 days), Insulin Regular Human 100\n unit/mL Solution Sig: sliding\n Events:\n readmit from rehab for fever of unknown origin\n Plan:pan cx,Vanco/cefipime.Prob urinary source(??pulm). ID involved.\n stopping anticoagulation\n Current medications:\n Albuterol-Ipratropium . Amiodarone . Artificial Tears Preserv. Free .\n Aspirin . Bisacodyl CefePIME . Clonazepam . . DiphenhydrAMINE .\n Docusate Sodium (Liquid) . Furosemide Glucagon Hydrocortisone Cream 1%\n . Insulin . Lorazepam . Lorazepam Metoprolol Tartrate Ranitidine\n (Liquid). Sarna Lotion . Sertraline TraMADOL (Ultram)\n Vancomycin\n 24 Hour Events:\n SPUTUM CULTURE - At 12:30 PM\n BLOOD CULTURED - At 03:00 PM 2 sets sent\n URINE CULTURE - At 10:49 PM\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 12:00 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 10:23 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: 36.9\nC (98.4\n HR: 84 (69 - 90) bpm\n BP: 119/56(71) {82/28(48) - 119/58(72)} mmHg\n RR: 32 (15 - 42) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.5 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 2,109 mL\n 732 mL\n PO:\n Tube feeding:\n 1,344 mL\n 593 mL\n IV Fluid:\n 605 mL\n 49 mL\n Blood products:\n Total out:\n 1,160 mL\n 0 mL\n Urine:\n 860 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 949 mL\n 732 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 372 (325 - 641) mL\n PS : 8 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 110\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///29/\n Ve: 13.9 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, blind\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), mid wound open area clean\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 405 K/uL\n 8.8 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.3 %\n 11.6 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n WBC\n 18.2\n 13.9\n 11.6\n Hct\n 26.7\n 27.1\n 27.3\n Plt\n \n Creatinine\n 1.1\n 1.1\n 1.0\n Glucose\n 85\n 92\n 106\n Other labs: PT / PTT / INR:16.5/29.6/1.5, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.1 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Microbiology: urine-GNR 10,000-100,000\n wound-NG\n BC-pending\n legioniella titre -neg\n Legionella sp-pending\n sputum-mod GNRs\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: afebrile, WBC down. Urine/sp both suggestive of\n infection. Continue antibiotics for now. To a rehab facility once this\n sorted out. Pruritis continues to improve.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: Trach, (Ventilator mode: CPAP + PS, Other), TC trials\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: st cath prn\n Hematology:\n Endocrine: RISS, Lantus (R)\n Infectious Disease:\n Lines / Tubes / Drains: G-tube, J-Tube\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery, P.T., O.T., Nutrition\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:16 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Agree with above note by .\n ------ Protected Section Addendum Entered By: , MD\n on: 05:46 PM ------\n" }, { "category": "Nursing", "chartdate": "2154-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736286, "text": "Pneumonia, other\n Assessment:\n 59 y/o male readmitted on from rehab with FUO and ? sepsis. Today,\n Afebrile. WBC 11.6. Awaiting culture results; current reports show GNR\n in urine and sputum. PERRL 4 mm brisk. Pt states can only see shadows.\n Follows commands. MAE. Strong upper extremity grips, moves legs on bed.\n SR on monitor without ectopy. LS clear. Strong productive cough,\n suctioned for moderate amounts thin white sputum throughout day. Abd\n soft, NT, ND. (+) BS, (-) BS. Straight cath today for 675 clear yellow\n urine. First CDiff specimen negative. Fingerstick glucose q6h per pt\n specific sliding scale. TF at goal. No residuals. J tube clogged\n (apparently so since admission from rehab facility), G tube patent.\n Stage III sacral pressure ulcer seen by wound care nurse today. See\n note for recs. No calls from family today. OOB to chair with LIKO lift,\n tolerated activity x 30 minutes before became anxious, uncomfortable,\n and requested to go back to bed. Tramadol given for c/o pain.\n Action:\n Continues on Vanco and Cefepime per ID recs. Introduced self and other\n caregivers with each interaction at bedside. Anxiolytics given per\n order with good effect. Pt reminded that he will get his next dose of\n klonopin at . Lopressor and amiodarone given per order. Sacral\n pressure ulcer cleaned with NS and new mepilex this afternoon.\n Response:\n Remains afebrile. Less anxious after meds. Pleasant and cooperative\n with all activities. Able to make needs known by mouthing sentences.\n Pending cultures.\n Plan:\n Monitor hemodynamics.\n Pulmonary hygiene. Trach collar trials as tolerated.\n Continue TF.\n Monitor glucose q6h and treat per pt specific sliding scale.\n Skin and wound care wound RN recs.\n Needs CDfiff specimen #2 and #3 sent.\n Update pt on POC and procedures. Reorient as needed.\n Continue to maintain safe environment for patient.\n" }, { "category": "Nursing", "chartdate": "2154-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736716, "text": "Pneumonia, other\n Assessment:\n Alert, anxious, cooperative. Some audible language around\n trach.\n Lungs congested in upper lobes and diminished at bases,\n trached on ventilator\n Pale pink, raised on thighs, full body rash continues to\n itch\n Foley draining clear yellow urine > 30 cc per hour\n Afebrile, vitals within parameters\n Tube feed at goal, PEGJ tube patent\n Action:\n Pulmo toilet, suction for thick white secretions\n Sarna lotion to rash, Benadryl via GT\n Response:\n Oxygen sats 98\n Lungs sounds clearing after suction and MDI\n Tube feed continues\n Becoming very anxious about transfer to rehab tomorrow,\n demanding excess amounts of attention and care from staff, short\n tempered, difficulty sleeping, pulling vent off trach for attention.\n Patient reports reduced need to itch after meds and lotions.\n Plan:\n Probable return to rehab tomorrow\n Continue care and monitoring per orders\n Limit setting with emotional support\n" }, { "category": "Respiratory ", "chartdate": "2154-03-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 736259, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\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:\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": "2154-03-07 00:00:00.000", "description": "Generic Note", "row_id": 736512, "text": "CVICU\n HPI:\n 59 y.o. M s/p thoracoabdominal AAA repair with post-op\n complications (CVA, blindness, respiratory failure s/p a trach).\n Eventually transferred to rehab and re-admitted back from Rehab with\n fever of unknown origin and new thoracoabdominal drainage.\n PMHx:\n Type A aortic dissection with rupture s/p thoracoabdominal,\n Hypertension, atrial fibrillation, blindness, respiratory failure s/p\n Trach and G-J tube\n Current medications:\n 2. Albuterol-Ipratropium 3. Amiodarone 4. Artificial Tears Preserv.\n Free 5. Aspirin 6. Bisacodyl 7. CefePIME 8. Clonazepam 9. Dextrose 50%\n 10. DiphenhydrAMINE 11. Docusate Sodium (Liquid) 12. Furosemide 13.\n Glucagon 14. Heparin 15. Hydrocortisone Cream 1% 16. Insulin 17.\n Lorazepam 18. Metoprolol Tartrate 19. Ranitidine (Liquid) 20. Sarna\n Lotion 21. Sertraline 22. Sodium Chloride 0.9% Flush 23. TraMADOL\n (Ultram)\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 12:00 AM\n Flowsheet Data as of 11:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.6\nC (97.8\n HR: 72 (67 - 87) bpm\n BP: 96/45(59) {90/36(51) - 116/56(70)} mmHg\n RR: 17 (15 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.7 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 2,266 mL\n 753 mL\n PO:\n Tube feeding:\n 1,336 mL\n 549 mL\n IV Fluid:\n 620 mL\n 155 mL\n Blood products:\n Total out:\n 950 mL\n 0 mL\n Urine:\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,316 mL\n 753 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 393 (290 - 438) mL\n PS : 8 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///30/\n Ve: 12 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 398 K/uL\n 8.7 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 5.0 mEq/L\n 30 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.0 %\n 11.8 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n 04:00 AM\n WBC\n 18.2\n 13.9\n 11.6\n 11.8\n Hct\n 26.7\n 27.1\n 27.3\n 27.0\n Plt\n 98\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.0\n Glucose\n 85\n 92\n 106\n 108\n Other labs: PT / PTT / INR:17.0/29.6/1.5, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: small bilateral effusions\n Microbiology: sputum w GNR\n urine w e.coli\n swab \n ECG: AF\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: 59 y.o. M s/p thoracoabdominal AAA repair \n with post-op complications (CVA, blindness, respiratory failure s/p a\n trach). Eventually transferred to rehab and re-admitted back from Rehab\n with fever of unknown origin and new thoracoabdominal drainage. On Abx\n and awaiting rehab bed\n Neurologic: Neuro checks Q: 4 hr, Pain controlled with ultram. Will\n start (resume) ativan PRN for anxiety.\n Cardiovascular: Aspirin, Beta-blocker, HD stable.\n Pulmonary: Trach, (Ventilator mode: CMV), OOB to chair. Please attempt\n trach collar trial today (did not tolerate it yesterday).\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding\n Renal: intermittent straight cath. On lasix for goal of 1 L negative\n overnight.\n Hematology: stable anemia, monitor for now.\n Endocrine: RISS, Lantus (R), Blood glucose well control. Goal BG<150\n Infectious Disease: continue cefepime for 5 more days per ID and stop\n Vanco tonight if no further growth,\n Lines / Tubes / Drains: G-tube, J-Tube, Trach\n Wounds: Dry dressings\n Consults: ID dept, P.T.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:20 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 20 min\n" }, { "category": "Physician ", "chartdate": "2154-03-07 00:00:00.000", "description": "ICU Note - CVI", "row_id": 736530, "text": "CVICU\n HPI:\n s/p TAAA repair .Tx from Rehab with fever of unknown origin and\n new thoracoabdominal drainage.\n PMHx:\n Type A aortic dissection with rupture s/p thoracoabdominal,\n Hypertension, atrial fibrillation, blindness, respiratory failure s/p\n Trach and G-J tube\n Current medications:\n 2. Albuterol-Ipratropium 3. Amiodarone 4. Artificial Tears Preserv.\n Free 5. Aspirin 6. Bisacodyl 7. CefePIME 8. Clonazepam 9. Dextrose 50%\n 10. DiphenhydrAMINE 11. Docusate Sodium (Liquid) 12. Furosemide 13.\n Glucagon 14. Heparin 15. Hydrocortisone Cream 1% 16. Insulin 17.\n Lorazepam 18. Metoprolol Tartrate 19. Ranitidine (Liquid) 20. Sarna\n Lotion 21. Sertraline 22. Sodium Chloride 0.9% Flush 23. TraMADOL\n (Ultram)\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 12:00 AM\n Flowsheet Data as of 11:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.6\nC (97.8\n HR: 72 (67 - 87) bpm\n BP: 96/45(59) {90/36(51) - 116/56(70)} mmHg\n RR: 17 (15 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.7 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 2,266 mL\n 753 mL\n PO:\n Tube feeding:\n 1,336 mL\n 549 mL\n IV Fluid:\n 620 mL\n 155 mL\n Blood products:\n Total out:\n 950 mL\n 0 mL\n Urine:\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,316 mL\n 753 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 393 (290 - 438) mL\n PS : 8 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///30/\n Ve: 12 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 398 K/uL\n 8.7 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 5.0 mEq/L\n 30 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.0 %\n 11.8 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n 04:00 AM\n WBC\n 18.2\n 13.9\n 11.6\n 11.8\n Hct\n 26.7\n 27.1\n 27.3\n 27.0\n Plt\n 98\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.0\n Glucose\n 85\n 92\n 106\n 108\n Other labs: PT / PTT / INR:17.0/29.6/1.5, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: small bilateral effusions\n Microbiology: sputum w GNR\n urine w e.coli\n swab \n ECG: AF\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: s/p TAAA repair .Tx from Rehab with fever\n of unknown origin and new thoracoabdominal drainage. Now awaiting\n placement to rehab.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, on ultram. Being\n given ativan PRN for anxiety.\n Cardiovascular: Aspirin, Beta-blocker, Hemodynamically stable.\n Pulmonary: Trach, (Ventilator mode: CMV), OOB to chair. Will attempt\n trach collar trial today, did not tolerate it yesterday.\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding\n Renal: intermittent straight cath. getting lasix for goal of 1 L\n negative overnight.\n Hematology: stable post-operative anemia\n Endocrine: RISS, Lantus (R), Adequate glucose control overnight, goal\n <150\n Infectious Disease: stop Vanco tonight if no further growth, continue\n cefepime for 5 more days per ID\n Lines / Tubes / Drains: G-tube, J-Tube, Trach\n Wounds: Dry dressings\n Consults: ID dept, P.T.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:20 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n ------ Protected Section ------\n Agree with above note by .\n ------ Protected Section Addendum Entered By: , MD\n on: 12:22 PM ------\n" }, { "category": "Physician ", "chartdate": "2154-03-08 00:00:00.000", "description": "ICU Note - CVI", "row_id": 736881, "text": "CVICU\n HPI:\n s/p TAAA repair .Tx from Rehab with fever of unknown origin and\n new thoracoabdominal drainage.\n PMHx:\n Type A aortic dissection with rupture s/p thoracoabdominal\n repair, Hypertension, atrial fibrillation, blindness, respiratory\n failure s/p Trach and G-J tube\n Current medications:\n 2. Acetaminophen (Liquid) 3. Albuterol-Ipratropium 4. Amiodarone 5.\n Artificial Tears Preserv. Free\n 6. Aspirin 7. Bisacodyl 8. Clonazepam 9. Dextrose 50% 10.\n DiphenhydrAMINE 11. Docusate Sodium (Liquid)\n 12. Furosemide 13. Glucagon 14. Heparin 15. Hydrocortisone Cream 1% 16.\n Insulin 17. Lorazepam 18. Metoprolol Tartrate 19. Meropenem 20.\n Ranitidine (Liquid) 21. Sarna Lotion 22. Sertraline 23. Sodium Chloride\n 0.9% Flush\n 24. Sodium Bicarbonate 25. TraMADOL (Ultram) 26. Viokase-8\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 12:00 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 AM\n Flowsheet Data as of 11:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.6\nC (97.8\n HR: 67 (67 - 94) bpm\n BP: 89/43(54) {89/43(54) - 124/66(79)} mmHg\n RR: 17 (10 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.3 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 1,639 mL\n 1,093 mL\n PO:\n Tube feeding:\n 1,202 mL\n 441 mL\n IV Fluid:\n 387 mL\n 212 mL\n Blood products:\n Total out:\n 1,300 mL\n 630 mL\n Urine:\n 1,300 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 339 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 385 (383 - 846) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Vent Dependant\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///31/\n Ve: 19 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: left base)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), packed W to D 2 inch section\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 450 K/uL\n 8.3 g/dL\n 109 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 4.8 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.9 %\n 10.6 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n 04:00 AM\n 03:07 AM\n WBC\n 18.2\n 13.9\n 11.6\n 11.8\n 10.6\n Hct\n 26.7\n 27.1\n 27.3\n 27.0\n 25.9\n Plt\n 98\n 450\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.0\n 0.9\n Glucose\n 85\n 92\n 106\n 108\n 109\n Other labs: PT / PTT / INR:15.1/29.5/1.3, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.6 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: sm left pleural effusion\n Microbiology: e.coli in urine\n ECG: SR\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: s/p TAAA repair .Tx from Rehab with fever\n of unknown origin and new thoracoabdominal drainage. Now stable and\n ready for transfer to rehab\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, on ultram\n Cardiovascular: Aspirin, Beta-blocker, Hemodynamically stable. No\n anticoagulation except SQ heparin for post-op afib which has resolved\n but amio will be continued per Dr. .\n Pulmonary: Trach, (Ventilator mode: CMV), Trach collar trials as\n tolerated, did not tolerate trial yesterday.\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding, at goal via G to J tube. G port unclotted\n with viokase.\n Renal: Foley, foley replaced overnight secondary to high volumes when\n straight cathed\n Hematology: stable post-operative anemia\n Endocrine: RISS, Lantus (R), Adequate glucose control overnight. Goal\n <150\n Infectious Disease: urine with e.coli -on meropenum for 10 days per ID\n Lines / Tubes / Drains: Foley, G-tube, J-Tube, Trach\n Wounds: Dry dressings, Wet / Dry dressings\n Consults: ID dept, P.T.\n ICU Care\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n" }, { "category": "General", "chartdate": "2154-03-08 00:00:00.000", "description": "Generic Note", "row_id": 736884, "text": "CVICU\n HPI:\n 59 y.o M s/p TAAA repair with post-op CVA, blindness and\n respiratory failure (s/p a trach) eventually transferred to rehab and\n re-admitted to ICU from rehabe with fever of and new thoracoabdominal\n drainage. Both resolved with Abx.\n PMHx:\n Type A aortic dissection with rupture s/p thoracoabdominal\n repair, Hypertension, atrial fibrillation, blindness, respiratory\n failure s/p Trach and G-J tube\n Meds at rehab: Ranitidine 150mg qd,Aspirin 325mg qd, Ophthalmic gtt\n PRN, Heparin SC 5K tid, Tramadol 50 1-2q4h for pain,\n Ipratropium-Albuterol 6puffs QID prn, Amiodarone 200 mg Tablet daily,\n Miconazole powder , Sertraline 50 (1), Metoprolol Tartrate 37.5 TID,\n Nystatin ML PO QID, Clonazepam 1 , Lorazepam 1 TID prn, Glargine 100\n 20 units, Furosemide 20 , Warfarin PRN\n Current medications:\n 2. Acetaminophen (Liquid) 3. Albuterol-Ipratropium 4. Amiodarone 5.\n Artificial Tears Preserv. Free\n 6. Aspirin 7. Bisacodyl 8. Clonazepam 9. Dextrose 50% 10.\n DiphenhydrAMINE 11. Docusate Sodium (Liquid)\n 12. Furosemide 13. Glucagon 14. Heparin 15. Hydrocortisone Cream 1% 16.\n Insulin 17. Lorazepam 18. Metoprolol Tartrate 19. Meropenem 20.\n Ranitidine (Liquid) 21. Sarna Lotion 22. Sertraline 23. Sodium Chloride\n 0.9% Flush\n 24. Sodium Bicarbonate 25. TraMADOL (Ultram) 26. Viokase-8\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 12:00 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 AM\n Flowsheet Data as of 11:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.6\nC (97.8\n HR: 67 (67 - 94) bpm\n BP: 89/43(54) {89/43(54) - 124/66(79)} mmHg\n RR: 17 (10 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.3 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 1,639 mL\n 1,093 mL\n PO:\n Tube feeding:\n 1,202 mL\n 441 mL\n IV Fluid:\n 387 mL\n 212 mL\n Blood products:\n Total out:\n 1,300 mL\n 630 mL\n Urine:\n 1,300 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 339 mL\n 463 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 385 (383 - 846) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Vent Dependant\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: ///31/\n Ve: 19 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: left base)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), packed W to D 2 inch section\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 450 K/uL\n 8.3 g/dL\n 109 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 4.8 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.9 %\n 10.6 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n 04:00 AM\n 03:07 AM\n WBC\n 18.2\n 13.9\n 11.6\n 11.8\n 10.6\n Hct\n 26.7\n 27.1\n 27.3\n 27.0\n 25.9\n Plt\n 98\n 450\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.0\n 0.9\n Glucose\n 85\n 92\n 106\n 108\n 109\n Other labs: PT / PTT / INR:15.1/29.5/1.3, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.6 mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: sm left pleural effusion\n Microbiology: e.coli in urine\n ECG: SR\n Assessment and Plan\n Assessment and Plan: 59 y.o M s/p TAAA repair with post-op\n CVA, blindness and respiratory failure (s/p a trach) eventually\n transferred to rehab and re-admitted to ICU from rehabe with fever of\n and new thoracoabdominal drainage. Both resolved with Abx.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled with ultram\n Cardiovascular: Aspirin, Beta-blocker, HD stable. Per Dr. no\n need for systemic anticoagulation (except prophylactic SQ heparin) as\n post-op afib resolved. Will continue with amio.\n Pulmonary: Trach collar trials as tolerated, (did not tolerate trial\n yesterday)\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding, at goal via G to J tube. G port unclotted\n with viokase.\n Renal: Foley, foley replaced overnight secondary to high volumes when\n straight cathed\n Hematology: stable anemia. Monitor for now\n Endocrine: RISS, Lantus (R), BG well controlled. Goal BG <150\n Infectious Disease: urine with e.coli -on meropenum for 10 days per ID\n Lines / Tubes / Drains: Foley, G-tube, J-Tube, Trach\n Wounds: Dry dressings, Wet / Dry dressings\n Consults: ID dept, P.T.\n ICU Care\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 20 min\n" }, { "category": "Physician ", "chartdate": "2154-03-07 00:00:00.000", "description": "ICU Note - CVI", "row_id": 736506, "text": "CVICU\n HPI:\n s/p TAAA repair .Tx from Rehab with fever of unknown origin and\n new thoracoabdominal drainage.\n PMHx:\n Type A aortic dissection with rupture s/p thoracoabdominal,\n Hypertension, atrial fibrillation, blindness, respiratory failure s/p\n Trach and G-J tube\n Current medications:\n 2. Albuterol-Ipratropium 3. Amiodarone 4. Artificial Tears Preserv.\n Free 5. Aspirin 6. Bisacodyl 7. CefePIME 8. Clonazepam 9. Dextrose 50%\n 10. DiphenhydrAMINE 11. Docusate Sodium (Liquid) 12. Furosemide 13.\n Glucagon 14. Heparin 15. Hydrocortisone Cream 1% 16. Insulin 17.\n Lorazepam 18. Metoprolol Tartrate 19. Ranitidine (Liquid) 20. Sarna\n Lotion 21. Sertraline 22. Sodium Chloride 0.9% Flush 23. TraMADOL\n (Ultram)\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 12:00 AM\n Flowsheet Data as of 11:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.6\nC (97.8\n HR: 72 (67 - 87) bpm\n BP: 96/45(59) {90/36(51) - 116/56(70)} mmHg\n RR: 17 (15 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.7 kg (admission): 96 kg\n Height: 68 Inch\n Total In:\n 2,266 mL\n 753 mL\n PO:\n Tube feeding:\n 1,336 mL\n 549 mL\n IV Fluid:\n 620 mL\n 155 mL\n Blood products:\n Total out:\n 950 mL\n 0 mL\n Urine:\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,316 mL\n 753 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 393 (290 - 438) mL\n PS : 8 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///30/\n Ve: 12 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 398 K/uL\n 8.7 g/dL\n 108 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 5.0 mEq/L\n 30 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.0 %\n 11.8 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n 03:07 AM\n 04:00 AM\n WBC\n 18.2\n 13.9\n 11.6\n 11.8\n Hct\n 26.7\n 27.1\n 27.3\n 27.0\n Plt\n 98\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.0\n Glucose\n 85\n 92\n 106\n 108\n Other labs: PT / PTT / INR:17.0/29.6/1.5, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: small bilateral effusions\n Microbiology: sputum w GNR\n urine w e.coli\n swab \n ECG: AF\n Assessment and Plan\n PNEUMONIA, OTHER, IMPAIRED SKIN INTEGRITY, FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n Assessment and Plan: s/p TAAA repair .Tx from Rehab with fever\n of unknown origin and new thoracoabdominal drainage. Now awaiting\n placement to rehab.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, on ultram. Being\n given ativan PRN for anxiety.\n Cardiovascular: Aspirin, Beta-blocker, Hemodynamically stable.\n Pulmonary: Trach, (Ventilator mode: CMV), OOB to chair. Will attempt\n trach collar trial today, did not tolerate it yesterday.\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Tube feeding\n Renal: intermittent straight cath. getting lasix for goal of 1 L\n negative overnight.\n Hematology: stable post-operative anemia\n Endocrine: RISS, Lantus (R), Adequate glucose control overnight, goal\n <150\n Infectious Disease: stop Vanco tonight if no further growth, continue\n cefepime for 5 more days per ID\n Lines / Tubes / Drains: G-tube, J-Tube, Trach\n Wounds: Dry dressings\n Consults: ID dept, P.T.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 06:20 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n" }, { "category": "Rehab Services", "chartdate": "2154-03-07 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 736607, "text": "Subjective:\n \"You guys help me\" Mouthing words and gesturing\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise (PROM/AAROM)\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n Max A with rail\n\n\n\n\n\n X\n Supine/\n Sidelying to Sit:\n Max A x2\n\n\n\n\n\n S\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 68\n 106/61\n 100% CPAP FiO2 40%\n Activity\n 78\n 125/61\n Recovery\n 75\n 96/45\n 99% CPAP FiO2 40%\n Total distance walked: n/a\n Minutes:\n Gait: n/a\n Balance: Maintains static sitting eob c B by therapist x10\n min c CG. Able to re-obtain midline from post LOB c mod A.\n Education / Communication: c RN re: pt status and mobility plan\n Pt education re: goal of session, DB&C, importance of therex program,\n plan of care\n Other: Bed mobility: Pt able to initiate rolling and participate using\n UEs on rail 25%. Sup to/from sit at eob c max A x2.\n Pain: c/o HA\n Assessment: 59 y.o. male with type A TAA s/p emergent\n repair/replacement with hypotensive infarcts causing blindness and\n trunk and LE weakness. Now readmit from rehab c rash/FUO. He presents\n today eager to participate in PT session but limited by fatigue. Pt\n continues to compensate for vision loss and communication deficit well.\n He will continue to benefit from PT intervention with d/c to structured\n intense rehab program.\n Anticipated Discharge: Rehab\n Plan: therex program c PT co-op student daily, bed mob, balance\n activities, pulm exercises, Pt education, d/c planning\n FACE TIME: 925-955\n" }, { "category": "Nutrition", "chartdate": "2154-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 736861, "text": "Subjective\n OOB --> chair, resting comfortably\n Objective\n Admit weight\n Daily weight\n 96 kg\n 97.3 kg ( 03:00 AM)\n Pertinent medications: ABX, Ranitidine, Colace, Humalog Insulin sliding\n scale, Glargine 20 units at breakfast\n Labs:\n Value\n Date\n Glucose\n 109 mg/dL\n 03:07 AM\n Glucose Finger Stick\n 120\n 06:00 AM\n BUN\n 26 mg/dL\n 03:07 AM\n Creatinine\n 0.9 mg/dL\n 03:07 AM\n Sodium\n 136 mEq/L\n 03:07 AM\n Potassium\n 4.8 mEq/L\n 03:07 AM\n Chloride\n 102 mEq/L\n 03:07 AM\n TCO2\n 31 mEq/L\n 03:07 AM\n pH (urine)\n 5.0 units\n 10:40 PM\n Albumin\n 2.7 g/dL\n 05:53 PM\n Calcium non-ionized\n 8.6 mg/dL\n 03:07 AM\n Phosphorus\n 2.8 mg/dL\n 03:07 AM\n Magnesium\n 2.0 mg/dL\n 03:07 AM\n ALT\n 33 IU/L\n 05:53 PM\n Alkaline Phosphate\n 99 IU/L\n 05:53 PM\n AST\n 22 IU/L\n 05:53 PM\n Amylase\n 58 IU/L\n 05:53 PM\n Total Bilirubin\n 0.7 mg/dL\n 05:53 PM\n WBC\n 10.6 K/uL\n 03:07 AM\n Hgb\n 8.3 g/dL\n 03:07 AM\n Hematocrit\n 25.9 %\n 03:07 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Isosource 1.5 @ 50ml/hr 21g Beneprotein; 3 packet banana\n flakes/day\n GI: soft, positive bowel sounds\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Patient re-admitted back from rehab with fever of unknown origin and\n new thoracoabdominal drainage. Tolerating tube feed at goal via J tube\n to provide 1875 calories and 100g protein. G tube clogged since admit\n pending trial of Viokase and Sodium Bicarbonate to unclog. BS well\n controlled. NP, plan to transfer to rehab today.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n tube feed at goal\n Agree with Viokase + Sodium Bicarbonate for unclogging tube\n Check chemistry 10 panel daily\n BS management\n Banana flakes if liquid stool\n Page 2 referral completed for discharge\n Will follow, page if questions *\n 10:33\n" }, { "category": "Nursing", "chartdate": "2154-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736679, "text": "1900-2300\n Pt straight cathed for 550cc of urine, foley placed\n Cortisone cream applied to body\n Shaved\n Turned\n Suctioned frequently for thick white secretions\n Pt anxious and asking for pain medication, ultram given @ 2200- pt\n seems to be calming down\n Tolerating meds via J-tube, G-tube clotted since readmission\n Tube feeds tolerated @ goal 50cc/h\n Plan: pt to return to rehab tomorrow\n" }, { "category": "Respiratory ", "chartdate": "2154-03-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 736650, "text": "Demographics\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\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: 20 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: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: Pt has frequent episodes of RR in the 30's.\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Comments: Pt continues on PSV as charted.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Trach collar wean when able to tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Nursing", "chartdate": "2154-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736914, "text": "Pneumonia, other\n Assessment:\n , . Follows commands. Afebrile. Off vent this morning for trach\n collar trials. SR on monitor without ectopy. SBP 100-120. LS\n rhonchorous bilaterally upper lobes, clear after coughing and\n diminished in bilateral bases. O2 sats 99-100%. Abd soft, NT, ND. (+)\n BS. (-) BM. G/J tube in place. TF at goal. J tube unclogged this AM\n with papain solution. Foley patent clear yellow urine. Adequate hourly\n amounts. Fingersticks q6h and coverage determined by patient\ns own\n humalog insulin sliding scale. Stage 3 pressure ulcer at sacrum/coccyx\n area cleaned with NS and patted dry per wound care nurse recs; applied\n clean and dry mepilex dressing. c/o pain at decubitus ulcer site. Given\n Tylenol, tramadol and one time dose hydromorphone IV with good effect.\n Red rash over body less pronounced today, red and itchy per pt. No\n calls from family today. Pt updated on POC, aware of discharge to Rehab this afternoon.\n Action:\n Started meropenem IV course for serratia/ecoli growth in cultures. Vent\n off. Trach mask on 40% FiO2. Antihypertensives per order. Continues TF\n as ordered. Wound care done wound RN recs. Applied hydrocortisone\n cream and sarna lotion for rash management. Benadryl for itching.\n Response:\n Tolerating trach mask without issue. Strong productive cough.\n Intermittently suctioned when unable to raise secretions on own. Pt\n reports less itching after creams and Benadryl. OOB to chair with LIKO\n lift, tolerated x 1.25 hours before c/o increasing sacral discomfort.\n Plan:\n IV abx therapy x 10 days as ordered.\n Maintain hemodynamics.\n Pulmonary hygiene.\n Continue TF.\n Skin and wound care.\n Pain management.\n Increase activity as tolerated; continue PT.\n Transfer to Rehab this afternoon.\n" }, { "category": "Nursing", "chartdate": "2154-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 735748, "text": "59 y/o M With history significant for HTN, AFIB, Blindness (post op);S/P rupture\nd thoracoabdominal aneurysm repair on . He was transferred today from Rehab with FUO and new L-thoracotomy drainage. On arrival he\ns pan cu\nltured.\nPt also experiencing moderate bleeding from site post RSC- TLC insertion; coag\ns on arrival showing marked elevation PT36.8 PTT 106 INR 3.8.\n - Emergent salvage repair of ruptured thoracoabdominal aortic aneurysm.\n - Chest and abdomen exploration, Removal of packs, Chest closure.\n - Abdomen closure/ PEG placement\n tracheostomy\n" }, { "category": "Nursing", "chartdate": "2154-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 735732, "text": "59 year old male well known to the\ncsurg service as he is status post ruptured thoracoabdominal\naneurysm repair on . Please see discharge summary for\nfurther details of hospital course. He was transferred today from\n Rehab with fever of unknown origin and new\nthoracoabdominal drainage. Mr. was transferrd to \nfor further workup.\nMajor Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\naortic aneurysm with a 34-mm Dacron tube graft using deep\nhypothermic circulatory arrest.\n - Chest and abdomen exploration, Removal of packs, Chest\nclosure.\n - abdomen closure/ feeding jejunostomy\n tracheostomy\n----------------------------------------------------------------\nPast Medical History:\nType A aortic dissection with rupture s/p thoracoabdominal\nrepair\nHypertension\natrial fibrillation\nblindness\nrespiratory failure s/p Trach and G-J tube\nSocial History:\nlives with fiance\nFamily History:\nUnknown\n----------------------------------------------------------------\nPast Surgical History:\n - Emergent salvage repair of ruptured thoracoabdominal\naortic aneurysm with a 34-mm Dacron tube graft using deep\nhypothermic circulatory arrest.\n - Chest and abdomen exploration, Removal of packs, Chest\nclosure.\n - abdomen closure/ feeding jejunostomy\n tracheostomy\n" }, { "category": "General", "chartdate": "2154-03-05 00:00:00.000", "description": "Generic Note", "row_id": 735931, "text": "CVICU\n HPI:\n 59 year old male status post ruptured thoracoabdominal aneurysm repair\n on . Complicated post-op course including CVAs and blindness.\n Eventually transferred to rehab facility, but last night transferred\n from Rehab with fever of unknown origin and new\n thoracoabdominal drainage.\n Major Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm with a 34-mm Dacron tube graft using deep\n hypothermic circulatory arrest.\n - Chest and abdomen exploration, Removal of packs, Chest\n closure.\n - abdomen closure/ feeding jejunostomy\n tracheostomy\n ----------------------------------------------------------------\n Past Medical History:\n Type A aortic dissection with rupture s/p thoracoabdominal\n repair,Hypertension,atrial fibrillation,blindness,respiratory failure\n s/p Trach and G-J tube\n ----------------------------------------------------------------\n Medications at Rehab\n 1. Ranitidine 150(1),Aspirin 325 (1),Polyvinyl Alcohol-Povidone 1.4-0.6\n % Dropperette Sig: 1-2Drops Ophthalmic PRN (as needed) as needed for\n dryness, Heparin SC 5K tid,Tramadol 50 1-2q4h for\n pain,Ipratropium-Albuterol 6puffs QID prn,Amiodarone 200 mg Tablet\n daily, Miconazole powder(1) Appl Topical , Sertraline 50 (1),\n Metoprolol Tartrate 37.5(3),Nystatin 100,000 unit/mL Suspension Sig:\n Five (5) ML PO QID,Clonazepam 1 (2),Lorazepam 1 (3)/prn for\n agitation/anxiety,Insulin Glargine 100 unit/mL Solution Sig: Twenty\n (20) units, SSI\n Subcutaneous once a day.\n 15. Furosemide 20 (2)\n 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily\n at 4 PM: 3mg on \n target INR 2-2.5\n (received 5mg last 4 days) .\n 17. Insulin Regular Human 100 unit/mL Solution Sig: sliding\n Events:\n readmit from rehab for fever of unknown origin\n Plan:pan cx,await final cultures.UA dirty also. 6eos on smear-?drug\n fever.ID seeing\n Current medications:\n Albuterol-Ipratropium . Amiodarone . Artificial Tears Preserv. Free .\n Aspirin . Bisacodyl CefePIME . Clonazepam .. DiphenhydrAMINE . Docusate\n Sodium (Liquid) . Furosemide Glucagon . Hydrocortisone Cream 1% .\n Insulin . orazepam . Metoprolol Tartrate . Ranitidine (Liquid) Sarna\n Lotion . Sertraline . TraMADOL (Ultram) . Vancomycin\n 24 Hour Events:\n WOUND CULTURE - At 04:30 PM\n MULTI LUMEN - START 04:30 PM\n URINE CULTURE - At 05:00 PM\n SPUTUM CULTURE - At 05:30 PM\n BLOOD CULTURED - At 05:50 PM\n NASAL SWAB - At 06:00 PM\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.4\n HR: 81 (70 - 95) bpm\n BP: 82/48(54) {82/42(54) - 123/71(79)} mmHg\n RR: 25 (15 - 38) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.2 kg (admission): 96 kg\n Total In:\n 680 mL\n 833 mL\n PO:\n Tube feeding:\n 538 mL\n IV Fluid:\n 270 mL\n 245 mL\n Blood products:\n Total out:\n 800 mL\n 430 mL\n Urine:\n 200 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -120 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 404 (325 - 451) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///28/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, Blind\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered coarse BS, well aerarted. No wheeze.), mod.\n thick secretions occ.Good cough\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, G\n 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 Skin: Rash: paling of rash from adm. Still pruritic but much less so.,\n (Incision: No(t) Clean / Dry / Intact), open area mid wd-clean/dry\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 374 K/uL\n 8.8 g/dL\n 92 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 32 mg/dL\n 100 mEq/L\n 138 mEq/L\n 27.1 %\n 13.9 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n WBC\n 18.2\n 13.9\n Hct\n 26.7\n 27.1\n Plt\n 347\n 374\n Creatinine\n 1.1\n 1.1\n Glucose\n 85\n 92\n Other labs: PT / PTT / INR:19.2/34.5/1.8, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:7.7 mg/dL, Mg:2.4 mg/dL, PO4:3.8 mg/dL\n Fluid Analysis / Other Labs: UA-bact/nitrites positive\n Imaging: CXR- no infiltrates\n Microbiology: Stool- c diff negX1\n Sput- nl \n -pending\n BC pending\n Assessment and Plan\n Assessment and Plan: 59 year old male status post ruptured\n thoracoabdominal aneurysm repair on . Complicated post-op course\n including CVAs and blindness. Eventually transferred to rehab facility,\n but last night transferred from Rehab with fever of unknown\n origin and new thoracoabdominal drainage.\n Neurologic: Neuro checks Q: 4 hr, Pain well controlled with tramadol.\n Sertraline, clonazepam.\n Cardiovascular: Aspirin, Beta-blocker, Statins, d/c Coumadin- SR for\n weeks. Continue Amiodarone for present.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS, Other). Wean to trach\n collar as tolerated\n Gastrointestinal / Abdomen: No issues so far\n Nutrition: Continue with tube feeding\n Renal: Foley, d/c Foley. GNR UTI. On Cefepime\n Hematology: Stable anemia. Monitor for now\n Endocrine: RISS, Lantus (R). BG well controlled. Goal BG < 150\n Infectious Disease: Check cultures. F/u on ID recs. GNR UTI, on\n cefepime\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery, ID dept, P.T., let surgery know of amdission\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments: Hold anticoagulation.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 20 min\n" }, { "category": "Nursing", "chartdate": "2154-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 735794, "text": "59 y/o M With history significant for HTN, AFIB, Blindness (post op);S/P rupture\nd thoracoabdominal aneurysm repair on . He was transferred today from Rehab with FUO and new L-thoracotomy drainage. On arrival he\ns pan cu\nltured.\nPt also experiencing moderate bleeding from site post RSC- TLC insertion; coag\ns on arrival showing marked elevation PT36.8 PTT 106 INR 3.8.\n - Emergent salvage repair of ruptured thoracoabdominal aortic aneurysm.\n - Chest and abdomen exploration, Removal of packs, Chest closure.\n - Abdomen closure/ PEG placement\n tracheostomy\n Re admit FUO.\n Low grade fever overnight. T max 100.1F PO. Alert, oriented x2.\n Following commands. PERRLA. LS Rhonchorous bilaterally. Trach intact,\n sutures intact. Vented on CPAP 40% 8/5. O2 sats 99-100% . Moist creamy\n copious secretions per inline suction. SR per tele HR 70\ns, SBP\n 100-110mmHg. Easily palpable PP bilaterally. Active BS 4Q\ns, passing\n gas this evening; restarted TF at goal 60cc/hr tolerating well with no\n residual seen on assessment. FSBS Q6hr 100-120mgdL . Lantus dose\n 20units am . Turned and repositioned per protocol. Stage 3 pressure\n wound over coccygeal area; skin is broken.Mepilex DSD replaced this am.\n Medium golden liquid Stool x2 HS. Perineal area reddened. Skin rash\n improving. Received Benadryl PRN pruritus. Skin care provided. Removed,\n cleaned and replaceed L-thoracotomy DSD w-D. Foley catheter draining\n clear yellow urine. RSC-TLC with moderate sanguinous drainage requiring\n surgicel and bulky pressure DSD. Hemostasis achieved 1-5hr. Cleaned and\n re-dressed this am, insertion site is intact . FSBS 100-120mgdL. Lantus\n and SS coverage.\n PLAN\n Monitor Temperature, WBC and culture results\n Monitor oxygenation.\n Monitor Coags, lytes , HCT.\n Monitor FSBS.\n" }, { "category": "Nursing", "chartdate": "2154-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 735709, "text": "Patient returned from rehab today after several days of fevers, most\n recent temp this morning was 103.5. After po Tylenol temp decreased to\n 102.1. Proximal end of L thoracotomy dehisced and draining\npurulent\n drainage rehab RN report. Rehab sent wound culture today. HR up to\n 130s but RN did report pt was agitated & restless, receiving\n clonopin/ativan. Wrist restraints were used. SBP stable. Patient\n developed rash over entire body while in rehab and was receiving PO\n benedryl, ?etiology. Pt was treated for cdiff with flagyl, team stopped\n flagyl after rash developed. Stool was negative though. Patient was\n receiving 100cc/hr of saline through 24g piv in L hand. Poor trach\n collar tolerance in rehab, patient was on ventilator. Rehab RN also\n reported L foot drop.\n Patient arrived to unit excorted by ACLS emts. Pt was vented on cmv\n settings for transport. No ivf was infusing. Pt was alert, oriented x3.\n Report received from EMTs. 24g pedi PIV was in L hand saline locked. HR\n 90s sbp 100-110. Temp 100.3 oral. Dr. assessed dehisced wound,\n drainage serosang, not purulent. Wound culture sent along with pan\n culture (only one blood culture, from TLC). TLC placed for access and\n insertion site has been oozing since placement. CXR confirmed placement\n per PA . After 2.5 hours of manual pressure & pressure\n dressings, one dose of Vit K ivp for elevated coags- surgicell was\n applied. Peripheral puncture for second blood culture held as patient\n is unsafely anticoagulated. Placed on cpap 10ps/5 peep. PS increased\n for tachypnea 50s. Pt was wearing flannel pants that had a rip in the\n seam which exposed skin on his coccyx/gluts where a stage 2-3 pressure\n ulcer is present. He is covered in a head to toe pink/red raised rash.\n Pt was very itchy and uncomfortable & attempting to scratch his rash\n everywhere. Soft wrist restraints dc\nd on arrival. Pt mouthing\n appropriate responses, oriented. IV benedryl and PO benedryl admin,\n hydrocortisone cream applied.\n Repeat INR and obtain order for repeat vit K if still elevated. Start\n iv vanco for broad spectrum coverage until cultures are back. Wound\n care consult in am.\n" }, { "category": "Physician ", "chartdate": "2154-03-05 00:00:00.000", "description": "ICU Note - CVI", "row_id": 735908, "text": "CVICU\n HPI:\n Pre-Op Weight:0 lbs 0 kgs\n TLD:RT SCV TLC:Day2\n 59 year old male status post ruptured thoracoabdominal aneurysm repair\n on . Transferred from Rehab with fever of unknown\n origin and new thoracoabdominal drainage.\n Major Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm with a 34-mm Dacron tube graft using deep\n hypothermic circulatory arrest.\n - Chest and abdomen exploration, Removal of packs, Chest\n closure.\n - abdomen closure/ feeding jejunostomy\n tracheostomy\n ----------------------------------------------------------------\n Past Medical History:\n Type A aortic dissection with rupture s/p thoracoabdominal\n repair,Hypertension,atrial fibrillation,blindness,respiratory failure\n s/p Trach and G-J tube\n ----------------------------------------------------------------\n Medications at Rehab\n 1. Ranitidine 150(1),Aspirin 325 (1),Polyvinyl Alcohol-Povidone 1.4-0.6\n % Dropperette Sig: 1-2Drops Ophthalmic PRN (as needed) as needed for\n dryness, Heparin SC 5K tid,Tramadol 50 1-2q4h for\n pain,Ipratropium-Albuterol 6puffs QID prn,Amiodarone 200 mg Tablet\n daily, Miconazole powder(1) Appl Topical , Sertraline 50 (1),\n Metoprolol Tartrate 37.5(3),Nystatin 100,000 unit/mL Suspension Sig:\n Five (5) ML PO QID,Clonazepam 1 (2),Lorazepam 1 (3)/prn for\n agitation/anxiety,Insulin Glargine 100 unit/mL Solution Sig: Twenty\n (20) units, SSI\n Subcutaneous once a day.\n 15. Furosemide 20 (2)\n 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily\n at 4 PM: 3mg on \n target INR 2-2.5\n (received 5mg last 4 days) .\n 17. Insulin Regular Human 100 unit/mL Solution Sig: sliding\n Events:\n readmit from rehab for fever of unknown origin\n Plan:pan cx,await final cultures.UA dirty also. 6eos on smear-?drug\n fever.ID seeing\n Current medications:\n Albuterol-Ipratropium . Amiodarone . Artificial Tears Preserv. Free .\n Aspirin . Bisacodyl CefePIME . Clonazepam .. DiphenhydrAMINE . Docusate\n Sodium (Liquid) . Furosemide Glucagon . Hydrocortisone Cream 1% .\n Insulin . orazepam . Metoprolol Tartrate . Ranitidine (Liquid) Sarna\n Lotion . Sertraline . TraMADOL (Ultram) . Vancomycin\n 24 Hour Events:\n WOUND CULTURE - At 04:30 PM\n MULTI LUMEN - START 04:30 PM\n URINE CULTURE - At 05:00 PM\n SPUTUM CULTURE - At 05:30 PM\n BLOOD CULTURED - At 05:50 PM\n NASAL SWAB - At 06:00 PM\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.4\n HR: 81 (70 - 95) bpm\n BP: 82/48(54) {82/42(54) - 123/71(79)} mmHg\n RR: 25 (15 - 38) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.2 kg (admission): 96 kg\n Total In:\n 680 mL\n 833 mL\n PO:\n Tube feeding:\n 538 mL\n IV Fluid:\n 270 mL\n 245 mL\n Blood products:\n Total out:\n 800 mL\n 430 mL\n Urine:\n 200 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -120 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 404 (325 - 451) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///28/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, Blind\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered coarse BS, well aerarted. No wheeze.), mod.\n thick secretions occ.Good cough\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, G\n 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 Skin: Rash: paling of rash from adm. Still pruritic but much less so.,\n (Incision: No(t) Clean / Dry / Intact), open area mid wd-clean/dry\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 374 K/uL\n 8.8 g/dL\n 92 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 32 mg/dL\n 100 mEq/L\n 138 mEq/L\n 27.1 %\n 13.9 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n WBC\n 18.2\n 13.9\n Hct\n 26.7\n 27.1\n Plt\n 347\n 374\n Creatinine\n 1.1\n 1.1\n Glucose\n 85\n 92\n Other labs: PT / PTT / INR:19.2/34.5/1.8, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:7.7 mg/dL, Mg:2.4 mg/dL, PO4:3.8 mg/dL\n Fluid Analysis / Other Labs: UA-bact/nitrites positive\n Imaging: CXR- no infiltrates\n Microbiology: Stool- c diff negX1\n Sput- nl \n -pending\n BC pending\n Assessment and Plan\n Assessment and Plan: CV stable, tolerating TC for 2 hrs so far- will go\n 4-6hr as tolerated. On Vanco/cefiipime for broad coverage. ID input\n pending. Suspect urine source of fever, although 6 eos could be drug\n induced(mult neg CX for fevers last admit).\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, stop Coumadin- SR for\n weeks.Continue Amiodarone for present.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS, Other)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Remove Foley\n Hematology:\n Endocrine: RISS, Lantus (R)\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery, ID dept, P.T., let surgery know of amdission\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments: Hold anticoagulation.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n aGREE WITH ABOVE NOTE BY .\n ------ Protected Section Addendum Entered By: , MD\n on: 01:53 PM ------\n" }, { "category": "Nursing", "chartdate": "2154-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 735997, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Low grade fever overnight. Pan cultured yesterday, all cultures pnd.\n Started in iv vanco yesterday.\n Action:\n ID consulted. IV Cefepime added. Foley dc\nd. Wound care. VAP prevention\n measures. Sputum/blood recultured per ID.\n Response:\n Likely pneumonia. ?urine infection and stage three pressure sore as\n other possible infection sources. Has not voided yet, or had the\n sensation to void. Straight cath at per PA if necessary\n and sent repeat urine culture.\n Plan:\n Continue to send stool daily for cdiff, next due . F/U with\n cultures. Continue vanco/cefepime until cultures/sensitivities back.\n Wet-dry dsg changes .\n Impaired Skin Integrity\n Assessment:\n Stage three pressure ulcer on coccyx covered with mepilex. Rash\n covering 90% of patient\ns body.\n Action:\n Frequent repositions, skin care. PO benedryl prn pruritis.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2154-03-05 00:00:00.000", "description": "ICU Note - CVI", "row_id": 735871, "text": "CVICU\n HPI:\n Pre-Op Weight:0 lbs 0 kgs\n TLD:RT SCV TLC:Day2\n 59 year old male status post ruptured thoracoabdominal aneurysm repair\n on . Transferred from Rehab with fever of unknown\n origin and new thoracoabdominal drainage.\n Major Surgical or Invasive Procedure:\n - Emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm with a 34-mm Dacron tube graft using deep\n hypothermic circulatory arrest.\n - Chest and abdomen exploration, Removal of packs, Chest\n closure.\n - abdomen closure/ feeding jejunostomy\n tracheostomy\n ----------------------------------------------------------------\n Past Medical History:\n Type A aortic dissection with rupture s/p thoracoabdominal\n repair,Hypertension,atrial fibrillation,blindness,respiratory failure\n s/p Trach and G-J tube\n ----------------------------------------------------------------\n Medications at Rehab\n 1. Ranitidine 150(1),Aspirin 325 (1),Polyvinyl Alcohol-Povidone 1.4-0.6\n % Dropperette Sig: 1-2Drops Ophthalmic PRN (as needed) as needed for\n dryness, Heparin SC 5K tid,Tramadol 50 1-2q4h for\n pain,Ipratropium-Albuterol 6puffs QID prn,Amiodarone 200 mg Tablet\n daily, Miconazole powder(1) Appl Topical , Sertraline 50 (1),\n Metoprolol Tartrate 37.5(3),Nystatin 100,000 unit/mL Suspension Sig:\n Five (5) ML PO QID,Clonazepam 1 (2),Lorazepam 1 (3)/prn for\n agitation/anxiety,Insulin Glargine 100 unit/mL Solution Sig: Twenty\n (20) units, SSI\n Subcutaneous once a day.\n 15. Furosemide 20 (2)\n 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily\n at 4 PM: 3mg on \n target INR 2-2.5\n (received 5mg last 4 days) .\n 17. Insulin Regular Human 100 unit/mL Solution Sig: sliding\n Events:\n readmit from rehab for fever of unknown origin\n Plan:pan cx,await final cultures.UA dirty also. 6eos on smear-?drug\n fever.ID seeing\n Current medications:\n Albuterol-Ipratropium . Amiodarone . Artificial Tears Preserv. Free .\n Aspirin . Bisacodyl CefePIME . Clonazepam .. DiphenhydrAMINE . Docusate\n Sodium (Liquid) . Furosemide Glucagon . Hydrocortisone Cream 1% .\n Insulin . orazepam . Metoprolol Tartrate . Ranitidine (Liquid) Sarna\n Lotion . Sertraline . TraMADOL (Ultram) . Vancomycin\n 24 Hour Events:\n WOUND CULTURE - At 04:30 PM\n MULTI LUMEN - START 04:30 PM\n URINE CULTURE - At 05:00 PM\n SPUTUM CULTURE - At 05:30 PM\n BLOOD CULTURED - At 05:50 PM\n NASAL SWAB - At 06:00 PM\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 10:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.4\n HR: 81 (70 - 95) bpm\n BP: 82/48(54) {82/42(54) - 123/71(79)} mmHg\n RR: 25 (15 - 38) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.2 kg (admission): 96 kg\n Total In:\n 680 mL\n 833 mL\n PO:\n Tube feeding:\n 538 mL\n IV Fluid:\n 270 mL\n 245 mL\n Blood products:\n Total out:\n 800 mL\n 430 mL\n Urine:\n 200 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -120 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 404 (325 - 451) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 14 cmH2O\n SPO2: 100%\n ABG: ///28/\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, Blind\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : scattered coarse BS, well aerarted. No wheeze.), mod.\n thick secretions occ.Good cough\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, G\n 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 Skin: Rash: paling of rash from adm. Still pruritic but much less so.,\n (Incision: No(t) Clean / Dry / Intact), open area mid wd-clean/dry\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 374 K/uL\n 8.8 g/dL\n 92 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 32 mg/dL\n 100 mEq/L\n 138 mEq/L\n 27.1 %\n 13.9 K/uL\n [image002.jpg]\n 05:53 PM\n 04:00 AM\n WBC\n 18.2\n 13.9\n Hct\n 26.7\n 27.1\n Plt\n 347\n 374\n Creatinine\n 1.1\n 1.1\n Glucose\n 85\n 92\n Other labs: PT / PTT / INR:19.2/34.5/1.8, ALT / AST:33/22, Alk-Phos / T\n bili:99/0.7, Amylase / Lipase:58/30, Differential-Neuts:85.3 %,\n Lymph:5.2 %, Mono:3.3 %, Eos:6.0 %, Albumin:2.7 g/dL, LDH:176 IU/L,\n Ca:7.7 mg/dL, Mg:2.4 mg/dL, PO4:3.8 mg/dL\n Fluid Analysis / Other Labs: UA-bact/nitrites positive\n Imaging: CXR- no infiltrates\n Microbiology: Stool- c diff negX1\n Sput- nl \n -pending\n BC pending\n Assessment and Plan\n Assessment and Plan: CV stable, tolerating TC for 2 hrs so far- will go\n 4-6hr as tolerated. On Vanco/cefiipime for broad coverage. ID input\n pending. Suspect urine source of fever, although 6 eos could be drug\n induced(mult neg CX for fevers last admit).\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, stop Coumadin- SR for\n weeks.Continue Amiodarone for present.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS, Other)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Remove Foley\n Hematology:\n Endocrine: RISS, Lantus (R)\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids:\n Consults: General surgery, ID dept, P.T., let surgery know of amdission\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:00 AM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Multi Lumen - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments: Hold anticoagulation.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nutrition", "chartdate": "2154-03-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 735884, "text": "Subjective\n Per rehab note, was on Nepro @ 40ml/hr then changed on to Osmolite\n 1.2 @ 60ml/hr (1728 calories and 80g protein)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 96 kg\n 96.2 kg ( 04:00 AM)\n Question fluid changes\n 32.1** per admit wt\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 137%** per admit wt\n 76 kg\n admit: ) 113.6 kg *\n discharge:\n ) 102.8 kg\n 85%* based on last admit\n Diagnosis: sternal wound infection\n PMHx: HTN, atrial fibrillation, Type A aortic dissection with rupture\n s/p thoracoabdominal repair complicated by blindness,\n respiratory failure s/p Tracheostomy and G-J tubes\n Food allergies and intolerances: none\n Pertinent medications: Humalog insulin sliding scale, Glargine 20 units\n at breakfast, Ranitidine, lasix, Colace (held), ABX\n Labs:\n Value\n Date\n Glucose\n 92 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 125\n 06:00 AM\n BUN\n 32 mg/dL\n 04:00 AM\n Creatinine\n 1.1 mg/dL\n 04:00 AM\n Sodium\n 138 mEq/L\n 04:00 AM\n Potassium\n 4.0 mEq/L\n 04:00 AM\n Chloride\n 100 mEq/L\n 04:00 AM\n TCO2\n 28 mEq/L\n 04:00 AM\n pH (urine)\n 5.5 units\n 05:54 PM\n Albumin\n 2.7 g/dL\n 05:53 PM\n Calcium non-ionized\n 7.7 mg/dL\n 05:53 PM\n Phosphorus\n 3.8 mg/dL\n 05:53 PM\n Magnesium\n 2.4 mg/dL\n 04:00 AM\n ALT\n 33 IU/L\n 05:53 PM\n Alkaline Phosphate\n 99 IU/L\n 05:53 PM\n AST\n 22 IU/L\n 05:53 PM\n Amylase\n 58 IU/L\n 05:53 PM\n Total Bilirubin\n 0.7 mg/dL\n 05:53 PM\n WBC\n 13.9 K/uL\n 04:00 AM\n Hgb\n 8.8 g/dL\n 04:00 AM\n Hematocrit\n 27.1 %\n 04:00 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Isosource 1.5 @ 60ml/hr; 1 packet Banana Flakes TID\n GI: soft/distended, positive bowel sounds, positive flatus; golden\n liquid guiac negative stool\n Skin: stage 2-3 on coccyx\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: tube feed dependent, skin breakdown\n Estimated Nutritional Needs\n Calories: 1675-1900 (22-25 cal/kg)\n Protein: 91-114 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate protein\n Estimation of current intake:\n Specifics:\n 59 YO male readmitted from rehab with fever and distal end of\n thoracotomy dehisced and draining\npurulent\n material. Previously long\n ICU stay s/p emergent salvage repair of ruptured thoracoabdominal\n aortic aneurysm resulting in tracheostomy and G-J tubes. Tube feed\n dependent at this time for 100% of nutrition needs. Tube feed at rehab\n likely underfeeding protein especially given skin breakdown. Tube feed\n resumed overnight, running at goal via J tube to provide 2160 calories\n and 98g protein, may be overfeeding calories. BS well controlled.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations:\n o Change to Isosource 1.5 @ 50ml/hr with 21g Beneprotein = 1875\n calories and 100g protein\n Monitor abdominal exam, N/V\n Multivitamin / Mineral supplement: in tube feed\n Continue banana flakes if liquid stool\n Check chemistry 10 panel\n Monitor skin integrity\n Will follow, page if questions *\n 12:04\n" }, { "category": "Nursing", "chartdate": "2154-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 736001, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Low grade fever overnight. Pan cultured yesterday, all cultures pnd.\n Started in iv vanco yesterday.\n Action:\n ID consulted. IV Cefepime added. Foley dc\nd. Wound care. VAP prevention\n measures. Sputum/blood re-cultured per ID.\n Response:\n Likely pneumonia. ?urine infection and stage three pressure sore as\n other possible infection sources. Has not voided yet, or had the\n sensation to void. Straight cath at per PA if necessary\n and sent repeat urine culture.\n Plan:\n Continue to send stool daily for cdiff, next due . F/U with\n cultures. Continue vanco/cefepime until cultures/sensitivities back.\n Wet-dry dsg changes .\n Impaired Skin Integrity\n Assessment:\n Stage three pressure ulcer on coccyx covered with mepilex. Rash\n covering 90% of patient\ns body.\n Action:\n Frequent repositions, skin care. PO benedryl prn pruritis. \n hydrocortisone cream. PRN sarna lotion. Wound care consult requested.\n Response:\n Pressure ulcer continues with yellow drainage. Mepilex in place until\n wound care can consult, did not see patient today. Rash improving.\n Patient states he is less itchy, but still requiring frequent\n interventions for pruritus.\n Plan:\n Cont freq repositions. Skin care. Awaiting wound are consult.\n Patient had trach mask trial today, lasted 4 hours before desatting\n despite suctioning. Has been on cpap this afternoon. Suctioning prn\n thick tan secretions.\n Patient calm and cooperative most of shift. Making jokes and\n interacting with staff. At 1800 patient became tachypneic, rr 50s,\n unable to calm down and he requested medicine to help him calm down. PO\n ativan admin, pt currently calmer.\n VSS throughout the day. Assists with repositions and turning.\n Requesting to use the bedpan appropriately. PT worked with patient to\n dangle on edge of bed. Unable to stand and pivot. Pt was lifted to\n chair. Unable to tolerate chair for more than 45 minutes d/t pain he\n felt from his pressure sore. PO ultram admin but was not effective,\n pain resolved with pt lifted back to bed. Team to order stronger pain\n meds so that patient can participate in rehab more.\n" }, { "category": "Nursing", "chartdate": "2154-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 735769, "text": "59 y/o M With history significant for HTN, AFIB, Blindness (post op);S/P rupture\nd thoracoabdominal aneurysm repair on . He was transferred today from Rehab with FUO and new L-thoracotomy drainage. On arrival he\ns pan cu\nltured.\nPt also experiencing moderate bleeding from site post RSC- TLC insertion; coag\ns on arrival showing marked elevation PT36.8 PTT 106 INR 3.8.\n - Emergent salvage repair of ruptured thoracoabdominal aortic aneurysm.\n - Chest and abdomen exploration, Removal of packs, Chest closure.\n - Abdomen closure/ PEG placement\n tracheostomy\n Low grade fever overnight. T max 100.1F PO. Alert, oriented x2.\n Following commands. PERRLA. LS Rhonchorous bilaterally. Trach intact,\n sutures intact. Vented on CPAP 40% 8/5. O2 sats 99-100% . Moist creamy\n copious secretions per inline suction. SR per tele HR 70\ns, SBP\n 100-110mmHg. Easily palpable PP bilaterally. Active BS 4Q\ns, passing\n gas this evening; restarted TF at goal 60cc/hr tolerating well with no\n residual seen on assessment. FSBS Q6hr 100-120mgdL . Lantus dose\n 20units am . Turned and repositioned per protocol. Stage 3 pressure\n wound over coccygeal area; skin is broken. Medium golden liquid Stool\n x2 HS. Perineal area reddened. Skin rash resolving. Received Benadryl\n PRN pruritus. Removed, cleaned and replaceed L-thoracotomy DSD w-D.\n Foley catheter draining clear yellow urine.\n PLAN\n Monitor Temperature, WBC and culture results\n Monitor oxygenation.\n Monitor Coags, lytes , HCT.\n Monitor FSBS.\n" }, { "category": "Respiratory ", "chartdate": "2154-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 735771, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve with suct lge th pale yellow sput. Pt in NARD on\n current vent settings, Cont PSV/? trach mask today.\n" }, { "category": "Rehab Services", "chartdate": "2154-03-05 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 735860, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: TAA / 441\n Reason of referral: and treat\n History of Present Illness / Subjective Complaint: 59 y.o. male admit\n from Rehab with fevers, rash, and new thoracoabdominal\n drainage. Pt previously at from to for treatment of\n ruptured thoracic abdominal aortic aneurysm and was DC to rehab with\n J-tube, trach to vent, and post-op complications of LE weakness and\n blindness. Underwent superficial debridement of thoracoabdominal\n incision and is being treated with wet to dry dressings. I&D involved\n as well. Plan is to wean pt to trach mask later today if able.\n Past Medical / Surgical History: HTN, Afib, emergency salvation\n and repair of ruptured thoracoabdominal aortic aneurysm, chest\n and abdominal exploration with closure, 3/5/1- jejunostomy, trach.\n Medications: amiodarone, furosemide, K+, metoproplol, clonazepam,\n ranitidine, albuterol, aspirin, lorazepam, tramadol.\n Radiology: NA\n Labs:\n 27.1\n 8.8\n 374\n 13.9\n [image002.jpg]\n Other labs:\n Activity Orders: bed rest per POE, Nurse to obtain OOB at rounds and\n was about to get him up to chair when I entered the unit.\n Social / Occupational History: unknown\n Living Environment: Per chart was living with fiance prior to initial\n injury in \n Prior Functional Status / Activity Level: Per pt was getting to up to\n chair sometimes but not every day. Prior to admit was independent.\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert and awake.\n Oriented to self and year via multiple choice questioning. Required\n re-orientation to place and month and date. Pt able to pass air\n through trach to speak a little but difficult to understand. Follows\n one step commands.\n Hemodynamic Response\n CPAP 40% FIO2 to trach\n Aerobic Capacity\n CPAP 40% FIO2 to trach\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n Supine\n 72\n 103/42\n 31\n 100\n Rest\n 72\n 103/42\n 31\n 100\n Sit\n 73\n 108/55\n 36\n 73\n Activity\n 73\n 108/55\n 36\n 100\n Stand\n NA\n NA/NA\n NA\n NA\n Recovery\n 72\n 96/47\n 36\n 100\n Total distance walked: Sat EOB x 10 min\n Minutes: NA\n Pulmonary Status: Pt on CPAP to trach at 40% FIO2, ronchi B, increased\n RR noted throughout. Mod weak cough. Immediately after PT, pt weaned\n to trach mask while up in chair.\n Integumentary / Vascular: Stage 3 per nursing on sacrum. Neg edema\n throughout. Dressing all CDI. Skin/extremities warm to touch. +Foley\n catheter, PIV, TLC\n Sensory Integrity: Difficult to assess light touch. PT answering\n either yes to everything or not answering. Not intact to pain at B\n great toe nail beds, no withdrawl. UEs appear intact. Pt appears to\n be completely blind and tracks head movement to voices only.\n Pain / Limiting Symptoms: Pt has no c/o pain during PT session. After\n session pt heard to be c/o pain at sacrum while up in chair. Nurse\n provided meds.\n Posture: Rounded shoulders noted, otherwise difficult to assess due to\n assist level needed for sitting and inability to stand.\n Range of Motion\n Muscle Performance\n B LE and UE ROM appear WFL.\n grossly, B DF appear to be 2+/5, knee extensors , hips 0/5. UE >/=\n throughout.\n Motor Function: Pt moves B UE in isolation. Decreased active control\n of motion to B LE. No increased tone noted in either B UE and LE. Pt\n noted to be tremulous vs fidgity while at rest.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt unable to amb at this time. Pt was transferred to\n chair via ceiling lift due to inadequate LE strength for WB transfer.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n NA\n\n\n\n\n\n\n Sit to Stand:\n NA\n\n\n\n\n\n\n Ambulation:\n NA\n\n\n\n\n\n\n Stairs:\n NA\n\n\n\n\n\n\n Balance: At EOB initially retropulsive. Once placed in BOS pt able to\n maintain upright sitting posture with B UE support and CG assist. With\n B UEs in lap, pt requires max A to maintain balance and leans post and\n to his L. In chair, required pillows for positioning to keep in\n upright.\n Education / Communication: Pt ed re PT role, POC, recommendations.\n Nurse present for entire evaluation.\n Intervention: , , mobility\n Diagnosis:\n Clinical impression / Prognosis: 59 y.o. male presents with above\n impairments a/w recent ruptured thoracoabdominal aortic aneurysm with\n hypotensive infarctions c/w cardiopulmonary pump dysfunction and\n non-progressive CNS d/o. Pt continues to function well below his\n baseline of independence. Currently requires max A for all mobility\n and unable to walk. Pt seems to have made some progress since initial\n PT evaluation on . Given his performance on evaluation and his\n motivation, anticipate pt to be able to continue to make gains towards\n prior level of fxn with intensive rehab program.\n Goals\n Time frame: 1 week\n 1.\n Sit EOB with B UE support x 15 min with close supervision\n 2.\n Tolerate OOB in chair x 3 hours\n 3.\n Participate in LE active assisted supine and seated therex program\n 4.\n Improve LE muscle strength by grade throughout.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-4x/wk x 1 week\n Progress sitting balance and endurance as well as LE muscle strength.\n Assess standing/ bed <> chair transfers as able.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n TREATMENT TIME: 0850 to 0950\n" }, { "category": "Rehab Services", "chartdate": "2154-03-05 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 735863, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: TAA / 441\n Reason of referral: and treat\n History of Present Illness / Subjective Complaint: 59 y.o. male admit\n from Rehab with fevers, rash, and new thoracoabdominal\n drainage. Pt previously at from to for treatment of\n ruptured thoracic abdominal aortic aneurysm and was DC to rehab with\n J-tube, trach to vent, and post-op complications of LE weakness and\n blindness. Underwent superficial debridement of thoracoabdominal\n incision and is being treated with wet to dry dressings. I&D involved\n as well. Plan is to wean pt to trach mask later today if able.\n Past Medical / Surgical History: HTN, Afib, emergency salvation\n and repair of ruptured thoracoabdominal aortic aneurysm, chest\n and abdominal exploration with closure, 3/5/1- jejunostomy, trach.\n Medications: amiodarone, furosemide, K+, metoproplol, clonazepam,\n ranitidine, albuterol, aspirin, lorazepam, tramadol.\n Radiology: NA\n Labs:\n 27.1\n 8.8\n 374\n 13.9\n [image002.jpg]\n Other labs:\n Activity Orders: bed rest per POE, Nurse to obtain OOB at rounds and\n was about to get him up to chair when I entered the unit.\n Social / Occupational History: unknown\n Living Environment: Per chart was living with fiance prior to initial\n injury in \n Prior Functional Status / Activity Level: Per pt was getting to up to\n chair sometimes but not every day. Prior to admit was independent.\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert and awake.\n Oriented to self and year via multiple choice questioning. Required\n re-orientation to place and month and date. Pt able to pass air\n through trach to speak a little but difficult to understand. Follows\n one step commands.\n Hemodynamic Response\n CPAP 40% FIO2 to trach\n Aerobic Capacity\n CPAP 40% FIO2 to trach\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n Supine\n 72\n 103/42\n 31\n 100\n Rest\n 72\n 103/42\n 31\n 100\n Sit\n 73\n 108/55\n 36\n 73\n Activity\n 73\n 108/55\n 36\n 100\n Stand\n NA\n NA/NA\n NA\n NA\n Recovery\n 72\n 96/47\n 36\n 100\n Total distance walked: Sat EOB x 10 min\n Minutes: NA\n Pulmonary Status: Pt on CPAP to trach at 40% FIO2, ronchi B, increased\n RR noted throughout. Mod weak cough. Immediately after PT, pt weaned\n to trach mask while up in chair.\n Integumentary / Vascular: Stage 3 per nursing on sacrum. Neg edema\n throughout. Dressing all CDI. Skin/extremities warm to touch. +Foley\n catheter, PIV, TLC\n Sensory Integrity: Difficult to assess light touch. PT answering\n either yes to everything or not answering. Not intact to pain at B\n great toe nail beds, no withdrawl. UEs appear intact. Pt appears to\n be completely blind and tracks head movement to voices only.\n Pain / Limiting Symptoms: Pt has no c/o pain during PT session. After\n session pt heard to be c/o pain at sacrum while up in chair. Nurse\n provided meds.\n Posture: Rounded shoulders noted, otherwise difficult to assess due to\n assist level needed for sitting and inability to stand.\n Range of Motion\n Muscle Performance\n B LE and UE ROM appear WFL.\n grossly, B DF appear to be 2+/5, knee extensors , hips 0/5. UE >/=\n throughout.\n Motor Function: Pt moves B UE in isolation. Decreased active control\n of motion to B LE. No increased tone noted in either B UE and LE. Pt\n noted to be tremulous vs fidgity while at rest.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt unable to amb at this time. Pt was transferred to\n chair via ceiling lift due to inadequate LE strength for WB transfer.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n NA\n\n\n\n\n\n\n Sit to Stand:\n NA\n\n\n\n\n\n\n Ambulation:\n NA\n\n\n\n\n\n\n Stairs:\n NA\n\n\n\n\n\n\n Balance: At EOB initially retropulsive. Once placed in BOS pt able to\n maintain upright sitting posture with B UE support and CG assist. With\n B UEs in lap, pt requires max A to maintain balance and leans post and\n to his L. In chair, required pillows for positioning to keep in\n upright.\n Education / Communication: Pt ed re PT role, POC, recommendations.\n Nurse present for entire evaluation.\n Intervention: , , mobility\n Diagnosis:\n Clinical impression / Prognosis: 59 y.o. male presents with above\n impairments a/w recent ruptured thoracoabdominal aortic aneurysm with\n hypotensive infarctions c/w cardiopulmonary pump dysfunction and\n non-progressive CNS d/o. Pt continues to function well below his\n baseline of independence. Currently requires max A for all mobility\n and unable to walk. Pt seems to have made some progress since initial\n PT evaluation on . Given his performance on evaluation and his\n motivation, anticipate pt to be able to continue to make gains towards\n prior level of fxn with intensive rehab program.\n Goals\n Time frame: 1 week\n 1.\n Sit EOB with B UE support x 15 min with close supervision\n 2.\n Tolerate OOB in chair x 3 hours\n 3.\n Participate in LE active assisted supine and seated therex program\n 4.\n Improve LE muscle strength by grade throughout.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-4x/wk x 1 week\n Progress sitting balance and endurance as well as LE muscle strength.\n Assess standing/ bed <> chair transfers as able.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n TREATMENT TIME: 0850 to 0950\n ------ Protected Section ------\n PT impairments:\n 1. Decreased endurance\n 2. Decreased ventilation\n 3. Decreased muscle performance\n 4. Decreased balance\n 5. Decreased fxn\nl mobility\n ------ Protected Section Addendum Entered By: , PT\n on: 10:26 ------\n" }, { "category": "Respiratory ", "chartdate": "2154-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 735955, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Trach collar trials\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2154-03-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 736041, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\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: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve with suct lge th pale yellow sput. Pt in NARD on\n current vent settings, Cont PSV/? trach mask today.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2176-07-10 00:00:00.000", "description": "Report", "row_id": 1309909, "text": "Respiratory Care\nPt transfered to T-SICU this evening from PACU s/p AAA repair. Pt currently extubated and weaned to 3L nasal cannula. SpO2 in mid 90's. BS coarse with scattered wheezing. Pt given Neb Alb/Atr as ordered. RR 20- mid 20s.\nPlan: Continue current therapy. ? floors\n" }, { "category": "Nursing/other", "chartdate": "2176-07-10 00:00:00.000", "description": "Report", "row_id": 1309910, "text": "Nursing (1900-0700)\nSee flow sheet for details. Pt. admitted s/p AAA repair, Aortobifem graft, ventral hernia repair, LOA. Pt. spent >24hrs. in PACU. (See previous admission data from 11.)\n\nPt. confused intermittently throughout shift. Forgetful of date and sequence of events; aware he is in the hospital, but does not know which one. Pt. redirected easily. Cranial nerves intact. Occasional complaint of incisional pain treated with dilaudid with effect.\n\nVSS. Pt. either in SR or Vpaced. Skin warm and dry. Color WNL. Nailbeds pink. Anasarcic, especially upper extremeties and scrotum, all elevated.\n\nPulmonary assessment improving as shift progresses. Nebs Q4hr for wheezes. Aggressive pulmonary toilet for lung hygiene. O2 weaned overnight. ABG's noted this a.m.\n\nPt. given lasix at 0230 as UO tapered off. Brisk response noted. Continue to monitor I and O's closely as cardiac funcion is limited and fluid balance is grossly positive.\n\nAbd large, benign. NGT removed inadvertantly by pt. during a period of restlessness. No difficulty swallowing few ice chips. BS's as per flow sheet.\n\nIncisions per flow sheet. Continue to monitor drainage via bilateral groins and change as necessary.\n\nPlan:\nContinue to monitor cardiopulmonary status, espicially signs and symptoms of CHF.\nMonitor wounds and level of comfort. Pt. to get OOB today if ordered by team.\nMonitor I's and O's and treat with lasix as necessary.\nAdvance diet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-07-10 00:00:00.000", "description": "Report", "row_id": 1309911, "text": "NPN \nROS: See carevue for details\n\nNEURO/MOBILITY: patient alert & oriented x1-2, occasionally will know that he is in the hospital. follows all commands, talks off and on about things that are completely unrelated to his hospital course (\"the war between the blacks and whites\")moves all extremities weakly. c/o pain to abdominal incision with turning and repositioning, medicated with dilaudid with good effect. able to swallow pills easily without s/s aspiration. OOB to chair pivot with max assist.\n\nCV: new VVIR pacer (interrogated recently in PACU, see info in chart), SR most of the time with rate in the 70s, occasionally V-paced with rate 80s. rare PVCs noted. BP stable, although aline positional. left DP pulse faintly heard via doppler, Left PT & right DP & PT pulse easily found with doppler. extremities warm, although left foot noted to be cooler than right. coreg given as ordered.\n\nRESP: ls clear, fine crackles noted at bases. O2 sat 94-98% on 3L NC. strong cough, although needs encouragement.\n\nGI: NPO w/meds maintained. abd slightly distended, tender to palpation. hypoactive bowel sounds. colostomy with formed brown stool out, stoma beefy red, moist > appliance changed by ostomy nurse today. denies nausea\n\nGU: adequate urine out via foley catheter. lasix as ordered with adequate response. lytes repleted PRN. scrotal and penile edema noted\n\nENDO: BS WNL, no coverage needed via RISS\n\nID: afebrile, no active issues\n\nSKIN: midline abdominal incision with staples intact, well approximated, no drainage noted, DSD in place. bilateral groin incisions with staples intact, large amounts of serosanginous drainage from both, DSD changed many times. scrotal/penile area with large amount of swelling, reddened area to groin > barrier cream applied. coccyx area with stage 2 pressure ulcer noted. 7 x8cm round, red/purple with open areas. wound care nurse up to see. allevyn foam dressing placed, to be changed QOD.\n\nSOCIAL: son into visit today. updated wife via phone\n\nPLAN: cont. diuresis > replete lytes PRN. OOB as tolerated. pain control. pulmonary toilet. monitor & support, cont. current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-11 00:00:00.000", "description": "Report", "row_id": 1309912, "text": "NPN\nneuro: alert, oriented to person, sometimes place, not time; calm and cooperative. No focal deficits. Med w/ dilaudid 0.5mg IV early eve w/ excellent analgesia.\n\nCV: NSR, MFVEA w/ rare v-pacing. SBP 120's. A-line d/c'd by pt. CVP 5-9. Pulses + Doppler signal throughout; LLE very weak signal. 2+ anasarca. Pboots in place.\n\nPulm: NP 3l sats 92-94 initially, to 98-100 w/ CDB. Thick yellow sputum raised. BS course initially, now clear bilaterally, dim bases.\n\nGI: abd softly distended, hypo BS. Colostomy pink, soft brown stool mod amount. NPO.\n\nGU: F/C urine clear amber, 60-80cc/hr; weak diuretic effect lasix 20mg 0200.\n\nSkin/skeletal: RIJ TL intact, patent x 3. Allevyn dressing C/D over stage 2 coccyx wound. Midline incision C/D. Bilateral groin wounds pink, draining mod-lge serous fluid. Scrotum painfully edematous, cradled.\n\nEndo: RISS, no coverage needed.\n\nA/P: S/P AAA repair, pacemaker placemnt, small bowel ilius resection.\nStable HD, needs aggressive bronchial hygeine. 5+ L volume overload still, cont lasix. Per Dr. , change po meds to parenteral. Tx to VICU today\n\n" }, { "category": "Echo", "chartdate": "2176-07-08 00:00:00.000", "description": "Report", "row_id": 81254, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Left ventricular function. Mitral valve disease. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 16:44\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in\nthe body of the LAA. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast\nor thrombus in the body of the RA or RAA. A catheter or pacing wire is seen in\nthe RA and extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH. Moderately dilated LV cavity. Severely depressed\nLVEF. TSI demonstrates significant LV dyssynchrony with significant septal\nwall contraction delay (vs. lateral wall). TSI demonstrates significant LV\ndyssynchrony with significant lateral wall contraction delay (vs. septum).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] 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 TEE probe was passed with assistance from the\nanesthesioology staff using a laryngoscope. The patient was under general\nanesthesia throughout the procedure.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium or left atrial appendage. No spontaneous\necho contrast or thrombus is seen in the body of the right atrium or the right\natrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is moderately dilated. Overall left ventricular systolic function is\nseverely depressed. Tissue synchronization imaging demonstrates significant\nleft ventricular dyssynchron. The right ventricular cavity is markedly\ndilated. There is severe global right ventricular free wall hypokinesis. There\nare three aortic valve leaflets. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. Trace aortic regurgitation is\nseen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral\nregurgitation is seen. The transmitral flow propagation velocity is .2 m/s (nl\n<=0.45m/s) The tricuspid valve leaflets are mildly thickened. Severe [4+]\ntricuspid regurgitation is seen. Tricuspid annulus is dilated 4.5 cm. In\ndiamtere.There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2176-07-17 00:00:00.000", "description": "Report", "row_id": 198412, "text": "Sinus rhythm\nLeft anterior fascicular block\nIV conduction defect\nLate transition\nNonspecific ST-T wave changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2176-07-16 00:00:00.000", "description": "Report", "row_id": 198413, "text": "Sinus rhythm\nMarked left axis deviation\nIntraventricular conduction defect\nSince previous tracing, left bundle branch block is gone\n\n" }, { "category": "ECG", "chartdate": "2176-07-16 00:00:00.000", "description": "Report", "row_id": 198414, "text": "Sinus rhythm\nLeft axis deviation\nLeft bundle branch block\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2176-07-09 00:00:00.000", "description": "Report", "row_id": 198415, "text": "Sinus rhythm with low amplitude P waves. Left bundle-branch block. Left axis\ndeviation. Diffuse non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of complete left bundle-branch block now present.\n\n" }, { "category": "ECG", "chartdate": "2176-07-08 00:00:00.000", "description": "Report", "row_id": 198416, "text": "Sinus rhythm\nLeft axis deviation\nIV conduction defect\nLeft anterior fascicular block\nT wave inversion in leads V1-V4 - consider ischemia\nNonspecific inferolateral T wave flattening\nSince previous tracing, inferolateral T wave flattening seen\n\n" }, { "category": "ECG", "chartdate": "2176-07-06 00:00:00.000", "description": "Report", "row_id": 198417, "text": "Sinus rhythm\nIntraventricular conduction delay\nLeft anterior fascicular block\nT wave changes in leads V2-V4 - consider ischemia\nReverse R wave - ? anteroseptal myocardial infarction\nSince previous tracing, QRS interval narrower\n\n" }, { "category": "ECG", "chartdate": "2176-07-07 00:00:00.000", "description": "Report", "row_id": 198418, "text": "Sinus rhythm\nMarked left axis deviation\nLeft anterior fascicular block\nIntraventricular conduction defect\nPossible anterior infarct\nLateral ST-T changes are nonspecific\nT wave inversion in leads V1-V4 - consider ischemia\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2176-07-19 00:00:00.000", "description": "Report", "row_id": 198411, "text": "Sinus rhythm. Left axis deviation. Intraventricular conduction delay. Probable\nold anterior myocardial infarction. Compared to the previous tracing\nof no change.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2204-12-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315453, "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 Comfortable on vent\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:29 AM\n SPUTUM CULTURE - At 09:36 AM\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 11:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:00 PM\n Furosemide (Lasix) - 09:19 PM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: Reviewed\n no changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea\n Psychiatric / Sleep: comfortable\n Signs or concerns for abuse : No\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: 36.8\nC (98.2\n Tcurrent: 36.3\nC (97.3\n HR: 91 (90 - 117) bpm\n BP: 121/65(79){111/65(76) - 148/80(92)} mmHg\n RR: 16 (16 - 18) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia) , VT (Ventricular Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,948 mL\n 942 mL\n PO:\n TF:\n 288 mL\n 508 mL\n IVF:\n 1,555 mL\n 223 mL\n Blood products:\n Total out:\n 3,115 mL\n 455 mL\n Urine:\n 3,115 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n 487 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 29 cmH2O\n Plateau: 17 cmH2O\n SpO2: 94%\n ABG: 7.39/66/86/34/11\n Ve: 7.5 L/min\n PaO2 / FiO2: 215\n Physical Examination\n General Appearance: Frail\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion:\n Hyperresonant: ), (Breath Sounds: Crackles : scattered mid insp,\n Wheezes : )\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.7 g/dL\n 389 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 97 mEq/L\n 138 mEq/L\n 40.5 %\n 14.9 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n WBC\n 8.2\n 17.6\n 14.9\n Hct\n 41.5\n 37.9\n 40.5\n Plt\n \n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n Glucose\n 159\n 148\n 117\n 150\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) comfortable on the\n ventilator. RSBI 40 so will change to PSV and start to taper. She is\n minimally sedated\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION - Remains on abx. Would be inclined to continue\n to diurese as we are starting to reduce positive pressure\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP) - Temp down. CXR\n minimally improved\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Radiology", "chartdate": "2204-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997605, "text": " 9:20 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for congestion.\n Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with COPD flare, now with acute SOB.\n REASON FOR THIS EXAMINATION:\n eval for congestion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old woman with COPD flare, now with acute SOB: evaluate\n for congestion.\n\n FINDINGS: Multiple prior studies including and .\n\n SINGLE VIEW, CHEST: Unchanged appearance of right lower lobe opacification\n with underlying right pleural effusion which could reflect atelectasis or\n pneumonia. Endotracheal tube with tip located approximately 3 cm above the\n carina is noted. Nasogastric tube with the tip located in the stomach is\n noted. Left-sided pleural chest tube is noted, no pneumothorax.\n\n IMPRESSION: Unchanged appearance of right lower lobe consolidation with\n underlying pleural effusion could reflect atelectasis or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2205-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998743, "text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate or pulm edema\n Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with continued respiratory distress; being treated for COPD\n and s/p antibiotics for possible pneumonia.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate or pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:26 A.M. ON \n\n HISTORY: Respiratory distress. COPD. Pneumonia or pulmonary edema.\n\n IMPRESSION: AP chest compared to and :\n\n Lateral aspect of the left lower chest is excluded from the examination.\n While there is some obscuration by overlying chest cage there may be new right\n perihilar consolidation. Lateral aspect of the left lower chest is excluded\n from the examination. Multiple healed rib fractures are seen on both sides of\n the chest. The heart is borderline enlarged. There is no abnormality of the\n imaged pleural surfaces. Thoracic aorta is tortuous but not focally dilated.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2204-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997570, "text": " 6:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in intrapulmonary pathol\n Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with COPD, CAD\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in intrapulmonary pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD and coronary artery disease.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. The cardiac silhouette remains enlarged, and there is some prominence\n of interstitial markings that could reflect chronic lung disease, increased\n pulmonary venous pressure, or both. No definite focal infiltrate. Multiple\n old healed rib fractures are again seen.\n\n IMPRESSION: Little overall change.\n\n\n" }, { "category": "Radiology", "chartdate": "2204-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997779, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, pulm edema\n Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman intubated for respiratory failure from COPD, ?fluid\n overloaded\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61-year-old woman, intubated for respiratory failure associated\n with COPD. Question fluid overload.\n\n CHEST, AP SEMI-UPRIGHT: The patient remains intubated, and a nasogastric tube\n again terminates in the stomach. The cardiac and mediastinal contours are\n unchanged. Aeration in the right lower lobe appears somewhat improved,\n although the area is somewhat obscured by a device lying outside the patient.\n There is no pulmonary edema. No effusion or pneumothorax. Multiple bilateral\n old rib fractures are demonstrated.\n\n IMPRESSION: Improving aeration in the right lower lobe, but area somewhat\n obscured. No pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2204-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998453, "text": " 1:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate edema effusion\n Admitting Diagnosis: ASTHMA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61F with COPD exacerbation with increased SOB\n REASON FOR THIS EXAMINATION:\n r/o infiltrate edema effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61-year-old woman with COPD exacerbation and increased shortness\n of breath.\n\n CHEST, AP SEMI-UPRIGHT: Comparison is made to . The patient has\n been extubated. Allowing for rotation on this view, the cardiac and\n mediastinal contours are probably unchanged. There are linear bibasilar\n opacities, most suggestive of atelectasis, but otherwise the lungs are clear.\n Flattening of the hemidiaphragms is again noted. Multiple old bilateral rib\n fractures are again visualized.\n\n IMPRESSION: Bibasilar linear opacities, most suggestive of atelectasis.\n Multiple old rib fractures bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2204-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997254, "text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: dyspena- eval for PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with\n REASON FOR THIS EXAMINATION:\n dyspena- eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n CLINICAL HISTORY: 61-year-old woman with dyspnea, evaluate for pneumothorax.\n\n Comparison is made with prior study from .\n\n FINDINGS: Portable upright AP chest radiograph is obtained. There is a\n stable appearance of bibasilar linear opacities, which likely reflect\n atelectasis. There is no evidence of pneumonia or CHF. No definite pleural\n effusions are appreciated. Heart size is grossly unchanged. Mediastinal\n contour is stable. There is no pneumothorax. Upper lobe lucency and splaying\n of bronchovasculature likely reflects underlying emphysema. Extensive ribcage\n deformity and thoracic kyphosis are again noted.\n\n IMPRESSION:\n\n No significant change. No evidence of pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2205-01-02 00:00:00.000", "description": "Report", "row_id": 127505, "text": "Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\nof the rate has slowed. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2204-12-25 00:00:00.000", "description": "Report", "row_id": 127506, "text": "Sinus tachycardia\nPremature ventricular contractions\nSupraventricular extrasystoles\nNormal ECG except for rate\nSince previous tracing of , premature beats are new\n\n" }, { "category": "ECG", "chartdate": "2204-12-24 00:00:00.000", "description": "Report", "row_id": 127507, "text": "Sinus tachycardia. Baseline artifact. Non-specific inferolateral T wave\nchanges. Compared to the previous tracing of there is no significant\nchange other than the ventricular rate is faster.\n\n" }, { "category": "Nursing", "chartdate": "2205-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 316088, "text": "Pt beginning screening process for rehab. Fam wondering why pt cannot\n return to the facility they are familiar with. Pt status has worsened\n over the last few months and now required closer medical monitoring as\n well as physical rehab. Case manager met w/ fam and pt and discussed\n options and will begin to look for bed availability. Pt may need\n another day or two in hospital to better stabilize proper med regimen\n for her HR and BP following steroid treatment. Physically therapy\n contact and will begin treatment and evaluate for rehab tomorrow.\n Delirium / confusion\n Assessment:\n Pt now A&Ox3, communicating needs, sleeping most of shift but easily\n arousable, able to understand case manager information during\n discussion and asking appropriate questions.\n Action:\n No PRN meds required or restraints for pt confusion/line safety.\n Response:\n Pt remains comfortable in bed\n Plan:\n Cont to monitor mental status, orientation, and treat w/ PRN meds\n and/or restraints as needed.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Yesterday Hct 43, this AM 35, noted hematuria (brownish bloody\n sediment), no stool to check guiac, abd soft/non-tender, repeat Hct\n later in AM 37, repeat afternoon Hct pending.\n Action:\n Type and screen sent\n Response:\n Hct remains stable @ this time w/ no evidence of bleeding.\n Plan:\n f/u on afternoon hct, guiac stool when pt stools, monitor for\n additional signs of bleeding\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n O2 sat >95%, RR 9-19 (slower when sleeping), remains on 3L NC, LS clear\n upper/diminished lower, crackles in bases @ times\n Action:\n 3L NC, neb treatments and INH\n Response:\n Stable respiratory status\n Plan:\n Transition patient to acute rehab facility that will manage medical\n issues as well as provide physical therapy.\n Hypertension, benign\n Assessment:\n SBP 137-96, HR 73-52, NSR w/o ectopy\n Action:\n Held several doses of cardiac meds d/t decreased HR and BP. MD\ns now\n ordering for lower doses since pt had not required most of the meds\n prior to this admission. ? HTN issues d/t high dose steroids which have\n now been tapered to lower doses. Mg repleted, K being repleted w/ 40mEq\n in 500cc, when this finishes will start 40mEq in 1000cc D5 @ 100cc/hr\n for 1L.\n Response:\n Cardiac VS remain stable\n Plan:\n Start lower dose medications, hold per parameters if indicated,\n" }, { "category": "Nursing", "chartdate": "2205-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 316111, "text": "Electrolyte & fluid disorder, other\n Assessment:\n K 3.1 on .\n Action:\n Given 10meq/100SW X4.\n Response:\n Morning labs pending\n Plan:\n Continue to monitor lytes\n Delirium / confusion\n Assessment:\n Short period of anxiety with slight confusion, otherwise pt oriented,\n appropriate and pleasant.\n Action:\n None\n Response:\n Plan:\n Continue zyprexa and low dose steroids\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Lungs clear upper lobes, diminished lower. O2 sat 95-99% on 3L NC.\n Denies increased SOB/dyspnea.\n Action:\n Steroids, nebs, supplemental O2.\n Response:\n Resp status stable\n Plan:\n Continue with O2, nebs/MDI\ns, encourage C&DB, increase activity as\n tolerated.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Most recent crit 37 (10 point drop in 24 hrs); hematuria is clearing\n Action:\n U/A sent and am crit pending; no stools to check guiac\n Response:\n Plan:\n Monitor crit, hematuria, guiac stools\n" }, { "category": "Case Management ", "chartdate": "2205-01-02 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 316084, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: Medicare A&B\n Hospital days authorized to:\n Current Discharge Plan: Acute rehab\n Acute rehab/LTAC placement\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n 1) NE at \n 2) - \n 3) Rehab - MACU and -\n Narrative / Plan:\n I met with the patient and her 2 daughters to discuss DC plans and\n their choices for rehab placement. I informed them that I was called\n by Hospital and and they are not going to make bed\n offers. I discussed the need for ongoing rehab care given Ms. \n de-conditioned state and that given that de-conditioning, a home\n discharge was not a safe discharge. We discussed LTAC facilities in\n and around the area. We discussed why this type of facility was\n preferable for rehab and I identified which facilities offered this\n type of care. Those facilities are as follows: NE at ,\n , - and Rehab-MACU. NE has\n already screened the patient and has medically accepted her. I will\n call all the remaining facilities in am of 2/ 7. The patient still\n needs a PT eval and medication adjustment before she is ready for\n transfer. I will continue to follow.\n" }, { "category": "Physician ", "chartdate": "2205-01-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 316196, "text": "Chief Complaint: hypoxia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 09:44 AM\n URINE CULTURE - At 02:11 PM\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: No cough or fevers.\n Flowsheet Data as of 10:46 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: 36.7\nC (98\n HR: 62 (52 - 71) bpm\n BP: 116/47(64){96/42(55) - 142/81(95)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 975 mL\n 627 mL\n PO:\n 160 mL\n 120 mL\n TF:\n IVF:\n 590 mL\n 507 mL\n Blood products:\n Total out:\n 701 mL\n 235 mL\n Urine:\n 701 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 274 mL\n 392 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///39/\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 12.4 g/dL\n 378 K/uL\n 76 mg/dL\n 0.8 mg/dL\n 39 mEq/L\n 4.8 mEq/L\n 31 mg/dL\n 99 mEq/L\n 141 mEq/L\n 39.7 %\n 16.3 K/uL\n [image002.jpg]\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n 05:30 PM\n 05:58 AM\n WBC\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n 16.3\n Hct\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n 38.7\n 39.7\n Plt\n 70\n 275\n 378\n Cr\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n 0.8\n TCO2\n 43\n 44\n Glucose\n 127\n 104\n 104\n 88\n 72\n 76\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPOGLYCEMIA: Resolved.\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING): Hct\n stable.\n DELIRIUM / CONFUSION: Likely due to steroids.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved. Will place back on home COPD regimen, spiriva, advair,\n d/c atrovent. Albuterol prn. Is on prednisone 10 mg at baseline.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition: Diabetic diet.\n Glycemic Control: Insulin sliding scale.\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: SQ heparin.\n Stress ulcer: PPI.\n VAP: Not intubated.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To rehab.\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2205-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315888, "text": "Delirium / confusion\n Assessment:\n Increasing delirium and auditory/visual hallucinations during the\n night.\n Disoriented to time/place and unable to remember instructions to\n remains in bed.\n Attempted to get OOB several times.\n Action:\n MD team aware Received additional dose of 5mg PO Zyprexa x2 doses,\n 0.5mg IV haldol x 2 doses, and 25mg PO trazadone.\n Frequent re-orientation to place/time\n Bed in lowest position, bed alarm on.\n Contact clinical advisor to obtain 1:1 sitter but non available, pt\n remains under close supervision by RN.\n Response:\n Pt remains disoriented and continues to have hallucinations. Unable to\n sleep.\n Plan:\n Continue to re-orient pt to environment\n Continue close observation r/t risk of falls.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 02 sats 97-100 on 2L NC, RR 15-20,\n No dyspnea/SOB, lungs clear/diminished bases.\n Congested/non-productive cough.\n Action:\n Encouraging coughing/deep breathing.\n Q4h nebs by RRT.\n Continues on steroid taper.\n Response:\n Pts oxygenation and breathing pattern remains stable.\n Plan:\n Continue to monitor pts 02 sats, RR, breathing pattern.\n Cont to encourage coughing/deep breathing.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pts urine output approx 30cc/hr, pink tinge.\n Action:\n MD\ns aware of urine output, cont to observe.\n Response:\n Pts urine output remains >30cc/hr.\n Plan:\n No plan for diuresis at present. (+112cc at MN)\n" }, { "category": "Rehab Services", "chartdate": "2205-01-01 00:00:00.000", "description": "Generic Note", "row_id": 315969, "text": "TITLE:\n Rehab services Department\n Received PT consult and appreciated. Spoke with RN and pt not\n appropriate to be seen at the time secondary to respiratory issues and\n confusion. RN reports pt was up OOB this AM. Will f/u to check status\n and evaluate as appropriate. Thanks\n" }, { "category": "Physician ", "chartdate": "2205-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315970, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n Continued to be very confused over the course of the day requiring\n zyprexa, haldol. Placed in restraints overnight.\n CXR obtained due to tachypnea showed atelectasis\n PCP came by to see; pt admitted having visual hallucinations to her\n Awaiting PT evaluation\n Subjective:\n Feels breathing is improving\n Denied further visual hallucinations\n Repeatedly asking to get up/change positions/move\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:53 PM\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 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: 36.5\nC (97.7\n HR: 84 (59 - 85) bpm\n BP: 173/65(87){102/62(47) - 177/97(128)} mmHg\n RR: 17 (14 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 997 mL\n 100 mL\n PO:\n 585 mL\n 100 mL\n TF:\n IVF:\n 412 mL\n Blood products:\n Total out:\n 885 mL\n 220 mL\n Urine:\n 885 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.44/61/62//13\n Physical Examination\n General Appearance: Anxious, Sitting in chair by bed, restrained.\n Easily distractable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Mucous membranes dry\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : ), not particularly tight; not using accessory muscles to\n breathe\n Abdominal: Soft, Non-tender, Bowel sounds present, appears distended\n kyphosis\n Extremities: No LE edema\n Skin: Not assessed, Rash: macules on feet improving\n Neurologic: Responds to: Not assessed, Oriented (to): person and date,\n but thinks she's at an airport, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 377 K/uL\n 14.4 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 95 mEq/L\n 141 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n WBC\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 389\n 382\n 432\n 391\n 377\n Cr\n 0.8\n 0.7\n 0.6\n 0.6\n 0.5\n TCO2\n 34\n 36\n 41\n 44\n 43\n Glucose\n 150\n 99\n 127\n 104\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR :\n Bibasilar linear opacities, most suggestive of atelectasis.\n Multiple old rib fractures bilaterally\n Microbiology: Blood, urine, and sputum Cx negative\n Assessment and Plan\n 61yo woman with COPD admitted with respiratory failure, now extubated.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - continues to have episodes of tachypnea and respiratory\n distress\n - continue prednisone taper\n - bronchodilators, singulair, flonase, frequent suctioning\n - treat anxiety as below\n # Delirium:\n - most likely has developed delirium from steroids, acute\n illness, hospitalization with disturbance of sleep/wake cycle\n - continue steroid taper\n - has prolonged QT; give zyprexa and haldol PRN; avoid\n additional zyprexa\n - monitor EKG\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC trending up\n - s/p treatment with azithromycin and ceftriaxone\n HYPERTENSION, BENIGN\n - BP volatile in setting of episodes of agitation\n - Continue current management with ACE I, beta blocker, and\n CCB; hydralazine PRN SBP > 160\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): resolved\n TACHYCARDIA, OTHER: resolved\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE):\n - appreciate PCP note clarifying that pt is not on ASA\n - continue plavix, statin, beta blocker, ACE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue outpatient management\\\n ICU Care\n Nutrition:\n Comments: low sodium diet\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 22 Gauge - 12:28 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU ; eventual placement at respiratory rehab once mental\n status improved\n" }, { "category": "Case Management ", "chartdate": "2205-01-01 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 315971, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: Medicare A&B\n Hospital days authorized to:\n Current Discharge Plan: Acute rehab\n Rehab versus Skilled Nursing Facility\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n Narrative / Plan:\n Screens for Hospital and are in process. I am not\n sure that the patient will be assessed asmeeting the guidelines for the\n acute rehab level of rehab care. I have contact the patient's\n daughter and plan to meet with her in the late afternoon on\n to further discuss dc possibilities.\n" }, { "category": "Nutrition", "chartdate": "2205-01-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 315977, "text": "Subjective\n Unable to speak w/ pt d/t poor mental status\n Objective\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 06:30 AM\n Glucose Finger Stick\n 152\n 12:00 PM\n BUN\n 31 mg/dL\n 06:30 AM\n Creatinine\n 0.7 mg/dL\n 06:30 AM\n Sodium\n 138 mEq/L\n 06:30 AM\n Potassium\n 3.9 mEq/L\n 06:30 AM\n Chloride\n 97 mEq/L\n 06:30 AM\n TCO2\n 30 mEq/L\n 06:30 AM\n PO2 (arterial)\n 60 mm Hg\n 01:36 PM\n PCO2 (arterial)\n 61 mm Hg\n 01:36 PM\n pH (arterial)\n 7.45 units\n 01:36 PM\n pH (urine)\n 6.5 units\n 01:11 PM\n CO2 (Calc) arterial\n 44 mEq/L\n 01:36 PM\n Calcium non-ionized\n 9.6 mg/dL\n 05:07 AM\n Phosphorus\n 3.1 mg/dL\n 05:07 AM\n Magnesium\n 2.1 mg/dL\n 05:07 AM\n WBC\n 17.0 K/uL\n 06:30 AM\n Hgb\n 14.5 g/dL\n 06:30 AM\n Hematocrit\n 45.4 %\n 06:30 AM\n Current diet order / nutrition support: Regular/ low Na W/ Ensure TID\n GI: Abd soft/distended/ +BS\n Assessment of Nutritional Status\n 61 y r F w/ altered MS, delirium, confused d/t presumed steroid\n therapy. Pt was on tube feeds previously while intubated, received FS\n Replete w/ Fiber @50cc/ hr providing 1200kcals and 74g prot/day. Pt\n diet advanced upon extubation on . ? if pt able to meet needs\n given the changes in MS.\n Noted rehab screening in process.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If pt unable to take adequate po intake d/t MS changes within\n 24-48 hrs, consider re-starting tube feeds to be able to meet pt\ns est.\n needs.\n 2. TF Rx: FS Replete w/ fiber @goal 50cc/ hr, initiate at 10cc/hr\n and adv to goal, will need FT placement.\n 3. Check residuals q 4-6hrs, hold TF if > 150cc\n 4. Monitor hydration status.\n 5. Continue to encourage po intake as tol.\n Will f/u on progress and plan.\n 15:37\n" }, { "category": "Physician ", "chartdate": "2205-01-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 316058, "text": "Chief Complaint: Dyspnea, now with delirium\n 24 Hour Events:\n continued to be agitated\n ABG done to check for CO2 retention, unchanged\n Had increased NC oxygen during day but able to wean back down to 2L\n Got 0.5mg Haldol overnight for agitation (tried the patient care\n channel first)\n sugar was 65 this AM, gave amp Dextrose\n EKG not done\n PT eval not done agitation\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:53 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: 58 (48 - 94) bpm\n BP: 121/56(71){94/44(59) - 178/91(101)} mmHg\n RR: 9 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 620 mL\n PO:\n 620 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,240 mL\n 210 mL\n Urine:\n 1,240 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.45/61/60/39/14\n PaO2 / FiO2: 2L\n Physical Examination\n General Appearance: Calmer, oriented to person and place. Smiling,\n somewhat confused but redirectable.\n Head, Ears, Nose, Throat: Mucous membranes moist\n Cardiovascular: (S1: Normal), (S2: Normal), regular, no murmur\n Respiratory / Chest: (Expansion: Symmetric),+ mid-inspiratory crackles;\n moving air well, no accessory muscle use\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No LE edema\n Labs / Radiology\n 275 K/uL\n 11.2 g/dL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 35.6 %\n 14.5 K/uL\n [image002.jpg]\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n WBC\n 18.2\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n Hct\n 42.1\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n Plt\n 382\n 432\n 391\n 377\n 370\n 275\n Cr\n 0.7\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 41\n 44\n 43\n 44\n Glucose\n 99\n 127\n 104\n 104\n 88\n 72\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.7 mg/dL\n EKG: NSR with QTc 480\n CXR :\n Lateral aspect of the left lower chest is excluded from the examination\n .\n While there is some obscuration by overlying chest cage there may be ne\n w right\n perihilar consolidation. Lateral aspect of the left lower chest is exc\n luded\n from the examination. Multiple healed rib fractures are seen on both s\n ides of\n the chest. The heart is borderline enlarged. There is no abnormality\n of the\n imaged pleural surfaces. Thoracic aorta is tortuous but not focally di\n lated.\n No pneumothorax.\n Assessment and Plan\n A/P: 61yo woman with COPD admitted with respiratory distress who\n developed delirium while on steroids.\n DELIRIUM / CONFUSION\n - improving with tapering steroid dose; continue to taper\n steroids to 10mg daily (which is her baseline dose) tomorrow so long as\n it is tolerated by her respiratory status\n - hold nortriptyline while confused\n - currently not requiring restraints\n - redirect as needed, monitor closely\n - continue zyprexa and give haldol only if needed\n - monitor QTc closely while on QT prolonging agents\n # Hematuria and Hct drop:\n - repeat Hct and send T+S\n - send UA, though of note, UA on admission showed large blood\n - do not suspect other source of bleeding as coags normal, no risk\n factors for retroperitoneal bleed, but monitor exam and Hct closely\n - stool OB negative\n # Hypoglycemia:\n - most likely from decreasing insulin requirement as steroids\n tapered\n - decrease doses of insulin sliding scale\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - s/p antibiotics for possible infection\n - continue bronchodilators, singulair, flonase, suctioning\n - at baseline O2 requirement\n - prednisone taper as above\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, statin, beta blocker, ACE I\n - not on ASA per home PCP\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue outpatient management\n ICU Care\n Nutrition:\n Comments: low sodium diet\n Glycemic Control: Regular insulin sliding scale, Comments: will make\n insulin sliding scale less aggressive\n Lines:\n 20 Gauge - 11:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU ; being screened for rehab ; appreciate PT and case\n management assistance\n" }, { "category": "Nursing", "chartdate": "2205-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315987, "text": "Delirium / confusion\n Assessment:\n Agitated, getting/climbing out bed, pulling her IV lines, taking off\n nasal cannula and O2 sensor, yelling and cursing when very agitated,\n visual, auditory and tactile hallucinations intermittently, talking to\n herself often likely due to high steroid doses\n patient with\n impressive history of hallucinations with steroids per her PCP\n :\n Kept patient safe with increased visibility. 1:1 with patient when very\n agitated; consistently reoriented to place, time and persons.\n Restraints reapplied, wrist restraints intermittently when very\n agitated, QTc followed, Zyprexa as scheduled. ABG to rule out CO2\n retention, steroids aggressively tapered down as tolerated by her\n respiratory status\n Response:\n Cooperative inconsistently, calm intermittently\n Plan:\n Continue to reorient patient, kept safe, follow QTc, EKG in am, taper\n steroids, needs sitter if continues to be agitated, gettingout of bed (\n \n psyche specialist , no sitter at the moment\n the one\n that should come for 2 hours hasn\nt arrived yet ( 1 hour post\n conversation\n was paged, waiting for call)\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Increased large amount of thick yellow secretions, lung sounds dim,\n congested cough, unable to cough up secretions, sats mid 80\ns at 2 lpm\n Action:\n NT suctioning x 3 this shift, xopenex and atrovent neb treatments, O2\n increased to 4 lpm\n Response:\n Patient O2 remains >95% at 4 lpm, lung sounds clear after NT suctioning\n Plan:\n Titrate O2 down, continue neb treatments q4hrs strictly, NTS as needed\n patient responds well post suctioning\n Hypertension, benign\n Assessment:\n SBP ranges 117-167 ( high when she is agitated)\n Action:\n Lopressor, diltiazem and captopril given\n Response:\n BP controlled decently\n Plan:\n Continue BP meds\n" }, { "category": "General", "chartdate": "2205-01-03 00:00:00.000", "description": "ICU Event Note", "row_id": 316171, "text": "Clinician: Nurse\n Pt was discharged to at Hospital. She was\n given a resp treatment prior to discharge and she had no complaints\n with discharge and vital signs were stable. She left via ambulance at\n 1400.\n" }, { "category": "Nursing", "chartdate": "2204-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315878, "text": "Anxiety\n Assessment:\n Pt c/o being anxious 1145\n Action:\n Pt given additional dose of po zyprexa,\n Response:\n Po dose of zyprexa marginal effect\n Plan:\n Will need to increase daily dose of zyprexa , add sitter tonight if\n possible since she is still confused\n Delirium / confusion\n Assessment:\n BY 1230 pt confused, wanting to leave, thinking daughters were here,\n wanting to go to other room, trying to get oob\n Action:\n Reoriented patient, however verbal reassurance had only marginal\n effect, pt required haldol .5 mg in x1\n Response:\n Less confused, less anxious\n Plan:\n Would consider haldol on prn bases\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt having several episodes of ^ sob, requiring frequent nebs\n Action:\n Pt has congested cough unable to clear sputum, refuses cpt or cough\n assist vest, given nebs q4 prn as needed\n Response:\n Nebs are effective in decreasing sob\n Plan:\n Continue with nebs as ordered , and antianxiety meds helps with sob\n" }, { "category": "Physician ", "chartdate": "2205-01-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 316132, "text": "Chief Complaint: 61F with COPD admitted with increased COPD\n 24 Hour Events:\n Hematuria improving despite keeping Foley in\n Continued to improve and become more oriented\n EKG showed QTc of 480\n Sliding scale insulin and BP med doses decreased\n Continues to be screened for rehab (has been accepted at one place,\n waiting to see if daughters agree and if bed available).\n EKG - At 09:44 AM\n URINE CULTURE - At 02:11 PM\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Cough, No(t) Dyspnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.9\nC (98.4\n HR: 62 (52 - 73) bpm\n BP: 116/47(64){96/42(55) - 142/81(95)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 975 mL\n 476 mL\n PO:\n 160 mL\n TF:\n IVF:\n 590 mL\n 476 mL\n Blood products:\n Total out:\n 701 mL\n 155 mL\n Urine:\n 701 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 274 mL\n 321 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin, sleeping quietly in bed\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , thought it was , Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 378 K/uL\n 12.4 g/dL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 39.7 %\n 16.3 K/uL\n [image002.jpg]\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n 05:30 PM\n 05:58 AM\n WBC\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n 16.3\n Hct\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n 38.7\n 39.7\n Plt\n 70\n 275\n 378\n Cr\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 43\n 44\n Glucose\n 127\n 104\n 104\n 88\n 72\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPOGLYCEMIA\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n DELIRIUM / CONFUSION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Consider D/C sliding scale\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2205-01-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 316135, "text": "Chief Complaint: 61F with COPD admitted with increased COPD\n 24 Hour Events:\n Hematuria improving despite keeping Foley in\n Continued to improve and become more oriented\n EKG showed QTc of 480\n Sliding scale insulin and BP med doses decreased\n Continues to be screened for rehab (has been accepted at one place,\n waiting to see if daughters agree and if bed available).\n EKG - At 09:44 AM\n URINE CULTURE - At 02:11 PM\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Cough, No(t) Dyspnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.9\nC (98.4\n HR: 62 (52 - 73) bpm\n BP: 116/47(64){96/42(55) - 142/81(95)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 975 mL\n 476 mL\n PO:\n 160 mL\n TF:\n IVF:\n 590 mL\n 476 mL\n Blood products:\n Total out:\n 701 mL\n 155 mL\n Urine:\n 701 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 274 mL\n 321 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin, sleeping quietly in bed\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , thought it was , Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 378 K/uL\n 12.4 g/dL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 39.7 %\n 16.3 K/uL\n [image002.jpg]\n Fingersticks: 65-158\n CXR \n Lateral aspect of the left lower chest is excluded from the\n examination.\n While there is some obscuration by overlying chest cage there may be\n new right\n perihilar consolidation. Lateral aspect of the left lower chest is\n excluded\n from the examination. Multiple healed rib fractures are seen on both\n sides of\n the chest. The heart is borderline enlarged. There is no abnormality\n of the\n imaged pleural surfaces. Thoracic aorta is tortuous but not focally\n dilated.\n No pneumothorax.\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n 05:30 PM\n 05:58 AM\n WBC\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n 16.3\n Hct\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n 38.7\n 39.7\n Plt\n 70\n 275\n 378\n Cr\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 43\n 44\n Glucose\n 127\n 104\n 104\n 88\n 72\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPOGLYCEMIA\n - Sugars improved since yesterday AM, likely insulin resistance\n decreased in setting of decreased steroids, follow fingersticks\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n - Likely due to hematuria, Hct stable from yesterday. Stool guiac\n negative. Transfuse Hb>7\n DELIRIUM / CONFUSION\n - Less confused as tapering steroids.\n - Hold nortriptyline HS, continue zyprexa with haldol prn (monitor QTc)\n - Provide frequent reorientation. D/C foley\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - s/p antibiotics for possible infection\n - continue bronchodilators, singulair, flonase, suctioning\n - at baseline O2 requirement\n - prednisone taper as above\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, statin, beta blocker, ACE I\n - not on ASA per home PCP\n ICU \n Nutrition: regular diet\n Glycemic Control: Consider D/C sliding scale\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Case Management ", "chartdate": "2205-01-03 00:00:00.000", "description": "Case Management Dicharge Plan", "row_id": 316161, "text": "Case manager: R.N.\n Pager #: \n Discharge Plan: Acute Rehab\n Home with services:\n VNA / Home infusion:\n Acute rehab: , Other - NE at Hospital\n Skilled nursing facility:\n Patient on Vent: Non-Vent\n Long term care custodial non-Medicare certified: No\n : No\n hospital: No\n Hospice inpatient: No\n Hospice home: No\n DME: No\n Transportation: Yes - Ambulance\n Free care pharmacy : No\n Patient/Family/Team understand and agree with plan: Yes\n Required documentation: Discharge Summary,Page 1,Page 2\n Comments: Contact number for NE at = \n" }, { "category": "Physician ", "chartdate": "2205-01-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 316164, "text": "Chief Complaint: 61F with COPD admitted with increased COPD\n 24 Hour Events:\n Hematuria improving despite keeping Foley in\n Continued to improve and become more oriented\n EKG showed QTc of 480\n Sliding scale insulin and BP med doses decreased\n Continues to be screened for rehab (has been accepted at one place,\n waiting to see if daughters agree and if bed available).\n EKG - At 09:44 AM\n URINE CULTURE - At 02:11 PM\n Allergies:\n Tetracyclines Unknown;\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Prednisone 10 daily\n Captopril 12.5 TID\n Diltiazem 60 QID\n Metoprolol 25 TID\n Montelukast\n Fluticasone, atrovent, levalbuterol\n Plavix, simvastatin\n Fentanyl patch, percocet prn\n Olanzapine, Paroxetine\n SQ heparin, Protonix\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Cough, No(t) Dyspnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.9\nC (98.4\n HR: 62 (52 - 73) bpm\n BP: 116/47(64){96/42(55) - 142/81(95)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 975 mL\n 476 mL\n PO:\n 160 mL\n TF:\n IVF:\n 590 mL\n 476 mL\n Blood products:\n Total out:\n 701 mL\n 155 mL\n Urine:\n 701 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 274 mL\n 321 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin, sleeping quietly in bed\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , thought it was , Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 378 K/uL\n 12.4 g/dL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 39.7 %\n 16.3 K/uL\n [image002.jpg]\n Fingersticks: 65-158\n Micro\n urine cx NGTD\n blood\n urine\n sputum spare OP flora\n CXR \n Lateral aspect of the left lower chest is excluded from the\n examination.\n While there is some obscuration by overlying chest cage there may be\n new right\n perihilar consolidation. Lateral aspect of the left lower chest is\n excluded\n from the examination. Multiple healed rib fractures are seen on both\n sides of\n the chest. The heart is borderline enlarged. There is no abnormality\n of the\n imaged pleural surfaces. Thoracic aorta is tortuous but not focally\n dilated.\n No pneumothorax.\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n 05:30 PM\n 05:58 AM\n WBC\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n 16.3\n Hct\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n 38.7\n 39.7\n Plt\n 70\n 275\n 378\n Cr\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 43\n 44\n Glucose\n 127\n 104\n 104\n 88\n 72\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - S/p empiric ceftriaxone/azithromycin\n - Continue singulair, flonase. Start tiotropium\n - At baseline O2 requirement, home dose prednisone\n DELIRIUM / CONFUSION\n - Less confused post steroid taper\n - Continue zyprexa with haldol prn (monitor QTc)\n - Provide frequent reorientation. D/C foley\n HYPOGLYCEMIA\n - Sugars improved since yesterday AM, likely insulin resistance\n decreased in setting of decreased steroids, follow fingersticks\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n - Likely due to hematuria, Hct stable from yesterday. Stool guiac\n negative. Transfuse Hb>7\n Hypertension\n BPs improved as agitation decreased and respiratory status improved.\n Not on BP meds at home, will DC them today.\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, statin, beta blocker, ACE I\n - not on ASA per home PCP\n ICU \n Nutrition: regular diet\n Glycemic Control: Consider D/C sliding scale\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: n/a\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to rehab\n" }, { "category": "Social Work", "chartdate": "2205-01-01 00:00:00.000", "description": "Social Work Admission Note", "row_id": 315951, "text": "Family Information\n Next of : (daughter)\n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record, Daughter also proxy \n Family Spokesperson designated: (daughter)\n Communication or visitation restriction:\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning:\n Previous or other hospital admissions: Yes\n Past psychiatric history: Unknown\n Past addictions history: Unknown\n Employment status: Disable\n Legal involvement: Unknown\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Patient recalled this writer from her\n previous visit in 10.. She said that her sister often\n talks about this worker. Ms. stated wanting to stop smoking\n because she does not want to die. The patient appeared tired and agreed\n to meeting later in the afternoon when she felt she would have more\n energy.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n 1. Meet with patient later in the PM.\n" }, { "category": "Physician ", "chartdate": "2205-01-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315956, "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 confused overnight requiring restraints\n 24 Hour Events:\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 12:15 AM\n Heparin Sodium (Prophylaxis) - 09:32 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, Wheeze\n Psychiatric / Sleep: Agitated, Delirious\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.6\n HR: 73 (64 - 94) bpm\n BP: 155/82(99){102/62(47) - 177/97(128)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 997 mL\n 220 mL\n PO:\n 585 mL\n 220 mL\n TF:\n IVF:\n 412 mL\n Blood products:\n Total out:\n 885 mL\n 500 mL\n Urine:\n 885 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.44/61/62/30/13\n Physical Examination\n General Appearance: frail\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion:\n Hyperresonant: ), (Breath Sounds: Crackles : mid ins. prolonged\n exhalation, Wheezes : few)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, ecchymoses\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 14.5 g/dL\n 370 K/uL\n 88 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 97 mEq/L\n 138 mEq/L\n 45.4 %\n 17.0 K/uL\n [image002.jpg]\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n WBC\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n 17.0\n Hct\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n 45.4\n Plt\n 389\n 382\n 432\n 391\n 377\n 370\n Cr\n 0.8\n 0.7\n 0.6\n 0.6\n 0.5\n 0.7\n TCO2\n 36\n 41\n 44\n 43\n Glucose\n 150\n 99\n 127\n 104\n 104\n 88\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION likely a consequence of steroid rx. We are\n tapering rapidly as her breathing tolerates. Trying to reorient and\n manage confusion with Zyprexa and Haldol. Will d/c prn Zyprexa and\n follow QTc\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION tapering setroids aggressively. Remains on\n MDIs.\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n TACHYCARDIA, OTHER - now controlled\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE) - no\n episodes of ischemia\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Case Management ", "chartdate": "2205-01-02 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 316050, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: Medicare A&B\n Hospital days authorized to:\n Current Discharge Plan: Acute rehab\n LTAC versus Skilled Nursing Facility\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n 1) NE - \n 2) - \n Narrative / Plan (Family, Multidisciplinary team):\n Contact by Hospital regarding my screen request, I was\n informed by their Liaison that admissions did not feel, based on her\n clinical presentation, that she was appropriate for placement in an\n Acute Rehab facility. Hospital has screened the patient.\n They will update today and will need a PT evaluation in order to assess\n the patient. I have asked the ICU team to follow up with PT as the\n patient's mental status is clearer and she can now participate in the\n eval. I am meeting with the patient's daughter, , late this\n afternoon. I have called her to inform her that will not be\n making a bed offer. I also offered several other alternative\n facilities and will discuss them at our meeting later today. Any\n Rehab/LTAC placement will have to be approved by Mass Pro.\n" }, { "category": "Physician ", "chartdate": "2205-01-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 316142, "text": "Chief Complaint: 61F with COPD admitted with increased COPD\n 24 Hour Events:\n Hematuria improving despite keeping Foley in\n Continued to improve and become more oriented\n EKG showed QTc of 480\n Sliding scale insulin and BP med doses decreased\n Continues to be screened for rehab (has been accepted at one place,\n waiting to see if daughters agree and if bed available).\n EKG - At 09:44 AM\n URINE CULTURE - At 02:11 PM\n Allergies:\n Tetracyclines Unknown;\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Prednisone 10 daily\n Captopril 12.5 TID\n Diltiazem 60 QID\n Metoprolol 25 TID\n Montelukast\n Fluticasone, atrovent, levalbuterol\n Plavix, simvastatin\n Fentanyl patch, percocet prn\n Olanzapine, Paroxetine\n SQ heparin, Protonix\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Cough, No(t) Dyspnea\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.9\nC (98.4\n HR: 62 (52 - 73) bpm\n BP: 116/47(64){96/42(55) - 142/81(95)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 975 mL\n 476 mL\n PO:\n 160 mL\n TF:\n IVF:\n 590 mL\n 476 mL\n Blood products:\n Total out:\n 701 mL\n 155 mL\n Urine:\n 701 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n 274 mL\n 321 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin, sleeping quietly in bed\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , thought it was , Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 378 K/uL\n 12.4 g/dL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 39.7 %\n 16.3 K/uL\n [image002.jpg]\n Fingersticks: 65-158\n CXR \n Lateral aspect of the left lower chest is excluded from the\n examination.\n While there is some obscuration by overlying chest cage there may be\n new right\n perihilar consolidation. Lateral aspect of the left lower chest is\n excluded\n from the examination. Multiple healed rib fractures are seen on both\n sides of\n the chest. The heart is borderline enlarged. There is no abnormality\n of the\n imaged pleural surfaces. Thoracic aorta is tortuous but not focally\n dilated.\n No pneumothorax.\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n 05:30 PM\n 05:58 AM\n WBC\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n 16.3\n Hct\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n 38.7\n 39.7\n Plt\n 70\n 275\n 378\n Cr\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 43\n 44\n Glucose\n 127\n 104\n 104\n 88\n 72\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPOGLYCEMIA\n - Sugars improved since yesterday AM, likely insulin resistance\n decreased in setting of decreased steroids, follow fingersticks\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n - Likely due to hematuria, Hct stable from yesterday. Stool guiac\n negative. Transfuse Hb>7\n DELIRIUM / CONFUSION\n - Less confused as tapering steroids.\n - Hold nortriptyline HS, continue zyprexa with haldol prn (monitor QTc)\n - Provide frequent reorientation. D/C foley\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - s/p antibiotics for possible infection\n - continue bronchodilators, singulair, flonase, suctioning\n - at baseline O2 requirement\n - prednisone taper as above\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, statin, beta blocker, ACE I\n - not on ASA per home PCP\n ICU \n Nutrition: regular diet\n Glycemic Control: Consider D/C sliding scale\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Rehab Services", "chartdate": "2205-01-03 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 316144, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 496 / COPD\n Reason of referral: eval, treat, CPT\n History of Present Illness / Subjective Complaint: 61 y/o female adm\n with dyspnea and productive cough. Was placed on 4L O2 and was\n stable until when pt had worsening SOB despite treatment with\n nebs. pt was intubated on . Diuresed and extubated on .\n Course was c/b delerium. pt now stable on 4L O2 and mental status has\n cleared.\n Past Medical / Surgical History: COPD, IgA deficiency, CAD s/p MI in\n , , and , s/p cath with PTCA and stent to LCx and second\n cath with stent to RCA and LCx, HTN, hyperlipidemia, gastritis,\n osteoporosis with multiple compression fx and rib fx from coughing,\n , esophagitis, depression, tremor, chronic pain\n Medications: paroxetine, fentanyl, percocet, hydralazine, NTG,\n prednisone, lidocaine, insulin, diltiazem, captopril, metoprolol\n Radiology: CXR : R perihilar consolidation, multiple B healed rib\n fractures\n Labs:\n 39.7\n 12.4\n 378\n 16.3\n [image002.jpg]\n Other labs:\n N/A\n Activity Orders: OOB with assist\n Social / Occupational History: Supportive daughter, widowed\n Environment: Lives with dtr, son-in-law, and 3 grandchildren, 2\n level home with bedroom and bathoom on , + railing; DME:\n shower chair, commode, RW, cane, grab bars in shower\n Prior Functional Status / Activity Level: I amb with RW, no h/o falls\n in past year, I dressing, assist with showering on \"bad days\", family\n does cooking and cleaning\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O to self,\n , and (thought she was in rehab), pleasant, cooperative,\n following all commands\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 82\n 108/52\n 18\n 98% 4L\n Rest\n 82\n 108/52\n 18\n 98% 4L\n Sit\n /\n Activity\n 84\n 144/60\n 23\n 88% 4L\n Stand\n /\n Recovery\n 86\n 142/61\n 92% 4L\n Total distance walked: 2 steps\n Minutes: 1\n Pulmonary Status: shallow respirations, primarilly an upper airway\n breather, + accessory muscle use, crackles L LL, otherwise good\n aeration, weak and congested cough (nonproductive)\n Integumentary / Vascular: fragile skin, multiple areas of ecchymosis in\n B UE, pIV, foley\n Sensory Integrity: intact to LT, c/o intermittent numbness B toes (pt\n has been told it is from long term steroid use)\n Pain / Limiting Symptoms: No c/o pain\n Posture: forward head, rounded shoulders, significantly increased\n thoracic kyphosis, posterior pelvic tilt\n Range of Motion\n Muscle Performance\n WFL\n B UE > , B LE > except B hip flexors 3+/5\n Motor Function: moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Performed stand pivot transfer with B UE support on\n PT, retropulsive, 1 LOB requiring min A to recover while taking step to\n chair.\n Rolling:\n T\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Seated: no LOB at EOB with B UE support x 10 minutes\n Standing: required B UE support on PT and min A to prevent posterior\n LOB, able to correct with verbal cues to lean forward\n Education / Communication: Educated patient as to role of PT, d/c plan.\n Communicated with RN.\n Intervention: N/A\n Other: N/A\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Transfers, Impaired\n 3.\n Gait, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: Patient is a 61 y/o female adm with\n COPD flare and pneumonia. Patient presents with above noted defecits\n c/w deconditioned (from prolonged bedrest) and chronic ventilatory pump\n dysfunction. Anticipate that patient will need rehab on d/c given need\n for assistance with mobility, and limited endurance with O2\n desaturation to 88% with transfers alone. Patient has fair rehab\n potential given chronic and severe nature of COPD, but does have\n potential to achieve functional independence and return home.\n Goals\n Time frame: 1 week\n 1.\n I sup to sit to stand\n 2.\n Amb with RW x 100' with CG\n 3.\n I HEP\n 4.\n O2 > 88% on 3L with ambulation\n 5.\n I'ly state importance of out of bed and ambulation\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-4x/week x 1 week\n Transfer training, gait training with RW, ther-ex, DB, PLB, IS, patient\n education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Rehab Services", "chartdate": "2205-01-03 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 316145, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 496 / COPD\n Reason of referral: eval, treat, CPT\n History of Present Illness / Subjective Complaint: 61 y/o female adm\n with dyspnea and productive cough. Was placed on 4L O2 and was\n stable until when pt had worsening SOB despite treatment with\n nebs. pt was intubated on . Diuresed and extubated on .\n Course was c/b delerium. pt now stable on 4L O2 and mental status has\n cleared.\n Past Medical / Surgical History: COPD, IgA deficiency, CAD s/p MI in\n , , and , s/p cath with PTCA and stent to LCx and second\n cath with stent to RCA and LCx, HTN, hyperlipidemia, gastritis,\n osteoporosis with multiple compression fx and rib fx from coughing,\n , esophagitis, depression, tremor, chronic pain\n Medications: paroxetine, fentanyl, percocet, hydralazine, NTG,\n prednisone, lidocaine, insulin, diltiazem, captopril, metoprolol\n Radiology: CXR : R perihilar consolidation, multiple B healed rib\n fractures\n Labs:\n 39.7\n 12.4\n 378\n 16.3\n [image002.jpg]\n Other labs:\n N/A\n Activity Orders: OOB with assist\n Social / Occupational History: Supportive daughter, widowed\n Environment: Lives with dtr, son-in-law, and 3 grandchildren, 2\n level home with bedroom and bathoom on , + railing; DME:\n shower chair, commode, RW, cane, grab bars in shower\n Prior Functional Status / Activity Level: I amb with RW, no h/o falls\n in past year, I dressing, assist with showering on \"bad days\", family\n does cooking and cleaning\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O to self,\n , and (thought she was in rehab), pleasant, cooperative,\n following all commands\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 82\n 108/52\n 18\n 98% 4L\n Rest\n 82\n 108/52\n 18\n 98% 4L\n Sit\n /\n Activity\n 84\n 144/60\n 23\n 88% 4L\n Stand\n /\n Recovery\n 86\n 142/61\n 92% 4L\n Total distance walked: 2 steps\n Minutes: 1\n Pulmonary Status: shallow respirations, primarilly an upper airway\n breather, + accessory muscle use, crackles L LL, otherwise good\n aeration, weak and congested cough (nonproductive)\n Integumentary / Vascular: fragile skin, multiple areas of ecchymosis in\n B UE, pIV, foley\n Sensory Integrity: intact to LT, c/o intermittent numbness B toes (pt\n has been told it is from long term steroid use)\n Pain / Limiting Symptoms: No c/o pain\n Posture: forward head, rounded shoulders, significantly increased\n thoracic kyphosis, posterior pelvic tilt\n Range of Motion\n Muscle Performance\n WFL\n B UE > , B LE > except B hip flexors 3+/5\n Motor Function: moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Performed stand pivot transfer with B UE support on\n PT, retropulsive, 1 LOB requiring min A to recover while taking step to\n chair.\n Rolling:\n T\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Seated: no LOB at EOB with B UE support x 10 minutes\n Standing: required B UE support on PT and min A to prevent posterior\n LOB, able to correct with verbal cues to lean forward\n Education / Communication: Educated patient as to role of PT, d/c plan.\n Communicated with RN.\n Intervention: N/A\n Other: N/A\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Transfers, Impaired\n 3.\n Gait, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: Patient is a 61 y/o female adm with\n COPD flare and pneumonia. Patient presents with above noted defecits\n c/w deconditioned (from prolonged bedrest) and chronic ventilatory pump\n dysfunction. Anticipate that patient will need rehab on d/c given need\n for assistance with mobility, and limited endurance with O2\n desaturation to 88% with transfers alone. Patient has fair rehab\n potential given chronic and severe nature of COPD, but does have\n potential to achieve functional independence and return home.\n Goals\n Time frame: 1 week\n 1.\n I sup to sit to stand\n 2.\n Amb with RW x 100' with CG\n 3.\n I HEP\n 4.\n O2 > 88% on 3L with ambulation\n 5.\n I'ly state importance of out of bed and ambulation\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-4x/week x 1 week\n Transfer training, gait training with RW, ther-ex, DB, PLB, IS, patient\n education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n ------ Protected Section ------\n Patient is not a candidate for chest PT given severe osteoporosis and\n history of rib fractures with couging. Would instead recommend OOB\n 2-3x/day, frequent use of IS and encouraging patient to deep breathe.\n ------ Protected Section Addendum Entered By: , PT\n on: 09:37 ------\n" }, { "category": "Physician ", "chartdate": "2205-01-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 316152, "text": "Chief Complaint: hypoxia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 09:44 AM\n URINE CULTURE - At 02:11 PM\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: No cough or fevers.\n Flowsheet Data as of 10:46 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: 36.7\nC (98\n HR: 62 (52 - 71) bpm\n BP: 116/47(64){96/42(55) - 142/81(95)} mmHg\n RR: 10 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 975 mL\n 627 mL\n PO:\n 160 mL\n 120 mL\n TF:\n IVF:\n 590 mL\n 507 mL\n Blood products:\n Total out:\n 701 mL\n 235 mL\n Urine:\n 701 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 274 mL\n 392 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///39/\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 12.4 g/dL\n 378 K/uL\n 76 mg/dL\n 0.8 mg/dL\n 39 mEq/L\n 4.8 mEq/L\n 31 mg/dL\n 99 mEq/L\n 141 mEq/L\n 39.7 %\n 16.3 K/uL\n [image002.jpg]\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n 05:30 PM\n 05:58 AM\n WBC\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n 16.3\n Hct\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n 38.7\n 39.7\n Plt\n 70\n 275\n 378\n Cr\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n 0.8\n TCO2\n 43\n 44\n Glucose\n 127\n 104\n 104\n 88\n 72\n 76\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:9.1 mg/dL, Mg++:2.4 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPOGLYCEMIA: Resolved.\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING): Hct\n stable.\n DELIRIUM / CONFUSION: Likely due to steroids.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved. Will place back on home COPD regimen, spiriva, advair,\n d/c atrovent. Albuterol prn. Is on prednisone 10 mg at baseline.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition: Diabetic diet.\n Glycemic Control: Insulin sliding scale.\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: SQ heparin.\n Stress ulcer: PPI.\n VAP: Not intubated.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To rehab.\n Total time spent:\n" }, { "category": "Case Management ", "chartdate": "2205-01-03 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 316159, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: Medicare A&B\n Hospital days authorized to:\n Current Discharge Plan: Acute rehab\n LTAC placement at NE at Hospital\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n Narrative / Plan (Patient, Family):\n A bed offer has been made at NE and the patient and her family\n have accepted the bed. She will be transferred there today by\n ambulance.\n" }, { "category": "Physician ", "chartdate": "2205-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315923, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n Continued to be very confused over the course of the day requiring\n zyprexa, haldol. Placed in restraints overnight.\n CXR obtained due to tachypnea showed atelectasis\n PCP came by to see; pt admitted having visual hallucinations to her\n Awaiting PT evaluation\n Subjective:\n Feels breathing is improving\n Denied further visual hallucinations\n Repeatedly asking to get up/change positions/move\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:53 PM\n Haloperidol (Haldol) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 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: 36.5\nC (97.7\n HR: 84 (59 - 85) bpm\n BP: 173/65(87){102/62(47) - 177/97(128)} mmHg\n RR: 17 (14 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 997 mL\n 100 mL\n PO:\n 585 mL\n 100 mL\n TF:\n IVF:\n 412 mL\n Blood products:\n Total out:\n 885 mL\n 220 mL\n Urine:\n 885 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.44/61/62//13\n Physical Examination\n General Appearance: Anxious, Sitting in chair by bed, restrained.\n Easily distractable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Mucous membranes dry\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : ), not particularly tight; not using accessory muscles to\n breathe\n Abdominal: Soft, Non-tender, Bowel sounds present, appears distended\n kyphosis\n Extremities: No LE edema\n Skin: Not assessed, Rash: macules on feet improving\n Neurologic: Responds to: Not assessed, Oriented (to): person and date,\n but thinks she's at an airport, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 377 K/uL\n 14.4 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 38 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 95 mEq/L\n 141 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n WBC\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 389\n 382\n 432\n 391\n 377\n Cr\n 0.8\n 0.7\n 0.6\n 0.6\n 0.5\n TCO2\n 34\n 36\n 41\n 44\n 43\n Glucose\n 150\n 99\n 127\n 104\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.6 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR :\n Bibasilar linear opacities, most suggestive of atelectasis.\n Multiple old rib fractures bilaterally\n Microbiology: Blood, urine, and sputum Cx negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n tachypneic, SOB using accesory muscles, I/E wheeze, confused, very\n anxious\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC trending up\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Comments: low sodium diet\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 22 Gauge - 12:28 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2205-01-02 00:00:00.000", "description": "Generic Note", "row_id": 316017, "text": "TITLE:\n Resp Care Note:\n Pt seen for medication nebulizer administration as per order. Lung\n sounds dim throughout both lung fields. Pt cont to be increasingly\n confused. VSS and O2 sats stable.\n" }, { "category": "Nursing", "chartdate": "2205-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 316021, "text": "Delirium / confusion\n Assessment:\n Pt alert and cooperative for the most part although disoriented. At\n 0200 she became agitated and uncooperative, yelling out, attempting to\n climb OOB.\n Action:\n 1:1 with calming environment but little response. Given haldol 0.5mg IV\n X1.\n Response:\n Pt slept the remainder of the night.\n Plan:\n Continue zyprexa, reorient pt, provide calm environment, haldol prn,\n monitor QTC, taper steroids, restraints prn, asess need for 1:1 sitter\n when agitated.\n Hypertension, benign\n Assessment:\n NBP 94-135/49-60\n Action:\n Given lopressor and captopril as ordered. Diltiazem held per\n parameters, HR <50.\n Response:\n Hypertension controlled.\n Plan:\n Continue meds, follow parameters\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n O2 sats 99-100% on 2L; lung sounds clear upper lobes, diminished lower\n lobes. Pt desats when she removes her oxygen\n Action:\n O2 at 2L, nebs as ordered.\n Response:\n Resp status stable during the night. Did not require suctioning.\n Plan:\n O2, nebs, encourage C&DB when awake, suction prrn steroid taper, limit\n activity.\n" }, { "category": "Physician ", "chartdate": "2205-01-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 316033, "text": "Chief Complaint: Dyspnea, now with delirium\n 24 Hour Events:\n continued to be agitated\n ABG done to check for CO2 retention, unchanged\n Had increased NC oxygen during day but able to wean back down to 2L\n Got 0.5mg Haldol overnight for agitation (tried the patient care\n channel first)\n sugar was 65 this AM, gave amp Dextrose\n EKG not done\n PT eval not done agitation\n Sleeping this AM\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 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 07:53 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: 58 (48 - 94) bpm\n BP: 121/56(71){94/44(59) - 178/91(101)} mmHg\n RR: 9 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 620 mL\n PO:\n 620 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,240 mL\n 210 mL\n Urine:\n 1,240 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.45/61/60/39/14\n PaO2 / FiO2: 2L\n Physical Examination\n General Appearance: Sleeping\n Head, Ears, Nose, Throat: Mucous membranes moist\n Cardiovascular: (S1: Normal), (S2: Normal), regular, no murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Rhonchorous: ), moving air well, no accessory muscle use\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: No LE edema\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 275 K/uL\n 11.2 g/dL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 35.6 %\n 14.5 K/uL\n [image002.jpg]\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n WBC\n 18.2\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n Hct\n 42.1\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n Plt\n 382\n 432\n 391\n 377\n 370\n 275\n Cr\n 0.7\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 41\n 44\n 43\n 44\n Glucose\n 99\n 127\n 104\n 104\n 88\n 72\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.7 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n # Hematuria and Hct drop:\n - repeat Hct and send T+S\n - send UA, though of note, UA on admission showed large blood\n # Hypoglycemia\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Comments: low sodium diet\n Glycemic Control: Regular insulin sliding scale, Comments: will make\n insulin sliding scale less aggressive\n Lines:\n 20 Gauge - 11:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2205-01-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 316047, "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 less agitated. Rested overnight\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:32 AM\n Pantoprazole (Protonix) - 09:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Genitourinary: hematuria\n Endocrine: Hyperglycemia\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: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 61 (48 - 94) bpm\n BP: 133/59(75){94/44(59) - 178/91(101)} mmHg\n RR: 15 (8 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 620 mL\n 100 mL\n PO:\n 620 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,240 mL\n 288 mL\n Urine:\n 1,240 mL\n 288 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -188 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.45/61/60/39/14\n Physical Examination\n General Appearance: frail\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.2 g/dL\n 275 K/uL\n 72 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 3.1 mEq/L\n 30 mg/dL\n 99 mEq/L\n 142 mEq/L\n 37.0 %\n 14.5 K/uL\n [image002.jpg]\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n 01:22 PM\n 06:30 AM\n 01:36 PM\n 04:14 AM\n 09:22 AM\n WBC\n 18.2\n 18.4\n 17.7\n 17.9\n 17.0\n 14.5\n Hct\n 42.1\n 41.4\n 43.7\n 46.5\n 45.4\n 35.6\n 37.0\n Plt\n 382\n 432\n 391\n 377\n 370\n 275\n Cr\n 0.7\n 0.6\n 0.6\n 0.5\n 0.7\n 0.5\n TCO2\n 44\n 43\n 44\n Glucose\n 99\n 127\n 104\n 104\n 88\n 72\n Other labs: PT / PTT / INR:11.0/37.5/0.9, CK / CKMB /\n Troponin-T:21/4/<0.01, Differential-Neuts:94.8 %, Lymph:2.4 %, Mono:2.6\n %, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPOGLYCEMIA - likely a consequence of steroid taper and continued\n aggressive SSI. Will back down dosing\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING) - hct\n drifting down.\n DELIRIUM / CONFUSION - better today after further reduction in\n prednisone. Will go to 10 mg tomorrow which is her out patient dose.\n remains on Zyprexa \n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - breathing now seems to be\n at baseline. Will continue her MDIs\n Now improved.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315148, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 61y.o. female admitted with three days increased SOB, congested cough\n with increased wheezes/resp distress.\n Action:\n Brought to EW by EMT\ns with 100% NRB RR 30\ns/O2 sat 95%. Treated with\n nebs/O2/antibiotics/IV steroids. O2 weaned to 4L N/C. CXR showing no\n evidence of PNA/CHF, no pneumothorax and no effusions. CXR shows\n emphysema. Pt admitted to MICU w/dx COPD exacerbation for frequent\n nebs/cont O2 sat monitoring\n Response:\n Lungs with exp wheezes and diminished breath sounds. RR 20-35 with O2\n sat 94%-96%. Tolerating soft diet well. States improvement in breathing\n after cont. nebs.\n Plan:\n Pt with have frequent nebs overnight. Pt to get IVF 100cc/hr NS for\n hydration for one liter. Follow I+O closely. Follow lung sounds and\n coordinate nebs with RT. Assist pt with ADL\ns as needed.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt with history of chronic pain from fractured ribs. She is on fent\n patch 25mcg/hr as well as PO percocet 1 tab TID/QID. Pt complained of\n back/rib pain at 1900.\n Action:\n Treated with percocet one tab when she requested pain med.\n Response:\n Pain better after one percocet tab.\n Plan:\n Continue to assess pain level and treat with percocet. Fentanyl patch\n to be changed on Wednesday.\n Alteration in Elimination Related to Constipation\n Assessment:\n Pt complains of chronic constipation related to pain medication\n regimen.\n Action:\n Pt requesting bowel meds to be given\n Response:\n PM senna and colace given at pt request.\n Plan:\n Follow response to bowel meds given.\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315151, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 61y.o. female admitted with three days increased SOB, congested cough\n with increased wheezes/resp distress.\n Action:\n Brought to EW by EMT\ns with 100% NRB RR 30\ns/O2 sat 95%. Treated with\n nebs/O2/antibiotics/IV steroids. O2 weaned to 4L N/C. CXR showing no\n evidence of PNA/CHF, no pneumothorax and no effusions. CXR shows\n emphysema. Pt admitted to MICU w/dx COPD exacerbation for frequent\n nebs/cont O2 sat monitoring\n Response:\n Lungs with exp wheezes and diminished breath sounds. RR 20-35 with O2\n sat 94%-96%. Tolerating soft diet well. States improvement in breathing\n after cont. nebs.\n Plan:\n Pt with have frequent nebs overnight. Pt to get IVF 100cc/hr NS for\n hydration for one liter. Follow I+O closely. Follow lung sounds and\n coordinate nebs with RT. Assist pt with ADL\ns as needed.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt with history of chronic pain from fractured ribs. She is on fent\n patch 25mcg/hr as well as PO percocet 1 tab TID/QID. Pt complained of\n back/rib pain at 1900.\n Action:\n Treated with percocet one tab when she requested pain med.\n Response:\n Pain better after one percocet tab.\n Plan:\n Continue to assess pain level and treat with percocet. Fentanyl patch\n to be changed on Wednesday.\n Alteration in Elimination Related to Constipation\n Assessment:\n Pt complains of chronic constipation related to pain medication\n regimen.\n Action:\n Pt requesting bowel meds to be given\n Response:\n PM senna and colace given at pt request.\n Plan:\n Follow response to bowel meds given.\n ------ Protected Section ------\n Pt has not voided since coming to , no void in EW either. Pt\n states she last voided at 12:30 PM today. informed MD about this and\n pt ordered for 500cc\ns NS fluid bolus at 2200 which is infusing over\n one hour. Please offer pt the bedpan after this bolus and inserted\n foley cath if she is unsuccessful at passing urine on her own. Pt\n Creatinine is .9 and her normal creat is .5 so pt may be a little dry.\n Pt also receiving 100cc/hr NS for one liter. Follow closely.\n ------ Protected Section Addendum Entered By: , RN\n on: 21:54 ------\n" }, { "category": "Physician ", "chartdate": "2204-12-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 315152, "text": "Chief Complaint: dyspnea\n HPI:\n 61 y/o female with severe COPD and frequent flares who presents with\n dyspnea, admitted to MICU for respiratory distress. She is on 2L\n oxygen by nasal cannula at baseline and has required intubation 2 times\n for COPD exacerbations. She reports three days of dyspnea despite\n using her home nebulizer machine. She also notes productive cough with\n greenish sputum. No fever or chills. No coryza, congestion, sinus\n pain, headache. No sick contacts. chest pain, palpitations.\n ROS: occ heartburn. occ constipation, requiring stool softeners. no\n BRBPR or melena. reports 'bone pain' with coughing.\n In the ED vitals were: 98.8 168/98 124 32 95% 5L. Lung exam\n with diffuse expiratory wheezes and crackles. Given albuterol\n nebulizer treatment continuously. Also given solumedrol 125 IV, mag 2\n g IV x 1. Ceftriaxone 1 gram and levofloxacin 750 mg given. She\n received an ASA 325 mg and morphine IV 2 mg. EKG with sinus\n tachycardia and no acute changes. She was admitted to the given\n need for frequent nebs.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Tetracycline, Bactrim--GI upset\n Last dose of Antibiotics:\n Ceftriaxone and Levofloxacin in ED \n Infusions:\n Other ICU medications:\n Other medications:\n -Albuterol nebs/INH prn\n -Ipratropium Q4H prn\n -Simvastatin 20mg po qam\n -Clopidogrel 75 mg po daily\n -Omeprazole 20 mg po daily\n -Fentanyl 25 mcg/hr Patch 72HR\n -Oxycodone-Acetaminophen 5-325 mg 1-2 Tabs po Q4-6H prn\n -Nortriptyline 25 mg po qhs\n -Fluticasone-Salmeterol 500-50 mcg \n -Calcium 500 mg po daily\n -Docusate Sodium 100 mg po bid prn\n -Prednisone 10 mg daily\n -Singulair 10 mg QDay\n -MVI\n -KCl 20 mEq QDay\n -paroxetine 10 mg QDay\n -fluticasone nasal 2 sprays QDay\n Past medical history:\n Family history:\n Social History:\n PCP \n Past Medical History:\n 1. COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61%\n and 40% predicted respectively); intubated twice. on 2L home O2.\n 2. IgA deficiency, was on IV gamma globulin with Dr. .\n 3. CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI\n in (chest pain with left arm discomfort). Cath in with\n PTCA/stent to LCx. Cath in with stent placement to RCA and LCx.\n 4. Hypertension\n 5. Hyperlipidemia\n 6. Gastritis, on PPI\n 7. Osteoporosis, with history of multiple compression and rib fractures\n from coughing\n 8. History of thrush/ esophagitis steroid therapy\n 9. Depression\n 10. Tremor\n Mother with DM, father with pancreatic cancer.\n Occupation:\n Drugs: no\n Tobacco: +30 pack years, quit \n Alcohol: no\n Other: She lives with her daughter, , son-in-law and 3\n grand-children. She is a widow. Uses a cane and walker to ambulate.\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: Constipation, +heartburn\n Musculoskeletal: \"bone pain\"\n Flowsheet Data as of 10:22 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: 37.1\nC (98.8\n HR: 102 (102 - 115) bpm\n BP: 139/66(84){131/64(80) - 151/115(119)} mmHg\n RR: 26 (25 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,227 mL\n PO:\n 480 mL\n TF:\n IVF:\n 747 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,227 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\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 371\n 96\n 0.9\n 13\n 33\n 97\n 3.8\n 141\n 45\n 14.5\n [image002.jpg]\n Ca .2, Mg 1.8, P 3.4\n CK 29; Trop 0.02\n pH\n 7.36\n pCO2\n 66\n pO2\n 22\n HCO3\n 39\n BaseXS\n 7\n Assessment and Plan\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:09 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": "2204-12-24 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 315153, "text": "Chief Complaint: dyspnea\n HPI:\n 61 y/o female with severe COPD and frequent flares who presents with\n dyspnea, admitted to MICU for respiratory distress. She is on 2L\n oxygen by nasal cannula at baseline and has required intubation 2 times\n for COPD exacerbations. She reports three days of dyspnea despite\n using her home nebulizer machine. She also notes productive cough with\n greenish sputum. No fever or chills. No coryza, congestion, sinus\n pain, headache. No sick contacts. chest pain, palpitations.\n ROS: occ heartburn. occ constipation, requiring stool softeners. no\n BRBPR or melena. reports 'bone pain' with coughing.\n In the ED vitals were: 98.8 168/98 124 32 95% 5L. Lung exam\n with diffuse expiratory wheezes and crackles. Given albuterol\n nebulizer treatment continuously. Also given solumedrol 125 IV, mag 2\n g IV x 1. Ceftriaxone 1 gram and levofloxacin 750 mg given. She\n received an ASA 325 mg and morphine IV 2 mg. EKG with sinus\n tachycardia and no acute changes. She was admitted to the given\n need for frequent nebs.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Tetracycline, Bactrim--GI upset\n Last dose of Antibiotics:\n Ceftriaxone and Levofloxacin in ED \n Infusions:\n Other ICU medications:\n Other medications:\n -Albuterol nebs/INH prn\n -Ipratropium Q4H prn\n -Simvastatin 20mg po qam\n -Clopidogrel 75 mg po daily\n -Omeprazole 20 mg po daily\n -Fentanyl 25 mcg/hr Patch 72HR\n -Oxycodone-Acetaminophen 5-325 mg 1-2 Tabs po Q4-6H prn\n -Nortriptyline 25 mg po qhs\n -Fluticasone-Salmeterol 500-50 mcg \n -Calcium 500 mg po daily\n -Docusate Sodium 100 mg po bid prn\n -Prednisone 10 mg daily\n -Singulair 10 mg QDay\n -MVI\n -KCl 20 mEq QDay\n -paroxetine 10 mg QDay\n -fluticasone nasal 2 sprays QDay\n Past medical history:\n Family history:\n Social History:\n PCP \n Past Medical History:\n 1. COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61%\n and 40% predicted respectively); intubated twice. on 2L home O2.\n 2. IgA deficiency, was on IV gamma globulin with Dr. .\n 3. CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI\n in (chest pain with left arm discomfort). Cath in with\n PTCA/stent to LCx. Cath in with stent placement to RCA and LCx.\n 4. Hypertension\n 5. Hyperlipidemia\n 6. Gastritis, on PPI\n 7. Osteoporosis, with history of multiple compression and rib fractures\n from coughing\n 8. History of thrush/ esophagitis steroid therapy\n 9. Depression\n 10. Tremor\n Mother with DM, father with pancreatic cancer.\n Occupation:\n Drugs: no\n Tobacco: +30 pack years, quit \n Alcohol: no\n Other: She lives with her daughter, , son-in-law and 3\n grand-children. She is a widow. Uses a cane and walker to ambulate.\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: Constipation, +heartburn\n Musculoskeletal: \"bone pain\"\n Flowsheet Data as of 10:22 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: 37.1\nC (98.8\n HR: 102 (102 - 115) bpm\n BP: 139/66(84){131/64(80) - 151/115(119)} mmHg\n RR: 26 (25 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,227 mL\n PO:\n 480 mL\n TF:\n IVF:\n 747 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,227 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n VS: 98.8 143/64 111 25 95% 4L 49kg\n GENERAL: thin female, sitting up in bed tremulous, in mild respiratory\n distress. Not using accessory muscles, able to speak in several word\n phrases.\n HEENT: MMM, OP clear, no exudates. non elevated JVP.\n HEART: tachycardic, regular rhythm. No murmur.\n CHEST/BACK: Kyphosis; ?pes excavatum\n LUNGS: Moving air reasonably well with increased expiratory phase.\n Decreased breath sounds bilaterally. Bilaterally expiratory wheeze.\n +rhonchi.\n ABDOMEN: Non-tender. + Distended. + BS.\n EXTREMETIES: Muscle wasting to LE, no edema.\n NEURO: 4+/5 strength in LE b/l\n SKIN: Warm, well perfused.\n Labs / Radiology\n 371\n 96\n 0.9\n 13\n 33\n 97\n 3.8\n 141\n 45\n 14.5\n [image002.jpg]\n Ca .2, Mg 1.8, P 3.4\n CK 29; Trop 0.02\n pH\n 7.36\n pCO2\n 66\n pO2\n 22\n HCO3\n 39\n BaseXS\n 7\n CXR: Portable upright AP chest radiograph is obtained. There is a\n stable appearance of bibasilar linear opacities, which likely reflect\n atelectasis. There is no evidence of pneumonia or CHF. No definite\n pleural effusions are appreciated. Heart size is grossly unchanged.\n Mediastinal contour is stable. There is no pneumothorax. Upper lobe\n lucency and splaying of bronchovasculature likely reflects underlying\n emphysema. Extensive ribcage deformity and thoracic kyphosis are again\n noted.\n IMPRESSION:\n No significant change. No evidence of pneumothorax.\n .\n EKG: sinus tach @ 129, nl axis/intervals. no ST-T wave changes,\n inferior Q waves (old)\n Assessment and Plan\n 61yo woman with h/o COPD admitted with respiratory distress in the\n setting of likely COPD exacerbation.\n # COPD Exacerbation/ Respiratory Distress:\n Patient is improved since her admission, but has required intubation in\n the past. Currently moving air well on 4L oxygen.\n - continue azithromycin, ceftriaxone for bronchitis/pneumonia\n - cont solumedrol 125 IV Q8H\n - change albuterol to levalbuterol nebs (due to tremulousness) Q2H with\n prns\n - cont atrovent nebs\n - if worsens, trial of BiPAP\n - obtain sputum cx\n # Acute Renal Failure: Baseline Cr 0.6, Current Cr 0.9\n Hematocrit supports hemoconcentration; most likely dehydrated.\n - support with IV fluids; if not improved in AM, would check urine\n lytes\n # CAD- no active issues\n - cont. Plavix, statin\n - Cont. Aspirin as tolerated\n - Monitor fluid status for overload/CHF\n # Osteoporosis:\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n active issues\n - cont. Plavix, statin\n - Cont. Aspirin as tolerated\n - Monitor fluid status for overload/CHF\n - Check cardiac enzymes in AM\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - Continue calcium, vitamin D\n - pain control with fentanyl patch, nortryptiline, and prn percocet\n ICU Care\n Nutrition: regular diet per patient request\n Glycemic Control: SSI while on steroids\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SubQ heparin\n Stress ulcer: PPI\n VAP: not on vent\n Comments:\n Communication: Comments: Daughters (), \n ()\n Code status: Full code\n Disposition: ICU pending improvement of respiratory status\n" }, { "category": "Nursing", "chartdate": "2204-12-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315159, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt. has PMH COPD. Expiratory wheezes noted bilat throughout shift. Pt.\n on 4L nasal cannula with sats much improved. Pt. was receiving\n albuterol and atrovent nebs, however, pt. increasingly tachycardic. Now\n on Xopenex nebs Q2h.\n Action:\n Pt. on continuous O2 sat monitoring. Receiving Xopenex nebs Q2h with\n good effect. HR has decreased to high 90\ns low 100\ns. Does become\n tachypneic with any activity. CXR shows no PNA or CHF. + Emphysema.\n Response:\n Pt. tolerating 4L nasal cannula well. States her breathing feels much\n improved on the xopenex nebs. Breath sounds continue to be wheezy.\n Plan:\n Follow breath sounds. Coordinate nebs with RT. Assist pt. with ADLs. ?\n c/o to floor if pt. remains stable.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n At start of shift pt. unable to void. ? If pt. was dry as her creat. Is\n 0.9 (baseline 0.4). Given IVFs along with a 500cc bolus with no effect.\n Action:\n Foley inserted and 450cc out. Am labs pending.\n Response:\n Awaiting am lab results.\n Plan:\n Continue with foley. Fluid boluses as needed to maintain UO.\n" }, { "category": "Nursing", "chartdate": "2204-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315855, "text": "Anxiety\n Assessment:\n Pt c/o being anxious 1145\n Action:\n Pt given additional dose of po zyprexa,\n Response:\n Po dose of zyprexa marginal effect\n Plan:\n Will need to increase daily dose of zyprexa\n Delirium / confusion\n Assessment:\n BY 1230 pt confused, wanting to leave, thinking daughters were here,\n wanting to go to other room, trying to get oob\n Action:\n Reoriented patient, however verbal reassurance had only marginal\n effect, pt required haldol .5 mg in x1\n Response:\n Less confused, less anxious\n Plan:\n Would consider haldol on prn bases\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt having several episodes of ^ sob, requiring frequent nebs\n Action:\n Pt has congested cough unable to clear sputum, refuses cpt or cough\n assist vest, given nebs q4 prn as needed\n Response:\n Nebs are effective in decreasing sob\n Plan:\n Continue with nebs as ordered , and antianxiety meds helps with sob\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315146, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 61y.o. female admitted with three days increased SOB, congested cough\n with increased wheezes/resp distress.\n Action:\n Brought to EW by EMT\ns with 100% NRB RR 30\ns/O2 sat 95%. Treated with\n nebs/O2/antibiotics/IV steroids. O2 weaned to 4L N/C. CXR showing no\n evidence of PNA/CHF, no pneumothorax and no effusions. CXR shows\n emphysema. Pt admitted to MICU w/dx COPD exacerbation for frequent\n nebs/cont O2 sat monitoring\n Response:\n Lungs with exp wheezes and diminished breath sounds. RR 20-35 with O2\n sat 94%-96%. Tolerating soft diet well. States improvement in breathing\n after cont. nebs.\n Plan:\n Pt with have frequent nebs overnight. Pt to get IVF 100cc/hr NS for\n hydration for one liter. Follow I+O closely. Follow lung sounds and\n coordinate nebs with RT. Assist pt with ADL\ns as needed.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt with history of chronic pain from fractured ribs. She is on fent\n patch 25mcg/hr as well as PO percocet 1 tab TID/QID. Pt complained of\n back/rib pain at 1900.\n Action:\n Treated with percocet one tab when she requested pain med.\n Response:\n Pain better after one percocet tab.\n Plan:\n Continue to assess pain level and treat with percocet. Fentanyl patch\n to be changed on Wednesday.\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315147, "text": "Alteration in Elimination Related to Constipation\n Assessment:\n Pt states she has chronic problems with her bowels due to her pain med\n regimen.\n Action:\n Pt requests bowel meds as ordered.\n Response:\n Pt given senna and colace at HS\n Plan:\n Follow pt\ns complaints of constipation and bowel response to meds\n given.\n" }, { "category": "Physician ", "chartdate": "2204-12-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315241, "text": "Chief Complaint: SOB\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Incr tremor overnight\n 24 Hour Events:\n CALLED OUT\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.3\n HR: 112 (94 - 115) bpm\n BP: 149/82(96){131/65(84) - 162/115(119)} mmHg\n RR: 25 (14 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,642 mL\n 1,745 mL\n PO:\n 720 mL\n 600 mL\n TF:\n IVF:\n 922 mL\n 1,145 mL\n Blood products:\n Total out:\n 0 mL\n 830 mL\n Urine:\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,642 mL\n 915 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///33/\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\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: Resonant : ),\n (Breath Sounds: Crackles : mid insp, Wheezes : prolonged, diffuse)\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, ecchymoses\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.9 g/dL\n 336 K/uL\n 159 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 5.5 mEq/L\n 14 mg/dL\n 102 mEq/L\n 140 mEq/L\n 41.5 %\n 8.2 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 8.2\n Hct\n 41.5\n Plt\n 336\n Cr\n 0.8\n TropT\n <0.01\n Glucose\n 159\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:93.4\n %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1 %, Ca++:9.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION improving after epsiode of bronchitis. Will\n wean steroids aggressively back to 10 mg/d. Still dry but drinking w/o\n difficulty. Will switch to oral abx\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) apparently due to\n dehydration\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE) no active\n ischemia\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: SSI\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : to floor\n Total time spent: 35 min\n" }, { "category": "Nursing", "chartdate": "2204-12-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 315242, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Receiving levalbuterol (less cardicac effects) q4hrs\nrr 20\ns..Extremley\n tachypnic with any movement/excertion. Wearing 2l nc..sats 95-96%.. Has\n weak productive cough. Wheezes persist throughout.\n Pt states she fells much better than when admitted.\n Action:\n Nebs q4hrs. 02 2l nc Tapering of steroids\n Response:\n Tolerating less frequent neb tx..\n Plan:\n Continue as above. Ongoing assessment of COPD\nkeep sats above 92\n Tachycardia, Other\n Assessment:\n Remains tachycardic, d/t neb tx and ?hypovolemic\n Action:\n Giving fluid boluses in attempt to decrease HR.\n Response:\n Becomes more tachycardic with coughing and exertion\n Plan:\n Continue hydration. Cardiac monitoring for tachycardia\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Poor urine output ?hypovolemia\n Action:\n Given fluid boluses to improve u/o\n Response:\n Slight increase in u/o\n Plan:\n Given fluid as needed\n" }, { "category": "General", "chartdate": "2204-12-25 00:00:00.000", "description": "Generic Note", "row_id": 315251, "text": "TITLE:\n Respiratory Care:\n Pt called out to floor but I think she needs to remain here at least\n over night due to her precarious Respiratory status\n She still easily de-compensates to ^^ SOB and de-saturation. Needs\n close monitoring at least over night.\n, RRT 18:44\n" }, { "category": "General", "chartdate": "2205-01-01 00:00:00.000", "description": "Generic Note", "row_id": 315904, "text": "TITLE: Resp Care Note:\n Pt seen for medication nebulizer multiple time throughout shift and\n refused each time. Pt confused but adamantly refused treatments.\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315144, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 61y.o. female admitted with three days increased SOB, congested cough\n with increased wheezes/resp distress.\n Action:\n Brought to EW by EMT\ns with 100% NRB RR 30\ns/O2 sat 95%. Treated with\n nebs/O2/antibiotics/IV steroids. O2 weaned to 4L N/C. CXR showing no\n evidence of PNA/CHF, no pneumothorax and no effusions. CXR shows\n emphysema. Pt admitted to MICU w/dx COPD exacerbation for frequent\n nebs/cont O2 sat monitoring\n Response:\n Lungs with exp wheezes and diminished breath sounds. RR 20-35 with O2\n sat 94%-96%. Tolerating soft diet well. States improvement in breathing\n after cont. nebs.\n Plan:\n Pt with have frequent nebs overnight. Pt to get IVF 100cc/hr NS for\n hydration for one liter. Follow I+O closely. Follow lung sounds and\n coordinate nebs with RT. Assist pt with ADL\ns as needed.\n" }, { "category": "Physician ", "chartdate": "2204-12-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315305, "text": "Chief Complaint: Dyspnea/COPD\n 24 Hour Events:\n CALLED OUT but not sent to floor poor air movement. added\n fluticasone-salmeterol\n tapering steroids\n hypertensive with tachycardia so started on diltiazem\n became acutely dyspneic with desat to 89% on 2L at 6:45am; started on\n nebs and O2 increased\n reaffirmed that she would be want to be intubated if necessary\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 10:10 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 Constitutional: tired\n Respiratory: Dyspnea\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.3\n HR: 106 (101 - 122) bpm\n BP: 169/83(104){143/66(85) - 176/96(112)} mmHg\n RR: 20 (16 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 3,267 mL\n 895 mL\n PO:\n 840 mL\n TF:\n IVF:\n 2,427 mL\n 895 mL\n Blood products:\n Total out:\n 1,495 mL\n 715 mL\n Urine:\n 1,495 mL\n 715 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,772 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.36/58/69/28/4\n Physical Examination\n General Appearance: Thin, working hard to breathe\n Eyes / Conjunctiva: pupils equal\n Head, Ears, Nose, Throat: face mask with albuterol treatment\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic, regular\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, Paradoxical), (Breath\n Sounds: Diminished: at bases), +accessory muscle use; +kyphosis and\n deformity of sternum; very tight with wheezes throughout\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, Rash: erythematous macules on feet\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 342 K/uL\n 11.9 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 16 mg/dL\n 103 mEq/L\n 140 mEq/L\n 37.9 %\n 17.6 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n WBC\n 8.2\n 17.6\n Hct\n 41.5\n 37.9\n Plt\n 336\n 342\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n TCO2\n 34\n Glucose\n 159\n 148\n 117\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:93.4\n %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n 61yo woman with COPD admitted with dyspnea and possible bronchitis.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - Acute worsening this morning; monitor closely for need to\n intubate\n - continue azithromycin and ceftriaxone for possible\n bronchitis\n - continue solumedrol 125mg IV q8h\n - continue albuterol, flonase, and atrovent\n - send sputum culture if sample obtainable\n - consider work-up for possible PE given worsening respiratory\n statusl\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n - baseline Cr 0.6, current Cr 0.7\n - improving with IV fluids; has good urine output\n - continue to support with maintenance IV fluids given poor po\n when dyspneic\n TACHYCARDIA, OTHER\n - PE work-up? Levalbuterol?\n # Leukocytosis\n - most likely secondary to steroids\n - continue to treat possible bronchitis\n - UA negative for evidence of infection\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - second set of cardiac enzymes negative; has no chest pain\n - continue ASA, plavix, statin\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue calcium, vitamin D\n - pain control per home regimen with fentanyl patch,\n mortryptiline, percocet prn\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2204-12-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315316, "text": "Chief Complaint: SOB/ 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 epsisode of incr SOB this am necessitating intubation\n 24 Hour Events:\n intubation this am\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 10:10 PM\n Midazolam (Versed) - 09:33 AM\n Fentanyl - 09:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Respiratory: Dyspnea, Tachypnea\n Endocrine: Hyperglycemia\n Flowsheet Data as of 10:14 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 (97.8\n HR: 119 (101 - 141) bpm\n BP: 136/76(89){136/66(85) - 180/99(131)} mmHg\n RR: 18 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 3,267 mL\n 1,151 mL\n PO:\n 840 mL\n TF:\n IVF:\n 2,427 mL\n 1,151 mL\n Blood products:\n Total out:\n 1,495 mL\n 960 mL\n Urine:\n 1,495 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,772 mL\n 191 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 32 cmH2O\n SpO2: 98%\n ABG: 7.36/58/69/28/4\n Ve: 10.6 L/min\n PaO2 / FiO2: 138\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 11.9 g/dL\n 342 K/uL\n 117 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 16 mg/dL\n 103 mEq/L\n 140 mEq/L\n 37.9 %\n 17.6 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n WBC\n 8.2\n 17.6\n Hct\n 41.5\n 37.9\n Plt\n 336\n 342\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n TCO2\n 34\n Glucose\n 159\n 148\n 117\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:93.4\n %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION - intubated this am. Hypertensive preintubation\n and now normotensive despite sedation and positive pressure. Has been\n pos in I&O for 3d. Will try to diurese and check echo since last echo 2\n years ago had mild MR and some hypokinesis.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - improved\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2204-12-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 315319, "text": "Subjective\n Constipation, Patient intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 160 cm\n 49 kg\n 49 kg ( 06:00 PM)\n was 44kg on \n 19.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 52\n 94\n Diagnosis: COPD\n PMH : COPD, IgA deficiency, CAD, hypertension, hyperlipidemia,\n gastritis, depressiong, chronic constipation d/t pain medication\n regimen\n Food allergies and intolerances: Unable to assess\n Pertinent medications: multiivitamin, calcium carbonate, vitamin D, NS\n @125ml/hr\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 04:56 AM\n Glucose Finger Stick\n 137\n 06:00 AM\n BUN\n 16 mg/dL\n 04:56 AM\n Creatinine\n 0.7 mg/dL\n 04:56 AM\n Sodium\n 140 mEq/L\n 04:56 AM\n Potassium\n 4.5 mEq/L\n 04:56 AM\n Chloride\n 103 mEq/L\n 04:56 AM\n Phosphorus\n 3.5 mg/dL\n 04:56 AM\n Magnesium\n 1.9 mg/dL\n 04:56 AM\n Current diet order / nutrition support: NPO, was on regular diet per\n patient's request until intubated\n GI: Abdomen soft/distended with +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1225-1470 (BEE x or / 25-30 cal/kg)\n Protein: 59-73 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 61 year old female admitted to MICU with respiratory distress now s/p\n intubation for SOB. Consult received for enteral feeding\n recommendations. Suggest enteral feeding of Replete with Fiber to goal\n rate of 50ml/hr to provide 1200kcal and 74g protein. Continue with\n bowel regimen as noted pt with chronic constipation.\n Medical Nutrition Therapy Plan - Recommend the Following\n -Multivitamin / Mineral supplement: via enteral feedings\n -Tube feeding / TPN recommendations: Recommend starting tube feeding of\n replete with fiber at 20ml/hr, advance by 20ml q6H to goal rate of\n 50ml/hr. Monitor residuals q4H and hold if >150ml\n 10:36\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315417, "text": "Ms is a 61 yo F with PMH significant for COPD, CAD, s/p MI x3,\n PCTA 01 & 05, HTN, hyperlipidemia, gastritis & osteoporosis, who\n presented to the EW on with worsening dyspnea. She was admitted\n to the ICU and course was uncomplicated and pt was called out to floor\n on . On AM of , pt was experiencing worsening dyspnea and\n asked to be intubated. Pt had also been hypertensive during the episode\n of worsening dyspnea. Pt was electively intubated and placed on\n mechanical ventilation, pt was also dosed with furosemide for positive\n fluid balance.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS are diminished with intermittent exp wheezes\n AC 16x500x0.4/+5\n Overbreathing vent 3-4 bpm\n Suctioning small amts thick white sputum\n Action:\n Aggressive pulmonary toilet\n Continue MDIs\n Wean resp support as tolerated\n Daily RSBI and SBT\n Response:\n Pt indicates increased comfort and decreased\n Plan:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315143, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 61y.o. female admitted with three days increased SOB, congested cough\n with increased wheezes/resp distress.\n Action:\n Brought to EW by EMT\ns with 100% NRB RR 30\ns/O2 sat 95%. Treated with\n nebs/O2/antibiotics/IV steroids. O2 weaned to 4L N/C. CXR showing no\n evidence of PNA/CHF, no pneumothorax and no effusions. CXR shows\n emphysema. Pt admitted to MICU w/dx COPD exacerbation for frequent\n nebs/cont O2 sat monitoring\n Response:\n Lungs with exp wheezes and diminished breath sounds. RR 20-35 with O2\n sat 94%-96%. Tolerating soft diet well. States improvement in breathing\n after cont. nebs.\n Plan:\n Pt with have frequent nebs overnight. Pt to get IVF 100cc/hr NS for\n hydration for one liter. Follow I+O closely. Follow lung sounds and\n coordinate nebs with RT. Assist pt with ADL\ns as needed.\n" }, { "category": "Nursing", "chartdate": "2204-12-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315145, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 61y.o. female admitted with three days increased SOB, congested cough\n with increased wheezes/resp distress.\n Action:\n Brought to EW by EMT\ns with 100% NRB RR 30\ns/O2 sat 95%. Treated with\n nebs/O2/antibiotics/IV steroids. O2 weaned to 4L N/C. CXR showing no\n evidence of PNA/CHF, no pneumothorax and no effusions. CXR shows\n emphysema. Pt admitted to MICU w/dx COPD exacerbation for frequent\n nebs/cont O2 sat monitoring\n Response:\n Lungs with exp wheezes and diminished breath sounds. RR 20-35 with O2\n sat 94%-96%. Tolerating soft diet well. States improvement in breathing\n after cont. nebs.\n Plan:\n Pt with have frequent nebs overnight. Pt to get IVF 100cc/hr NS for\n hydration for one liter. Follow I+O closely. Follow lung sounds and\n coordinate nebs with RT. Assist pt with ADL\ns as needed.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt with history of chronic pain from fractured ribs. She is on fent\n patch 25mcg/hr as well as PO percocet 1 tab TID/QID. Pt complained of\n back/rib pain at 1900.\n Action:\n Treated with percocet one tab when she requested pain med.\n Response:\n Pain better after one percocet tab.\n Plan:\n Continue to assess pain level and treat with percocet. Fentanyl patch\n to be changed on Wednesday.\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315399, "text": "Ms is a 61 yo F with PMH significant for COPD, CAD, s/p MI x3,\n PCTA 01 & 05, HTN, hyperlipidemia, gastritis & osteoporosis, who\n presented to the EW on with worsening dyspnea. She was admitted\n to the ICU and course was uncomplicated and pt was called out to floor\n on . On AM of , pt was experiencing worsening dyspnea and\n asked to be intubated. Pt was intubated and placed on AC\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315400, "text": "Ms is a 61 yo F with PMH significant for COPD, CAD, s/p MI x3,\n PCTA 01 & 05, HTN, hyperlipidemia, gastritis & osteoporosis, who\n presented to the EW on with worsening dyspnea. She was admitted\n to the ICU and course was uncomplicated and pt was called out to floor\n on . On AM of , pt was experiencing worsening dyspnea and\n asked to be intubated. Pt had also been hypertensive during the episode\n of worsening dyspnea. Pt was electively intubated and placed on\n mechanical ventilation, pt was also dosed with furosemide for positive\n fluid balance.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2205-01-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 316077, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: 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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\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: very sleepy; treated with xopenex&Atrovent nebulzer via\n mask.Patient is ordered for Levalbuterol(Xopenex)Q2 , atrovent Q6.\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315493, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS trial, completed 4 hours of pressure support,\n able to following commands and lift head off pillow appropriately.\n Lung sounds clear, diminished in bases. Cough/gag intact. Noted\n increase work of breathing with turning, resolves appropriately after\n care is completed.\n Action:\n Extubated at 1600, currently on 3L NC (pt with COPD history)\n Response:\n Pt tolerating extubation well, maintaining sats 88-92%, lung sounds\n remain clear to diminished.\n Plan:\n Monitor respiratory status and work of breathing, ? need for ABG,\n maintain sats 88-92% per respiratory, reintubation if necessary.\n Hypertension, benign\n Assessment:\n Pt becoming increasingly hypertensive during CPAP trial, BP starting to\n come down now that pt is extubated.\n Action:\n Received PO Diltiazem as ordered, Lopressor held at this time due to\n bronchospastic side effects.\n Response:\n No effects noted from recent PO Diltiazem\n Plan:\n Continue to monitor BP and HR, consider Lopressor or additional\n Diltiazem dose if hypertension not resolved.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with positive fluid balance for LOS, increased BUN/Cr from baseline\n level.\n Action:\n Received total 40mg IV lasix for positive fluid balance and in\n anticipation of extubation.\n Response:\n Duiresed appropriately, at this writing currently -200cc negative\n Plan:\n Goal fluid balance is even to -500 cc.\n" }, { "category": "Respiratory ", "chartdate": "2204-12-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315496, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\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: 8 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 / Thin\n Sputum source/amount: Suctioned / None\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:\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 Extubation (15:35)\n Comments: Pt extubated w/o incident. Cuff leak noted, no stridor\n present.\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315497, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS trial, completed 4 hours of pressure support,\n able to following commands and lift head off pillow appropriately.\n Lung sounds clear, diminished in bases. Cough/gag intact. Noted\n increase work of breathing with turning, resolves appropriately after\n care is completed.\n Action:\n Extubated at 1600, currently on 3L NC (pt with COPD history)\n Response:\n Pt tolerating extubation well, maintaining sats 88-92%, lung sounds\n remain clear to diminished.\n Plan:\n Monitor respiratory status and work of breathing, ? need for ABG,\n maintain sats 88-92% per respiratory, reintubation if necessary.\n Hypertension, benign\n Assessment:\n Pt becoming increasingly hypertensive during CPAP trial, BP starting to\n come down now that pt is extubated.\n Action:\n Received PO Diltiazem as ordered, Lopressor held at this time due to\n bronchospastic side effects.\n Response:\n No effects noted from recent PO Diltiazem\n Plan:\n Continue to monitor BP and HR, consider Lopressor or additional\n Diltiazem dose if hypertension not resolved.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with positive fluid balance for LOS, increased BUN/Cr from baseline\n level.\n Action:\n Received total 40mg IV lasix for positive fluid balance and in\n anticipation of extubation.\n Response:\n Duiresed appropriately, at this writing fluid goal met as pt is -500cc.\n Plan:\n Goal fluid balance met, will ask MD re further diuresis since pt\n hemodynamically stable.\n" }, { "category": "General", "chartdate": "2204-12-24 00:00:00.000", "description": "ICU Event Note", "row_id": 315130, "text": "Clinician: Attending\n Critical Care Note\n Total time spent: 35 minutes\n Patient is critically ill.\n Patient with severe COPD adm through ED with incr SOB over 3 days asso\n with incr green sputum. No fever, chills. Progressive SOB now sl better\n after nebs in ED. Steroids started, abx, and MDIs. She has not eaten in\n 3 days and w/ incr hct is quite dry\n will allow pos but supplement\n with IVF. Not in need of intubation acutely.\n" }, { "category": "Nutrition", "chartdate": "2204-12-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 315559, "text": "Subjective\n Patient now extubated\n Labs:\n Value\n Date\n Glucose\n 99 mg/dL\n 03:11 AM\n Glucose Finger Stick\n 163\n 06:00 AM\n BUN\n 35 mg/dL\n 03:11 AM\n Creatinine\n 0.7 mg/dL\n 03:11 AM\n Sodium\n 138 mEq/L\n 03:11 AM\n Potassium\n 3.7 mEq/L\n 03:11 AM\n Chloride\n 95 mEq/L\n 03:11 AM\n Phosphorus\n 3.2 mg/dL\n 03:11 AM\n Magnesium\n 2.2 mg/dL\n 03:11 AM\n Medications: noted\n Current diet order / nutrition support: Regular diet\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n Patient extubated around 4pm, tolerated well. Patient was\n tolerating tube feedings at goal rate prior to extubation. Now has diet\n advanced to regular diet. Will follow PO intake and add supplements as\n needed.\n Medical Nutrition Therapy Plan - Recommend the Following\n -Continue with diet as ordered\n -Monitor PO intake, encourage Pos PRN. If PO intake consistently <60%,\n suggest adding supplements \n -Monitor for any problems with s/p extubation\n 10:06\n" }, { "category": "Physician ", "chartdate": "2204-12-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315560, "text": "Chief Complaint: SOB\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Extubated\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:48 PM\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:13 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, Denies thirst\n Cardiovascular: HTN\n Respiratory: Cough, Dyspnea, Tachypnea\n Flowsheet Data as of 10:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 99 (79 - 102) bpm\n BP: 181/81(106){116/63(75) - 181/92(110)} mmHg\n RR: 20 (16 - 23) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,212 mL\n 1,022 mL\n PO:\n 90 mL\n 420 mL\n TF:\n 492 mL\n IVF:\n 419 mL\n 602 mL\n Blood products:\n Total out:\n 1,781 mL\n 227 mL\n Urine:\n 1,781 mL\n 227 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n 795 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n PS : 5 cmH2O\n FiO2: 40%\n SpO2: 89%\n ABG: ///40/\n Physical Examination\n General Appearance: Frail\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion:\n Hyperresonant: ), (Breath Sounds: Crackles : mid insp, Wheezes :\n diffuse)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.9 g/dL\n 382 K/uL\n 99 mg/dL\n 0.7 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 35 mg/dL\n 95 mEq/L\n 138 mEq/L\n 42.1 %\n 18.2 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n Plt\n 82\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n Glucose\n 159\n 148\n 117\n 150\n 99\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) has improved but not at\n baseline. We have diuresed her substantially over last several days\n but seems sl dry now. Continuing steroids, MDIs, abx. Still fragile.\n Remains very tenuous.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n HYPERTENSION, BENIGN - BP labile but up this am with primarily\n systolic HTN. Increasing dilt and metoprolol\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2204-12-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315563, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:48 PM\n Had been oversedated due to medication error in AM, which is why she\n did poorly on initial trial of PS\n Later trial of PS when she was awake went very well; extubated around\n 4pm\n Increased SSI\n Diuresed >500cc for the day with one-time lasix dose\n Started metoprolol for continued tachycardia with episodes of NSVT\n Given 250cc NS bolus at 5am for low urine output\n Episode of 10 beat NSVT yesterday morning\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:13 AM\n Other medications:\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: feels much better; very hungry and thirsty\n Cardiovascular: No(t) Chest pain\n Respiratory: breathing improved since admission\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.9\nC (96.7\n HR: 89 (79 - 106) bpm\n BP: 181/79(103){114/58(71) - 181/85(106)} mmHg\n RR: 19 (16 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,212 mL\n 618 mL\n PO:\n 90 mL\n 300 mL\n TF:\n 492 mL\n IVF:\n 419 mL\n 318 mL\n Blood products:\n Total out:\n 1,781 mL\n 147 mL\n Urine:\n 1,781 mL\n 147 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n 471 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 29 cmH2O\n SpO2: 92%\n ABG: 7.39/66/86/40/11\n Ve: 7.5 L/min\n PaO2 / FiO2: 215\n Physical Examination\n General Appearance: No acute distress, Thin, smiling, menu\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic),\n borderline tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : ), somewhat tight with diffuse wheezing; +kyphosis,\n +sternal deformity\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: pneumoboots in place; no LE edema\n Skin: Not assessed, +rosacea\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): time,\n place, person, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 382 K/uL\n 12.9 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 35 mg/dL\n 95 mEq/L\n 138 mEq/L\n 42.1 %\n 18.2 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n Plt\n 82\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n Glucose\n 159\n 148\n 117\n 150\n 99\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR :\n Improving aeration in the right lower lobe, but area somewhat obscured.\n No pulmonary edema.\n Microbiology: Sputum Cx : sparse growth oropharyngeal flora\n UCx negative\n BCx pending\n Assessment and Plan\n 61yo woman admitted with dyspnea in the setting of COPD and possible\n respiratory infection.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - s/p extubation \n - improving, at baseline O2 requirement\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - solumedrol 125mg iv q8h\n - continue atrovent and levalbuterol as well as flonase\n - restart montelukast now that she is extubated\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - possible pneumonia on CXR; may have triggered worsening COPD\n - ceftriaxone and azithromycin day 5 of \n HYPERTENSION, BENIGN\nworsening this AM, unclear why. Gave dose of\n metoprolol early\n - increase diltiazem and metoprolol for improved control\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) / Fluid Status\n - baseline Cr 0.6, current Cr 0.7\n - although Cr was stable with diuresis, BUN increased and\n urine output dropped overnight\n - gave back 500cc NS this AM; currently 800cc positive for the\n day and would leave her there and monitor for continued fluid\n requirement if urine output remains low\n - continue Foley for good I/Os at present\n TACHYCARDIA, OTHER\n - sinus tachycardia somewhat improved as respiratory status\n returns to baseline\n - started metoprolol given persistent sinus tachycardia and\n episodes of ectopy; would increase given continued HTN\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - home meds: ASA, plavix, statin\n - started metoprolol\n # Worsening metabolic alkalosis:\n - has chronic respiratory acidosis with compensatory metabolic\n alkalosis; jump in HCO3- could be do to volume contraction from\n diuresis\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis:\n - home medications, including Ca/Vit D and fentanyl patch,\n nortryptiline, percocet\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: not on vent\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Stay in ICU overnight for monitoring of respiratory status\n and improved BP control\n" }, { "category": "Case Management ", "chartdate": "2204-12-25 00:00:00.000", "description": "Case Managment Initial Patient Assessment", "row_id": 315223, "text": "Insurance information\n Primary insurance: Medicare A&B\n Secondary insurance: OOS PPO\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: Active with Caregroup Home Care\n DME / Home O[2]: Home O2 with Medical - ;\n Walker\n Functional Status / Home / Family Assessment:\n Pt. lives with family in . She is O2 dependent. She needs\n some assistance with ADL's but is independent with personal care ADL's.\n She ambulates with a walker at baseline.\n Primary Contact(s): (daughter) \n Health Care Proxy: Yes - But NO copy of signed proxy form in medical\n record. Daughter also proxy \n Dialysis: No\n Referrals Recommended: Physical Therapy\n Current plan: Home\n Home, when treatment completed, with services, Ms. is active\n with Caregroup Home Care. I have been contact by their Liaison and\n upon discharge she will be receiving telehealth services where her O2\n sats can be monitored on a daily basis.\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: No\n" }, { "category": "Nursing", "chartdate": "2204-12-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315282, "text": "Hypertension, benign\n Assessment:\n BP 150\ns -170\ns for a period of time\n Action:\n 10 mg of iv dilt given with good effect, then started on 30mg of po\n dilt tid.\n Response:\n Bp 140\ns-150\n Plan:\n Continue po dilt. Increased as needed. Monitor bp frequently.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Extremely tachypnic with any exertion. In o2 cont. via n/c at 2l.\n Action:\n Nebs. Q 4hrs. continue o2.\n Response:\n Tolerating nebs and o2, continue to sound tight no moving much air\n despite nebs and o2.\n Plan:\n Continue as above, goal is sats above 92%.\n Tachycardia, Other\n Assessment:\n HR to 120\ns d/t freq. nebs.\n Action:\n Received fluid bolus earlier now continuing on maintenance fluid at\n 100cc/hr.\n Response:\n Hr to low 100\n Plan:\n Continue fluid and monitor hr\n" }, { "category": "Respiratory ", "chartdate": "2204-12-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315390, "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: ICU\n Reason: Elective; Comments: Resp Failure COPD\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\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 response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2204-12-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315393, "text": "Demographics\n Day of intubation: 1\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: Unknown\n Procedure location: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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:\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support:\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": "2204-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315628, "text": "Delirium / confusion\n Assessment:\n Pt easily arousable and oriented x . had lovely conversation about\n her anniversary picture of husband. sleeping in naps .was slightly\n confused about time. 1 am vs 1 pm. Easily reoriented. denies pain. No\n pain or sleeping meds given. Turning self in bed- comfortable all\n crumpled up in bed. Takes pills well.\n Action:\n Bed alarm on, all side rails up\n Response:\n Uneventful night\n Plan:\n Provide safe environment, reorient prn\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Lungs with mild wheezing, inhalers as per RT. No c/o SOB. O2 sats\n 88-95% on 2L nasal cannula. Sats down to 83% when o2 off. Able to lie\n quite flat.\n Action:\n As per RT\n Response:\n Comfortable night, no SOB\n Plan:\n continue\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Vs stable. taking increased doses po lopressor, dilt, started\n captopril. No hypotension after diuresis yesterday\n Action:\n Fine tune meds as per team\n Response:\n Tolerating increased doses\n Plan:\n Assess vs\n" }, { "category": "Physician ", "chartdate": "2204-12-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315642, "text": "Chief Complaint: COPD\n 24 Hour Events:\n confused, she thought it was due to steroids (she has had similar\n problems with steroids in past)\n changed from IV to PO steroids\n nutrition saw her, recommened following intake and supplements if <60%\n SUBJ:\n Feels that breathing is improved but still not at baseline\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36\nC (96.8\n HR: 70 (69 - 102) bpm\n BP: 151/81(96){134/66(82) - 202/102(121)} mmHg\n RR: 17 (16 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,622 mL\n 209 mL\n PO:\n 600 mL\n 130 mL\n TF:\n IVF:\n 1,022 mL\n 79 mL\n Blood products:\n Total out:\n 2,372 mL\n 185 mL\n Urine:\n 2,372 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -750 mL\n 24 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 89% on 2L\n ABG: 7.40/69/68//13\n Physical Examination\n General Appearance: frail, elderly\n Head, Ears, Nose, Throat: plethoric\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n 1/2way up b/l, Wheezes : scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 432 K/uL\n 13.0 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 35 mg/dL\n 95 mEq/L\n 138 mEq/L\n 41.4 %\n 18.4 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n 18.4\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n 41.4\n Plt\n 82\n 432\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 159\n 148\n 117\n 150\n 99\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: none new\n Microbiology: none new\n 9:47 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n .\n 11:44 am URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ): NO GROWTH.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n tachypneic, SOB using accesory muscles, I/E wheeze, confused, very\n anxious\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC trending up\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Comments: regular diet, consider supplements per nutrition recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2204-12-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315648, "text": "Chief Complaint: COPD\n 24 Hour Events:\n confused, she thought it was due to steroids (she has had similar\n problems with steroids in past)\n changed from IV to PO steroids\n nutrition saw her, recommened following intake and supplements if <60%\n SUBJ:\n Feels that breathing is improved but still not at baseline\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36\nC (96.8\n HR: 70 (69 - 102) bpm\n BP: 151/81(96){134/66(82) - 202/102(121)} mmHg\n RR: 17 (16 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,622 mL\n 209 mL\n PO:\n 600 mL\n 130 mL\n TF:\n IVF:\n 1,022 mL\n 79 mL\n Blood products:\n Total out:\n 2,372 mL\n 185 mL\n Urine:\n 2,372 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -750 mL\n 24 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 89% on 2L\n ABG: 7.40/69/68//13\n Physical Examination\n General Appearance: frail, elderly\n Head, Ears, Nose, Throat: plethoric\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n 1/2way up b/l, Wheezes : scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 432 K/uL\n 13.0 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 35 mg/dL\n 95 mEq/L\n 138 mEq/L\n 41.4 %\n 18.4 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n 18.4\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n 41.4\n Plt\n 82\n 432\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 159\n 148\n 117\n 150\n 99\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: none new\n Microbiology: none new\n 9:47 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n .\n 11:44 am URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ): NO GROWTH.\n Assessment and Plan\n 61yo woman admitted with dyspnea in the setting of COPD and possible\n respiratory infection.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n s/p extubation . Not\n tenuous but not at baseline\n - improving, not tachypneic at rest, and at baseline O2\n requirement with sats 89-94%\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - continue prednisone 60mg daily, plan slow taper\n - continue atrovent and levalbuterol. Montelukast, as well as\n flonase\n - supplementsal O2 per home regimen\n - continue abx as below\n HYPERTENSION, BENIGN\n - increased diltiazem to 90 qid and metoprolol to 37.5 tid on\n for improved control, but still hypertensive\n - would further increase metoprolol to 50 tid as tolerated by\n HR\n - prn hydralazine if sbp > 160\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - possible pneumonia on CXR; may have triggered worsening COPD\n - ceftriaxone and azithromycin day 6 of (Day 1 = )\n H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, statin. ? not on ASA\n - started metoprolol, uptitrating\n Worsening metabolic alkalosis: chronic respiratory acidosis with\n compensatory metabolic alkalosis;\n - On had jump in HCO3- could also be do to volume\n contraction from diuresis\n - f/u AM labs today\n Osteoporosis:\n - home medications, including Ca/Vit D and fentanyl patch,\n nortryptiline, percocet\n ICU Care\n Nutrition:\n Comments: regular diet, consider supplements per nutrition recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: c/o to floor if remains at baseline today\n" }, { "category": "Physician ", "chartdate": "2204-12-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315195, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n Did well with levalbuterol Q2H-> switched to Q4H.\n Feels less jittery on levalbuterol, though tremor still above baseline\n Feels that breathing continues to improve.\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n h/o tremor\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: sleepy\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\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: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.7\n HR: 95 (94 - 115) bpm\n BP: 146/83(97){131/64(80) - 162/115(119)} mmHg\n RR: 21 (14 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,642 mL\n 578 mL\n PO:\n 720 mL\n TF:\n IVF:\n 922 mL\n 578 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,642 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n General Appearance: Thin, No(t) Diaphoretic, markedly kyphotic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: MMM\n Cardiovascular: (S1: Normal), (S2: Normal, Distant), no murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Rhonchorous: ), Chest wall deformity; Good air movement with\n prolonged expiratory phase; +wheezes, +rhonchi\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, Rash: pinpoint erythematous macules on left foot\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place, +resting tremor of UE b/l but improved from yesterday\n Labs / Radiology\n 336 K/uL\n 12.9 g/dL\n 159 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 5.5 mEq/L\n 14 mg/dL\n 102 mEq/L\n 140 mEq/L\n 41.5 %\n 8.2 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 8.2\n Hct\n 41.5\n Plt\n 336\n Cr\n 0.8\n Glucose\n 159\n Other labs: Differential-Neuts:93.4 %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1\n %, Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 61yo woman with COPD admitted with respiratory distress in setting of\n suspected pulmonary infection.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - azithromycin and ceftriaxone for possible bronchitis or\n pneumonia\n - solumedrol 125mg IV q8h for one more day, then wean down\n - levalbuterol nebs (has not tolerated albuterol due to\n tremulousness)\n - atrovent standing\n - flonase\n - f/u sputum culture\n - wean oxygen as she is % on 4L this AM\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Baseline Cr 0.6,\n Current Cr 0.8\n - Cr improving with IV fluids, but still appears dry with\n elevated Cr and poor urine output\n - Most likely is behind on fluids because of poor po over last\n few days\n - bolus with 500cc NS over 30 minutes then 1L of NS\n maintenance\n - follow Cr closely\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - denies chest pain despite continued tachycardia\n - continue ASA, plavix and statin\n - repeat cardiac enzymes this morning\n - repeat EKG\n # Tachycardia: DDx includes albuterol side effect, dehydration, or PE.\n - trial of more aggressive IV fluids (but careful given report\n of volume overload at prior admission)\n - continue levalbuterol\n - defer work-up of PE for the time being as low clinical\n suspicion given that her dyspnea responded so quickly to COPD treatment\n # Leukocytosis: Noted on admission, resolving.\n - given that urine appears cloudy, will check UA\n - covered for possible UTI with ceftriaxone/azithromycin\n # Hyperkalemia: unclear etiology\n - repeat EKG\n - recheck K+ this AM\n - may require calcium gluconate/kayexalate\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue calcium, vitamin D\n - pain control with fentanyl patch, nortryptiline, prn\n percocet\n ICU Care\n Nutrition: Regular diet per patient request\n Glycemic Control: not needed\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SubQ Heparin\n Stress ulcer: PPI\n VAP: not on vent\n Comments:\n Communication: Comments: Daughters and \n \n Code status: Full code\n Disposition: Callout to floor\n" }, { "category": "Respiratory ", "chartdate": "2204-12-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315279, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Accessory muscle use, Prolonged\n exhalation, Active exhalations\n Assessment of breathing comfort: Pt acknowledges dyspnea; Comments:\n Patient has dypsnea upon any type of exertion.\n Plan\n Next 24-48 hours: Plan to continue nebulizers every four hours.\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315487, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315491, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CPAP+PS trial, completed 4 hours of pressure support,\n able to following commands and lift head off pillow appropriately.\n Lung sounds clear, diminished in bases. Cough/gag intact. Noted\n increase work of breathing with turning, resolves appropriately after\n care is completed.\n Action:\n Extubated at 1600, currently on 3L NC (pt with COPD history)\n Response:\n Pt tolerating extubation well, maintaining sats 88-92%, lung sounds\n remain clear to diminished.\n Plan:\n Monitor respiratory status and work of breathing, ? need for ABG,\n maintain sats 88-92% per respiratory, reintubation if necessary.\n Hypertension, benign\n Assessment:\n Pt becoming increasingly hypertensive during CPAP trial, BP starting to\n come down now that pt is extubated.\n Action:\n Received PO Diltiazem as ordered, Lopressor held at this time due to\n bronchospastic side effects.\n Response:\n No effects noted from recent PO Diltiazem\n Plan:\n Continue to monitor BP and HR, Lopressor or additional Diltiazem dose\n if hypertension not resolved.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with positive fluid balance for LOS, increased BUN/Cr from baseline\n level.\n Action:\n Received IV multiple doses IV lasix.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2204-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315742, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n - sats in AM were 89-94% on baseline O2, but still working hard to\n breathe, was tachypneic simply moving in bed, so not called out\n - less confusion, improved mental status\n - episode of 13 beat NSVT\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Other medications:\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: Hoping to get to floor so she can go home\n Cardiovascular: No(t) Chest pain\n Respiratory: breathing improving slowly\n Musculoskeletal: + back pain\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.4\nC (97.6\n HR: 70 (64 - 89) bpm\n BP: 165/82(102){139/65(82) - 182/94(110)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 800 mL\n 81 mL\n PO:\n 510 mL\n TF:\n IVF:\n 290 mL\n 81 mL\n Blood products:\n Total out:\n 697 mL\n 450 mL\n Urine:\n 697 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 103 mL\n -369 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///39/\n PaO2 / FiO2: 2L NC\n Physical Examination\n General Appearance: +Work of breathing, appears frustrated\n Head, Ears, Nose, Throat: Mucous membranes moist; no thrush\n Cardiovascular: (S1: Normal), (S2: Normal), no longer tachycardic, no\n murmur\n Peripheral 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: Wheezes : , Rhonchorous: ), still\n somewhat tight; dyspneic with talking or moving in bed\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: +Pneumoboots; no LE edema\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): place,\n person, time, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 391 K/uL\n 13.6 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 43.7 %\n 17.7 K/uL\n [image002.jpg]\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n Plt\n 342\n 389\n 382\n 432\n 391\n Cr\n 0.7\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 148\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Microbiology: Respiratory Cx :\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n Assessment and Plan\n 61yo woman admitted with dyspnea in the setting of worsening COPD and\n possible pulmonary infection.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - s/p extubation , at baseline O2 requirement but dyspneic\n with the slightest activity\n - continue treatment of COPD and pneumonia as below\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - continue slow prednisone taper\n - continue atrovent, levalbuterol, flonase, singulair\n - Abx as below\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - continue ceftriaxone day 7 of (day 1 = )\n - leukocytosis most likely from steroids and not from\n infection given that she has no fevers\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n - improved BP control yesterday, but still in 160s-180s\n systolic\n - increase metoprolol and captopril to 50 TID today\n - hydralazine PRN for SBP > 160\n - ? to steroids given that she is not on\n anti-hypertensives at baseline\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr at baseline\n (0.6); resolved\n - would aim for even I/Os\n TACHYCARDIA, OTHER: resolved on beta blocker and diltiazem\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue statin, plavix; now on beta blocker and ACE I\n - not on ASA as outpatient--? b/c of h/o gastric ulcer; will\n discuss with PCP\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis:\n - home meds, including Ca, Vit D, fentanyl patch, percocet,\n nortryptiline\n ICU Care\n Nutrition:\n Comments: Regular diet with ensure\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2204-12-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315172, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n Did well with levalbuterol Q2H-> switched to Q4H.\n Feels less jittery on levalbuterol.\n Feels that breathing continues to improve.\n History obtained from Patient\n Allergies:\n History obtained from Patient\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 Constitutional: sleepy\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\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: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.7\n HR: 95 (94 - 115) bpm\n BP: 146/83(97){131/64(80) - 162/115(119)} mmHg\n RR: 21 (14 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,642 mL\n 578 mL\n PO:\n 720 mL\n TF:\n IVF:\n 922 mL\n 578 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,642 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n General Appearance: Thin, No(t) Diaphoretic, markedly kyphotic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: MMM\n Cardiovascular: (S1: Normal), (S2: Normal, Distant), no murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Rhonchorous: ), Chest wall deformity; Good air movement with\n prolonged expiratory phase; +wheezes, +rhonchi\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, Rash: pinpoint erythematous macules on left foot\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 336 K/uL\n 12.9 g/dL\n 159 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 5.5 mEq/L\n 14 mg/dL\n 102 mEq/L\n 140 mEq/L\n 41.5 %\n 8.2 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 8.2\n Hct\n 41.5\n Plt\n 336\n Cr\n 0.8\n Glucose\n 159\n Other labs: Differential-Neuts:93.4 %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1\n %, Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:09 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": "2204-12-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315173, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n Did well with levalbuterol Q2H-> switched to Q4H.\n Feels less jittery on levalbuterol, though tremor still above baseline\n Feels that breathing continues to improve.\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n h/o tremor\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: sleepy\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\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: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.7\n HR: 95 (94 - 115) bpm\n BP: 146/83(97){131/64(80) - 162/115(119)} mmHg\n RR: 21 (14 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,642 mL\n 578 mL\n PO:\n 720 mL\n TF:\n IVF:\n 922 mL\n 578 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,642 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///33/\n Physical Examination\n General Appearance: Thin, No(t) Diaphoretic, markedly kyphotic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: MMM\n Cardiovascular: (S1: Normal), (S2: Normal, Distant), no murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Rhonchorous: ), Chest wall deformity; Good air movement with\n prolonged expiratory phase; +wheezes, +rhonchi\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, Rash: pinpoint erythematous macules on left foot\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place, +resting tremor of UE b/l but improved from yesterday\n Labs / Radiology\n 336 K/uL\n 12.9 g/dL\n 159 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 5.5 mEq/L\n 14 mg/dL\n 102 mEq/L\n 140 mEq/L\n 41.5 %\n 8.2 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 8.2\n Hct\n 41.5\n Plt\n 336\n Cr\n 0.8\n Glucose\n 159\n Other labs: Differential-Neuts:93.4 %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1\n %, Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - continues to do well on 4L oxygen\n - azithromycin and ceftriaxone for possible bronchitis or\n pneumonia\n - solumedrol 125mg IV q8h\n - levalbuterol nebs (has not tolerated albuterol due to\n tremulousness)\n - atrovent standing\n - flonase\n - f/u sputum culture\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Baseline Cr 0.6,\n Current Cr 0.8\n - Cr improving with IV fluids\n - ? bolus given tachycardia\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - denies chest pain despite continued tachycardia\n - continue ASA, plavix and statin\n - ? repeat cardiac enzymes\n # Tachycardia: DDx includes albuterol side effect, dehydration, or PE.\n - trial of more aggressive IV fluids (but careful given report\n of volume overload at prior admission)\n - continue levalbuterol\n - defer work-up of PE for the time being as low clinical\n suspicion given that her dyspnea responded so quickly to COPD treatment\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue calcium, vitamin D\n - pain control with fentanyl patch, nortryptiline, prn\n percocet\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: not needed\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SubQ Heparin\n Stress ulcer: PPI\n VAP: not on vent\n Comments:\n Communication: Comments: Daughters and \n \n Code status: Full code\n Disposition: To floor\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315529, "text": "Hypertension, benign\n Assessment:\n b/p of 150\ns-160\ns/ 70\ns-80\ns . denies any CP , nausea or headache\n Action:\n Restarted on metoprolol and diltiazem\n Response:\n No change in VS maintaining b/p of 160\ns/70\n Plan:\n Continue monitor VS , cont w/hypertensive med regiment,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Nc-2l. sats high 80\ns-low 90\ns bil LS clear diminished at the bases\n w/exp wheezes, use of accessory muscle noted. Tachypneic upon exertion,\n Action:\n Nebs/In q4-6 hr, cough and deep breathing encouraged, diuresed earlier\n w/negative fluid balance\n Response:\n Maintains Sats of 90\ns ( as high as 95% on NC2L)\n Plan:\n Continue monitor respiratory status, consider ABG\ns , wean off O2\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n During the shift decreasing urine output , patient maintains b/p\n Action:\n 250cc NS bolus given\n Response:\n No response noted\n Plan:\n Continue to monitor I&O, Reevaluate at 7am consider additional bolus,\n encourage PO fluids\n" }, { "category": "Physician ", "chartdate": "2204-12-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315537, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:48 PM\n Had been oversedated due to medication error in AM, which is why she\n did poorly on initial trial of PS\n Later trial of PS when she was awake went very well; extubated around\n 4pm\n Increased SSI\n Diuresed >500cc for the day with one-time lasix dose\n Started metoprolol for continued tachycardia with episodes of NSVT\n Given 250cc NS bolus at 5am for low urine output\n Episode of 10 beat NSVT yesterday morning\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:13 AM\n Other medications:\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: feels much better; very hungry and thirsty\n Cardiovascular: No(t) Chest pain\n Respiratory: breathing improved since admission\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.9\nC (96.7\n HR: 89 (79 - 106) bpm\n BP: 181/79(103){114/58(71) - 181/85(106)} mmHg\n RR: 19 (16 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,212 mL\n 618 mL\n PO:\n 90 mL\n 300 mL\n TF:\n 492 mL\n IVF:\n 419 mL\n 318 mL\n Blood products:\n Total out:\n 1,781 mL\n 147 mL\n Urine:\n 1,781 mL\n 147 mL\n NG:\n Stool:\n Drains:\n Balance:\n -569 mL\n 471 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n Vt (Set): 500 (500 - 500) mL\n PS : 5 cmH2O\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 29 cmH2O\n SpO2: 92%\n ABG: 7.39/66/86/40/11\n Ve: 7.5 L/min\n PaO2 / FiO2: 215\n Physical Examination\n General Appearance: No acute distress, Thin, smiling, menu\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic),\n borderline tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Wheezes : ), somewhat tight with diffuse wheezing; +kyphosis,\n +sternal deformity\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: pneumoboots in place; no LE edema\n Skin: Not assessed, +rosacea\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): time,\n place, person, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 382 K/uL\n 12.9 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 35 mg/dL\n 95 mEq/L\n 138 mEq/L\n 42.1 %\n 18.2 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n Plt\n 82\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n Glucose\n 159\n 148\n 117\n 150\n 99\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR :\n Improving aeration in the right lower lobe, but area somewhat obscured.\n No pulmonary edema.\n Microbiology: Sputum Cx : sparse growth oropharyngeal flora\n UCx negative\n BCx pending\n Assessment and Plan\n 61yo woman admitted with dyspnea in the setting of COPD and possible\n respiratory infection.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - s/p extubation \n - improving, at baseline O2 requirement\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - solumedrol 125mg iv q8h\n - continue atrovent and levalbuterol as well as flonase\n - restart montelukast now that she is extubated\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - possible pneumonia on CXR; may have triggered worsening COPD\n - ceftriaxone and azithromycin day 5 of \n HYPERTENSION, BENIGN\nworsening this AM, unclear why. Gave dose of\n metoprolol early\n - continue diltiazem and metoprolol\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) / Fluid Status\n - baseline Cr 0.6, current Cr 0.7\n - although Cr was stable with diuresis, BUN increased and\n urine output dropped overnight\n - gave back 250cc NS this AM; will hydrate gently if needed to\n support urine output\n - continue Foley for good I/Os at present\n TACHYCARDIA, OTHER\n - sinus tachycardia somewhat improved as respiratory status\n returns to baseline\n - started metoprolol given persistent sinus tachycardia and\n episodes of ectopy\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - home meds: ASA, plavix, ASA\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis:\n - home medications, including Ca/Vit D and fentanyl patch,\n nortryptiline, percocet\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "General", "chartdate": "2204-12-31 00:00:00.000", "description": "Generic Note", "row_id": 315811, "text": "TITLE:\n Pt given medication nebulizer as per order. Lung sounds dim bilat. Cont\n present regime.\n" }, { "category": "Physician ", "chartdate": "2204-12-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315378, "text": "Chief Complaint: SOB/ 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 epsisode of incr SOB this am necessitating intubation\n 24 Hour Events:\n intubation this am\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 10:10 PM\n Midazolam (Versed) - 09:33 AM\n Fentanyl - 09:33 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Respiratory: Dyspnea, Tachypnea\n Endocrine: Hyperglycemia\n Flowsheet Data as of 10:14 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 (97.8\n HR: 119 (101 - 141) bpm\n BP: 136/76(89){136/66(85) - 180/99(131)} mmHg\n RR: 18 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 3,267 mL\n 1,151 mL\n PO:\n 840 mL\n TF:\n IVF:\n 2,427 mL\n 1,151 mL\n Blood products:\n Total out:\n 1,495 mL\n 960 mL\n Urine:\n 1,495 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,772 mL\n 191 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 32 cmH2O\n SpO2: 98%\n ABG: 7.36/58/69/28/4\n Ve: 10.6 L/min\n PaO2 / FiO2: 138\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 11.9 g/dL\n 342 K/uL\n 117 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 16 mg/dL\n 103 mEq/L\n 140 mEq/L\n 37.9 %\n 17.6 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n WBC\n 8.2\n 17.6\n Hct\n 41.5\n 37.9\n Plt\n 336\n 342\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n TCO2\n 34\n Glucose\n 159\n 148\n 117\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:93.4\n %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION - intubated this am. Hypertensive preintubation\n and now normotensive despite sedation and positive pressure. Has been\n pos in I&O for 3d. Will try to diurese and check echo since last echo 2\n years ago had mild MR and some hypokinesis.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - improved\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 55\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2204-12-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315383, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt with increased resp distress this AM unresponsive to extra\n nebs/steroids requiring intubation at 9AM. Lungs remains with exp\n wheezes throughout. Pt with copious secretions initially requiring\n frequent suction for thin white secretions.\n Action:\n Pt sedated and intubated on the vent on AC 18, TV 600, FIO2 50% with\n 5cm peep. Sputum sent for culture and pt given 20mg IV lasix and fluids\n stopped.\n Response:\n Pt comfortable on the fentanyl 100mcg and versed 2mg/hr. Diuresing well\n from the lasix and awaiting blood gas results once team insertes\n a-line.\n Plan:\n A-line attempts unsuccessful so far. Team has drawn individual blood\n gas this eve. Follow blood gases and wean vent as needed. Keep pt\n comfortable with sedation. Suction PRN. Provide emotional support as\n needed,\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n BP extremely high with pt distressed and needing to be intubated. BP\n was up to 190\ns prior to intubation. BP improved after\n sedation/intubation. HR remains 100-110 sinus tach. BP 120-140\ns. Pt\n denied complaints of chest pain. Poor IV access. One of her IV\n infiltrated.\n Action:\n BP meds continue to be given.Pt is on dilt for elevated HR and BP\n control and pt also getting lasix to help diureses. New peripheral IV\n inserted.\n Response:\n BP improved with diuresis/sedation. UO great response to lasix.\n Plan:\n Continue to watch BP closely and inform team if BP becomes high again.\n Keep two PIV\ns at all times. Pt may need CVL at some point.\n" }, { "category": "Respiratory ", "chartdate": "2204-12-28 00:00:00.000", "description": "Generic Note", "row_id": 315525, "text": "TITLE:\n TITLE:\n ------ Protected Section------\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use\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: Cont present medication regime.\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 given HHN with Xopenex and Atrovent as per order. VSS and Oxygen\n sat stable.\n ------ Protected Section Error Entered By: , RRT\n on: 05:31 ------\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315527, "text": "Hypertension, benign\n Assessment:\n b/p of 150\ns-160\ns/ 70\ns-80\ns . denies any CP , nausea or headache\n Action:\n Restarted on metoprolol and diltiazem\n Response:\n No change in VS maintaining b/p of 160\ns/70\n Plan:\n Continue monitor VS , cont w/hypertensive med regiment,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Nc-2l. sats high 80\ns-low 90\ns bil LS clear diminished at the bases\n w/exp wheezes, use of accessory muscle noted. Tachypneic upon exertion,\n Action:\n Nebs/In q4-6 hr, cough and deep breathing encouraged, diuresed earlier\n w/negative fluid balance\n Response:\n Maintains Sats of 90\ns ( as high as 95% on NC2L)\n Plan:\n Continue monitor respiratory status, consider ABG\ns , wean off O2\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n During the shift decreasing urine output , patient maintains b/p\n Action:\n 250cc NS bolus given\n Response:\n No response noted\n Plan:\n Continue to monitor I&O, consider additional bolus, encourage PO fluids\n" }, { "category": "Respiratory ", "chartdate": "2204-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315623, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\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: 8 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: Accessory muscle use\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 given medication nebulizer as per order.\n" }, { "category": "Nursing", "chartdate": "2204-12-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315362, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt with increased resp distress this AM unresponsive to extra\n nebs/steroids requiring intubation at 9AM. Lungs remains with exp\n wheezes throughout. Pt with copious secretions initially requiring\n frequent suction for thin white secretions.\n Action:\n Pt sedated and intubated on the vent on AC 18, TV 600, FIO2 50% with\n 5cm peep. Sputum sent for culture and pt given 20mg IV lasix and fluids\n stopped.\n Response:\n Pt comfortable on the fentanyl 100mcg and versed 2mg/hr. Diuresing well\n from the lasix and awaiting blood gas results once team insertes\n a-line.\n Plan:\n A-line being inserted for blood gas analysis. Follow blood gases and\n wean vent as needed. Keep pt comfortable with sedation. Suction PRN.\n Provide emotional support as needed,\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n BP extremely high with pt distressed and needing to be intubated. BP\n was up to 190\ns prior to intubation. BP improved after\n sedation/intubation. HR remains 100-110 sinus tach. BP 120-140\ns. Pt\n denied complaints of chest pain. Poor IV access. One of her IV\n infiltrated.\n Action:\n BP meds continue to be given.Pt is on dilt for elevated HR and BP\n control and pt also getting lasix to help diureses. New peripheral IV\n inserted.\n Response:\n BP improved with diuresis/sedation. UO great response to lasix.\n Plan:\n Continue to watch BP closely and inform team if BP becomes high again.\n Keep two PIV\ns at all times. Pt may need CVL at some point.\n" }, { "category": "Physician ", "chartdate": "2204-12-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315470, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:29 AM\n SPUTUM CULTURE - At 09:36 AM\n - remains intubated\n - a-line placement attempted x 2, failed both times bilaterally!\n - ABG done with e/o overventilation and overoxygenation, vent settings\n adjusted accordingly\n - plan to get another ABG for morning rounds\n - diuresed negative 1L\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 11:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 09:33 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Midazolam (Versed) - 09:00 PM\n Furosemide (Lasix) - 09:19 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: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.1\n HR: 92 (90 - 141) bpm\n BP: 133/72(88){111/53(76) - 180/99(131)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,948 mL\n 550 mL\n PO:\n TF:\n 288 mL\n 340 mL\n IVF:\n 1,555 mL\n 150 mL\n Blood products:\n Total out:\n 3,115 mL\n 390 mL\n Urine:\n 3,115 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 6\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.47/48/167/34/10 at 5pm \n Ve: 7.8 L/min\n PaO2 / FiO2: 418\n Physical Examination\n General Appearance: Intubated, sedated but wakens easily and nods\n appropriately\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), HR 90s, regular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present), LE cool to touch but hands warm\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds b/l;\n kyphosis and sternal deformity\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: No LE edema; + UE restraints\n Musculoskeletal: Muscle wasting\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 389 K/uL\n 12.7 g/dL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 97 mEq/L\n 138 mEq/L\n 40.5 %\n 14.9 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n WBC\n 8.2\n 17.6\n 14.9\n Hct\n 41.5\n 37.9\n 40.5\n Plt\n \n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n TropT\n <0.01\n TCO2\n 34\n 36\n Glucose\n 159\n 148\n 117\n 150\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.7 mg/dL\n Respiratory cx and BCx pending; UCx negative\n CXR :\n Unchanged appearance of right lower lobe consolidation with\n underlying pleural effusion could reflect atelectasis or pneumonia.\n Assessment and Plan\n 61yo woman with respiratory failure from COPD and\n bronchitis/?pneumonia.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - most likely due to COPD, but may have had a component of\n volume overload in the setting of fluid resuscitation\n - continue to diurese and treat COPD as below\n - trial of pressure support today\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - treating with ceftriaxone and azithromycin day 4\n - currently intubated\n - solumedrol 125mg iv q8h\n - continue albuterol and atrovent\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n - baseline Cr 0.6, current Cr 0.8\n - continue gentle diuresis; monitor Cr\n TACHYCARDIA, OTHER\n - improved s/p intubation\n - was most likely due to sympathetic discharge in setting of\n respiratory distress\n - given ectopy this morning, will start beta blocker to better\n control rate\n # HTN:\n - resolved s/p intubation\n - continue diltiazem 60 TID; start metoprolol as above\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - ruled out with negative CE x 2 on admission\n - continue statin, plavix, ASA\n - start metoprolol as discussed above\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue Ca and vitamin D\n - continue home pain meds (fentanyl patch, nortryptiline)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 50 mL/hour\n Glycemic Control: Comments: BS 150 this AM on tube feeds; will tighten\n SSI\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: restraints while intubated\n Communication: Comments: PCP and daughters aware that patient is\n intubated\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315476, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear, exp wheeze rul, sputum cult pending to date, o2 sat 93-97,\n on assist cont, pt alert and very responsive+\n Action:\n Preparation to extubate, tube feeds off at 0950, sedation decreased at\n 0950 and then stopped at 1150. pt is still sleepy but able to respond\n approp and moves self to sitting position in bed.\n Response:\n Still too lethargic and will need press support trial prior to\n extubation\n Plan:\n Press support trial, cont iv steroids, extubate when ready\n" }, { "category": "Respiratory ", "chartdate": "2204-12-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315524, "text": "TITLE:\n ------ Protected Section------\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use\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: Cont present medication regime.\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 given HHN with Xopenex and Atrovent as per order. VSS and Oxygen\n sat stable.\n ------ Protected Section Error Entered By: , RRT\n on: 05:31 ------\n" }, { "category": "Respiratory ", "chartdate": "2204-12-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315522, "text": "TITLE:\n" }, { "category": "Nursing", "chartdate": "2204-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315713, "text": "Hypertension, benign\n Assessment:\n NBP 149-182/65-89; BP elevated when pt awake and anxious at times\n Action:\n Continues on captopril, metoprolol and diltiazem po\n Response:\n NBP range as above. BP\ns elevated with anxiety; pt denies pain\n Plan:\n Continue BP meds; assess for pain and medicate prn; ? add anti-anxiety\n med such as zyprexa; hydralazine prn BP > 160.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN trending up recently. Urine output 15-55cc/hr clear dark yellow\n urine.\n Action:\n Encourage fluids, avoid lasix, continue to monitor urine output.\n Response:\n 24hr fluid balance is +91cc\n Plan:\n Monitor daily BUN/Cr\n Delirium / confusion\n Assessment:\n Pt alert and oriented X2 -> wasn\nt sure of exact date or month but knew\n the year was .\n Action:\n Pt reoriented.\n Response:\n Some increased confusion at night, otherwise A&O X2-3, pleasant and\n cooperative.\n Plan:\n Reorient prn, Check pain level q 4hrs.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n O2 sats 94-96% on 2L NC, some I&E wheezing LUL, clear RUL, diminished\n bilat bases.\n Action:\n Atr/levalb nebs q 4hrs, prednisone po tapering doses.\n Response:\n Pt has a weak non-productive cough, RR 17-26, more tachypneic with\n activity.\n Plan:\n Continue antibiotic for pneumonia coverage, steroids, nebs and monitor\n resp status regularly.\n" }, { "category": "Respiratory ", "chartdate": "2204-12-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315715, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt given med neb as per order. Cont present regime.\n" }, { "category": "Nursing", "chartdate": "2204-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315800, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 02 sats 98-100 on 2 L NC, RR 15-20. denies dyspnea/SOB. LS clear\n upper/diminished bases.\n Action:\n On going assessment of resp status, nebs q4hours by RRT when awake.\n Response:\n No changes in resp function, 02 sats cont to be stable.\n Plan:\n Cont to monitor and assess resp function, wean off 02 as tolerated.\n Hypertension, benign\n Assessment:\n BP 130-150/50-70 overnight\n Action:\n Received PO captopril and diltiazem overnight\n Response:\n Pts BP remains within acceptable range, 133/55 at present.\n Plan:\n Cont to monitor BP, prn hydralazine ordered if SBP >160\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2204-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315801, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n 02 sats 98-100 on 2 L NC, RR 15-20. denies dyspnea/SOB. LS clear\n upper/diminished bases.\n Action:\n On going assessment of resp status, nebs q4hours by RRT when awake.\n Response:\n No changes in resp function, 02 sats cont to be stable.\n Plan:\n Cont to monitor and assess resp function, wean off 02 as tolerated.\n Hypertension, benign\n Assessment:\n BP 130-150/50-70 overnight\n Action:\n Received PO captopril and diltiazem overnight\n Response:\n Pts BP remains within acceptable range, 133/55 at present.\n Plan:\n Cont to monitor BP, prn hydralazine ordered if SBP >160\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Overnight urine output 30-60cc/hr, clear amber urine. UO noted to\n slowly trend downward overnight\n Action:\n Cont to monitor UO, diuretics being held r/t contraction alkalosis,\n MD\ns aware.\n Response:\n Urine output remains >30cc/hr.\n Plan:\n Cont to monitor UO.\n Delirium / confusion\n Assessment:\n Intermittent delerium/confusion, pt stated she felt\nsomething on her\n that was not there at start of shift. otherwise oriented, calm,\n comfortable. No attempts to get OOB.\n Action:\n Pt received zyprexa dose in evening, bed low and locked, bed alarm on.\n Response:\n Pt sleeping comfortably during night.\n Plan:\n Cont to monitor pts mental status for delirium/confusion\n" }, { "category": "Nursing", "chartdate": "2204-12-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315355, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt with increased resp distress this AM unresponsive to extra\n nebs/steroids requiring intubation at 9AM. Lungs remains with exp\n wheezes throughout. Pt with copious secretions initially requiring\n frequent suction for thin white secretions.\n Action:\n Pt sedated and intubated on the vent on AC 18, TV 600, FIO2 50% with\n 5cm peep. Sputum sent for culture and pt given 20mg IV lasix and fluids\n stopped.\n Response:\n Pt comfortable on the fentanyl 100mcg and versed 2mg/hr. Diuresing well\n from the lasix and awaiting blood gas results once team insertes\n a-line.\n Plan:\n A-line being inserted for blood gas analysis. Follow blood gases and\n wean vent as needed. Keep pt comfortable with sedation. Suction PRN.\n Provide emotional support as needed,\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n BP extremely high with pt distressed and needing to be intubated. BP\n was up to 190\ns prior to intubation. BP improved after\n sedation/intubation. HR remains 100-110 sinus tach. BP 120-140\ns. Pt\n denied complaints of chest pain.\n Action:\n BP meds continue to be given.Pt is on dilt for elevated HR and BP\n control and pt also getting lasix to help diureses\n Response:\n BP improved with diuresis/sedation. UO great response to lasix.\n Plan:\n Continue to watch BP closely and inform team if BP becomes high again.\n" }, { "category": "Respiratory ", "chartdate": "2204-12-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 315426, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Respiratory Failure,elective\n Tube Type\n ETT:\n Position: 21 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: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Crackles\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:\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Possible air trapping\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:CXR consistent with RLL infiltrate. AM RSBI-40. Would\n transition patient to CPAP/PSV this am.\n" }, { "category": "Physician ", "chartdate": "2204-12-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315431, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:29 AM\n SPUTUM CULTURE - At 09:36 AM\n - remains intubated\n - a-line placement attempted x 2, failed both times bilaterally!\n - ABG done with e/o overventilation and overoxygenation, vent settings\n adjusted accordingly\n - plan to get another ABG for morning rounds\n - diuresed negative 1L\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 11:18 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Fentanyl - 09:33 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Midazolam (Versed) - 09:00 PM\n Furosemide (Lasix) - 09:19 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: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.1\n HR: 92 (90 - 141) bpm\n BP: 133/72(88){111/53(76) - 180/99(131)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,948 mL\n 550 mL\n PO:\n TF:\n 288 mL\n 340 mL\n IVF:\n 1,555 mL\n 150 mL\n Blood products:\n Total out:\n 3,115 mL\n 390 mL\n Urine:\n 3,115 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 6\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.47/48/167/34/10 at 5pm \n Ve: 7.8 L/min\n PaO2 / FiO2: 418\n Physical Examination\n General Appearance: Intubated, sedated but wakens easily and nods\n appropriately\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), HR 90s, regular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present), LE cool to touch but hands warm\n Respiratory / Chest: (Expansion: Symmetric), coarse breath sounds b/l;\n kyphosis and sternal deformity\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: No LE edema\n Musculoskeletal: Muscle wasting\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 389 K/uL\n 12.7 g/dL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 97 mEq/L\n 138 mEq/L\n 40.5 %\n 14.9 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n WBC\n 8.2\n 17.6\n 14.9\n Hct\n 41.5\n 37.9\n 40.5\n Plt\n \n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n TropT\n <0.01\n TCO2\n 34\n 36\n Glucose\n 159\n 148\n 117\n 150\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.7 mg/dL\n Respiratory cx and BCx pending; UCx negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - most likely due to COPD, but may have had a component of\n volume overload in the setting of fluid resuscitation\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - treating with ceftriaxone and azithromycin day 4\n - currently intubated\n - solumedrol 125mg iv q8h\n - continue albuterol and atrovent\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n - baseline Cr 0.6, current Cr 0.8\n TACHYCARDIA, OTHER\n - improved s/p intubation\n - was most likely due to sympathetic discharge in setting of\n respiratory distress\n # HTN:\n - resolved s/p intubation\n - continue diltiazem 30 TID\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - ruled out with negative CE x 2 on admission\n - continue statin, plavix, ASA\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue Ca and vitamin D\n - continue home pain meds (fentanyl patch, nortryptiline)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 50 mL/hour\n Glycemic Control: Comments: BS 150 this AM on tube feeds\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: PCP and daughters aware that patient is\n intubated\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315516, "text": "Hypertension, benign\n Assessment:\n b/p of 150\ns-160\ns/ 70\ns-80\ns . denies any CP , nausea or headache\n Action:\n Restarted on metoprolol and diltiazem\n Response:\n No change in VS maintaining b/p of 160\ns/70\n Plan:\n Continue monitor VS , cont w/hypertensive med regiment,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Nc-2l. sats high 80\ns-low 90\ns bil LS clear diminished at the bases\n w/exp wheezes, use of accessory muscle noted. Tachypneic upon exertion,\n Action:\n Nebs/In q4-6 hr, cough and deep breathing encouraged, diuresed earlier\n w/negative fluid balance\n Response:\n Maintains Sats of 90\ns ( as high as 95% on NC2L)\n Plan:\n Continue monitor respiratory status, consider ABG\ns , wean off O2\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n During the shift decreasing urine output , patient maintains b/p\n Action:\n 250cc NS bolus given\n Response:\n Plan:\n Continue to monitor I&O, consider additional bolus, encourage PO fluids\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315609, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt remains on 2L N/C with O2 sat 88%-91% RR 22-30. Pt with insp wheezes\n and very diminished breath sounds. Remains in moderate resp distress\n and increased DOE.\n Action:\n Pt sleeping on/off in naps and assisted with all care.\n Response:\n Pt becomes dyspneic with minimal exertion. O2 sat drops to 86% with\n activity (even taking PO meds)\n Plan:\n Pt needs to continue frequent nebs, minimize activity. Intubate if\n necessary. OK to keep sat >88%.\n" }, { "category": "Nursing", "chartdate": "2204-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315794, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n At noontime patient became tachypneic with labored breathing,\n diaphoretic, looked more flushed than usual, lung sounds diminished\n throughout, increased non-productive cough weak but sounds junky\n Action:\n NTS done, copious amount of yellow secretions noted, neb treatments\n done strictly q4hrs\n Response:\n Responded well after NTS, sats >>95% at 2 lpm, however lung sounds\n remains dim.\n Plan:\n Continue strict q4hrs neb treatments, wean off O2 if sats remains > 95%\n at 2 lpm\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, yellow secretions per NTS\n Action:\n Antibiotics given\n Response:\n Remains afebrile, felt better post NTS\n Plan:\n Continue ceftriaxone and azithromycin\n Hypertension, benign\n Assessment:\n BP ranges 130\ns-160\ns ( usually high when patient is awake and\n anxious), BP 180\ns @ 1830\n Action:\n Captopril and diltiazem given, Lopressor increased to 50mgs TID, Nitro\n paste 1 inch @ Hydralazine 10 mgs IV\n Response:\n BP remains high, result of Hydralazine pending\n Plan:\n Continue to monitor BP, keep patient comfortable and calm\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO trending down past days, intermittent borderline OU\n Action:\n No diuretics for the meantime due to contraction alkalosis\n Response:\n Negative 400 since MN, UO getting better\n Plan:\n Continue to monitor UO, no diuretics, keep patient negative if not even\n Delirium / confusion\n Assessment:\n Intermittently confused\n Action:\n Reoriented, kept safe\n bed low, alarm on, zyprexa started\n Response:\n Remains confused but not getting out of bed\n Plan:\n Continue to reorient that she is at the hospital, reassure and give\n emotional support\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315602, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypeniec, SOB, i/e wheeze sats 88-90% at 2 lpm, increased use of\n accessory muscle\n Action:\n Xopenex, albuterol and atrovent inhalation, ABG within her baseline,\n lasix 40 mgs IV given\n Response:\n Sats 94-95% at 2 lpm, wheezing resolved, lung sounds clear\n Plan:\n Continue monitor respiratory status, give neb treatments as schedules\n and PRN\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n I/E wheeze\n Action:\n Atrovent, albuterol and xoponex inhalations\n Response:\n Wheezing resolved, lung sounds clear, sats 94-95%\n Plan:\n Continue neb treatments\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, WBC trending up\n Action:\n Antibiotics given ( on ceftriaxone and azithromycin\n Response:\n Remains afebrile, weak non-productive cough\n Plan:\n Hypertension, benign\n Assessment:\n BP 180-200\n Action:\n Nirtopaste 1 inch, lopressor 5 mg IV x1, diltiazem and lopressor\n increased, started on captopril, anti-anxiety given (ativan 1mg and\n 0.5mg x 1)\n Response:\n Responded well BP 130\ns after nitro paste and BP meds adjustments\n Plan:\n Continue BP meds, monitor hemodynamics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO decreasing 10cc/hr, amber cloudy with sediments urine, BUN trending\n up\n Action:\n 250cc NS fluid bolus\n not responded well, Lasix 40mgs\n Response:\n -945 since MN, dumping 500cc/hr x 3 hrs after lasix\n Plan:\n Continue monitor UO, goal keep patient even\n Delirium / confusion\n Assessment:\n Getting out of bed, oriented x 1, hallucinating most likely due to high\n dose of steroids, agitated ? due to ativan as well\n Action:\n Solumedrol dc\nd, change to PO, reoriented to place and time, bed alarm\n set, bed locked and set low, increased visibility\n Response:\n Calm, not getting out of bed but still confused\n Plan:\n Continue reorienting patient, keep patient safe\n bed alarm on\n Anxiety\n Assessment:\n Tachypneic, verbalized she is very anxious, crying\n wants to go home,\n frustrated\n Action:\n Lorazepam given, emotional support given\n Response:\n Calmer after ativan was given\n Plan:\n given emotional support to patient, may give haldol if very agitated\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315508, "text": "Hypertension, benign\n Assessment:\n b/p of 150\ns-160\ns/ 70\ns-80\ns . denies any CP , nausea or headache\n Action:\n Restarted on metoprolol and diltiazem\n Response:\n No change in VS maintaining b/p of 160\ns/70\n Plan:\n Continue monitor VS , cont w/hypertensive med regiment,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Nc-2l. sats high 80\ns-low 90\ns bil LS clear diminished at the bases\n w/exp wheezes, use of accessory muscle noted. Tachypnic upon excretion,\n Action:\n Nebs/In q4-6 hr, cough and deep breathing encouraged, diuresed earlier\n w/negative fluid balance\n Response:\n Maintains Sats of 90\ns ( as high as 95% on NC2L)\n Plan:\n Continue monitor respiratory status, consider ABG\ns , wean off O2\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315509, "text": "Hypertension, benign\n Assessment:\n b/p of 150\ns-160\ns/ 70\ns-80\ns . denies any CP , nausea or headache\n Action:\n Restarted on metoprolol and diltiazem\n Response:\n No change in VS maintaining b/p of 160\ns/70\n Plan:\n Continue monitor VS , cont w/hypertensive med regiment,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Nc-2l. sats high 80\ns-low 90\ns bil LS clear diminished at the bases\n w/exp wheezes, use of accessory muscle noted. Tachypniec upon\n excertion,\n Action:\n Nebs/In q4-6 hr, cough and deep breathing encouraged, diuresed earlier\n w/negative fluid balance\n Response:\n Maintains Sats of 90\ns ( as high as 95% on NC2L)\n Plan:\n Continue monitor respiratory status, consider ABG\ns , wean off O2\n" }, { "category": "Nursing", "chartdate": "2204-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315510, "text": "Hypertension, benign\n Assessment:\n b/p of 150\ns-160\ns/ 70\ns-80\ns . denies any CP , nausea or headache\n Action:\n Restarted on metoprolol and diltiazem\n Response:\n No change in VS maintaining b/p of 160\ns/70\n Plan:\n Continue monitor VS , cont w/hypertensive med regiment,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Nc-2l. sats high 80\ns-low 90\ns bil LS clear diminished at the bases\n w/exp wheezes, use of accessory muscle noted. Tachypneic upon exertion,\n Action:\n Nebs/In q4-6 hr, cough and deep breathing encouraged, diuresed earlier\n w/negative fluid balance\n Response:\n Maintains Sats of 90\ns ( as high as 95% on NC2L)\n Plan:\n Continue monitor respiratory status, consider ABG\ns , wean off O2\n" }, { "category": "Nursing", "chartdate": "2204-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315784, "text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n At noontime patient became tachypneic with labored breathing,\n diaphoretic, looked more flushed than usual, lung sounds diminished\n throughout, increased non-productive cough weak but sounds junky\n Action:\n NTS done, copious amount of yellow secretions noted, neb treatments\n done strictly q4hrs\n Response:\n Responded well after NTS, sats >>95% at 2 lpm, however lung sounds\n remains dim.\n Plan:\n Continue strict q4hrs neb treatments, wean off O2 if sats remains > 95%\n at 2 lpm\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, yellow secretions per NTS\n Action:\n Antibiotics given\n Response:\n Remains afebrile, felt better post NTS\n Plan:\n Continue ceftriaxone and azithromycin\n Hypertension, benign\n Assessment:\n BP ranges 130\ns-160\ns ( usually high when patient is awake and anxious)\n Action:\n Captopril and diltiazem given, Lopressor increased to 50mgs TID\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2204-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315696, "text": "61 year old women with severe COPD on home Oxygen, prior intubations,\n presented with SOB, increased sputum, presented to ED - started on\n steroids, abtibiotics, oxygen and admitted to ICU on . Respiratory\n status declined and was intubated. Subsequently improved and\n extubated on .\n 24 Hour Events:\n Yesterday got confused and tearful, steroids reduced.\n Otherwise respiratory status has been stable. Feels better, but not\n back to baseline.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Inspiratory wheeze intermittently, tachypneic with labored breathing\n Action:\n Atrovent increased to q4hrs, continues on xopenex\n Response:\n Sats within goal, decreased episodes of shortness of breath, tolerated\n turns, independently or with 2 assist\n Plan:\n Continue neb treatments, encourage deep breathing, optimize ventilation\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afebrile, non-producitve cough, WBC remains high 18.2\n Action:\n Continues on azithromycin and ceftriaxone, steroids tapered\n Response:\n Remains afebrile\n Plan:\n Continue antibiotics, monitor for temp spikes\n Hypertension, benign\n Assessment:\n Intermittent BP > 160\n Action:\n Remains on captopril, lopressor and diltiazem; nitropaste off\n Response:\n BP well controlled highest SBP 167\n Plan:\n Continue to monitor BP keep BP < 160\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO borderline, BUN trending up\n Action:\n Monitor UO, no diuretics at the moment since patient BUN increasing\n Response:\n Remains stable even with 250cc positive although goal is to make\n patient even, UO responsive to increased PO intake\n Plan:\n Monitor UO, keep patient even, no diuretics this time\n Delirium / confusion\n Assessment:\n Oriented x1, remains confused\n Action:\n Reoriented to time, place, maintain safe\n bed alarm on, bed low and\n locked, increased visibility\n Response:\n No longer agitated, not getting out of bed, cooperative though remains\n disoriented to place and time intermittently\n Plan:\n Continue to reorient patient, keep safe\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315419, "text": "Ms is a 61 yo F with PMH significant for COPD, CAD, s/p MI x3,\n PCTA 01 & 05, HTN, hyperlipidemia, gastritis & osteoporosis, who\n presented to the EW on with worsening dyspnea. She was admitted\n to the ICU and course was uncomplicated and pt was called out to floor\n on . On AM of , pt was experiencing worsening dyspnea and\n asked to be intubated. Pt had also been hypertensive during the episode\n of worsening dyspnea. Pt was electively intubated and placed on\n mechanical ventilation, pt was also dosed with furosemide for positive\n fluid balance.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS are diminished with intermittent exp wheezes\n AC 16x500x0.4/+5\n Overbreathing vent 3-4 bpm\n Suctioning small amts thick white sputum\n Action:\n Aggressive pulmonary toilet\n Continue MDIs\n Wean resp support as tolerated\n Daily RSBI and SBT\n Response:\n Pt indicates increased comfort and decreased WOB\n Plan:\n Continue to monitor respiratory status\n Continue resp support as needed\n Wean resp support as tolerated\n Daily RSBI and SBT\n Continue steroids and ABX as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt has had positive fluid balance > 48h\n Creatinine stable at 0.7-0.8\n Urine output has been dropping\n Action:\n Dosed with 20mg IV furosemide x1\n Response:\n Urine output improved transiently\n AM Hct 40.5 up from 37.9\n Plan:\n Continue to monitor urine output\n Continue to follow creatnine\n" }, { "category": "Physician ", "chartdate": "2204-12-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315663, "text": "Chief Complaint: SOB/Respiratory Failure\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 61 yo women with severe COPD on home Oxygen, prior intubations,\n presented with SOB, increased sputum, presented to ED - started on\n steroids, abtx, oxygen and admitted to ICU on . Respiratory status\n declined and was intubated. Subseqently improved and extubated on\n .\n 24 Hour Events:\n Yesterday got confused and tearful, steroids reduced.\n Otherwise respiratory status has been stable. Feels better, but not\n back to baseline.\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n simvastatin\n plavix\n fentanyl patch\n nortryptiline\n singulair\n MVI\n Flonase\n Tums\n Vitamin D\n SSI\n protonix\n atrovent\n diltiazem\n lopressor\n captopril\n prednisone 60mg\n percocet PRN\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 73 (69 - 102) bpm\n BP: 139/66(83){134/66(82) - 202/102(121)} mmHg\n RR: 16 (16 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,622 mL\n 339 mL\n PO:\n 600 mL\n 230 mL\n TF:\n IVF:\n 1,022 mL\n 109 mL\n Blood products:\n Total out:\n 2,372 mL\n 282 mL\n Urine:\n 2,372 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n -750 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/69/68/42/13\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal, Absent)\n Peripheral 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 : b/l , Wheezes :\n diffuse)\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 13.0 g/dL\n 432 K/uL\n 127 mg/dL\n 0.6 mg/dL\n 42 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 94 mEq/L\n 140 mEq/L\n 41.4 %\n 18.4 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n 18.4\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n 41.4\n Plt\n 82\n 432\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n 0.6\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 159\n 148\n 117\n 150\n 99\n 127\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n tachypneic, SOB using accesory muscles, I/E wheeze, confused, very\n anxious\n Some Improvement. Still SOB, but weaned to nasal cannula.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC stable. Can start prednisone\n taper., CTX day . Completed azithro course.\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n Better controlled on multiple medications.\n TACHYCARDIA, OTHER Better controlled\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2204-12-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315671, "text": "Chief Complaint: SOB/Respiratory Failure\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 61 yo women with severe COPD on home Oxygen, prior intubations,\n presented with SOB, increased sputum, presented to ED - started on\n steroids, abtx, oxygen and admitted to ICU on . Respiratory status\n declined and was intubated. Subseqently improved and extubated on\n .\n 24 Hour Events:\n Yesterday got confused and tearful, steroids reduced.\n Otherwise respiratory status has been stable. Feels better, but not\n back to baseline.\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n simvastatin\n plavix\n fentanyl patch\n nortryptiline\n singulair\n MVI\n Flonase\n Tums\n Vitamin D\n SSI\n protonix\n atrovent\n diltiazem\n lopressor\n captopril\n prednisone 60mg\n percocet PRN\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Mild SOB, feels better No Hypotension. No ventilatory support.\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 73 (69 - 102) bpm\n BP: 139/66(83){134/66(82) - 202/102(121)} mmHg\n RR: 16 (16 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,622 mL\n 339 mL\n PO:\n 600 mL\n 230 mL\n TF:\n IVF:\n 1,022 mL\n 109 mL\n Blood products:\n Total out:\n 2,372 mL\n 282 mL\n Urine:\n 2,372 mL\n 282 mL\n NG:\n Stool:\n Drains:\n Balance:\n -750 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.40/69/68/42/13\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal, Absent)\n Peripheral 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 : b/l , Wheezes :\n diffuse)\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to voice, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 13.0 g/dL\n 432 K/uL\n 127 mg/dL\n 0.6 mg/dL\n 42 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 94 mEq/L\n 140 mEq/L\n 41.4 %\n 18.4 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n 18.4\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n 41.4\n Plt\n 82\n 432\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n 0.6\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 159\n 148\n 117\n 150\n 99\n 127\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:8.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n tachypneic, SOB using accesory muscles, I/E wheeze, confused, very\n anxious\n Some Improvement. Still SOB, but weaned to nasal cannula.\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC stable. Can start prednisone\n taper., CTX day . Completed azithro course.\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n Better controlled on multiple medications.\n TACHYCARDIA, OTHER Better controlled\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2204-12-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315678, "text": "Chief Complaint: COPD\n 24 Hour Events:\n confused, she thought it was due to steroids (she has had similar\n problems with steroids in past)\n changed from IV to PO steroids\n nutrition saw her, recommened following intake and supplements if <60%\n SUBJ:\n Feels that breathing is improved but still not at baseline\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36\nC (96.8\n HR: 70 (69 - 102) bpm\n BP: 151/81(96){134/66(82) - 202/102(121)} mmHg\n RR: 17 (16 - 24) insp/min\n SpO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 1,622 mL\n 209 mL\n PO:\n 600 mL\n 130 mL\n TF:\n IVF:\n 1,022 mL\n 79 mL\n Blood products:\n Total out:\n 2,372 mL\n 185 mL\n Urine:\n 2,372 mL\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -750 mL\n 24 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 89% on 2L\n ABG: 7.40/69/68//13\n Physical Examination\n General Appearance: frail, elderly\n Head, Ears, Nose, Throat: plethoric\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n 1/2way up b/l, Wheezes : scattered)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 432 K/uL\n 13.0 g/dL\n 99 mg/dL\n 0.7 mg/dL\n 40 mEq/L\n 3.7 mEq/L\n 35 mg/dL\n 95 mEq/L\n 138 mEq/L\n 41.4 %\n 18.4 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n WBC\n 8.2\n 17.6\n 14.9\n 18.2\n 18.4\n Hct\n 41.5\n 37.9\n 40.5\n 42.1\n 41.4\n Plt\n 82\n 432\n Cr\n 0.8\n 0.7\n 0.7\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 159\n 148\n 117\n 150\n 99\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: none new\n Microbiology: none new\n 9:47 am SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n <10 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n QUALITY OF SPECIMEN CANNOT BE ASSESSED.\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n .\n 11:44 am URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ): NO GROWTH.\n Assessment and Plan\n 61yo woman admitted with dyspnea in the setting of COPD and possible\n respiratory infection.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n s/p extubation . Not\n tenuous but still not at baseline, using accessory muscles to breathe\n - improving, not tachypneic at rest, and at baseline O2\n requirement with sats 89-94%\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - continue prednisone 60mg daily, plan slow taper\n - Continue atrovent (increase to q4h and levalbuterol.\n Montelukast, as well as flonase\n - supplemental O2 per home regimen\n - continue abx as below\n HYPERTENSION, BENIGN\n - increased diltiazem to 90 qid and metoprolol to 37.5 tid on\n for improved control, but still hypertensive\n - would further increase metoprolol to 50 tid as tolerated by\n HR\n - prn hydralazine if sbp > 160\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - possible pneumonia on CXR; may have triggered worsening COPD\n - ceftriaxone day 6 of (Day 1 = )\n H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, statin\n - ? not on ASA\n d/w PCP at future date\n - started metoprolol, uptitrating\n Worsening metabolic alkalosis: chronic respiratory acidosis with\n compensatory metabolic alkalosis;\n - On had jump in HCO3- a chronic CO2 retainer - could also\n be do to volume contraction from diuresis\n - Hold off on diuresis for now\n Osteoporosis:\n - home medications, including Ca/Vit D and fentanyl patch,\n nortryptiline, percocet\n ICU Care\n Nutrition:\n Comments: regular diet, consider supplements per nutrition recs\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: c/o to floor if remains at baseline today\n" }, { "category": "Physician ", "chartdate": "2204-12-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315756, "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 Severe COPD exacerbation, s/p extubation.\n 24 Hour Events:\n Still SOB intermittently , but slow improvement overall\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Other medications:\n simvastatin\n plavix\n fentanyl patch\n nortryptiliine\n singulair\n MVI\n paxil\n flonase\n CaCO3\n Vitamin D\n SSI\n Protonix\n Diltiazem\n lopressor\n Captropril\n Atrovent\n Prednisone 60mg\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:10 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.4\nC (97.6\n HR: 92 (64 - 92) bpm\n BP: 160/69(91){132/65(82) - 182/97(110)} mmHg\n RR: 27 (17 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 800 mL\n 239 mL\n PO:\n 510 mL\n 120 mL\n TF:\n IVF:\n 290 mL\n 119 mL\n Blood products:\n Total out:\n 697 mL\n 532 mL\n Urine:\n 697 mL\n 532 mL\n NG:\n Stool:\n Drains:\n Balance:\n 103 mL\n -293 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///39/\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: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Paradoxical), (Breath Sounds:\n Rhonchorous: slightly )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): times\n 3 , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 13.6 g/dL\n 391 K/uL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 43.7 %\n 17.7 K/uL\n [image002.jpg]\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n Plt\n 342\n 389\n 382\n 432\n 391\n Cr\n 0.7\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 148\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n tachypneic, SOB using accesory muscles, I/E wheeze, confused, very\n anxious\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC trending up\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n Improved control. Can increase lopressor.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n Still intermittently extremely short of breath. There seems to be\n prominent component of anxiety.\n Will add Zyprexa for anxiety/agititation and also wean prednisone to\n 40mg.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2204-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315762, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n - sats in AM were 89-94% on baseline O2, but still working hard to\n breathe, was tachypneic simply moving in bed, so not called out\n - less confusion, improved mental status\n - episode of 13 beat NSVT\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:17 AM\n Other medications:\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: Hoping to get to floor so she can go home\n Cardiovascular: No(t) Chest pain\n Respiratory: breathing improving slowly\n Musculoskeletal: + back pain\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.4\nC (97.6\n HR: 70 (64 - 89) bpm\n BP: 165/82(102){139/65(82) - 182/94(110)} mmHg\n RR: 23 (16 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 800 mL\n 81 mL\n PO:\n 510 mL\n TF:\n IVF:\n 290 mL\n 81 mL\n Blood products:\n Total out:\n 697 mL\n 450 mL\n Urine:\n 697 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 103 mL\n -369 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///39/\n PaO2 / FiO2: 2L NC\n Physical Examination\n General Appearance: +Work of breathing, appears frustrated\n Head, Ears, Nose, Throat: Mucous membranes moist; no thrush\n Cardiovascular: (S1: Normal), (S2: Normal), no longer tachycardic, no\n murmur\n Peripheral 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: Wheezes : , Rhonchorous: ), still\n somewhat tight; dyspneic with talking or moving in bed\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: +Pneumoboots; no LE edema\n Musculoskeletal: Muscle wasting\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): place,\n person, time, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 391 K/uL\n 13.6 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 43.7 %\n 17.7 K/uL\n [image002.jpg]\n 02:06 AM\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n Plt\n 342\n 389\n 382\n 432\n 391\n Cr\n 0.7\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 148\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Microbiology: Respiratory Cx :\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n Assessment and Plan\n 61yo woman admitted with dyspnea in the setting of worsening COPD and\n possible pulmonary infection.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - s/p extubation , at baseline O2 requirement but dyspneic\n with the slightest activity\n - continue treatment of COPD and pneumonia as below\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - taper prednisone to 40mg tomorrow\n - continue atrovent, levalbuterol, flonase, singulair;\n increase levalbuterol to q2h\n - Abx as below\n - Increase suctioning to clear airways\n - Not a candidate for pulmonary toilet b/c of bad osteoporosis\n - Treat anxiety as it appears to be contributing to dyspnea\n and HTN; start zyprexa \n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - continue ceftriaxone day 7 of (day 1 = )\n - leukocytosis most likely from steroids and not from\n infection given that she has no fevers\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n - improved BP control yesterday, but still in 160s-180s\n systolic\n - increase metoprolol and captopril to 50 TID today\n - hydralazine PRN for SBP > 160\n - ? to steroids given that she is not on\n anti-hypertensives at baseline\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr at baseline\n (0.6); resolved\n - would aim for even I/Os\n TACHYCARDIA, OTHER: resolved on beta blocker and diltiazem\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue statin, plavix; now on beta blocker and ACE I\n - not on ASA as outpatient--? b/c of h/o gastric ulcer; will\n discuss with PCP\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis:\n - home meds, including Ca, Vit D, fentanyl patch, percocet,\n nortryptiline\n ICU Care\n Nutrition:\n Comments: Regular diet with ensure\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 06:09 PM\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: Family meeting held with both daughters;\n patient discussed on team rounds\n Code status: Full code\n Disposition: continue ICU level care\n" }, { "category": "Physician ", "chartdate": "2204-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315841, "text": "Chief Complaint: 61F with COPD exacerbation\n 24 Hour Events:\n - Started Zyprexa b/c of continued agitation and anxiety; helped\n somewhat\n - Met with patient and her daughters to explain why still in ICU\n - Increased dose of metoprolol; pt required one-time dose of\n hydralazine with good BP response\n - Decided to increase rate of prednisone taper (to get 40mg tomorrow)\n - Increased suctioning with lots of thick yellow secretions\n Allergies:\n Antibiotics:\n Ceftriaxone 1g IV daily day 8\n Other ICU medications:\n Hydralazine - 06:28 PM\n Other medications:\n Ipratropium\n Levalbuterol\n Olanzapine, Paroxetine\n Metoprolol 50mg PO TID\n Prednisone 30 mg daily on taper\n Captopril 37.5mg PO TID\n Diltiazem 90mg PO QID\n Protonix\n Fluticasone, Montelukast\n Nortriptyline\n Fentanyl patch\n Plavix 75 daily, simvastatin\n SQ heparin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough, Dyspnea, Wheeze, improved\n Neurologic: anxious\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: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 68 (62 - 95) bpm\n BP: 154/67(87){132/58(78) - 187/104(112)} mmHg\n RR: 23 (17 - 30) insp/min\n SpO2: 94% on 2L NC\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 652 mL\n 343 mL\n PO:\n 360 mL\n 75 mL\n TF:\n IVF:\n 292 mL\n 268 mL\n Blood products:\n Total out:\n 1,115 mL\n 410 mL\n Urine:\n 1,115 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -463 mL\n -67 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Wheezes :\n few)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 377 K/uL\n 14.4 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n CXR no recent chest film\n Micro\n blood cx x2 negative\n urine cx negative\n sputum gram <10 polys no organisms on gram, culture with sparse\n growth oropharyngeal flora\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 342\n 389\n 382\n \n Cr\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - Improved, at her baseline level of supplemental O2\n - continue prednisone taper, bronchodilators, singulair and\n flonase\n - Treat anxiety as it appears to be contributing to dyspnea\n and HTN; zyprexa \n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - Can d/c ceftriaxone (today day 8), s/p azithromycin x5\n days.\n - leukocytosis most likely from steroids and not from\n infection\n - reculture if febrile\n HYPERTENSION, BENIGN\n Improved BP control yesterday, but still up to 180s systolic. Suspect\n that anxiety and steroids are contributing\n - continue metoprolol, captopril, diltiazem with prn\n hydralazine. Will increase captopril today.\n -\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr at baseline\n (0.6); resolved follow urine output\n TACHYCARDIA, OTHER: Resolve with CCB/beta blocker\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue statin, plavix; now on beta blocker and ACE I\n - not on ASA as outpatient--? b/c of h/o gastric ulcer; will\n discuss with PCP\n ICU \n Nutrition: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:07 PM\n DC foley\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: PPI\n VAP: n/a\n Communication: with family\n Code status: Full code\n Disposition: floor vs. Rehab today, screen and PT consult\n" }, { "category": "Case Management ", "chartdate": "2204-12-31 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 315845, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer: Medicare A&B\n Hospital days authorized to:\n Current Discharge Plan: Acute rehab\n Barrier(s) To Discharge: None\n Family Meeting: Yes\n Referrals:\n 1) Northeast - \n 2) - \n Narrative / Plan (Family):\n Contact by ICU team to begin the screening process for Rehab for this\n patient. I have asked for a PT eval in order to facilitate the\n screening process. I have communicated with the patient's daughter,\n , and discussed facilities that she would consider for\n rehab placement. She has identified facility in \n and . I have contact both facilities and will await\n their screens. I will follow up with team and the patient's daughter\n with . I did not discuss dc plans with the patient as she is\n aggitated and somewhat confused at this time.\n" }, { "category": "Physician ", "chartdate": "2204-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315821, "text": "Chief Complaint: 61F with COPD exacerbation\n 24 Hour Events:\n - Started Zyprexa b/c of continued agitation and anxiety; helped\n somewhat\n - Met with patient and her daughters to explain why still in ICU\n - Increased dose of metoprolol; pt required one-time dose of\n hydralazine with good BP response\n - Decided to increase rate of prednisone taper (to get 40mg tomorrow)\n - Increased suctioning with lots of thick yellow secretions\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:28 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 Respiratory: Cough, Dyspnea, Wheeze, improved\n Neurologic: anxious\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: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 68 (62 - 95) bpm\n BP: 154/67(87){132/58(78) - 187/104(112)} mmHg\n RR: 23 (17 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 652 mL\n 343 mL\n PO:\n 360 mL\n 75 mL\n TF:\n IVF:\n 292 mL\n 268 mL\n Blood products:\n Total out:\n 1,115 mL\n 410 mL\n Urine:\n 1,115 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -463 mL\n -67 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Wheezes :\n few)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 377 K/uL\n 14.4 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n CXR no recent chest film\n Micro\n blood cx x2 negative\n urine cx negative\n sputum gram <10 polys no organisms on gram, culture with sparse\n growth oropharyngeal flora\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 342\n 389\n 382\n \n Cr\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n tachypneic, SOB using accesory muscles, I/E wheeze, confused, very\n anxious\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n i/e wheeze, ABG wihtin baseline, continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile, WBC trending up\n HYPERTENSION, BENIGN\n BP 190's started on captopril, nitro paste; lopressor and diltiazem\n increased, 5mgs IV lopressor given\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT:\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": "2204-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315823, "text": "Chief Complaint: 61F with COPD exacerbation\n 24 Hour Events:\n - Started Zyprexa b/c of continued agitation and anxiety; helped\n somewhat\n - Met with patient and her daughters to explain why still in ICU\n - Increased dose of metoprolol; pt required one-time dose of\n hydralazine with good BP response\n - Decided to increase rate of prednisone taper (to get 40mg tomorrow)\n - Increased suctioning with lots of thick yellow secretions\n Allergies:\n Antibiotics:\n Ceftriaxone 1g IV daily day 8\n Other ICU medications:\n Hydralazine - 06:28 PM\n Other medications:\n Ipratropium\n Levalbuterol\n Olanzapine, Paroxetine\n Metoprolol 50mg PO TID\n Prednisone 30 mg daily on taper\n Captopril 37.5mg PO TID\n Diltiazem 90mg PO QID\n Protonix\n Fluticasone, Montelukast\n Nortriptyline\n Fentanyl patch\n Plavix 75 daily, simvastatin\n SQ heparin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough, Dyspnea, Wheeze, improved\n Neurologic: anxious\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: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 68 (62 - 95) bpm\n BP: 154/67(87){132/58(78) - 187/104(112)} mmHg\n RR: 23 (17 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 652 mL\n 343 mL\n PO:\n 360 mL\n 75 mL\n TF:\n IVF:\n 292 mL\n 268 mL\n Blood products:\n Total out:\n 1,115 mL\n 410 mL\n Urine:\n 1,115 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -463 mL\n -67 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Wheezes :\n few)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 377 K/uL\n 14.4 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n CXR no recent chest film\n Micro\n blood cx x2 negative\n urine cx negative\n sputum gram <10 polys no organisms on gram, culture with sparse\n growth oropharyngeal flora\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 342\n 389\n 382\n \n Cr\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - s/p extubation , at baseline O2 requirement but dyspneic\n with the minimal activity\n - continue treatment of COPD and pneumonia as below\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - continue prednisone taper, bronchodilators, singulair and\n flonase\n - Treat anxiety as it appears to be contributing to dyspnea\n and HTN; zyprexa \n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - continue ceftriaxone day 8 of 10 day course (day 1 = ),\n s/p azithromycin x5 days\n - leukocytosis most likely from steroids and not from\n infection\n - reculture if febrile\n HYPERTENSION, BENIGN\n Improved BP control yesterday, but still up to 180s systolic\n - continue metoprolol, captopril, diltiazem with prn\n hydralazine\n - ? to steroids and anxiety given that she is not on\n anti-hypertensives at baseline\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr at baseline\n (0.6); resolved follow urine output\n TACHYCARDIA, OTHER: Resolve with CCB/beta blocker\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue statin, plavix; now on beta blocker and ACE I\n - not on ASA as outpatient--? b/c of h/o gastric ulcer; will\n discuss with PCP\n ICU \n Nutrition: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: PPI\n VAP: n/a\n Communication:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2204-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315824, "text": "Chief Complaint: 61F with COPD exacerbation\n 24 Hour Events:\n - Started Zyprexa b/c of continued agitation and anxiety; helped\n somewhat\n - Met with patient and her daughters to explain why still in ICU\n - Increased dose of metoprolol; pt required one-time dose of\n hydralazine with good BP response\n - Decided to increase rate of prednisone taper (to get 40mg tomorrow)\n - Increased suctioning with lots of thick yellow secretions\n Allergies:\n Antibiotics:\n Ceftriaxone 1g IV daily day 8\n Other ICU medications:\n Hydralazine - 06:28 PM\n Other medications:\n Ipratropium\n Levalbuterol\n Olanzapine, Paroxetine\n Metoprolol 50mg PO TID\n Prednisone 30 mg daily on taper\n Captopril 37.5mg PO TID\n Diltiazem 90mg PO QID\n Protonix\n Fluticasone, Montelukast\n Nortriptyline\n Fentanyl patch\n Plavix 75 daily, simvastatin\n SQ heparin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough, Dyspnea, Wheeze, improved\n Neurologic: anxious\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: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 68 (62 - 95) bpm\n BP: 154/67(87){132/58(78) - 187/104(112)} mmHg\n RR: 23 (17 - 30) insp/min\n SpO2: 94% on 2L NC\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 652 mL\n 343 mL\n PO:\n 360 mL\n 75 mL\n TF:\n IVF:\n 292 mL\n 268 mL\n Blood products:\n Total out:\n 1,115 mL\n 410 mL\n Urine:\n 1,115 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -463 mL\n -67 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilateral, Wheezes :\n few)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 377 K/uL\n 14.4 g/dL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n CXR no recent chest film\n Micro\n blood cx x2 negative\n urine cx negative\n sputum gram <10 polys no organisms on gram, culture with sparse\n growth oropharyngeal flora\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 342\n 389\n 382\n \n Cr\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n - s/p extubation , at baseline O2 requirement but dyspneic\n with the minimal activity\n - continue treatment of COPD and pneumonia as below\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n - continue prednisone taper, bronchodilators, singulair and\n flonase\n - Treat anxiety as it appears to be contributing to dyspnea\n and HTN; zyprexa \n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n - continue ceftriaxone day 8 of 10 day course (day 1 = ),\n s/p azithromycin x5 days\n - leukocytosis most likely from steroids and not from\n infection\n - reculture if febrile\n HYPERTENSION, BENIGN\n Improved BP control yesterday, but still up to 180s systolic\n - continue metoprolol, captopril, diltiazem with prn\n hydralazine\n - ? to steroids and anxiety given that she is not on\n anti-hypertensives at baseline\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr at baseline\n (0.6); resolved follow urine output\n TACHYCARDIA, OTHER: Resolve with CCB/beta blocker\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue statin, plavix; now on beta blocker and ACE I\n - not on ASA as outpatient--? b/c of h/o gastric ulcer; will\n discuss with PCP\n ICU \n Nutrition: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: PPI\n VAP: n/a\n Communication:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2204-12-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315836, "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 OOB this am\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:28 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 Respiratory: Dyspnea, Tachypnea\n Heme / Lymph: Anemia\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 11:23 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: 36.4\nC (97.6\n HR: 82 (59 - 95) bpm\n BP: 152/65(83){135/58(78) - 187/104(112)} mmHg\n RR: 19 (14 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 652 mL\n 499 mL\n PO:\n 360 mL\n 195 mL\n TF:\n IVF:\n 292 mL\n 304 mL\n Blood products:\n Total out:\n 1,115 mL\n 510 mL\n Urine:\n 1,115 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n -463 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: frail\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion:\n Hyperresonant: ), (Breath Sounds: Crackles : mid-insp, Diminished: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 14.4 g/dL\n 377 K/uL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 342\n 389\n 382\n \n Cr\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n anxious but somewhat better with Zyprexa\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - resolved\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: SSI on steroid taper\n Lines:\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Rehab or floor\n Total time spent: 35\n" }, { "category": "Physician ", "chartdate": "2204-12-31 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 315837, "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 OOB this am\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Ceftriaxone - 02:00 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:28 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 Respiratory: Dyspnea, Tachypnea\n Heme / Lymph: Anemia\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 11:23 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: 36.4\nC (97.6\n HR: 82 (59 - 95) bpm\n BP: 152/65(83){135/58(78) - 187/104(112)} mmHg\n RR: 19 (14 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 50.9 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 652 mL\n 499 mL\n PO:\n 360 mL\n 195 mL\n TF:\n IVF:\n 292 mL\n 304 mL\n Blood products:\n Total out:\n 1,115 mL\n 510 mL\n Urine:\n 1,115 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n -463 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: frail\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion:\n Hyperresonant: ), (Breath Sounds: Crackles : mid-insp, Diminished: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 14.4 g/dL\n 377 K/uL\n 104 mg/dL\n 0.6 mg/dL\n 39 mEq/L\n 4.2 mEq/L\n 32 mg/dL\n 97 mEq/L\n 142 mEq/L\n 46.5 %\n 17.9 K/uL\n [image002.jpg]\n 04:56 AM\n 05:51 AM\n 05:36 PM\n 04:32 AM\n 07:52 AM\n 03:11 AM\n 12:58 PM\n 06:43 AM\n 03:46 AM\n 05:07 AM\n WBC\n 17.6\n 14.9\n 18.2\n 18.4\n 17.7\n 17.9\n Hct\n 37.9\n 40.5\n 42.1\n 41.4\n 43.7\n 46.5\n Plt\n 342\n 389\n 382\n \n Cr\n 0.7\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 34\n 36\n 41\n 44\n Glucose\n 117\n 150\n 99\n 127\n 104\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:94.8\n %, Lymph:2.4 %, Mono:2.6 %, Eos:0.1 %, Ca++:9.3 mg/dL, Mg++:2.1 mg/dL,\n PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n anxious but somewhat better with Zyprexa\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n continues on xoponex and atrovent\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n cont on antibiotics, afebrile\n HYPERTENSION, BENIGN\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - resolved\n TACHYCARDIA, OTHER\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n ICU Care\n Nutrition:\n Glycemic Control: SSI on steroid taper\n Lines:\n 22 Gauge - 03:07 PM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Rehab or floor\n Total time spent: 35\n" }, { "category": "Physician ", "chartdate": "2204-12-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 315349, "text": "Chief Complaint: Dyspnea/COPD\n 24 Hour Events:\n CALLED OUT but not sent to floor poor air movement. added\n fluticasone-salmeterol\n tapering steroids\n hypertensive with tachycardia so started on diltiazem\n became acutely dyspneic with desat to 89% on 2L at 6:45am; started on\n nebs and O2 increased\n reaffirmed that she would be want to be intubated if necessary\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Diltiazem - 10:10 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 Constitutional: tired\n Respiratory: Dyspnea\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.3\n HR: 106 (101 - 122) bpm\n BP: 169/83(104){143/66(85) - 176/96(112)} mmHg\n RR: 20 (16 - 31) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 49 kg (admission): 49 kg\n Height: 63 Inch\n Total In:\n 3,267 mL\n 895 mL\n PO:\n 840 mL\n TF:\n IVF:\n 2,427 mL\n 895 mL\n Blood products:\n Total out:\n 1,495 mL\n 715 mL\n Urine:\n 1,495 mL\n 715 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,772 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.36/58/69/28/4\n Physical Examination\n General Appearance: Thin, working hard to breathe\n Eyes / Conjunctiva: pupils equal\n Head, Ears, Nose, Throat: face mask with albuterol treatment\n Cardiovascular: (S1: Normal), (S2: Normal), tachycardic, regular\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, Paradoxical), (Breath\n Sounds: Diminished: at bases), +accessory muscle use; +kyphosis and\n deformity of sternum; very tight with wheezes throughout\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, Rash: erythematous macules on feet\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 342 K/uL\n 11.9 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 16 mg/dL\n 103 mEq/L\n 140 mEq/L\n 37.9 %\n 17.6 K/uL\n [image002.jpg]\n 04:25 AM\n 02:06 AM\n 04:56 AM\n 05:51 AM\n WBC\n 8.2\n 17.6\n Hct\n 41.5\n 37.9\n Plt\n 336\n 342\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n TCO2\n 34\n Glucose\n 159\n 148\n 117\n Other labs: CK / CKMB / Troponin-T:21/4/<0.01, Differential-Neuts:93.4\n %, Lymph:4.4 %, Mono:1.9 %, Eos:0.1 %, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n 61yo woman with COPD admitted with dyspnea and possible bronchitis.\n Respiratory failure/ CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n - Acute worsening this morning; monitor closely for need to\n intubate\n - continue azithromycin and ceftriaxone for possible\n bronchitis\n - continue solumedrol 125mg IV q8h\n - continue albuterol, flonase, and atrovent\n will switch to\n MDI if intubated\n - on singulair\n - f/u sputum cx\n - has had positive fluid balance since admission with\n worsening respiratory status and elevated BP, so may be volume\n overloaded. Will give trial of diuresis with lasix while observing Cr\n closely\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n - baseline Cr 0.6, current Cr 0.7\n - improving with IV fluids; has good urine output\n - currently suspect that she is volume high, so will diurese\n and watch Cr closely\n TACHYCARDIA, OTHER\n - has been tachycardic in past during COPD exacerbations; this\n is likely due to sympathetic outflow in setting of acute illness as\n well as albuterol side effect\n - continue levalbuterol\n - monitor on telemetry\n # HTN:\n - continue diltiazem for control of elevated BP as needed\n - note that she may require decreased doses if sedated for\n intubation\n # Leukocytosis\n - most likely secondary to steroids\n - continue to treat possible bronchitis\n - UA negative for evidence of infection\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - second set of cardiac enzymes negative; has no chest pain\n - continue ASA, plavix, statin\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Osteoporosis\n - continue calcium, vitamin D\n - pain control per home regimen with fentanyl patch,\n mortryptiline, percocet prn\n ICU Care\n Nutrition:\n Comments: regular diet; if intubated, will put on tube feeds\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 06:09 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: mouth care if intubated\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code ; states that she would not want tracheostomy\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2204-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 315418, "text": "Ms is a 61 yo F with PMH significant for COPD, CAD, s/p MI x3,\n PCTA 01 & 05, HTN, hyperlipidemia, gastritis & osteoporosis, who\n presented to the EW on with worsening dyspnea. She was admitted\n to the ICU and course was uncomplicated and pt was called out to floor\n on . On AM of , pt was experiencing worsening dyspnea and\n asked to be intubated. Pt had also been hypertensive during the episode\n of worsening dyspnea. Pt was electively intubated and placed on\n mechanical ventilation, pt was also dosed with furosemide for positive\n fluid balance.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS are diminished with intermittent exp wheezes\n AC 16x500x0.4/+5\n Overbreathing vent 3-4 bpm\n Suctioning small amts thick white sputum\n Action:\n Aggressive pulmonary toilet\n Continue MDIs\n Wean resp support as tolerated\n Daily RSBI and SBT\n Response:\n Pt indicates increased comfort and decreased WOB\n Plan:\n Continue to monitor respiratory status\n Continue resp support as needed\n Wean resp support as tolerated\n Daily RSBI and SBT\n Continue steroids and ABX as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt has had positive fluid balance > 48h\n Creatinine stable at 0.7-0.8\n Urine output has been dropping\n Action:\n Dosed with 20mg IV furosemide x1\n Response:\n Urine output improved transiently\n AM Hct 40.5 up from 37.9\n Plan:\n Continue to monitor urine output\n Continue to follow creatnine\n" } ]

[ { "category": "Nursing/other", "chartdate": "2149-11-07 00:00:00.000", "description": "Report", "row_id": 1336308, "text": "Micu Acceptance Note and Review of Systems\n\n83 yo female with hx of htn, cad and ? afib admitted with ICH. Pt was eating dinner with her family when at 1730 she slumped over anf fell to the floor. She was able to respond to simple commands when EMS arrived and was brought to Hosp where a CT showed a large putamenal/capsular bleed on the R. She was moving purposefully but not following commands. She was loaded on mannitol and dilantin, intubated and sent to for further mgt. Pt is Full .\n\nReview of Systems\n\nNeuro - Pt with no response to verbal stimuli. Withdraws and localizes to pain on the right, withdraws left leg less than right and withdraws left arm weakly. + gag, + weak corneal reflexes. R pupil 1 mm, L irregular ( surgical). Mannitol administered q 4 hrs. Pt had repeat CT prior to arrival to MICU - results unknown. HOB elev 30 degrees. Pt medicated with 50 mcgs fentanyl after becoming agitated and grimacing when aline insertion attempted.\n\nResp - Intubated on CMV 450 x 16 5 peep 50%. RR 16-18. LS clear. 02 sat 100%. Sx for scant amts thin white secretions.\n\nC-V - HR 37-60 afib with slow vent response. HR increases with stimulation. Dig level .7. EKG in ER without acute changes. Cardiac enzymes being cycled, first set neg. Second set to be sent at 0530 and third set needs to be sent at 1330. Pt ordered for nipride to titrate SBP 140-160. Nipride not initiated as BP 115-140/40-60 and no aline access available. NBP checked q 15 mins. + distal pulses. No edema. Hct 36.1. INR 1.2\n\nF/E - Pt given 500cc NS fluid bolus on arrival for BP 110/70. As per above receiving iv mannitol q 4hrs. Voiding 50-100ccs/hr clear yellow urine via foley cath.\n\nGI - Abd soft and mildly distended. Hypoactive BS. NPO. OGT clamped.\n\nProphylaxis - pneumoboots, protonix.\n\nEndo - RISS\n\nSkin/MS - Quarter sixed abrasion noted on thoracic spine. R scapular area has abrasion with a blackened scab. Pt not placed on c-spine precautions. ER RN, fall was witnessed and not traumatic.\n\nAccess - 2 peripheral #18 angios, L femoral multi-lumen. Several unsuccessful attempts were made to place an aline.\n\nSocial - Dtr visited and updated on pts condition by RN and MD. has been under alot of stress lately as her husband has dz.\n\nA+P - Continue to assess neuro status closely. Initiate nipride for SBP > 160. Monitor C-V and f+e status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-11-07 00:00:00.000", "description": "Report", "row_id": 1336309, "text": "RESP CARE: Pt recieved intubated/ on vent with settings as follows: CMV/16/450/.50/5PEEP. Coarse lungs bilat. Sxd thick white secretions. No RSBI due to apnea at this time\n" }, { "category": "Nursing/other", "chartdate": "2149-11-07 00:00:00.000", "description": "Report", "row_id": 1336310, "text": "Respiratory Care Note:\n Patient remains intubated, off sedation and minimally responsive. BS bilat with good aeration. She has been on PSV today, now with increased periods of apnea, RN. Patient changed over ot MMV for back up support as needed. See vent data screen for spontaneous breathing info.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-07 00:00:00.000", "description": "Report", "row_id": 1336311, "text": "Nursing Progress Note 0700-1900\nPt remains minimally responsive to stimuli. repeat head CT showed no significant change from previous dx of large R temporal bleed. Pt has been intermittently bradycardic down to rate of 38-40. Febrile w/ Tmax 100.9 (?d/t hypothalamic injury).\n\nROS-\n\nCV- A fib w/ slow vent response, rate 40-60. ? new dx of afib. not heparinized. cardiac enzymes cycled, neg. for MI. BP stable at 110-140's/30-50's. has not needed Nipride to keep SBP <150. previously on Digoxin, am dig level =0.70. INR 1.2. hct stable at 36.1\n\nRESP- recieved pt on SIMV, placed on PS 10/5/40% and had poor minute volumes of 2-3L/min, placed on MMV, continued to have decreased MV's, so pt placed back on SIMV 10X450/40%/5. Pt had periods of ?apnea. suctioning small amt thick yellow secretions. CXR yesterday unremarkable. LS clear, decreased in bases. will need f/u CXR (?aspiration -pt eating dinner when bleed occured).\n\nNEURO- q 1hr neuro checks. Pt moves R extermities, not moving left. Right arm restrained, makes attempts to reach toward ETT. pupils= L eye surgical, R eye pinpoint and sluggish to react. not following commands and has not opened her eyes. has recieved no sedation this shift. Loaded w/ mannitol and dilantin in ED\n\nGI/GU- NPO, OGT clamped. hypoactive to absent BS's. Foley draining 50-80cc/hr clear yellow urine. IVF at TKO.\n\nACCESS- Piv X1. TLC in L fem. previous attempts at A line unsuccessful.\n\nSOCIAL- daughter updated on condition/ pronosis. plan to meet w/ team tonoc to discuss code status and tx plan.\n\nPLAN- elevate HOB >30deg. keep Sbp <150. ? add amiodarone vs. cardioversion of afib. q 1hr neuro checks.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-09 00:00:00.000", "description": "Report", "row_id": 1336318, "text": "Micu Nursing Progress Notes\nResp: Pt maintained on A/C 450 x 12, Peep 5, FiO2 35%. Suctioned frequently for thick tan secretions. She failed the RSBI this am by increasing her B/P to 165/50, HR 80 and she had increased apnea periods. There were no further attempts to wean her during the day.\n\nCardiac: When left alone her B/P was 120-130, with HR 60'd. If she is quiet her HR dropped to the 30's but lasted a short time (seconds). When stimulated her B/P increases to 160-170/70's HR 80's. Around 1400 the brady episodes started increasing. By 1500 her HR was 32-44. SICU resident was called and ordered a head CT to check the status of her head bleed.\n\nNeuro: Neuro status unchanged with her intermittantly responding to verbal command. She is moving the right more than the left. She opened her eyes for the first time at 1600 but she continued to be extremely bradycardic. The head CT showed worsening status with mass effect edema and progressing to herniation. Neuro states there is nothing to do.\n\nGU: Foley draining dark yellow urine. IVF continues of NS with 20 meq Kcl at 80cc/hr.\n\nGI: remains NPO, (+) bowel sounds, No stool\n\nSocial: Daughter called for an update midday and stated that she would be up to visit but so far she has not arrived. She doesn't know the results of the CT scan.\n\nPlan: Monitor neuro status for possible herniation, inform and support the daughter with the change of status.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-10 00:00:00.000", "description": "Report", "row_id": 1336319, "text": "MICU NURSING PROGRESS NOTE 7 PM TO 7AM.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Arouses to stimulation, moves rt upper extrem. and bilat lower extrem. but does not open eyes. Will follow commands and at present appears to understand all that is occurring. No indicationsof discomfort. Temperature max. 98.9 oral.\n\n Respiratory: Lung sounds are ocarse in upper fields, diminished in lower fields bilat. Ventilator settings were assist control but at present are ps .30/0/5. RR is 14-20 with O2 saturation 98-100% Tolerating well at present. Suctioned several times for sm to mod. amts thick yellow sputum.\n\n CV: Af with rare to occn ectopy, rate in 50's to 80's with numerous episodes of severe bradycardia into high 20's. Abp very labile from low 100's to 180's systolic. Aline is positional at times with poor waveform. Ivf ns with 20meq kcl at 80cc/hr.\n\n GI/GU: Abdomen soft with + bs. Ogt in place, clamped. No bm this shift. Foley catheter patent and draining concentrated urine in poor amts.\n\n Plan: Monitor hr, provide comfort and empathy to family.\n\n CT: Ct done yesterday showed mass effect with herniation. No intervenions that can assist.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-08 00:00:00.000", "description": "Report", "row_id": 1336312, "text": "NPN 7PM-7AM\n\nNO MAJOR NEUROLOGICAL CHANGES OVERNOC. HR BECAME MORE BRADYCARDIC THROUGHOUT THE NIGHT 45-50'S. PT CODE STATUS CHANGED TO DNR PER WISHES OF FAMILY.\n\nNEURO: NEURO CHECKS Q 1-2 HOURS. NO CHANGES NOTED. RIGHT SIDE CONTINUES TO HAVE MOVEMENT, MAINLY NONPURPOSEFUL. LEFT LEG AND ARM MINIMALLY WITHDRAW TO PAINFUL STIMULI. PT DOES NOT FOLLOW COMMANDS. PT HAS NOT OPENED EYES. RT PUPIL 2-3MM AND BRISK. LEFT PUPIL, SURGICAL AND NON REACTIVE. GAG REFLEX ABSENT.\n\nCV: HR AFIB 53-84, ALTHOUGH PT NOTED TO BECOME BRADYCARDIC TO 38 AT TIME. BP REMAINS STABLE 99-150/29-60. K 3.4, MG 1.9. NO REPLETION. HCT STABLE 38.9%\n\nRESP: REMAINS ON SIMVX12 (RR 16-18)/450/40/5. LS DIMINISHD @ BASES. SXNED Q 2-4 HOURS FOR THICK YELLOW SPUTUM.\n\nGI/GU: OGT REMAINS CLAMPED. ? STARTING TF SOON. NUTRITION REC SEEN IN CHART. LOW URINE OUTPUT. DR. AWARE AND LR STARTED @ 80CC/HR. PT CURRENTLY NEG. LOS.\n\nID: TMAX 99.2. PT IS NOT ON ANTIBX.\n\nSKIN: 2 ABRASIONS NOTED ON BACK. CONTINUE TO MONITOR.\n\nSOCIAL: DR. SPOKE C DAUGHTER AND SON AND UPDATED THEM ON PT'S CONDITION AND PROGNOSIS. DR. ALSO SPOKE C THEM REGARDING CODE STATUS AND THEY AGREED TO MAKING PT DNR.\n\nDISPO: REMAIN IN MICU. DNR\n" }, { "category": "Nursing/other", "chartdate": "2149-11-08 00:00:00.000", "description": "Report", "row_id": 1336313, "text": "Respiratory Care Note:\n Patient more responsive today, following simple commands. She is tolerating PSV without apneic periods. See Carevue flowsheet. Plan; to consider extubation tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-08 00:00:00.000", "description": "Report", "row_id": 1336314, "text": "Micu Nursing Progress Notes\nResp/cardiac: Pt was on a spontaneous breathing trial when received this am. She had a TV of ~300cc but within the hour her TV dropped to the 200cc and her B/P increased to 160's/75, HR 76 so she was changed from the PSV 5/Peep0 to PSV 10 and her B/P dropped to 135/39,HR 57. She was dropped to PS 5 but she again became hypertensive w/i 3h so was increased to 7 then 10 PSV before her B/P returned to her BL of 130-140/40, HR 60's. She remained on PSV 10/Peep5 with FIO2 of 40% but had episodes of apnea when sleeping. She may need to go back to A/C overnight if periodic apnea continues. She was suctioned q3-4h for mod amount of thick yellow/tan secretions. She was repleted with 2 gm MgSO4, 2 gm calcium gluconate, and 20 meq Kcl.\n\nGI: Tube feedings started with Promote with fiber at 20cc/hr. Abd soft and non tender, (+) BS, No stool.\n\nGU: Foley draining clear yellow urine, U/O increased after the bolus of 500cc NS but started to fall again. Started on NS with 20meq KCL at 80cc/hr. Her U/O ended at about 30cc/hr.\n\nNeuro: Pt responding to commands inconsistantly. She wiggled her toes to command and appeared to \"look\" in the direction when her name was called. She has not opened her eyes even to command. Her right side is stronger than her left and her left leg seems stronger than her left arm.\n\nSocial: Daughter called to inquire about her mother but was not comming in today. She stated she will be in tomorrow. She was informed of her mothers condition and her questions answered.\n\nPlan: Possible extubation tomorrow so hold tube feedings at midnight. Continue to try and wean off vent.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-09 00:00:00.000", "description": "Report", "row_id": 1336315, "text": "Nursing Progress Note 1900-0700\nVent settings changed to AC 12X450/40%/5 after pt became increasingly hypertensive and tachycardic on PS. was also experiencing period of apnea. No change in neurological status. hemodynamically stable. see below.\n\nROS-\n\nCV- Afib w/ rate 50-60 while asleep, does continue to frequently brady down to 37-40 at X's. HR up to 80-90's w/ stimulation. had one episode of tachy at 170's for a few seconds. BP stable at 120-150's/30-50's, has not needed nipride gtt. EKG repeated and more cardiac enzymes sent d/t last troponin of 0.13 (from ). repeat EKG shows ?T wave elevation. am K 3.8. hct stable at 37.3 Tmax 99.7.\n\nRESP- suctioning thick blood-tinged yellow secretions q2-4hrs. strong cough. LS diminished at bases. vent setting as above. Pt has been NPO since MN for ?extubation today. am CXR to r/o aspiration pnm. While doing mouth care, food contents were removed from mouth. ?whether pt aspirated food when ICH occured.\n\nNEURO- q2hr neuro checks. not consistently following commands, will occasionally weakly squeeze her R hand. move R extremities on bed, but no movement note of L extremities. has not opened her eyes. R pupil 2 and sluggish, L surgical. cough and gag present.\n\nGI/GU- NPO since MN. otherwise TF, promote w/ fiber, was at 30cc/hr w/ goal rate of 40cc/hr. good residuals <30cc. hypoactive BS's. no stool. foley draining approx 25-40cc/hr dark yellow colored urine. IVF = NS w/20K at 80cc/hr.\n\nSKIN- old abrasions to back. R scapular abrasion covered w/ DSD. skin thin and dry, otherwise intact.\n\nSOCIAL- no calls or visits from family overnoc.\n\nPLAN- ? attempt at extubation. Pt is DNR/DNI, having apneic periods, does not tolerate PS mode for long periods of time. f/u on am CXR and troponin. restarted TF once decision is made not to extubate. q2hr neuro checks. ?echocardiogram. continue to provide pt and family w/ encouragement and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-11-09 00:00:00.000", "description": "Report", "row_id": 1336316, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN CMV MODE, CHANGED FROM CPAP/PS DUE TO APNEA. PT WELL IN SYNCH W/VENT, NARD. BS GROSSLY CLEAR, SXN FOR SM AMT YEL SEC. NO RECENT ABG, SPO2 98-100%. OVERBREATHING VENT BY 5-10BPM. RSBI 56.7 THIS AM, SBT STARTED @ 0515M ABORTED @ 0600 DUE TO HYPERTENSION TO 165. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-09 00:00:00.000", "description": "Report", "row_id": 1336317, "text": "Respiratory Care Note:\n Patient remains intubated and on full vent support today due to failed RSBI, SBT and increased periods of apnea off support. Arterila line placed today and ABG with noramal acid-base status, hyperoxic on 40%, FIO2 decreased to 30%. Patient with thick yellow secretions, changed to a heated wire circuit to increase humidity. Will maintain.\n" }, { "category": "Radiology", "chartdate": "2149-11-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808582, "text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: is there any infiltrate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH, extubated now with aspiration event\n REASON FOR THIS EXAMINATION:\n is there any infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE.\n\n INDICATION: 83 year old woman with aspiration, intracranial hemorrhage.\n\n COMMENTS: Portable AP radiograph of the chest was reviewed, and compared with\n a study of yesterday.\n\n There is continued mild pulmonary edema with cardiomegaly. There is continued\n patchy opacity seen in the right lower lobe indicating pneumonia vs.\n aspiration.\n\n A feeding tube terminates in the descending duodenum. No pneumothorax is\n identified.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808074, "text": " 8:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MS , EVAL FOR CHANGES\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH\n\n REASON FOR THIS EXAMINATION:\n evaluate for changes - please get scan at 0700 \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage. Assess interval change.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISONS: Head CT .\n\n FINDINGS: The right temporal hemorrhage is unchanged in size, density, or\n amount of associated mass effect. There is no evidence of new bleeding. The\n previously described scattered foci of high density are again noted. They are\n located in the subarachnoid spaces, and they may be secondary to residual\n pantopaque contrast from a prior myelogram or cisternogram. Alternatively,\n these could be parenchymal calcifications, as discussed in the previous\n report.\n\n IMPRESSION: Stable appearance of right temporal hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808751, "text": " 10:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess progression of aspiration PNA/pneumonitis, CHF\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH, s/p aspiration\n REASON FOR THIS EXAMINATION:\n Assess progression of aspiration PNA/pneumonitis, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 83-year-old woman with intracranial hemorrhage status post\n aspiration.\n\n COMMENT: Portable AP radiograph of the chest was reviewed and compared to the\n previous study of .\n\n There is increase in bilateral multifocal consolidation involving the left\n lower lobe, right lower lobe, and right upper lobe indicating aspiration\n pneumonia. The tip of the feeding tube is identified in the descending\n duodenum. The patient has prior cholecystectomy. The heart is normal in\n size. There is no evidence of pneumothorax. There is a small right pleural\n effusion.\n\n IMPRESSION: New multifocal consolidation indicating aspiration pneumonia. A\n small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808235, "text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH s/p intubation, ?aspiration\n\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 83-year-old woman with intracranial hemorrhage, question\n aspiration.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed and compared to the\n previous study of .\n\n The tip of the endotracheal tube is identified at the thoracic inlet. A\n nasogastric tube is coiled within the stomach. There are increased diffuse\n opacities, probably due to pulmonary edema or volume overload. The\n possibility of aspiration is also considered. No pneumothorax is identified.\n The heart is normal in size. There is continued tortuosity of the thoracic\n aorta with calcification. The patient has prior cholecystectomy.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808290, "text": " 5:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: continued mental status changes and bradycardia in woman wit\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH\n\n REASON FOR THIS EXAMINATION:\n continued mental status changes and bradycardia in woman with known head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: f/u intra parenchymal hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Comparison is made with the study from . Again\n identified is a large focus of intraparenchymal hemorrhage originating in the\n right insular cortex. The size of the bleed is unchanged. There is slight\n interval increase in the amount of surrounding edema and mass effect, with\n minimal leftward subfalcine herniation. The intraparenchymal calcifications\n are unchanged in appearance. -white matter differentiation remains\n preserved.\n\n IMPRESSION: Worsening mass effect adjacent to patient's known\n intraparenchymal hemorrhage.\n\n Findings were discussed with Dr. , at 6:30 PM on .\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808784, "text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: to assess location of PICC tip inserted in patient's left ba\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH, s/p aspiration.\n REASON FOR THIS EXAMINATION:\n to assess location of PICC tip inserted in patient's left basilic vein. Please\n notify IV nurse at beeper number 9-2439. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Inserted PICC line. Assess position.\n\n CHEST AP: Comparison is made to a film obtained 5 hours earlier. The tip of\n the left PICC line is in the distal SVC. No pneumothorax is seen. There is\n unchanged bilateral multifocal consolidation mainly in the right middle lobe\n but also involving the right lower lobe and right upper lobes. Persistent\n aspiration pneumonia. The tip of the Dobbhoff tube is in the stomach. There\n is evidence of prior cholecystectomy. The heart size is normal. There is no\n pneumothorax.\n\n IMPRESSION: Satisfactory position of the left PICC line. Unchanged\n appearance of aspiration pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808499, "text": " 11:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 83 year old woman with ICH, extubated w/ new doboff placemen\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH, extubated w/ new doboff placement\n REASON FOR THIS EXAMINATION:\n 83 year old woman with ICH, extubated w/ new doboff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placement. Evaluate for position.\n\n COMPARISON: .\n\n CHEST, PORTABLE AP: The tip of the Dobbhoff is visualized in the distal\n stomach. There is interval removal of the ETT. No pneumothorax is seen.\n There is mild enlargement of the left ventricle. Tortuosity of the thoracic\n aorta with calcification is again visualized. The hila are prominent with\n some upper zone redistribution of the pulmonary vasculature. A small left\n sided pleural effusion is also visualized. The patient has had a\n cholecystectomy.\n\n IMPRESSION: Appropriate position of the Dobbhoff tube. Mild congestive heart\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808043, "text": " 9:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: head, assess size of ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH\n REASON FOR THIS EXAMINATION:\n head, assess size of ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: In the right basal ganglia and extending into the temporal and\n frontal lobes, there is a region of high attenuation measuring approximately\n 4.4 x 3.2 cm consistent with a parenchymal hemorrhage. There is low\n attenuation surrounding this, which is associated edema. There is effacement\n of the adjacent sulci and narrowing of the right lateral ventricle. The\n temporal of the right lateral ventricle is not enlarged and therefore\n there does not appear to be obstruction associated with the mass effect. There\n is slight shift of the midline structures at the level of the thalami. The\n suprasellar cisterns are not effaced. The -white matter differentiation\n is preserved. There is hypoattenuation of the periventricular white matter\n consistent with chronic microvascular infarction. There are multiple coarse\n calcifications which are predominantly subcortical in nature bilaterally in\n the cerebral hemispheres.\n\n The bones and soft tissues are unremarkable. There is mucosal thickeing in\n the lateral aspect of the right sphenoid sinus. The remainder of the\n paranasal sinuses and the mastoid air cells are clear.\n\n IMPRESSION:\n 1) Large parenchymal hemorrhage in right temporal lobe with associated edema\n and mass effect as described. There is no evidence of herniation associated\n with the mass effect. Note is also made of a trace amount of subarachnoid\n blood running along adjacent sulci posteriorly.\n\n 2) Scattered subcortical coarse calcifications throughout both cerebral\n hemispheres which may relate to prior history of infectious or treated\n neoplastic process, or prior hemorrhages - clinical correlation is\n recommended.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-12 00:00:00.000", "description": "PL VENOUS DUP EXT UNI (MAP/DVT) PORT LEFT", "row_id": 808609, "text": " 1:37 PM\n VENOUS DUP EXT UNI (MAP/DVT) PORT LEFT Clip # \n Reason: Does this patient have a left upper extremity DVT?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with left arm edema\n REASON FOR THIS EXAMINATION:\n Does this patient have a left upper extremity DVT?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left arm edema.\n\n VENOUS DUPLEX ULTRASOUND OF LEFT UPPER EXTREMITY: scale and Doppler\n son of the left internal jugular, subclavian, axillary, cephalic,\n brachial and basilic veins were performed. Normal flow, augmentation,\n compressibility and waveforms are demonstrated. Intraluminal thrombus is not\n identified.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808042, "text": " 9:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess intubation tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH s/p intubation\n REASON FOR THIS EXAMINATION:\n assess intubation tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage. Status post intubation.\n\n PORTABLE AP CHEST: The endotracheal tube is well positioned approximately 3\n cm above the carina. An NG tube is coiled in the stomach. The\n cardiomediastinal and hilar contours are unremarkable. The lungs demonstrate\n a diffuse interstitial pattern of opacification consistent with mild pulmnory\n edema. There are no pleural effusions or pneumothorax. The bones are\n unremarkable.\n\n IMPRESSION:\n 1. Mild congestive heart failure.\n 2. Well positioned endotracheal tube approximately 3 cm above the carina.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-11-10 00:00:00.000", "description": "Report", "row_id": 1336320, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN CMV MODE, WELL IN SYNCH W/VENT, BREATHING OVER VENT BY 2-7BPM. PT EXPERIENCING BRADYCARDIC EPISODES, HTN ALSO NOTED. BS GROSSLY CLEAR, OCCAS SL COARSE, SXN FOR SM AMTS THIN PALE YEL SEC. AM ABG NOT YET AVAILABLE, RSBI 52.4. SBT STARTED @ 0445. PLAN TO ASSESS FOR POSSIBLE EXTUBATION PENDING SUCCESSFUL COMPLETION OF SBT.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-10 00:00:00.000", "description": "Report", "row_id": 1336321, "text": "Resp. Care Note\nPt received on SBT of PSV 5 peep 0 and 30%. Pt did well on this with ABG 7.42/33/81/26/1. Pt remained on SBT almost 4 hrs and then placed on PSV 10 peep 5 for a time while Pt diuresed to lasix given. Pt sxn for sm-mod. amount of tannish secretions, cough effort with sxn but gag impaired. Decision made to extubate pt in afternoon and not to reintubate. Pt following some commands. Placed on 40% face tent post-ext.\n" }, { "category": "Nursing/other", "chartdate": "2149-11-10 00:00:00.000", "description": "Report", "row_id": 1336322, "text": "Nursin gProgress Note 0700-1900\nReview of Systems:\n\nEvents: Extubated @ 1530 without incident. Started on Lisinopril QD.\n\nNeuro: Pt responding more consistantly to verbal stimuli, usually opening eyes and squeezing right hand to command. No movement from left side seen, raising right arm/leg off bed briefly. No verbalization. After extubation, pt removing O2 mask so right hand remains restrained.\n\nResp: Sating 95-99% with face tent @ 50%. RR 15-27 and unlabored. Pt initiating strong cough, but requiring oral suctioning to totally clear oral secretions. Gag impaired. Lungs coarse throughout. Rec'd Lasix 40mg X 1 with resulting urine output of 2+liters.\n\nCV: HR 43-85Afib with rare PVC's. BP 132/65-184/80, trending down after pt rec'd Lisinopril 5mg. After receiving Lasix, K+ of 3.1 repleted with total of 80meq KCl.\n\nGI: OGT removed, pt has remained NPO. Bowel snds +, no stool.\n\nGU: Urine output good per carevue. 24hr net balance -1595ml with LOS balance +330ml.\n\nSocial: Son/dgtr called. Dgtr to visit pt this pm. Son caring for father with end-stage . Son reports one of pt's sisters died last year, and other sister is dying in another hospital. Son stated that he has been in touch with social sxs for care of pt's husband/family support.\n\nPlan: transfer to floor in am. DNR/DNI.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-11-11 00:00:00.000", "description": "Report", "row_id": 1336323, "text": "MICU NURSING PROGRESS NOTE. 7PM TO 7AM.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Arouses to stimuli, did open eyes on several occn. and nodded head weakly in response to yes/no questions. Rt pupil 2mm and brisk, lt surgical. No speach. Lift and holding rt upper extrem., rt lower extrem. Temperature max. 98.3 axillary.\n\n Respiratory: Lung sounds are coarse throughout. RR 16-28 and non labored. Congested, non productive cough. Suctioned several times throughout for sm to moderate amts thick tan/yellow sputum. Appears to be tolerating extubation well.\n\n CV: Af with no ectopy noted, rate mid 50's to low 100's. Abp 120's to 180's systolic. Aline difficult to draw off of. Brachial A line site bruised. Labs drawn and sent this am.\n\n GI/GU: Abdomen soft with + bs. No bm this shift. Remains npo.\nFoley catheter patent and draining clear amber urine in inadequate amts.\n\n Social: Daughter and her husband in to visit pt last PM. Several calls made to team to come and speak with family. Very concerned about the differing prognosis they are recieving from different sources. Advised family that team will call them when they are free from trauma. Family still awaits call as of this am.\n\n Plan: transfer pt to floor today? Have team contact family, Have social services become involved with family as there are several family members that are sick and hospitilized.\n" }, { "category": "ECG", "chartdate": "2149-11-07 00:00:00.000", "description": "Report", "row_id": 193558, "text": "Atrial fibrillation, mean ventricular rate 63. Compared to the previous tracing\nof left axis deviation is no longer present, a non-specific finding.\n\n" }, { "category": "ECG", "chartdate": "2149-11-06 00:00:00.000", "description": "Report", "row_id": 193559, "text": "Atrial fibrillation with a slow ventricular response. Left anterior fascicular\nblock. Borderline intraventricular conduction delay. No previous tracing\navailable for comparison.\n\n" }, { "category": "ECG", "chartdate": "2149-11-09 00:00:00.000", "description": "Report", "row_id": 197328, "text": "Atrial fibrillation with a controlled ventricular response. Low limb lead\nvoltage. Q-T interval prolongation. Prominent U waves. Tall peaked precordial\nT waves as recorded on . The ventricular response has slowed.\nOtherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2141-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199984, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval rt apical ptx\n Admitting Diagnosis: AORTIC STENOSIS\\RE-DO STERNOTOMY, AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n eval rt apical ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: To evaluate right pneumothorax.\n\n TECHNIQUE: Portable AP radiograph of the chest.\n\n Comparison was made with prior radiograph through , the most\n recent being .\n\n FINDINGS: There is no demonstrable pneumothorax on the radiograph. Bibasilar\n atelectasis and left lower volume loss have improved since .\n Cardiac size is borderline. The mediastinal silhouette is normal.\n\n IMPRESSION: There is no demonstrable pneumothorax on the radiograph, improved\n bibasilar atelectasis and left lower lobe volume loss.\n\n" }, { "category": "Radiology", "chartdate": "2141-07-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199437, "text": " 9:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o collection\n Admitting Diagnosis: AORTIC STENOSIS\\RE-DO STERNOTOMY, AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man s/p avr with ooziness,labile hemodynamics\n REASON FOR THIS EXAMINATION:\n r/o collection\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:15 P.M., \n\n HISTORY: AVR and labile hemodynamics. Rule out fluid collection.\n\n IMPRESSION: AP chest compared to only prior postoperative chest radiographs,\n at 1:32 p.m.:\n\n Moderate right pleural effusion has increased. Normal postoperative\n appearance of the cardiomediastinal silhouette is stable. Moderate bibasilar\n atelectasis has worsened slightly. Pneumomediastinum is clinically\n insignificant so soon after surgery. There is no pneumothorax. ET tube is in\n standard placement. Nasogastric tube would need to be advanced 10 cm to move\n all the side ports into the stomach. Swan-Ganz catheter is traceable as far\n as the proximal pulmonary artery, but the tip is indistinct. Mediastinal and\n right pleural drains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1199333, "text": " 1:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: AORTIC STENOSIS\\RE-DO STERNOTOMY, AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with redo AVR\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: An 89-year-old male patient with redo aortic valve replacement,\n fast track early extubation protocol.\n\n FINDINGS: AP single view of the chest was obtained with patient in supine\n position. An ETT has been placed seen to terminate in the trachea some 4 cm\n above the level of the carina. A right-sided internal jugular sheath carries\n a Swan-Ganz catheter tip of which reaches the central portion of the pulmonary\n artery. Two mediastinal drainage tubes advance from below are seen and a\n right-sided chest tube terminates in the right lateral pleural sinus. An NG\n tube reaches well below the diaphragm. Lungs remain well ventilated and no\n pneumothorax can be identified. The lateral pleural sinuses remain free from\n fluid accumulation. Comparison with the preoperative chest examination of\n , the pulmonary vasculature is more plethoric. There is no\n evidence of interstitial or alveolar edema.\n\n IMPRESSION: Satisfactory first postoperative chest findings after aortic\n valve redo. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199866, "text": " 9:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ptx\n Admitting Diagnosis: AORTIC STENOSIS\\RE-DO STERNOTOMY, AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with s/p redo, AVR, CTs d/c'd\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 89-year-old man status post redo CABG with aortic valve\n replacement, chest tubes were discontinued, evaluate for pneumothorax.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show confluent lower lobe opacities and a\n small right apical pneumothorax. The cardiac silhouette is top normal. The\n mediastinal silhouette is normal. No definite pleural effusions are noted.\n Sternal wires are intact. Multiple lines and tubes have been removed.\n\n IMPRESSION:\n\n Confluent lower lobe opacities could represent atelectasis. Small right\n pneumothorax.\n\n These findings were communicated to PA at 12:04 pm on\n .\n\n" }, { "category": "Echo", "chartdate": "2141-07-27 00:00:00.000", "description": "Report", "row_id": 71973, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Chest pain. Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Right ventricular function. Valvular heart disease.\nHeight: (in) 69\nWeight (lb): 165\nBSA (m2): 1.91 m2\nBP (mm Hg): 109/51\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 09:22\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: 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. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mild global LV hypokinesis. Mildly\ndepressed LVEF.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(area 0.8-1.0cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: TR present - cannot be quantified.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nResults were personally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-CARDIOPULMONARY BYPASS: No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. There is mild\nglobal left ventricular hypokinesis (LVEF = 45-50 %). Overall left ventricular\nsystolic function is mildly depressed. The right ventricular cavity is mildly\ndilated with borderline normal free wall function. The ascending aorta is\nmildly dilated. There are simple atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets are\nseverely thickened/deformed. There is severe aortic valve stenosis (valve area\n0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. Tricuspid\nregurgitation is present but cannot be quantified. There is no pericardial\neffusion. Dr. was notified in person of the results on at time\nof surgery.\n\nPOST-CARDIOPULMONARY BYPASS: Bioprosthetic aortic valve in place. It appears\nwell seated and the leaflets move well. Trace aortic regurgitation. No aortic\nstenosis. Mean gradient 6 mmHg. Trace mitral regurgitation. LV function is\nunchanged. There is a 1-1.5 cm pericardial effusion inferiorly.\n\n\n" }, { "category": "ECG", "chartdate": "2141-07-27 00:00:00.000", "description": "Report", "row_id": 178273, "text": "Sinus rhythm with first degree atrio-ventricular conduction delay.\nAnteroseptal myocardial infarction of indeterminate age. Compared to the\nprevious tracing of there is no significant change.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527396, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT partly; RN was able to push back in; good placement on\n repeat CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales, wheezes, or\n rhonchi.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Neuro: Normal lower extremity tone. Knee and ankle jerks absent\n bilaterally.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Elevated CK: Pt noted to have an elevated in CK on labwork yesterday.\n Not likely cardiac in nature, as MB is normal. Serotonin syndrome is a\n possibility in this patient on fentanyl and with high fevers. However,\n physical exam not consistent with serotonin syndrome. Also, the patient\n has been on fentanyl for some time, and you would expect this to have\n shown up sooner. Another possibility is rhabdomyolysis in the setting\n of infection. At this point, etiology not clear. Pt was given 500 cc\n overnight to help prevent renal damage from the elevated CK. CK\n trending down this morning.\n - continue to trend CK\n - IV fluids as needed to promote elimination of CK\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically as of yesterday. Suspect multifactorial etiology of\n CHF + pneumonia. Of note, pt spiked high temperatures yesterday despite\n being on vanc/cefepime/flagyl. Started on a cooling blanket and\n switched to meropenem\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n - consider bronch today\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. After spike to\n 103.8 yesterday, ID was consulted. One concern would be for empyema,\n although lack of pleural enhancement of chest CT argues against this.\n - continue meropenem monotherapy, per ID recs\n - f/u respiratory viral screen\n - f/u repeat CXR this AM\n - consider bronch\n - continue cooling blanket\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic. Was being diuresed with goal negative 1-2 L. However,\n ended up getting some fluid overnight elevated CK.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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": "Radiology", "chartdate": "2141-03-20 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1127955, "text": " 2:22 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please assess swallow function\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with AMS and question of aspiration\n REASON FOR THIS EXAMINATION:\n please assess swallow function\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: AMS, question of aspiration.\n\n SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing video fluoroscopy was\n performed in conjunction with speech and swallow division. Multiple\n consistencies of barium were administered.\n\n Barium passes freely through the oropharynx and esophagus without evidence of\n obstruction. There was aspiration with thin liquids and penetration of nectar\n and puree. Pharyngeal residue was noted with all three consistencies of\n barium.\n\n IMPRESSION: Aspiration with thin and gross penetration with nectar and puree.\n\n For details and recommendations, please refer to speech and swallow division\n notes in OMR.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-21 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1128063, "text": " 9:55 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please replace PICC\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CHF and dysphagia\n REASON FOR THIS EXAMINATION:\n please replace PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE EXCHANGE / REPOSITIONING\n\n INDICATION: Malposition of indwelling PICC line.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. ,\n the attending interventional radiologist, supervised and reviewed the study.\n\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 then placed over the guidewire. A new double lumen PICC\n line measuring 38 cm in length was then placed through the peel-away sheath\n with its tip positioned in the SVC under fluoroscopic guidance. Position of\n the catheter was confirmed by a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new\n 5\n French double lumen PICC line. Final internal length is 38 cm, with the tip\n positioned in the SVC. The line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128167, "text": " 7:10 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval dobhoff placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with dobhoff removed and replaced (prior appeared to be in\n airway)\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement\n ______________________________________________________________________________\n WET READ: AJy TUE 7:44 PM\n dobhoff now in proximal stomach. no other interval chnage, though note that\n lateral left hemithorax is excluded from the film.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff tube replacement.\n\n Shortly after the study, a preliminary interpretation provided by \n stated \"Dobbhoff now in proximal stomach. No other interval change, though\n note that lateral left hemithorax is excluded from the film.\"\n\n CHEST, SEMI-UPRIGHT AP VIEW: Comparison is made to the most recent prior\n radiograph. A Dobbhoff tube, previously extending into the right lung, has\n been repositioned and its tip now terminates in the stomach. However, it has\n little purchase in the stomach and if clinically indicated, advancing the tube\n somewhat could be considered for more optimal positioning. Multiple pacer\n leads appear unchanged. The cardiac and mediastinal contours are also\n unchanged. Much of the left lateral hemithorax is excluded, but the\n visualized portions of the lungs remain clear.\n\n IMPRESSION: Dobbhoff tube terminating in the stomach, although if clinically\n indicated, it could be advanced somewhat in order to gain better purchase in\n the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128546, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for lead placement, left hilum, mediastinum,\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with ICD lead replacement yesterday. He has been more\n hypotensive than previously, without pulsus/tamponade physiology.\n REASON FOR THIS EXAMINATION:\n Please evaluate for lead placement, left hilum, mediastinum, interval change in\n lung edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with ICD lead replacement.\n\n COMPARISON: .\n\n CHEST, AP: A left chest wall pacemaker is again seen with leads overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are normal.\n\n IMPRESSION: ICD lead revision, without complications.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1128282, "text": " 3:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: Evaluate nasogastric tube placement.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p nasogastric tube placement.\n REASON FOR THIS EXAMINATION:\n Evaluate nasogastric tube placement.\n ______________________________________________________________________________\n WET READ: AJy WED 7:37 PM\n dobhoff reaches the upper stomach, minimally retracted from one day prior.\n could be advanced for optimal positioning. no other significant interval\n chnage from prior cxr. d.w Dr .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n PORTABLE SUPINE ABDOMEN: A Dobhoff tube is within the stomach, could be\n advanced about 10 cm further for optimal positioning Bowel gas is\n nonobstructive with air seen in non-dilated loops of small and large bowel.\n Multiple surgical clips are in the right mid and upper abdomen, related to\n prior Whipple's surgery. Multiple cardiac pacing leads are noted, unchanged.\n\n IMPRESSION: Dobhoff within the stomach, could be advanced by 10 cm for\n optimal positioning.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128161, "text": " 5:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess location of DH tube\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with dobhof tube placed\n REASON FOR THIS EXAMINATION:\n please assess location of DH tube\n ______________________________________________________________________________\n WET READ: AJy TUE 6:21 PM\n Dobhof now located in bronchial tree extending to right lower or middle lobe.\n pacer/icd and assoc leads unchanged. stable cardiomegally without over t\n volume overload. retrocardiac opacity c/w volume loss is unchnaged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff tube placement.\n\n Shortly after the study, a preliminary interpretation was provided by Dr.\n , which stated \"Dobbhoff now located in bronchial tree extending to\n right lower middle lobe. Pacer/ICD and associated leads unchanged. Stable\n cardiomegaly without overt volume overload. Retrocardiac opacity consistent\n with volume loss is unchanged. Discussed with Dr. - already aware of\n tube malposition.\"\n\n CHEST, PORTABLE AP SEMI-UPRIGHT: Comparison is made to the prior day. A\n Dobbhoff tube has been repositioned and extends through the right mainstem\n bronchus terminating in the right mid lung. Otherwise, there has been no\n significant change.\n\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531607, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n - \n - extubated\n - too agitated to get PA/Lat (will need that )\n - very agitated overnight, received ativan IV 0.5 mg x 2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (75 - 83) bpm\n BP: 106/57(73) {91/49(63) - 126/69(87)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,363 mL\n 336 mL\n PO:\n TF:\n 90 mL\n IVF:\n 1,993 mL\n 336 mL\n Blood products:\n Total out:\n 1,895 mL\n 340 mL\n Urine:\n 1,895 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: ///23/\n Ve: 11.4 L/min\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18th. Was reoriented.\n Labs / Radiology\n 309 K/uL\n 10.3 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 107 mEq/L\n 136 mEq/L\n 31.1 %\n 8.3 K/uL\n [image002.jpg]\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n 8.3\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n Plt\n 448\n 424\n 407\n 315\n 309\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 28\n 26\n Glucose\n 122\n 120\n 100\n 88\n 193\n 171\n 132\n Other labs: PT / PTT / INR:14.6/83.2/1.3, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n CXR AP :\n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restarting Coumadin\n -heparin IV weight based protocol bridge to coumadin\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Hypoxia: Resolving. Patient was intubated from for\n hypoxemic respiratory failure. Etiology likely pneumonia + heart\n failure. Currently resolving, was on room air, but drifts down to high\n 80s while sleeping, possibly related to undiagnosed OSA. Got some 2L or\n so of fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Look into speech and swallow evaluations to see if delirium has been\n masking ability to swallow. If not, then consider surgery consult for\n PEG\n -wean O2 as tolerated\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. U/A negative. Abx course for PNA complete. Failed\n videoswallow so NPO for now.\n - Frequent reorientation\n - Maintain adequate bowel regimen\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Probable call out to cardiology floor today\n ------ Protected Section ------\n Labs\n [image002.jpg]\n WBC\n Hgb\n Hct (Serum)\n Hct (Whole blood)\n Plt\n INR\n PTT\n Na+\n K + (Serum)\n K + (Whole blood)\n Cl\n HCO3\n BUN\n Creatinine\n Glucose\n CK\n CK-MB\n Troponin T\n O2 sat (mixed venous)\n O2 sat (arterial)\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 have also reviewed the notes of Dr(s).\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 08:34 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531086, "text": "Chief Complaint: Dyspnea\n From HPI admission note:\n \"71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum for the past week.\n He also had some low-grade temps at home (Tm 99.8) earlier this week.\n He called his cardiologist on , complaining of this cough and LE\n edema. He was told to increase his lasix to 60mg TIW and 40 mg daily\n the rest of the week. He then presented to gerontology clinic on\n with similar complaints. CXR and CBC done that day were\n unremarkable. He then developed dyspnea over the past 24-36 hours. He\n called cardiology clinic this morning and was instructed to present to\n the ED.\"\n 24 Hour Events:\n \n -Pt still confused\n -Pulled out NG tube a second time on , NG tube replaced again and\n confirmed in correct position\n - NPO for probable lead revision, family aware of high risks involved\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:05 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 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 81) bpm\n BP: 114/61(73) {85/44(58) - 118/73(103)} mmHg\n RR: 20 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,143 mL\n 162 mL\n PO:\n TF:\n 479 mL\n IVF:\n 323 mL\n 162 mL\n Blood products:\n Total out:\n 2,385 mL\n 210 mL\n Urine:\n 2,385 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,242 mL\n -48 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 407 K/uL\n 10.5 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 109 mEq/L\n 143 mEq/L\n 32.2 %\n 5.8 K/uL\n [image002.jpg]\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n 5.8\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n 32.2\n Plt\n 521\n 523\n 478\n 448\n 424\n 407\n Cr\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n Glucose\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n 100\n Other labs: PT / PTT / INR:13.9/74.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: dobhoff reaches the upper stomach, minimally retracted from\n one day prior.\n could be advanced for optimal positioning. no other significant\n interval\n chnage from prior cxr. d.w Dr .\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be after MN, and will have 4 units crossmatched for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n Diuresis gently continues, and likely to be safe.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2141-03-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527222, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 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: Clear\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 Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Still spiking fevers. Will have\n bronchoscopy on Fri. Sputum sent today. No vent changes this shift.\n" }, { "category": "Physician ", "chartdate": "2141-03-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528476, "text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - PM sodium 152, free water deficit of 3.2L. Ordered for 2L D5W at 125\n cc/hr.\n - TBB -500-1000 at 8pm\n - ID recs: continue meropenem, TEE if feasible, C. diff if diarrhea,\n consider cycling lines\n - Was afebrile over the course of the day, so held off on re-siting CVL\n for now.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 04:00 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 53 (48 - 67) bpm\n BP: 106/52(66) {99/46(60) - 129/60(78)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 9 (3 - 13)mmHg\n Total In:\n 1,514 mL\n 973 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,044 mL\n 973 mL\n Blood products:\n Total out:\n 2,132 mL\n 467 mL\n Urine:\n 2,130 mL\n 465 mL\n NG:\n 2 mL\n 2 mL\n Stool:\n Drains:\n Balance:\n -618 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/48/112/35/11\n Ve: 6.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. No m/r/g appreciated.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted\n Labs / Radiology\n 371 K/uL\n 9.5 g/dL\n 198 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 106 mEq/L\n 147 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n WBC\n 3.7\n 12.4\n 10.4\n 9.2\n Hct\n 32.6\n 31.9\n 30.7\n 30.4\n Plt\n 343\n 439\n 386\n 371\n Cr\n 1.0\n 1.3\n 1.3\n 1.2\n 0.9\n TropT\n 0.03\n 0.10\n TCO2\n 29\n 33\n 35\n 37\n 37\n Glucose\n 196\n 178\n 130\n 164\n 130\n 198\n Other labs: PT / PTT / INR:21.5/137.9/2.0, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:84.9 %, Lymph:9.3 %, Mono:4.5 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:7.8 mg/dL,\n Mg++:3.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - if above is negative, will need to consider other causes, such as CNS\n infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation has been\n sedation.\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - wean sedation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt; Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-14 00:00:00.000", "description": "Cardiology Teaching Physician Note", "row_id": 528478, "text": "TITLE:\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n History\n Afebrile today but BC reported pos for gram pos cocci but possible\n contaminant\n TEE shows no evidence of vegetations on multiple wires in heart.\n WBC down 9.2.\n Resp status better.\n Na better 152 to 147.\n Medical Decision Making\n will need central line resited today.\n Hope to move to extubation soon.\n EP to follow regarding AICD revision.\n Total time spent on patient care: 30 minutes of critical care time.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527530, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 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: Tan / 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 claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt on MMV ventilation because his RR drops with the IV\n Fentanyl\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Bronchoscopy at bedside for sputum culture, BAL. Repeat\n nasopharyngeal swab done per ID,\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526965, "text": "71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Chest CT:\n Subtotal atelectasis of the lower lobes, with air-bronchogram. Focal\n consolidation in the left uppper lobe,\n could also represent atelectasis, less likely PNA. Bilateral pleural\n effusions, small-to-moderate, non-hemorrhagic\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527001, "text": "71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Chest CT:\n Subtotal atelectasis of the lower lobes, with air-bronchogram. Focal\n consolidation in the left uppper lobe,\n could also represent atelectasis, less likely PNA. Bilateral pleural\n effusions, small-to-moderate, non-hemorrhagic\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated and sedated.\n Versed at 2mg/hr & Fentanyl at 25mcgs/hr.\n Vent settings SMV .\n Suctioned for thick tan sputum.\n Lungs diminished in bases otherwise clear.\n Action:\n Sedation dc\nd at 0730.\n Vent settings changed to CPAP/PS \n Conts on Vancomycin & Cefepime.\n Response:\n Unable to tolerate PS.\n Having long periods of apnea with low TV & MV\ns alternating with ^\nd RR\n and TV 800\n Sedation remains off.\n Placed back on A/C with RR of 14. overbreathing x\ns /min.\n Plan:\n Cont A/C overnite until pt more awake.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TM 101.4 WBC\ns wnl.\n Action:\n Bld cultures x\n Urine & sputum cultures sent.\n 650mg Tylenol x\ns 2.\n Flagyl 500mg IV Q8hrs.\n Response:\n Pt conts with fever\n Plan:\n Check cultures. Prn Tylenol.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced with periods of AF. HR mostly in 50\n Action:\n Lopressor remains on hold.\n Given lasix 60mg IV x\ns 1.\n Response:\n Good diuresis from lasix.\n Improved abg\n Plan:\n Lasix as needed.\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527292, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527293, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated on 40% 10/10. LS diminished/ bronchial @\n bases.\n Pt on low dose sedation 25mcgs/hr fentanyl. Pt is very restless,\n kicking and trying to reposition himself. Withdraws to painful\n stimuli. Eyes are slightly open, although pt does not track or appear\n to focus.\n Rec\nd pt w/ temp 100.4 on cooling blanket.\n Pt receiving TF Isosource at goal rate of 55cc/hr.\n Remains on droplet precautions\n Action:\n d/t increase agitation, Fentanyl increased to 100mcg/hr.\n Vent changed to MMV\n Pulmonary toileting q2hrs.\n VAP care per protocol.\n Meropenem per dose.\n Tylenol 650 q6hrs.\n Response:\n Pt appears more comfortable on increased dose of fentanyl.\n ABG ____\n Producing thick tan secretions.\n Temp___-\n Plan:\n continue aggressive pulmonary toileting, abx and Tylenol. Check pnd\n cultures ()\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n BP 130-140/50-60.\n Rec\nd pt at 8pm, 40cc negative for the day.\n Action:\n Lopressor parameters discussed w/ MD. Lopressor has been held d/t HR\n parameter of 50. Parameter changed to 50.\n Given lasix 60mg IV at and 2230 in order to reach goal of 1.5\n liter neg for day. .\n Response:\n Good diuresis from lasix w/ midnight i/o negative 950cc.\n Only 200cc negative at 6am.\n Plan:\n Consider lasix gtt as intake is approx 3000cc per day.\n Social\n HCP/ has called multiple times this shift and has\n been updated by this RN. would like to be called if for any\n reason medical service is to be changed (i.e pt is changed from CCU to\n MICU service).\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528547, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on TuesdayPt is NPO for\n this procedure. Sedation dc\nd (yesterday) at 9:30am. Pt more\n awake over the course of the evening. Now rare movement\n of right upper extremitie, moves feet wiggles in bed. Opens eyes,\n appears nods head to question, resists mouth care. Wrist restraints in\n place as pt did raise up right arm toward tube.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient placed on CPAP 5/5 40%- lung sounds clear- suctioned small amt\n thick tan.\n Action:\n RSBI 55 this am- ABG on CPAP 7.50-48-115-39 sat 97%- successfully\n extubated @ 1600- In O2 50% CN.\n Response:\n More awake- no resp distress.\n Plan:\n Monitor resp status- follow ABG\ns- encourage coughing and deep\n breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n D5W 2L 125 cc per hour for high sodium- D/C\nd after 1500cc.\n Action:\n TEE done this am- lasix 60mg IV given- heparin gtt D/C\nd @ 1400- INR\n 2.0 this am- repeat 1.8- Coumadin given @ 1600.\n Response:\n Diuresed well- hemodynamically stable.\n Plan:\n Follow U/O- con\nt cardiac meds as ordered- keep family updated on plan\n of care.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n 1 blood culture from taken from CL growning gm (+) cocci. WBC 6.0\n today- afebrile.\n Action:\n Pt recultured- meropenum given as ordered- vanco restarted- PICC line\n inserted @ IR- TLCL R IJ to be D/C\n Response:\n Remains afebrile.\n Plan:\n D/C TL tonight- follow temps and culture results- reculture if patient\n spikes temp- con\nt ABX.\n" }, { "category": "Physician ", "chartdate": "2141-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528772, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -extubated 4PM\n -left PICC placed by IR\n -left IJ pulled, tip sent for culture\n -TEE: Severe (4+ MR). No vegetations seen on the right atrial leads\n (four identified) or on mitral, aortic, tricuspid or pulmonic valves.\n Severely depressed left ventricular function with septal, inferoseptal\n and inferior wall hypokinesis. Moderate tricuspid regurgitation. At\n least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n Echo in 09 - 2+ MR - possibility endocarditis.\n -Ucx negative, blood cx pending.\n -GPC in clusters. f/u cx data - no s/s yet. Possible contaminant.\n -started vanc\n -Got lasix 60 IV x 1 with UOP ***, likely need to repeat 9pm (got lasix\n late )goal negative 1L\n -3pm crit/lytes\n -heparin discontinued\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 08:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:05 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 52 (50 - 59) bpm\n BP: 105/45(62) {101/42(56) - 127/60(76)} mmHg\n RR: 16 (7 - 18) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 10 (9 - 10)mmHg\n Total In:\n 2,770 mL\n 67 mL\n PO:\n TF:\n IVF:\n 2,380 mL\n 67 mL\n Blood products:\n Total out:\n 3,972 mL\n 580 mL\n Urine:\n 3,970 mL\n 580 mL\n NG:\n 2 mL\n Stool:\n Drains:\n Balance:\n -1,202 mL\n -513 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 630 (630 - 630) mL\n RR (Set): 0\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SpO2: 99%\n ABG: 7.50/52/67/34/14\n Ve: 8.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 468 K/uL\n 10.4 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 30 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 9.3 K/uL\n [image002.jpg]\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n WBC\n 10.4\n 9.2\n 9.3\n Hct\n 30.7\n 30.4\n 31.8\n Plt\n \n Cr\n 1.3\n 1.2\n 0.9\n 0.7\n 0.7\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 130\n 164\n 130\n 198\n 151\n 137\n 122\n Other labs: PT / PTT / INR:19.5/29.4/1.8, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.6 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n continued to spike high fevers in spite of Tylenol, antibiotics, and\n improvement in respiratory status. CT abd/pelvis and CT sinuses were\n neg. Pt has been afebrile over 24 hours at this point. However, he did\n have a positive blood cx (GPC\ns) this am. This could represent true\n infection versus contaminant.\n - continue meropenem; adding vanc in the setting of positive blood cx\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - will need to pull CVL in setting of positive blood cx; d/w team\n whether we should place another CVL versus try to obtain peripheral\n access until patient is able to get a PICC\n - if above is negative and pt continues to spike fevers, will need to\n consider other causes, such as CNS infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Mental status greatly improved this\n morning; RSBI in the 30\n - attempt extubation after TEE\n - f/u pending cultures\n - f/u bronch data\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L; will give 60 mg IV lasix now\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -TEE to look for lead endocarditis, as above\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: subtherapeutic INR\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528773, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -extubated 4PM\n -left PICC placed by IR\n -left IJ pulled, tip sent for culture\n -TEE: Severe (4+ MR). No vegetations seen on the right atrial leads\n (four identified) or on mitral, aortic, tricuspid or pulmonic valves.\n Severely depressed left ventricular function with septal, inferoseptal\n and inferior wall hypokinesis. Moderate tricuspid regurgitation. At\n least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n Echo in 09 - 2+ MR - possibility endocarditis.\n -Ucx negative, blood cx pending.\n -GPC in clusters. f/u cx data - no s/s yet. Possible contaminant.\n -started vanc\n -Got lasix 60 IV x 1 with UOP ***, likely need to repeat 9pm (got lasix\n late )goal negative 1L\n -3pm crit/lytes\n -heparin discontinued\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 08:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:05 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 52 (50 - 59) bpm\n BP: 105/45(62) {101/42(56) - 127/60(76)} mmHg\n RR: 16 (7 - 18) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 10 (9 - 10)mmHg\n Total In:\n 2,770 mL\n 67 mL\n PO:\n TF:\n IVF:\n 2,380 mL\n 67 mL\n Blood products:\n Total out:\n 3,972 mL\n 580 mL\n Urine:\n 3,970 mL\n 580 mL\n NG:\n 2 mL\n Stool:\n Drains:\n Balance:\n -1,202 mL\n -513 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 630 (630 - 630) mL\n RR (Set): 0\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SpO2: 99%\n ABG: 7.50/52/67/34/14\n Ve: 8.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 468 K/uL\n 10.4 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 30 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 9.3 K/uL\n [image002.jpg]\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n WBC\n 10.4\n 9.2\n 9.3\n Hct\n 30.7\n 30.4\n 31.8\n Plt\n \n Cr\n 1.3\n 1.2\n 0.9\n 0.7\n 0.7\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 130\n 164\n 130\n 198\n 151\n 137\n 122\n Other labs: PT / PTT / INR:19.5/29.4/1.8, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.6 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Now afebrile x 48 hours. Previously, patient was spiking high\n fevers in spite of Tylenol, antibiotics, and improvement in respiratory\n status. CT abd/pelvis and CT sinuses were neg. Pt has been afebrile\n over 24 hours at this point. However, he did have a positive blood cx\n (GPC\ns) this am. This could represent true infection versus\n contaminant.\n - continue meropenem; adding vanc in the setting of positive blood cx\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - will need to pull CVL in setting of positive blood cx; d/w team\n whether we should place another CVL versus try to obtain peripheral\n access until patient is able to get a PICC\n - if above is negative and pt continues to spike fevers, will need to\n consider other causes, such as CNS infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Mental status greatly improved this\n morning; RSBI in the 30\n - attempt extubation after TEE\n - f/u pending cultures\n - f/u bronch data\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L; will give 60 mg IV lasix now\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -TEE to look for lead endocarditis, as above\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: subtherapeutic INR\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526647, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - weaned FiO2 to 40%\n - started tube feeds\n - weaned sedation from 50&4 to 25&2\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Meropenem - 12:44 AM\n Vancomycin - 08:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.3\n HR: 65 (59 - 78) bpm\n BP: 76/47(53) {0/0(0) - 0/0(0)} mmHg\n RR: 22 (20 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 8 (5 - 12)mmHg\n Total In:\n 1,778 mL\n 440 mL\n PO:\n TF:\n 145 mL\n 179 mL\n IVF:\n 1,453 mL\n 161 mL\n Blood products:\n Total out:\n 590 mL\n 240 mL\n Urine:\n 590 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,188 mL\n 200 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 58.8 cmH2O/mL\n SpO2: 95%\n ABG: 7.47/41/84./26/5\n Ve: 10.3 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GENERAL: intubated, sedated, unresponsive.\n NECK: Unable to appreciate JVP.\n CARDIAC: Quiet heart sounds. Difficult to hear over breath sounds; No\n m/r/g appreciated.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness noted.\n EXTREMITIES: No significant LE edema noted. Extremities warm and\n well-perfused\n Labs / Radiology\n 205 K/uL\n 9.6 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.5 %\n 6.4 K/uL\n [image002.jpg]\n 04:55 AM\n 09:20 AM\n 01:51 PM\n 06:28 PM\n 04:26 AM\n 04:40 AM\n 07:02 AM\n 09:35 PM\n 04:35 AM\n 04:52 AM\n WBC\n 6.6\n 6.4\n Hct\n 30.6\n 28.5\n Plt\n 197\n 205\n Cr\n 0.8\n 0.7\n TCO2\n 30\n 26\n 26\n 29\n 28\n 30\n 30\n 31\n Glucose\n 109\n 132\n Other labs: PT / PTT / INR:31.1/42.8/3.1, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:81.8 %, Lymph:8.5 %,\n Mono:5.6 %, Eos:3.9 %, Lactic Acid:0.9 mmol/L, Ca++:7.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. have superimposed component\n of heart failure as well. On vancomycin, cefepime, azithromycin for\n broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation with CMV 500/22/0.7/8. Wean FiO2,\n peep as tolerated.\n - continue vancomycin, cefepime, azithromycin. Gram stain no growth\n prelim\n - f/u pending cultures\n .\n # Hypotension/sepsis: BPs high 90s to low 100s. Likely pneumonia.\n On levophed for pressor support. CVP 6-9 suggesting not volume up.\n Wean levo as tolerated.\n - holding metoprolol\n - holding diuresis\n - IV fluids PRN\n - norepinephrine\n ..\n # Chronic systolic heart failure: Patient with EF 20-25%. CVP suggests\n CHF contributing less than other factors. UOP 40cc/hr with pt net +ve\n 628, -ve 1.3L. On norepinephrine.\n - continue norepinephrine, wean as tolerated/\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension\n - continue Coumadin at 1mg/day , with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # s/p ICD: high impedance, unclear why.\n -pacer revison in future.\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple: NGT output bilous. Did not initiate tube feeds.\n - holding pancreatic enzyme repletio\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:37 PM 25 mL/hour\n Glycemic Control: none\n Lines:\n Arterial Line - 09:13 PM\n 20 Gauge - 12:58 AM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526959, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526962, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526964, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2141-03-09 00:00:00.000", "description": "Generic Note", "row_id": 527198, "text": "TITLE: CCU Attending Progress Note\n CCU Attending\n I agree with the detailed note by Dr. delineated above.\n History and Physical. I was present for the pertinent portions of the\n history and physical examination. I concur with the treatment plan\n outlined above.\n Medical Decision Making. This 71 year old man with LVEF 20-25% is\n ventilatory dependent due to possible pneumonia v. volume overload. He\n is re-spiking fevers. We will continue ventilatory support,\n diuresis, antibiotic therapy, and control of his intermittent\n hypertension.\n , MD\n" }, { "category": "Physician ", "chartdate": "2141-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527204, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - spiked to 101, pancultured.\n - Per pulm, pt has ARDS, (did not respond to peep) and has bilat\n infiltrate, wedge up, AA grad) but improving with right lung now clear.\n If not improving over a few days transfer to MICU.\n - insulin sliding scale started given GFS 190\n - stopped sedation\n - vancomycin dose increased\n - restarted coumadin, metoprolol\n - updated wife\n - From respiratory standpoint, patient did not do well on pressure\n support mode; was switched back to assist control in afternoon and\n overnight\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 50 (50 - 82) bpm\n BP: 141/62(80) {110/54(69) - 147/66(84)} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 13 (8 - 14)mmHg\n Total In:\n 2,203 mL\n 952 mL\n PO:\n TF:\n 1,273 mL\n 382 mL\n IVF:\n 620 mL\n 270 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,155 mL\n Urine:\n 3,160 mL\n 1,155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -957 mL\n -203 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): 604 (604 - 604) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 122 cmH2O/mL\n SpO2: 96%\n ABG: 7.46/37/151/29/3\n Ve: 13.9 L/min\n PaO2 / FiO2: 377\n Physical Examination\n GENERAL: Intubated, sedated, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Cool lower extremities. Minimal bilateral LE edema.\n Labs / Radiology\n 312 K/uL\n 11.1 g/dL\n 170 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 104 mEq/L\n 142 mEq/L\n 32.6 %\n 10.0 K/uL\n [image002.jpg]\n 03:41 AM\n 04:21 AM\n 06:41 AM\n 09:37 AM\n 04:32 PM\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n WBC\n 7.2\n 10.0\n Hct\n 31.5\n 32.6\n Plt\n 258\n 312\n Cr\n 0.9\n 1.0\n 1.0\n 1.0\n TCO2\n 28\n 30\n 23\n 23\n 27\n 27\n Glucose\n 191\n 180\n 191\n 170\n Other labs: PT / PTT / INR:22.8/32.4/2.2, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:83.3 %, Lymph:6.5 %,\n Mono:6.5 %, Eos:3.5 %, Lactic Acid:0.9 mmol/L, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Now with increasing O2 requirement (FiO2 50%).Chest CT more consistent\n with atelectasis/effusion rather than pneumonia. Nonetheless, will\n complete course of abx. Will diurese.\n - continue mechanical ventilation\n - continue vancomycin, cefepime. Course of azithromycin is complete.\n - f/u pending cultures (no positive micro data to date)\n - pulm consult\n - diuresis as below\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hpyervolemic.\n - continue diuresis with goal negative 2 L today\n - restart metoprolol\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - restart metoprolol as tolerate by blood pressure\n - restart Coumadin in setting of therapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds. Pancreatic enzyme repletion has been\n difficult to get down tube.\n - discuss pancreatic supplementation with pharmacy\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:47 AM 55 mL/hour\n Glycemic Control: insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine, HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527206, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - spiked to 101, pancultured.\n - Per pulm, pt has ARDS, (did not respond to peep) and has bilat\n infiltrate, wedge up, AA grad) but improving with right lung now clear.\n If not improving over a few days transfer to MICU.\n - insulin sliding scale started given GFS 190\n - stopped sedation\n - vancomycin dose increased\n - restarted coumadin, metoprolol\n - updated wife\n - From respiratory standpoint, patient did not do well on pressure\n support mode; was switched back to assist control in afternoon and\n overnight\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 50 (50 - 82) bpm\n BP: 141/62(80) {110/54(69) - 147/66(84)} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 13 (8 - 14)mmHg\n Total In:\n 2,203 mL\n 952 mL\n PO:\n TF:\n 1,273 mL\n 382 mL\n IVF:\n 620 mL\n 270 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,155 mL\n Urine:\n 3,160 mL\n 1,155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -957 mL\n -203 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): 604 (604 - 604) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 122 cmH2O/mL\n SpO2: 96%\n ABG: 7.46/37/151/29/3\n Ve: 13.9 L/min\n PaO2 / FiO2: 377\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales, wheezes, or\n rhonchi.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Neuro: Normal lower extremity tone. Knee and ankle jerks absent\n bilaterally.\n Labs / Radiology\n 312 K/uL\n 11.1 g/dL\n 170 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 104 mEq/L\n 142 mEq/L\n 32.6 %\n 10.0 K/uL\n [image002.jpg]\n 03:41 AM\n 04:21 AM\n 06:41 AM\n 09:37 AM\n 04:32 PM\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n WBC\n 7.2\n 10.0\n Hct\n 31.5\n 32.6\n Plt\n 258\n 312\n Cr\n 0.9\n 1.0\n 1.0\n 1.0\n TCO2\n 28\n 30\n 23\n 23\n 27\n 27\n Glucose\n 191\n 180\n 191\n 170\n Other labs: PT / PTT / INR:22.8/32.4/2.2, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:83.3 %, Lymph:6.5 %,\n Mono:6.5 %, Eos:3.5 %, Lactic Acid:0.9 mmol/L, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically. Suspect multifactorial etiology of CHF + pneumonia.\n - continue mechanical ventilation, with minimized sedation and daily\n spontaneous breathing trials\n - continue vancomycin, cefepime, Flagyl. Course of azithromycin is\n complete.\n - f/u pending cultures (no positive micro data to date)\n - appreciate pulmonary consult recs\n - diuresis as below\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic.\n - continue diuresis with goal negative 1-2 L today\n - uptitrate metoprolol to dosing\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. One concern would\n be for empyema, although lack of pleural enhancement of chest CT argues\n against this.\n - trend fever curves\n - Tylenol\n - antibiotics as above\n - consider ID consult\n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - add basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - uptitrate metoprolol to \n - continue Coumadin; trend INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:47 AM 55 mL/hour\n Glycemic Control: insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: warfarin\n Stress ulcer: lansoprazole\n VAP: chlorhexidine, HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528761, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. CT head, chest, & pelvis-without noted\n infectious process.\n vf arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n HCP: significant other , 2 daughter\n and live out of\n state.\n Pneumonia, Bacterial, Community Acquired (CAP)\n Assessment:\n Received on 50% shovel mask, with sats >95% when mask on, desatting to\n 88% when he removed mask. Lungs with crackles L base, bronchial at L\n base, few rhonchi.\n Action:\n * Rare, strong cough\n thick brown sputum (like a small ball)\n * O2 weaned to 2 L NP maintaining sats\n * Turned s\nS, enc to c & db, he is not cognitively ready for inc\n .\n Response:\n Plan:\n Heart Failure (CHF)/VT\n Assessment:\n Remains V paced.\n Action:\n Response:\n Plan:\n Delirium\n Assessment:\n Oriented x1 only\nself and family. At times thought he was in a Hotel\n Action:\n * Bed low/locked position\n * Frequent re-orientation\n * Hearing aides in\n * A-line removed.\n Response:\n Remains oriented x1 only.\n Plan:\n Continue present management. Frequent reorientation. Appropriate safety\n measures.\n Dysphagia\n Assessment:\n Pulled out his NGT at the end of night shift. Speech and swallow in to\n evaluate patient. Coughing with thin liqs and nectar thick. Able to\n swallow pills whole with applesauce without difficulty\n Action:\n * Plan of care discussed with S&S re: ? to replace NGT or whether\n this would slow down his swallow recovery process. They recommend\n keeping NGT out today. Give pills whole in applesauce, but no\n other po\ns. They will re-evaluate patient in 24 hours as they\n anticipate his swallow to come back as he was able to have regular\n diet pre-intubation.\n * HOB ^ 90 degrees with po\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526915, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - increased vancomycin to 1250 mg IV Q12H\n - held Coumadin for supratherapeutic INR\n - Chest CT was initially read as pneumonia, then reread as follow:\n 1. No intrathoracic abscess. Bilateral non-hemorrhagic\n small-to-moderate pleural effusions, minimally loculated, if at all, on\n the right.\n 2. Severe lower lobe and moderate upper lobe atelectasis. Minimal\n pneumonia cannot be excluded.\n 3. Mediastinal lymphadenopathy, likely reactive.\n - bolused 500 cc for low urine output, without improvement in urine\n output\n - ordered Lasix 60 mg IV x 1. Put out almost 2 L of urine overnight\n - did recruitment maneuvers and increased PEEP\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 12:00 PM\n Vancomycin - 09:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 78 (50 - 83) bpm\n BP: 106/58(70) {92/47(60) - 127/71(84)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 12 (5 - 15)mmHg\n Total In:\n 2,565 mL\n 326 mL\n PO:\n TF:\n 884 mL\n 309 mL\n IVF:\n 1,201 mL\n 17 mL\n Blood products:\n Total out:\n 1,580 mL\n 850 mL\n Urine:\n 1,580 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 985 mL\n -524 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): 313 (313 - 313) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 88\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 95%\n ABG: 7.44/40/107/27/2\n Ve: 9.2 L/min\n PaO2 / FiO2: 214\n Physical Examination\n GENERAL: Intubated, sedated, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Cool lower extremities. Minimal bilateral LE edema.\n Labs / Radiology\n 258 K/uL\n 10.6 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 105 mEq/L\n 139 mEq/L\n 31.5 %\n 7.2 K/uL\n [image002.jpg]\n 04:26 AM\n 04:40 AM\n 07:02 AM\n 09:35 PM\n 04:35 AM\n 04:52 AM\n 05:51 PM\n 11:27 PM\n 03:41 AM\n 04:21 AM\n WBC\n 6.6\n 6.4\n 7.2\n Hct\n 30.6\n 28.5\n 31.5\n Plt\n 197\n 205\n 258\n Cr\n 0.8\n 0.7\n 0.9\n TCO2\n 28\n 30\n 30\n 31\n 22\n 29\n 28\n Glucose\n 109\n 132\n 191\n Other labs: PT / PTT / INR:22.8/32.4/2.2, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:83.3 %, Lymph:6.5 %,\n Mono:6.5 %, Eos:3.5 %, Lactic Acid:0.9 mmol/L, Ca++:8.3 mg/dL, Mg++:2.2\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Now with increasing O2 requirement (FiO2 50%).Chest CT more consistent\n with atelectasis/effusion rather than pneumonia. Nonetheless, will\n complete course of abx. Will diurese.\n - continue mechanical ventilation\n - continue vancomycin, cefepime. Course of azithromycin is complete.\n - f/u pending cultures (no positive micro data to date)\n - pulm consult\n - diuresis as below\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hpyervolemic.\n - continue diuresis with goal negative 2 L today\n - restart metoprolol\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - restart metoprolol as tolerate by blood pressure\n - restart Coumadin in setting of therapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds. Pancreatic enzyme repletion has been\n difficult to get down tube.\n - discuss pancreatic supplementation with pharmacy\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:35 AM 45 mL/hour\n Glycemic Control: insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n 20 Gauge - 12:58 AM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine, HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nutrition", "chartdate": "2141-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 526928, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated.\n Objective\n Admit weight\n Daily weight\n 105 kg\n 104 kg ( 12:00 AM)\n Pertinent medications: Azithromycin, fentanyl drip, cefepime,\n midazolam, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 191 mg/dL\n 03:41 AM\n BUN\n 24 mg/dL\n 03:41 AM\n Creatinine\n 0.9 mg/dL\n 03:41 AM\n Sodium\n 139 mEq/L\n 03:41 AM\n Potassium\n 4.4 mEq/L\n 03:41 AM\n Chloride\n 105 mEq/L\n 03:41 AM\n TCO2\n 27 mEq/L\n 03:41 AM\n PO2 (arterial)\n 135 mm Hg\n 09:37 AM\n PCO2 (arterial)\n 35 mm Hg\n 09:37 AM\n pH (arterial)\n 7.41 units\n 09:37 AM\n pH (urine)\n 5.0 units\n 10:23 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:37 AM\n Calcium non-ionized\n 8.3 mg/dL\n 03:41 AM\n Phosphorus\n 3.0 mg/dL\n 03:41 AM\n Magnesium\n 2.2 mg/dL\n 03:41 AM\n WBC\n 7.2 K/uL\n 03:41 AM\n Hgb\n 10.6 g/dL\n 03:41 AM\n Hematocrit\n 31.5 %\n 03:41 AM\n Current diet order / nutrition support: NPO; Tube feedings: Isosource\n 1.5 @ 55 mL/ hr + 14 g Beneprotein (currently running at goal rate)\n GI:\n Specifics: 72 y.o. M admitted with dyspnea, likely CHF exacerbation.\n Patient remains intubated, diuresed overnight. Tube feeds started \n and reached goal rate late yesterday. Per discussion with RN patient\n continues to tolerate tube feeds with minimal residuals, no emesis or\n diarrhea. Patient with elevated FSBG this afternoon and RISS ordered.\n Recommend continue current tube feeding formula at this with BS\n management as patient needs fluid restricted formula. Will continue to\n follow and monitor tube feed tolerance.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue current tube feeding as ordered: Isosource 1.5 @ 55\n mL/hr + 14 g Beneprotein to provide kcal and 102 g protein\n Monitor tube feed tolerance with residual checks q4hr, hold\n if greater than 200 mL\n Check chemistry 10 panel daily, replete as needed\n BS management as you are\n Bowel regimen as needed\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2141-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 526931, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated.\n Objective\n Admit weight\n Daily weight\n 105 kg\n 104 kg ( 12:00 AM)\n Pertinent medications: Azithromycin, fentanyl drip, cefepime,\n midazolam, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 191 mg/dL\n 03:41 AM\n BUN\n 24 mg/dL\n 03:41 AM\n Creatinine\n 0.9 mg/dL\n 03:41 AM\n Sodium\n 139 mEq/L\n 03:41 AM\n Potassium\n 4.4 mEq/L\n 03:41 AM\n Chloride\n 105 mEq/L\n 03:41 AM\n TCO2\n 27 mEq/L\n 03:41 AM\n PO2 (arterial)\n 135 mm Hg\n 09:37 AM\n PCO2 (arterial)\n 35 mm Hg\n 09:37 AM\n pH (arterial)\n 7.41 units\n 09:37 AM\n pH (urine)\n 5.0 units\n 10:23 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:37 AM\n Calcium non-ionized\n 8.3 mg/dL\n 03:41 AM\n Phosphorus\n 3.0 mg/dL\n 03:41 AM\n Magnesium\n 2.2 mg/dL\n 03:41 AM\n WBC\n 7.2 K/uL\n 03:41 AM\n Hgb\n 10.6 g/dL\n 03:41 AM\n Hematocrit\n 31.5 %\n 03:41 AM\n Current diet order / nutrition support: NPO; Tube feedings: Isosource\n 1.5 @ 55 mL/ hr + 14 g Beneprotein (currently running at goal rate)\n GI: abdomen soft, bowel sounds present\n Specifics: 72 y.o. M admitted with dyspnea, likely CHF exacerbation,\n intubated for respiratory distress. Per chart CT did not\n suggest PNA, likely all CHF and atelectasis. Patient remains\n intubated, diuresed overnight. Tube feeds started via OGT and\n reached goal rate late yesterday. Per discussion with RN patient\n continues to tolerate tube feeds with minimal residuals, no emesis or\n diarrhea. Patient with elevated FSBG this afternoon and RISS ordered.\n Recommend continue current tube feeding formula at this with BS\n management as patient needs fluid restricted formula. Will continue to\n follow and monitor tube feed tolerance.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue current tube feeding as ordered: Isosource 1.5 @ 55\n mL/hr + 14 g Beneprotein to provide kcal and 102 g protein\n Monitor tube feed tolerance with residual checks q4hr, hold\n if greater than 200 mL\n Check chemistry 10 panel daily, replete as needed\n BS management as you are\n Bowel regimen as needed\n Following #\n" }, { "category": "Nutrition", "chartdate": "2141-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 526932, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated.\n Objective\n Admit weight\n Daily weight\n 105 kg\n 104 kg ( 12:00 AM)\n Pertinent medications: Azithromycin, fentanyl drip, cefepime,\n midazolam, RISS, lasoprazole, colace, Creon 12, others noted\n Labs:\n Value\n Date\n Glucose\n 191 mg/dL\n 03:41 AM\n BUN\n 24 mg/dL\n 03:41 AM\n Creatinine\n 0.9 mg/dL\n 03:41 AM\n Sodium\n 139 mEq/L\n 03:41 AM\n Potassium\n 4.4 mEq/L\n 03:41 AM\n Chloride\n 105 mEq/L\n 03:41 AM\n TCO2\n 27 mEq/L\n 03:41 AM\n PO2 (arterial)\n 135 mm Hg\n 09:37 AM\n PCO2 (arterial)\n 35 mm Hg\n 09:37 AM\n pH (arterial)\n 7.41 units\n 09:37 AM\n pH (urine)\n 5.0 units\n 10:23 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:37 AM\n Calcium non-ionized\n 8.3 mg/dL\n 03:41 AM\n Phosphorus\n 3.0 mg/dL\n 03:41 AM\n Magnesium\n 2.2 mg/dL\n 03:41 AM\n WBC\n 7.2 K/uL\n 03:41 AM\n Hgb\n 10.6 g/dL\n 03:41 AM\n Hematocrit\n 31.5 %\n 03:41 AM\n Current diet order / nutrition support: NPO; Tube feedings: Isosource\n 1.5 @ 55 mL/ hr + 14 g Beneprotein (currently running at goal rate)\n GI: abdomen soft, bowel sounds present\n Specifics: 72 y.o. M admitted with dyspnea, likely CHF exacerbation,\n intubated for respiratory distress. Per chart CT did not\n suggest PNA, likely CHF and atelectasis. Patient remains intubated,\n diuresed overnight. Tube feeds started via OGT and reached goal\n rate late yesterday. Per discussion with RN patient continues to\n tolerate tube feeds with minimal residuals, no emesis or diarrhea.\n Patient with elevated BG this AM and RISS ordered. Recommend continue\n current tube feeding formula at this with BG management as patient\n needs fluid restricted formula. Will continue to follow and monitor\n tube feed tolerance.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue current tube feeding as ordered: Isosource 1.5 @ 55\n mL/hr + 14 g Beneprotein to provide kcal and 102 g protein\n Monitor tube feed tolerance with residual checks q4hr, hold\n if greater than 200 mL\n Check chemistry 10 panel daily, replete as needed\n BG management as you are\n Bowel regimen as needed\n Following #\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527266, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 103.8 PR at 12 noon. WBC=10. AM lactate 2.1.\n Action:\n *ID following- unclear if PNA is source of temp spike as CXR w/\n improvement\n *Triple IV anbx- cefepime/ flagyl/ vanco\n *Tylenol ATC q 6 hrs for pt comfort\n *Ice packs to groin/ armpits; tepid bath\n *Pt pan cultured \n Response:\n Temp remained elevated despite above interventions. Ice packs removed\n and cooling blanket applied at 13:00 w/ Temp down low 100 F range.\n Continuous rectal temp probe placed for better monitoring. Afternoon\n lactate 1.6. ID recommended antibiotic change- DC prior anbx and start\n meropenem. Flu swab sent, initiated on droplet precautions until rules\n out.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort. If\n remains febrile, pulm will likely perform bronch tomorrow to obtain\n deeper sputum sample.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated PSV 12/ 10 Peep. LS diminished/ bronchial @\n bases. Small-mod amts thick/ yellow tan secretions via ETT. SPO2\n >94%. Pt had been off sedation since :30, - Upon initial exam,\n pt w/ occasional eye opening, no tracking. No response to verbal\n stimuli/ nail bed pressure/ sternal rub. MAE, non-purposeful. Restless\n legs in bed (present on admission).\n Action:\n * Resp therapy this AM did PS trial . Pt w/ SPO2 down 89%, RR >35,\n SBP 180s. Discussed w/ team-> No plans to extubate today given pt\n mental status and need to further diurese. Vent settings changed to\n 10PSV/ 10 Peep w/ ABG: 7.49/ 37/ 112/ 29.\n *Repeat sputum sample sent when pt pan cultured\n *Pt at times w/ SBP as high as 180s even after vent settings changed.\n Presumed hypertension r/t pain-> initiated fentanyl gtt at 25mcg/min.\n VSS since gtt started. Pt appearing more comfortable.\n *Pulmonary toileting q2hrs. VAP care per protocol.\n *Abx changed to meropenem as noted above.\n *Nutrition w/ tubefeeds via NGT.\n *In afternoon, pt turning head to verbal response but no eye contact or\n focusing.\n Response:\n *Cont w/ fevers and small-mod amts thick/yellow sputum production.\n Plan:\n As noted above, possible bronch in AM by pulmonary. Continue to\n monitor resp status. Daily RSBI/SBT, wean vent as tolerated. IV\n fentanyl for comfort. VAP care/ pulm toileting. IV meropenem Q 8 hrs.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 mainly>95%. Bilat LE edema. HR paced at\n 50. Underlying rythum appears to be aflutter. NIBP\n 120s-150s/60s-70s.\n Action:\n *IV lasix 60mg x one\n *Lopressor increased to twice daily dosing; holding parameters removed\n *E-lytes monitored. K+ repleted this AM and again this afternoon.\n Response:\n *Pt negative 500ml at 18:00- team alerted, plan to order another dose\n of lasix this PM.\n Plan:\n *Continue to monitor resp status/ volume status.\n *Goal diuresis 1-2L negative by midnight, awaiting order for 2^nd dose\n IVP lasix.\n *Daily wts/ 1500ml fluid restriction\n **Other: Elevated FS 150s-200s. RISS as ordered, glargine to start\n tonight, HS. NGT noted to be out of place at 1600 (nasal tape loosened\n r/t diaphoresis). NGT readvanced and CXR confirmed placement. TF off\n briefly during episode and resumed at 1800. INR subtherapeutic, no\n heparin gtt required at this time per team- SC heparin TID ordered and\n pneumoboots applied.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527874, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n 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: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done on 0 peep/ 5ips 64.\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: Will cont to wean to extubate. Will place on SBT later this\n AM. MDI\nS given.\n Seems to respond to commands.Having some sml periods of apnea. need\n autoset after extubation.\n" }, { "category": "Nutrition", "chartdate": "2141-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 526934, "text": "TITLE: Clinical Nutrition Follow Up\n Subjective\n Patient remains intubated.\n Objective\n Admit weight\n Daily weight\n 105 kg\n 104 kg ( 12:00 AM)\n Pertinent medications: Azithromycin, fentanyl drip, cefepime,\n midazolam, RISS, lasoprazole, colace, Creon 12, others noted\n Labs:\n Value\n Date\n Glucose\n 191 mg/dL\n 03:41 AM\n BUN\n 24 mg/dL\n 03:41 AM\n Creatinine\n 0.9 mg/dL\n 03:41 AM\n Sodium\n 139 mEq/L\n 03:41 AM\n Potassium\n 4.4 mEq/L\n 03:41 AM\n Chloride\n 105 mEq/L\n 03:41 AM\n TCO2\n 27 mEq/L\n 03:41 AM\n PO2 (arterial)\n 135 mm Hg\n 09:37 AM\n PCO2 (arterial)\n 35 mm Hg\n 09:37 AM\n pH (arterial)\n 7.41 units\n 09:37 AM\n pH (urine)\n 5.0 units\n 10:23 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:37 AM\n Calcium non-ionized\n 8.3 mg/dL\n 03:41 AM\n Phosphorus\n 3.0 mg/dL\n 03:41 AM\n Magnesium\n 2.2 mg/dL\n 03:41 AM\n WBC\n 7.2 K/uL\n 03:41 AM\n Hgb\n 10.6 g/dL\n 03:41 AM\n Hematocrit\n 31.5 %\n 03:41 AM\n Current diet order / nutrition support: NPO; Tube feedings: Isosource\n 1.5 @ 55 mL/ hr + 14 g Beneprotein (currently running at goal rate)\n GI: abdomen soft, bowel sounds present\n Specifics: 72 y.o. M admitted with dyspnea, likely CHF exacerbation,\n intubated for respiratory distress. Per chart CT did not\n suggest PNA, likely CHF and atelectasis. Patient remains intubated,\n diuresed overnight. Tube feeds started via OGT and reached goal\n rate late yesterday. Per discussion with RN patient continues to\n tolerate tube feeds with minimal residuals, no emesis or diarrhea.\n Patient with elevated BG this AM and RISS ordered. Recommend continue\n current tube feeding formula at this with BG management as patient\n needs fluid restricted formula. Will continue to follow and monitor\n tube feed tolerance.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue current tube feeding as ordered: Isosource 1.5 @ 55\n mL/hr + 14 g Beneprotein to provide kcal and 102 g protein\n Monitor tube feed tolerance with residual checks q4hr, hold\n if greater than 200 mL\n Check chemistry 10 panel daily, replete as needed\n BG management as you are\n Bowel regimen as needed\n Following #\n ------ Protected Section ------\n Per discussion with RN, having trouble giving Creon through OGT.\n Patient currently without signs/symptoms of malabsorption of feeds.\n Plan to discuss with pharmacy. Recommend continue current tube feed as\n ordered, will continue to monitor.\n ------ Protected Section Addendum Entered By: , RD\n on: 12:16 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527327, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated on 40% 10/10. LS diminished/ bronchial @\n bases.\n Pt on low dose sedation 25mcgs/hr fentanyl. Pt is very restless,\n kicking and trying to reposition himself. Withdraws to painful\n stimuli. Eyes are slightly open, although pt does not track or appear\n to focus.\n Rec\nd pt w/ temp 100.4 on cooling blanket.\n Pt receiving TF Isosource at goal rate of 55cc/hr.\n Remains on droplet precautions\n Action:\n d/t increase agitation, Fentanyl increased to 100mcg/hr.\n Vent changed to MMV\n Pulmonary toileting q2hrs.\n VAP care per protocol.\n Meropenem per dose.\n Tylenol 650 q6hrs.\n Response:\n Pt appears more comfortable on increased dose of fentanyl.\n ABG ____\n Producing thick tan secretions.\n Temp down to 98.8\n Plan:\n continue aggressive pulmonary toileting, abx and Tylenol. Check pnd\n cultures (3/17,18)\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n BP 130-140/50-60.\n Rec\nd pt at 8pm, + for the day\n CPK elevated to 2600.\n Action:\n Given lasix 60mg IV at \n CVP monitored 14-19\n 500cc IVF over 2hrs for increased CPK.\n Response:\n Good diuresis from lasix w/ approx 1liter out, but down to 45cc/hr post\n diuresis.\n No increase in u/o post IVF bolus.\n Now is positive for day.\n No change in CVP.\n Plan:\n ? i/o goal, monitor hemodynamics including CVP.\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527428, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax_____. WBC= 11.4. AM lactate 1.6. Remains on droplet precautions\n while ruling out influenza.\n Action:\n *ID following- unclear if PNA is source of temp spike as CXR w/\n improvement\n *IV meropenem q 8 hours\n *Tylenol ATC q 6 hrs for pt comfort\n *Pt pan cultured \n Response:\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated MMV- PSV10/ 10 Peep, FiO2 40%. LS diminished/\n bronchial @ bases. Mod amts thick/ yellow secretions via ETT. SPO2\n >95%. Sedation w/ IV fentanyl @ 100mcg/min. Pt w/ open opening to\n speech, though no eye contact. Not following commands but moving all\n extremities in bed, non-purposeful. Restless legs in bed (present on\n admission).\n Action:\n *\n *IV meropenem q 8 hours.\n *Nutrition w/ tubefeeds via NGT.\n *.\n Response:\n *\n Plan:\n Continue to monitor resp status. Daily RSBI/SBT, wean vent as\n tolerated. IV fentanyl for comfort. VAP care/ pulm toileting. IV\n meropenem Q 8 hrs.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 mainly>95%. Bilat LE edema. HR paced at\n 50. Underlying rythum appears to be aflutter. NIBP\n 120s-150s/60s-70s.\n Action:\n *\n *Lopressor NGT \n *E-lytes monitored.\n Response:\n *\n Plan:\n *Continue to monitor resp status/ volume status.\n *\n *Daily wts/ 1500ml fluid restriction\n" }, { "category": "Nursing", "chartdate": "2141-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526740, "text": "71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated and sedated.\n Vent A/C 40% 500 X22 5.\n RR 22-24.\n Suctioned for thick tan sputum.\n Lungs diminished.\n Versed at 2mg/hr & Fentanyl at 25mcgs/hr.\n Action:\n Chest CT done.\n Conts on Vancomycin and Cefepime.\n Given 500cc NS bolus.\n Response:\n Chest CT shows bilateral LL infiltrates with pleural effusions.\n ^ In sputum production.\n Plan:\n Cont with antibiotics & pulmonary toilet. Vancomycin dose ^\nd to 1250mg\n .\n Wean sedation in am for pressure support trial.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced.\n Levophed remains off.\n SBP 90\ns-110\n INR 3.1 this am.\n Action:\n Lopressor remains on hold.\n Coumadin dc\n Response:\n Hemodynamcially stable.\n Plan:\n Cont to monitor.\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527036, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527135, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n , EP interogated, found that LV pacer not working, ICD not working, A\n sensing ok, RV sensing OK since beginning of . Magnet to bedside\n in case of inappropriate shock. If VF/VT manage medically.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T 100.6 max , SAT 97 0N 60/500/22/8 .BS DIM ,MIN SECRETIONS VERY\n SEDATED ON VERSED 4MG/FENTANYL 50 MIC. V PACED HR 60 TO 70 .BP 90 T0\n 100 SYSTOLIC ON LEVOPHED .04 MIC/KG ,CVP 6 TO 8 .HUO 20 TO 30 CC/HR\n neg 900cc.MOD AMT BILIOUS FROM OG TUBE,ABD SOFT C BS\n Action:\n SX FOR MIN ,VAP PROTOCOL\n CONTINUE ANTIBX\n WEAN SEDATION ,LEVOPHED AS TOL\n ATTEMPTING TO WEAN FIO2,PEEP\n FAMILY UPDATED\n TUBE FEEDINGS STARTED\n Response:\n TOL SLOW WEAN LEVOPHED ,BEGINNING TO RESPOND ON LESS SEDATION\n Plan:\n CONTINUE SLOW WEAN LEVOPHED,MAINTAIN MINIMAL SEDATION\n WEAN FIO2,PEEP AS TOL\n INCREASE TF AS TOL\n FOLLOW TEMP\n" }, { "category": "Nursing", "chartdate": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526095, "text": "72 y/o M with PMHx significant for systolic HF (EF 20-25%), MI,\n arrhythmias, s/p BiV ICD implantation with subsequent revisions due to\n the presence of malfunctioning lead, who presented to the ED this\n morning with a chief complaint of dyspnea and chest pressure. CXR LLL\n opacity and fluid overload. Started Abx and diuresed. Admitted to CCU.\n Pan cultured. Need sputum sample?\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele Vpaced.\n SBP 90\ns-100\n Lungs diminished in bases.\n High flow O2 at 65% with 3lnp.\n O2 sats 88-98%.\n Action:\n Lasix 40mg IV.\n Conts on Coumadin daily.\n Response:\n Good response to lasix.\n Plan:\n Monitor I&O.\n Check lytes.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Low grade temp.\n Normal wbc\n Cultures negative to date.\n CXR LL infiltrate.\n Pt conts to have frequent jerking movements. ?\n restless leg syndrome\n Action:\n Conts on Vancomycin Q 12hrs.\n Started on Azithromycin & Ceftriaxone\n Instruction given regarding use of IS.\n OOB to chair x\ns 2.\n Response:\n Pt conts to have high O2 requirement.\n Plan:\n Cont with course of antibiotics.\n Repeat abg\n Encourage C&DB with use of IS.\n Attempt to wean O2 as tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526291, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n 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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear, suctioned for scant amount of thin tan secretions,\n FiO2 weaned down to 50%, will continues to be followed.\n" }, { "category": "Physician ", "chartdate": "2141-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527114, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n spiked to 101, pancultured.\n 50cc -ve (has lots of intake from abx etc). Got Lasix 60 x3.\n Consider lasix gtt in am\n - Per pulm, pt has ARDS, (did not respond to peep) and has bilat\n infiltrate, wedge up, AA grad) but improving with right lung now clear.\n If not improving over a few days transfer to MICU.\n - Get good quality film in am with pt sitting up, ordered for 8am.\n - RISS started given GFS 190\n - d/c'd sedation\n - vanc dose increased\n - restarted coumadin, metoprolol\n - updated wife\n - From respiratory standpoint, patient did not do well on pressure\n support mode; was switched back to assist control in afternoon and\n overnight; in morning....\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 PM\n Furosemide (Lasix) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 50 (50 - 82) bpm\n BP: 141/62(80) {110/54(69) - 147/66(84)} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 13 (8 - 14)mmHg\n Total In:\n 2,203 mL\n 952 mL\n PO:\n TF:\n 1,273 mL\n 382 mL\n IVF:\n 620 mL\n 270 mL\n Blood products:\n Total out:\n 3,160 mL\n 1,155 mL\n Urine:\n 3,160 mL\n 1,155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -957 mL\n -203 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): 604 (604 - 604) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 122 cmH2O/mL\n SpO2: 96%\n ABG: 7.46/37/151/29/3\n Ve: 13.9 L/min\n PaO2 / FiO2: 377\n Physical Examination\n GENERAL: Intubated, sedated, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Cool lower extremities. Minimal bilateral LE edema.\n Labs / Radiology\n 312 K/uL\n 11.1 g/dL\n 170 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 33 mg/dL\n 104 mEq/L\n 142 mEq/L\n 32.6 %\n 10.0 K/uL\n [image002.jpg]\n 03:41 AM\n 04:21 AM\n 06:41 AM\n 09:37 AM\n 04:32 PM\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n WBC\n 7.2\n 10.0\n Hct\n 31.5\n 32.6\n Plt\n 258\n 312\n Cr\n 0.9\n 1.0\n 1.0\n 1.0\n TCO2\n 28\n 30\n 23\n 23\n 27\n 27\n Glucose\n 191\n 180\n 191\n 170\n Other labs: PT / PTT / INR:22.8/32.4/2.2, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:83.3 %, Lymph:6.5 %,\n Mono:6.5 %, Eos:3.5 %, Lactic Acid:0.9 mmol/L, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Now with increasing O2 requirement (FiO2 50%).Chest CT more consistent\n with atelectasis/effusion rather than pneumonia. Nonetheless, will\n complete course of abx. Will diurese.\n - continue mechanical ventilation\n - continue vancomycin, cefepime. Course of azithromycin is complete.\n - f/u pending cultures (no positive micro data to date)\n - pulm consult\n - diuresis as below\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hpyervolemic.\n - continue diuresis with goal negative 2 L today\n - restart metoprolol\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - restart metoprolol as tolerate by blood pressure\n - restart Coumadin in setting of therapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds. Pancreatic enzyme repletion has been\n difficult to get down tube.\n - discuss pancreatic supplementation with pharmacy\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:47 AM 55 mL/hour\n Glycemic Control: insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine, HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526167, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -started meropenem and discontinued ceftriaxone\n -consulted EP, will check ICD tomorrow\n -6 p.m., noted to be more hypoxemic, blood gas 7.50/37/50\n -gave Lasix and placed on non-rebreather without improvement\n -7 p.m. intubated for hypoxemic respiratory failure\n -8 p.m. A-line placed\n -febrile, pan-cultured\n -9 p.m. bolused 500 cc NS for SBP 70s\n -10 p.m. started levophed for SBP 70s\n -11 p.m. bolused additional 500 cc NS for SBP 70s\n -2 a.m. ET tube advanced 2 cm.\n -4 a.m. bolused with 500 cc NS for low urine output\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Vancomycin - 11:16 PM\n Meropenem - 12:44 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100\n HR: 60 (60 - 103) bpm\n BP: 76/47(53) {76/47(53) - 124/83(96)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,049 mL\n 712 mL\n PO:\n 560 mL\n TF:\n IVF:\n 1,489 mL\n 712 mL\n Blood products:\n Total out:\n 1,610 mL\n 145 mL\n Urine:\n 1,610 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n 439 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n Compliance: 51.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/44/117/27/3\n Ve: 10.7 L/min\n PaO2 / FiO2: 167\n Physical Examination\n GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.\n High-flow O2 mask on.\n HEENT: NC/AT.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: Difficult to hear over breath sounds; No m/r/g appreciated.\n LUNGS: Resp slightly labored; bilateral crackles and coarse breath\n sounds.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain.\n Labs / Radiology\n 172 K/uL\n 10.6 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 31.5 %\n 7.5 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n 10:00 AM\n 03:08 PM\n 06:29 PM\n 09:17 PM\n 11:16 PM\n 04:44 AM\n 04:55 AM\n WBC\n 7.4\n 7.5\n Hct\n 33.9\n 31.5\n Plt\n 174\n 172\n Cr\n 1.2\n 1.1\n 0.9\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 28\n 30\n 30\n 27\n 26\n 30\n Glucose\n 134\n 131\n 140\n 134\n Other labs: PT / PTT / INR:24.2/34.4/2.3, CK / CKMB /\n Troponin-T:374/4/<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but now\n suspicious for pneumonia.\n .\n # Dyspnea: Overnight, the patient had recurrent of dyspnea. Repeat CXR\n showed a more clear left-sided infiltrate. Also, of note, pt had fevers\n overnight. This presentation now more consistent with pneumonia, with a\n possible superimposed CHF component. Pt given\n vanc/cefepime/levofloxacin yesterday evening.\n - vanc/cefepime/azithromycin for broad coverage for pneumonia at this\n point\n - attempt to get sputum cultures\n - restarting Lasix 60 mg PO daily to prevent CHF exacerbation on top of\n PNA\n - continue metoprolol 12.5 mg daily, per home med list\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first 2 sets of CE's was\n negative. Of note, the patient did report some chest pressure\n previously, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3 on presentation. Telemetry\n currently showing v-paced rhythm.\n - continue coumadin, with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix as above\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526174, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -started meropenem and discontinued ceftriaxone\n -consulted EP, will check ICD tomorrow\n -6 p.m., noted to be more hypoxemic, blood gas 7.50/37/50\n -gave Lasix and placed on non-rebreather without improvement\n -7 p.m. intubated for hypoxemic respiratory failure\n -8 p.m. A-line placed\n -febrile, pan-cultured\n -9 p.m. bolused 500 cc NS for SBP 70s\n -10 p.m. started levophed for SBP 70s\n -11 p.m. bolused additional 500 cc NS for SBP 70s\n -2 a.m. ET tube advanced 2 cm.\n -4 a.m. bolused with 500 cc NS for low urine output\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Vancomycin - 11:16 PM\n Meropenem - 12:44 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100\n HR: 60 (60 - 103) bpm\n BP: 76/47(53) {76/47(53) - 124/83(96)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,049 mL\n 712 mL\n PO:\n 560 mL\n TF:\n IVF:\n 1,489 mL\n 712 mL\n Blood products:\n Total out:\n 1,610 mL\n 145 mL\n Urine:\n 1,610 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n 439 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n Compliance: 51.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/44/117/27/3\n Ve: 10.7 L/min\n PaO2 / FiO2: 167\n Physical Examination\n GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.\n High-flow O2 mask on.\n HEENT: NC/AT.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: Difficult to hear over breath sounds; No m/r/g appreciated.\n LUNGS: Resp slightly labored; bilateral crackles and coarse breath\n sounds.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain.\n Labs / Radiology\n 172 K/uL\n 10.6 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 31.5 %\n 7.5 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n 10:00 AM\n 03:08 PM\n 06:29 PM\n 09:17 PM\n 11:16 PM\n 04:44 AM\n 04:55 AM\n WBC\n 7.4\n 7.5\n Hct\n 33.9\n 31.5\n Plt\n 174\n 172\n Cr\n 1.2\n 1.1\n 0.9\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 28\n 30\n 30\n 27\n 26\n 30\n Glucose\n 134\n 131\n 140\n 134\n Other labs: PT / PTT / INR:24.2/34.4/2.3, CK / CKMB /\n Troponin-T:374/4/<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but now more\n consistent with pneumonia.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. have superimposed component\n of heart failure as well. On vancomycin, meropenem, azithromycin for\n broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation with CMV 500/22/0.7/5. Wean FiO2 as\n tolerated.\n - continue vancomycin, meropenem, azithromycin\n - f/u pending cultures\n .\n # Hypotension/sepsis: Likely pneumonia.\n - holding metoprolol\n - holding diuresis\n - IV fluids PRN\n - norepinephrine\n - place central venous line given pressor requirement\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Heart failure\n may be contributing to patient\ns dyspnea, on top of pneumonia. Has\n required fluids overnight for low urine output. On norepinephrine.\n - continue norepinephrine\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI rules out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension\n - continue coumadin, with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # s/p ICD: Based on EKG, left ventricular lead may not be functioning\n properly.\n - EP consulted\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition: consult nutrition for tube feeds\n Glycemic Control: none\n Lines:\n 20 Gauge - 12:58 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: pantoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526113, "text": "72 y/o M with PMHx significant for systolic HF (EF 20-25%), MI,\n arrhythmias, s/p BiV ICD implantation with subsequent revisions due to\n the presence of malfunctioning lead, who presented to the ED this\n morning with a chief complaint of dyspnea and chest pressure. CXR LLL\n opacity and fluid overload. Started Abx and diuresed. Admitted to CCU.\n Pan cultured. Need sputum sample?\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele Vpaced.\n SBP 90\ns-100\n Lungs diminished in bases.\n High flow O2 at 65% with 3lnp.\n O2 sats 88-98%.\n Action:\n Lasix 40mg IV.\n Conts on Coumadin daily.\n Response:\n Good response to lasix.\n Plan:\n Monitor I&O.\n Check lytes.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Low grade temp.\n Normal wbc\n Cultures negative to date.\n CXR LL infiltrate.\n Pt conts to have frequent jerking movements. ?\n restless leg syndrome\n Action:\n Conts on Vancomycin Q 12hrs.\n Started on Azithromycin & Ceftriaxone\n Instruction given regarding use of IS.\n OOB to chair x\ns 2.\n Response:\n Pt conts to have high O2 requirement.\n Plan:\n Cont with course of antibiotics.\n Repeat abg\n Encourage C&DB with use of IS.\n Attempt to wean O2 as tolerated.\n ------ Protected Section ------\n At approx 1830 O2 sats decreased into 80\ns house staff aware. Up to\n see pt abg done PO2 53. RR increased into 30\ns. Decision made to\n intubate pt. Anesthesia called. Intubated without problem. Requiring\n sedation for agitation and increased RR. CXR done.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:42 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528295, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet in\n room. CT head, chest, & pelvis-without noted infectious process.\n pt sustained a VF arrest on days, rec\nd 2min CPR. defibx 1\n 200j shock with return of spontaneous circulation and paced HR. No\n further arrhythmias o/n. cpk\ns are being cycled. Plan is to do TEE\n today, postponed.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Remains on ac 500x14, 8 peep. 40%. Minimal secretions. Bs dim and cta.\n Sedation dc\nd at 9:30am. Pt more awake over the course of the evening.\n No spon movement of upper extremities, moves feet in bed. Opens eyes,\n nods head, resists mouth care. Wrist restraints in place.\n Action:\n ? to PSV after TEE tomorrow\n Response:\n Plan:\n Follow sats. Assess mental status, safety precautions\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Started on heparin at 1650units. Also cont on warfarin. PTT >150 at 7pm\n gtt on hold.\n Action:\n Response:\n Plan:\n Resume heparin at 1300units at 8pm.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this shift. Cont on meropenum. Cultures ntd. Will do TEE\n tomorrow. Poss resite line this eve.\n Peripheral line placed on r by IV team.\n Discussed patient\ns status and plan with , HCP, and other. She\n is anxious about pt\ns course, particularly about move to MICU and\n return. Explained and answered questions.\n Dtr to visit tomorrow.\n Tubefeed resumed at 5:30pm at 55cc/hr(goal). Abd soft. Hold at mn as pt\n is npo for tee tomorrow\n Action:\n Follow temp\n Response:\n Plan:\n Provide support to patient and family. Consult SW for support.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527314, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / 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: Prolonged exhalation\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: Reduce PEEP as tolerated; Comments: Unable to protect\n airway. Biting on ETT. Having periods of apnea. Placed on MMV overnite.\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: MDI\ns given. Will cont to monitor resp status.\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526168, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening SOB.\n CXR with LLL infiltrate and CHF exacerbation. High 02 requirements\n since admit to the CCU. Intubated on for increased work of\n breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Received patient dysynchronis with the vent . RR up to the 40\ns. Vent\n settings 100% /TV 500/ RR 22 /Peep 5\n Action:\n Fentanyl and versed drps begun. Aline inserted. Post intubation\n hypotension despite 500 cc boluses times 3. SBP to the 70\ns. Levophed\n begun. Minimal urine output. 2 PIVs inserted. Trial wean of levophed\n during fluid challenge unsuccessful.\n Response:\n Able to wean Fi02 to 70%. Better BP with initiation of pressor. Poor\n urine output to fluid challenge and levophed support.\n Plan:\n Wean Fi02 as tolerated. Daily wake-up deferred due to hemodynamic\n iinstability. Consider central access as peripheral access tenuous.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T max 100.8\n Action:\n Maintained on Azithromycin, Vanco and meropenem. 2 sets of bld\n cultures, urine and sputum. Suctoned times 4 for minimal secretions.\n VAP care q3-4. Tylenol\n Response:\n Remains low grade temp\n Plan:\n Continue ABXS. ? pulmonary consult\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526288, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated. A/C 70% 500 22 8.\n Lungs diminished.\n Low grade fever.\n Suctioned for minimal sputum.\n Sedated with versed & fentanyl drips.\n Pt agitated with minimal stimulation.\n Not able to follow commands.\n Responsive to some verbal stimulation.\n Action:\n Sedation not lightened today d/t agitation.\n FIO2 weaned to 50%.\n Restarted on Cefepime per ID.\n Meropenem dc\n Response:\n Improved abg\n Plan:\n Pt to remain sedated overnight.\n Cont with antibiotics.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced 50\ns-60\n SBP 100\ns-120\n Lungs diminished.\n Levophed at .08mcgs/kg/min.\n Action:\n Lopressor & lasix held.\n Device interrogated by EP fellow.\n Levophed weaned to .05mcgs/kg/min.\n Given 500cc\ns NS x\ns 1.\n Response:\n CVP 5-14.\n Only RV lead is functional.\n Hemodynamically stable with wean of Levo\n Plan:\n Cont to monitor I&O.\n Cont to hold lasix.\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526289, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated. A/C 70% 500 22 8.\n Lungs diminished.\n Low grade fever.\n Suctioned for minimal sputum.\n Sedated with versed & fentanyl drips.\n Pt agitated with minimal stimulation.\n Not able to follow commands.\n Responsive to some verbal stimulation.\n Action:\n Sedation not lightened today d/t agitation.\n FIO2 weaned to 50%.\n Restarted on Cefepime per ID.\n Meropenem dc\n Response:\n Improved abg\n Plan:\n Pt to remain sedated overnight.\n Cont with antibiotics.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced 50\ns-60\n SBP 100\ns-120\n Lungs diminished.\n Levophed at .08mcgs/kg/min.\n Action:\n Lopressor & lasix held.\n Device interrogated by EP fellow.\n Levophed weaned to .05mcgs/kg/min.\n Given 500cc\ns NS x\ns 1.\n Response:\n CVP 5-14.\n Only RV lead is functional.\n Hemodynamically stable with wean of Levo\n Plan:\n Cont to monitor I&O.\n Cont to hold lasix.\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528047, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.2\nC - 08:00 AM\n Overnight Events:\n - Brief trial of 0/5 with RISBI 50-60S, will stay on MMV (5L) on \n overnight with plan for pressure support trial in am.\n - Added on LFTs, elevated (CK's now trending down)\n - Fentanyl stopped at 4pm after CT scan.\n - Ready to extubate in am.\n - BAL- -ve PCP, stuff pending.\n - DFA negative, resp precautions dc'd.\n - Having Fevers through out day. I.D recommended imaging. Head/Torso CT\n negative. Will need TEE on Monday to eval leads ? endocarditis\n (ordered)\n - Defervesced with ibuprofen.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.7\nC (99.9\n HR: 52 (50 - 52) bpm\n BP: 126/55(73) {89/50(67) - 136/80(299)} mmHg\n RR: 17 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 23 (10 - 24)mmHg\n Total In:\n 2,474 mL\n 392 mL\n PO:\n TF:\n 1,104 mL\n 225 mL\n IVF:\n 610 mL\n 167 mL\n Blood products:\n Total out:\n 1,780 mL\n 395 mL\n Urine:\n 1,780 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 694 mL\n -3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 471 (456 - 859) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.47/54/175/34/14\n Ve: 15.2 L/min\n PaO2 / FiO2: 438\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. 2/6 systolic murmur at the apex.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. No significant pitting edema noted.\n Labs / Radiology\n 372 K/uL\n 10.2 g/dL\n 171 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 104 mEq/L\n 145 mEq/L\n 32.0 %\n 9.5 K/uL\n [image002.jpg]\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n 06:14 AM\n 06:58 AM\n 03:36 AM\n 04:12 AM\n WBC\n 11.4\n 10.1\n 9.5\n Hct\n 30.8\n 32.6\n 31.2\n 32.0\n Plt\n \n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 0.9\n TropT\n 0.02\n TCO2\n 36\n 37\n 35\n 40\n Glucose\n 157\n 167\n 175\n 170\n 171\n Other labs: PT / PTT / INR:15.7/27.9/1.4, CK / CKMB /\n Troponin-T:434/3/0.02, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials, including this p.m.\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following.\n - CT abd/pelvis and CT sinuses\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - holding diuresis today\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nutrition", "chartdate": "2141-03-13 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 528209, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: warfarin, RISS, heparin, lasix, others noted\n Labs:\n Value\n Date\n Glucose\n 130 mg/dL\n 04:26 AM\n Glucose Finger Stick\n 150\n 10:00 AM\n BUN\n 55 mg/dL\n 04:26 AM\n Creatinine\n 1.3 mg/dL\n 04:26 AM\n Sodium\n 148 mEq/L\n 04:26 AM\n Potassium\n 4.4 mEq/L\n 04:26 AM\n Chloride\n 107 mEq/L\n 04:26 AM\n TCO2\n 34 mEq/L\n 04:26 AM\n Albumin\n 3.3 g/dL\n 01:07 AM\n Calcium non-ionized\n 8.0 mg/dL\n 04:26 AM\n Phosphorus\n 3.5 mg/dL\n 04:26 AM\n Ionized Calcium\n 1.10 mmol/L\n 08:00 AM\n Magnesium\n 3.3 mg/dL\n 04:26 AM\n Current diet order / nutrition support: Isosource 1.5 with 14g\n beneprotein at 55ml/hr x 24 hours (provides 2029kcal and 102g protein)\n - currently not running\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n Specifics: 72 year old male admitted with dyspnea, likely CHF\n exacerbation, intubated for respiratory distress. Patient has\n been receiving tube feedings, are currently stopped. Noted patient s/p\n Code Blue yesterday. Would restart tube feedings when medically\n possible.\n Medical Nutrition Therapy Plan - Recommend the Following\n Restart current tube feeding as ordered: Isosource 1.5 with\n 14g beneprotein at 55ml/hr x 24 hours\n Monitor tube feed tolerance with residual checks q4hr, hold\n if greater than 200 mL\n Will follow\n 11:15 AM\n" }, { "category": "Nutrition", "chartdate": "2141-03-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 526255, "text": "Subjective\n Unable to assess as patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 104 kg ( 12:00 AM)*\n increased due to fluid\n 31.1 * based on daily wt\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 129%* based on daily wt\n 86.5 kg\n per OMR note ): 107 kg\n ) 90.72 kg\n Diagnosis: CHF\n PMHx:\n Food allergies and intolerances: none noted\n Pertinent medications: Fentanyl drip, versed drip, norepinphrine drip,\n ABX, Colace (held), Creon, Lansoprazole, Potassium Chloride (20mEq\n repletion)\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 04:44 AM\n BUN\n 29 mg/dL\n 04:44 AM\n Creatinine\n 0.9 mg/dL\n 04:44 AM\n Sodium\n 139 mEq/L\n 04:44 AM\n Potassium\n 3.7 mEq/L\n 04:44 AM\n Chloride\n 105 mEq/L\n 04:44 AM\n TCO2\n 27 mEq/L\n 04:44 AM\n PO2 (arterial)\n 175 mm Hg\n 01:51 PM\n PCO2 (arterial)\n 37 mm Hg\n 01:51 PM\n pH (arterial)\n 7.44 units\n 01:51 PM\n pH (urine)\n 5.0 units\n 10:23 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 01:51 PM\n Calcium non-ionized\n 7.7 mg/dL\n 04:44 AM\n Phosphorus\n 2.1 mg/dL\n 04:44 AM\n Magnesium\n 2.1 mg/dL\n 04:44 AM\n WBC\n 7.5 K/uL\n 04:44 AM\n Hgb\n 10.6 g/dL\n 04:44 AM\n Hematocrit\n 31.5 %\n 04:44 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, positive bowel sounds\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1730-2160 (BEE x or / 20-25 cal/kg)\n Protein: 95-112 (1.1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement:\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2141-03-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 526261, "text": "Subjective\n Unable to assess as patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 104 kg ( 12:00 AM)*\n increased due to fluid\n 31.1 * based on daily wt\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 129%* based on daily wt\n 86.5 kg\n per OMR note ): 107 kg\n ) 90.72 kg\n Diagnosis: CHF\n PMHx:\n CARDIAC HISTORY:\n - Hypertension\n - Anterior wall myocardial infarction in with ventricular\n tachycardia and complete heart block requiring pacemaker\n - Systolic heart failure (EF 20-25%)\n - Atrial fibrillation\n 1. Hypertension.\n 2. Hypothyroidism.\n 3. Anemia.\n 4. Irritable bowel syndrome.\n 5. Constipation.\n 6. Obesity.\n 7. Hearing loss, requiring bilateral hearing aids.\n 8. Squamous cell carcinoma of the left lower eyelid.\n 9. Vitamin D deficiency.\n 10. Cerebral infarct.\n 11. Falls.\n 12. Compression fractures.\n 13. History of Whipple operation, with subsequent E. coli and\n Klebsiella bacteremia\n 14. History of possible C3-C4 osteomyelitis\n PAST SURGICAL HISTORY:\n 1. Placement of pacemaker and ICD.\n 2. Knee surgery.\n 3. Removal of squamous cell carcinoma of his left lower eyelid.\n 4. Recent Whipple's procedure for which he was diagnosed with\n dysplasia.\n Food allergies and intolerances: none noted\n Pertinent medications: Fentanyl drip, versed drip, norepinphrine drip,\n ABX, Colace (held), Creon, Lansoprazole, Potassium Chloride (20mEq\n repletion)\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 04:44 AM\n BUN\n 29 mg/dL\n 04:44 AM\n Creatinine\n 0.9 mg/dL\n 04:44 AM\n Sodium\n 139 mEq/L\n 04:44 AM\n Potassium\n 3.7 mEq/L\n 04:44 AM\n Chloride\n 105 mEq/L\n 04:44 AM\n TCO2\n 27 mEq/L\n 04:44 AM\n PO2 (arterial)\n 175 mm Hg\n 01:51 PM\n PCO2 (arterial)\n 37 mm Hg\n 01:51 PM\n pH (arterial)\n 7.44 units\n 01:51 PM\n pH (urine)\n 5.0 units\n 10:23 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 01:51 PM\n Calcium non-ionized\n 7.7 mg/dL\n 04:44 AM\n Phosphorus\n 2.1 mg/dL\n 04:44 AM\n Magnesium\n 2.1 mg/dL\n 04:44 AM\n WBC\n 7.5 K/uL\n 04:44 AM\n Hgb\n 10.6 g/dL\n 04:44 AM\n Hematocrit\n 31.5 %\n 04:44 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, positive bowel sounds\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: 1730-2160 (20-25 cal/kg)\n Protein: 95-112 (1.1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 72 YO male admitted with dyspnea, likely CHF exacerbation. Wt\n increased x few weeks, 4lb increase x2 days,\nadmits to dietary\n indiscretion\n per chart. Seen by SLP for S+S evaluation due to\n concern with dysphagia. Per SLP note, patient with difficulty\n swallowing hard solid foods since his Whipple, follows regular diet,\n but eats soft foods if he is without his dentures and thin liquids.\n SLP recommended to continue usual diet consistency. Intubated for\n respiratory distress. CXR showed LLL infiltrate. Consulted for tube\n feeds. RN, patient with bilious output from OGT, ~ 300ml, no bm\n yet; was eating yesterday before intubation. Could hold off on tube\n feed for 1-2 days considering patient presents well nourished. Needs\n fluid restricted formula. Noted low phosphorus.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations:\n Once OGT output decreases, begin tube feed:\n 1. Isosource 1.5 @ 15ml/hr, advance as tolerated to goal of\n 55ml/hr + 14g Beneprotein = calories and 102g protein\n 1. Check residuals, hold tube feed if greater than 200ml\n 2. Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel daily\n 1. Replete phosphorus\n BS management\n Bowel regimen p.r.n.\n Will follow, page if questions *\n" }, { "category": "Respiratory ", "chartdate": "2141-03-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526332, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\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: Tan / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526344, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Received patient on Levophed at .08 mcgs. V ( RV ) paced in the mid\n 50\ns to low 60\ns. SBP hovering in the low 90\n Action:\n Slow wean of levophed attempted. Lasix and fluid challenge on hold\n Response:\n Unsuccessful as SBP dropping into the mid 70\ns. Urine output 20-40\n cc/hr .. urine dark amber in appearance\n Plan:\n Per EP note .. No Capture of LV lead. Device reprogrammed to DDD\n 50/125and LV pacing lead turned off by EP.. Underlying SR with long AV\n delay. Magnet at doorwayin case of complete RV lead failure.. Monitor\n electrolytes.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received patient orally intubated and sedated. Lungs diminished at\n the bases. Resp rate in sync\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528292, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527372, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated on 40% 10/10. LS diminished/ bronchial @\n bases.\n Pt on low dose sedation 25mcgs/hr fentanyl. Pt is very restless,\n kicking and trying to reposition himself. Withdraws to painful\n stimuli. Eyes are slightly open, although pt does not track or appear\n to focus.\n Rec\nd pt w/ temp 100.4 on cooling blanket.\n Pt receiving TF Isosource at goal rate of 55cc/hr.\n Remains on droplet precautions.\n Action:\n d/t increase agitation, Fentanyl increased to 100mcg/hr.\n Vent changed to MMV\n Pulmonary toileting q2hrs.\n VAP care per protocol.\n Meropenem per dose.\n Tylenol 650 q6hrs.\n Glargine started at HS w/ RISS q6hrs.\n Response:\n Pt appears more comfortable on increased dose of fentanyl.\n ABG on MMV\n 7.42/53/141\n Producing thick tan secretions.\n Temp down to 97.9-100. WBC 11.4\n AM BS down to 159.\n Plan:\n continue aggressive pulmonary toileting, abx and Tylenol. Check pnd\n cultures (3/17,18)\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n BP 130-140/50-60.\n Rec\nd pt at 8pm, + for the day\n CPK elevated to 2600.\n Action:\n Given lasix 60mg IV at \n CVP monitored 14-19\n 500cc IVF over 2hrs for increased CPK.\n Response:\n Good diuresis from lasix w/ approx 1liter out, but down to 15cc/hr 6hrs\n post diuresis.\n No increase in u/o post IVF bolus.\n Now is positive for day.\n CPK down to \n No change in CVP.\n Plan:\n ? i/o goal, monitor hemodynamics including CVP.\n" }, { "category": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527375, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT partly; RN was able to push back in; good placement on\n repeat CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales, wheezes, or\n rhonchi.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Neuro: Normal lower extremity tone. Knee and ankle jerks absent\n bilaterally.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Elevated CK: Pt noted to have an elevated in CK on labwork yesterday.\n Not likely cardiac in nature, as MB is normal. Serotonin syndrome is a\n possibility in this patient on fentanyl and with high fevers. However,\n physical exam not consistent with serotonin syndrome. Also, the patient\n has been on fentanyl for some time, and you would expect this to have\n shown up sooner. Another possibility is rhabdomyolysis in the setting\n of infection. At this point, etiology not clear. Pt was given 500 cc\n overnight to help prevent renal damage from the elevated CK. CK\n trending down this morning.\n - continue to trend CK\n - IV fluids as needed to promote elimination of CK\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically as of yesterday. Suspect multifactorial etiology of\n CHF + pneumonia. Of note, pt spiked high temperatures yesterday despite\n being on vanc/cefepime/flagyl. Started on a cooling blanket and\n switched to meropenem\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n - consider bronch today\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. After spike to\n 103.8 yesterday, ID was consulted. One concern would be for empyema,\n although lack of pleural enhancement of chest CT argues against this.\n - continue meropenem monotherapy, per ID recs\n - f/u respiratory viral screen\n - f/u repeat CXR this AM\n - consider bronch\n - continue cooling blanket\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic. Was being diuresed with goal negative 1-2 L. However,\n ended up getting some fluid overnight elevated CK.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526081, "text": "72 y/o M with PMHx significant for systolic HF (EF 20-25%), MI,\n arrhythmias, s/p BiV ICD implantation with subsequent revisions due to\n the presence of malfunctioning lead, who presented to the ED this\n morning with a chief complaint of dyspnea and chest pressure. CXR LLL\n opacity and fluid overload. Started Abx and diuresed. Admitted to CCU.\n Pan cultured. Need sputum sample?\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele Vpaced.\n SBP 90\ns-100\n Lungs diminished in bases.\n High flow O2 at 65% with 3lnp.\n O2 sats 88-98%.\n Action:\n Lasix 40mg IV.\n Conts on Coumadin daily.\n Response:\n Good response to lasix.\n Plan:\n Monitor I&O.\n Check lytes.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Low grade temp.\n Normal wbc\n CXR LL infiltrate.\n Pt conts to have frequent jerking movements. ?\n restless leg syndrome\n Action:\n Conts on Vancomycin Q 12hrs.\n Started on Azithromycin & Ceftriaxone\n Instruction given regarding use of IS.\n OOB to chair x\ns 2.\n Response:\n Pt conts to have high O2 requirement.\n Plan:\n Cont with course of antibiotics.\n Encourage C&DB with use of IS.\n Attempt to wean O2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526460, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n , EP interogated, found that LV pacer not working, ICD not working, A\n sensing ok, RV sensing OK since beginning of . Magnet to bedside\n in case of inappropriate shock. If VF/VT manage medically.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T 100.6 max , SAT 97 0N 60/500/22/8 .BS DIM ,MIN SECRETIONS VERY\n SEDATED ON VERSED 4MG/FENTANYL 50 MIC .BP 90 T0 100 SYSTOLIC ON\n LEVOPHED .04 MIC/KG ,CVP 6 TO 8 .HUO 20 TO 50 CC/HR .MOD AMT BILIOUS\n FROM OG TUBE,ABD SOFT C BS\n Action:\n SX FOR MIN ,VAP PROTOCOL\n CONTINUE ANTIBX\n WEAN SEDATION ,LEVOPHED AS TOL\n ATTEMPTING TO WEAN FIO2,PEEP\n FAMILY UPDATED\n TUBE FEEDINGS STARTED\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2141-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526152, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\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: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526412, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n , EP interogated, found that LV pacer not working, ICD not working, A\n sensing ok, RV sensing OK since beginning of . Magnet to bedside\n in case of inappropriate shock. If VF/VT manage medically.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T 100.6, SAT 97 0N 60/500/22/8 .BS DIM ,MIN SECRETIONS VERY SEDATED ON\n VERSED 4MG/FENTANYL 50 MIC .BP 90 T0 100 SYSTOLIC ON LEVOPHED .04\n MIC/KG ,CVP 6 TO 8 .HUO 20 TO 50 CC/HR .MOD AMT BILIOUS FROM OG\n TUBE,ABD SOFT C BS\n Action:\n SX FOR MIN ,VAP PROTOCOL\n CONTINUE ANTIBX\n WEAN SEDATION ,LEVOPHED AS TOL\n FAMILY UPDATED\n TUBE FEEDINGS STARTED\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526582, "text": "CCU Nursing Progess Note.\n 71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Pneumonia\n Assessment:\n Intubated . On broad coverage abx-vanco, azithromycin,\n ceftriaxone, & cefepime. Continued low grade temp. Cltures pending.\n Continues on low dose pressor ( norepinephrine) with maps >50\ns to 60.\n Responds to stimuli with restlessness/agitation-presently not following\n commands or purposeful movements.\n Action:\n Weaning vent as tolerated. VAP protocol. Abx as ordered. Wean pressor\n as tolerated.\n Response:\n Low grade temp. Tolerating pressor dc. Stable abg/sats.\n Plan:\n Continue present management.\n Heart Failure (CHF), Systolic, Acute\n Assessment:\n Overall LOS i&o slightly negative. Borderline uo. Requiring pressor\n (low dose) to maintain adequate maps.\n Action:\n Titrating pressor as indicated.\n Response:\n Tolerating pressor dc. Slight increase in uo.\n Plan:\n Continue present management.\n Chronic Antibiotic Use\n Assessment:\n On abx for ongoing suppression of high-grade viridans streptococcal\n bacteremia & for life-long suppression of suspected klebsiella\n pneumonia lead endocarditis.\n Action:\n Holding cefpodoxime while on broad spectum abx.\n Response:\n Plan:\n Continue present management.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526456, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Switch over to PS as tol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528641, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway. CT head, chest, & pelvis-without\n noted infectious process.\n vf arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient placed on CPAP 5/5 40%- lung sounds clear- suctioned small amt\n thick tan.\n Action:\n RSBI 55 this am- ABG on CPAP 7.50-48-115-39 sat 97%- successfully\n extubated @ 1600- In O2 50% CN.\n Response:\n More awake- no resp distress.\n Plan:\n Monitor resp status- follow ABG\ns- encourage coughing and deep\n breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n D5W 2L 125 cc per hour for high sodium- D/C\nd after 1500cc.\n Action:\n TEE done this am- lasix 60mg IV given- heparin gtt D/C\nd @ 1400- INR\n 2.0 this am- repeat 1.8- Coumadin given @ 1600.\n Response:\n Diuresed well- hemodynamically stable.\n Plan:\n Follow U/O- con\nt cardiac meds as ordered- keep family updated on plan\n of care.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n 1 blood culture from taken from CL growning gm (+) cocci. WBC 6.0\n today- afebrile.\n Action:\n Pt recultured- meropenum given as ordered- vanco restarted- PICC line\n inserted @ IR- TLCL R IJ to be D/C\n Response:\n Remains afebrile.\n Plan:\n D/C TL tonight- follow temps and culture results- reculture if patient\n spikes temp- con\nt ABX.\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526251, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated. A/C 70% 500 22 8.\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced 50\ns-60\n SBP 100\ns-120\n Lungs diminished.\n Action:\n Lopressor & lasix held.\n Device interrogated by EP fellow.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526695, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - weaned FiO2 to 40%\n - started tube feeds\n - weaned sedation from 50&4 to 25&2\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Meropenem - 12:44 AM\n Vancomycin - 08:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.3\n HR: 65 (59 - 78) bpm\n BP: 76/47(53) {0/0(0) - 0/0(0)} mmHg\n RR: 22 (20 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 8 (5 - 12)mmHg\n Total In:\n 1,778 mL\n 440 mL\n PO:\n TF:\n 145 mL\n 179 mL\n IVF:\n 1,453 mL\n 161 mL\n Blood products:\n Total out:\n 590 mL\n 240 mL\n Urine:\n 590 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,188 mL\n 200 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 58.8 cmH2O/mL\n SpO2: 95%\n ABG: 7.47/41/84./26/5\n Ve: 10.3 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GENERAL: Intubated, sedated, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Labs / Radiology\n 205 K/uL\n 9.6 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.5 %\n 6.4 K/uL\n [image002.jpg]\n 04:55 AM\n 09:20 AM\n 01:51 PM\n 06:28 PM\n 04:26 AM\n 04:40 AM\n 07:02 AM\n 09:35 PM\n 04:35 AM\n 04:52 AM\n WBC\n 6.6\n 6.4\n Hct\n 30.6\n 28.5\n Plt\n 197\n 205\n Cr\n 0.8\n 0.7\n TCO2\n 30\n 26\n 26\n 29\n 28\n 30\n 30\n 31\n Glucose\n 109\n 132\n Other labs: PT / PTT / INR:31.1/42.8/3.1, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:81.8 %, Lymph:8.5 %,\n Mono:5.6 %, Eos:3.9 %, Lactic Acid:0.9 mmol/L, Ca++:7.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. On vancomycin, cefepime,\n azithromycin for broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation. Consider trial on pressure support\n if patient becomes more alert.\n - continue vancomycin, cefepime, azithromycin.\n - f/u pending cultures (no positive micro data to date)\n - chest CT to better evaluate lung fields\n .\n # Hypotension/sepsis: BPs high 90s to low 100s. Likely pneumonia.\n On levophed for pressor support. CVP 6-9 suggesting not volume up.\n Wean levo as tolerated.\n - holding metoprolol\n - holding diuresis\n - IV fluids PRN\n - norepinephrine\n ..\n # Chronic systolic heart failure: Patient with EF 20-25%. CVP suggests\n CHF contributing less than other factors. UOP 40cc/hr with pt net +ve\n 628, -ve 1.3L. On norepinephrine.\n - continue norepinephrine, wean as tolerated/\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension\n - continue Coumadin at 1mg/day , with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # s/p ICD: high impedance, unclear why.\n -pacer revison in future.\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple: NGT output bilous. Did not initiate tube feeds.\n - holding pancreatic enzyme repletio\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:37 PM 25 mL/hour\n Glycemic Control: none\n Lines:\n Arterial Line - 09:13 PM\n 20 Gauge - 12:58 AM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2141-03-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528284, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n 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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: sedated passively breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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 Patient transfered from Micu-6 to CCU on mechanical ventilation. No\n recent ABG drawn, BS diminished clear ,episodes of tachycardia\n ,suctioned for scant amount of thick tan secretion .Plan to wean to\n extubate patient at the appropriate time ; now vent dependent.\n" }, { "category": "Physician ", "chartdate": "2141-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528780, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -extubated 4PM\n -left PICC placed by IR\n -left IJ pulled, tip sent for culture\n -TEE: Severe (4+ MR). No vegetations seen on the right atrial leads\n (four identified) or on mitral, aortic, tricuspid or pulmonic valves.\n Severely depressed left ventricular function with septal, inferoseptal\n and inferior wall hypokinesis. Moderate tricuspid regurgitation. At\n least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n Echo in 09 - 2+ MR - possibility endocarditis.\n -Ucx negative, blood cx pending.\n -GPC in clusters. f/u cx data - no s/s yet. Possible contaminant.\n -started vanc\n -Got lasix 60 IV x 1 with UOP ***, likely need to repeat 9pm (got lasix\n late )goal negative 1L\n -3pm crit/lytes\n -heparin discontinued\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 08:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:05 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 52 (50 - 59) bpm\n BP: 105/45(62) {101/42(56) - 127/60(76)} mmHg\n RR: 16 (7 - 18) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 10 (9 - 10)mmHg\n Total In:\n 2,770 mL\n 67 mL\n PO:\n TF:\n IVF:\n 2,380 mL\n 67 mL\n Blood products:\n Total out:\n 3,972 mL\n 580 mL\n Urine:\n 3,970 mL\n 580 mL\n NG:\n 2 mL\n Stool:\n Drains:\n Balance:\n -1,202 mL\n -513 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 630 (630 - 630) mL\n RR (Set): 0\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SpO2: 99%\n ABG: 7.50/52/67/34/14\n Ve: 8.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 468 K/uL\n 10.4 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 30 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 9.3 K/uL\n [image002.jpg]\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n WBC\n 10.4\n 9.2\n 9.3\n Hct\n 30.7\n 30.4\n 31.8\n Plt\n \n Cr\n 1.3\n 1.2\n 0.9\n 0.7\n 0.7\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 130\n 164\n 130\n 198\n 151\n 137\n 122\n Other labs: PT / PTT / INR:19.5/29.4/1.8, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.6 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever/Pneumonia: Now afebrile x 48 hours. Previously, patient was\n spiking high fevers in spite of Tylenol, antibiotics, and improvement\n of pneumonia. This led to concern about an occult infection or\n non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue meropenem/vanc\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Hypoxemic respiratory failure: Now s/p extubation. Was intubated on\n for hypoxemic respiratory failure. Etiology likely pneumonia\n + heart failure.\n - f/u pending cultures\n - treat pneumonia as above\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during VT/VF arrest.\n -f/u EP recs\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Pulled NG tube yesterday. Will under repeat speech and\n swallow evaluation tomorrow, as mental status is rapidly improving.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n PICC\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526405, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 10:00 AM\n central line placed, CVP 9-15, EP interogated, found that LV pacer not\n working, ICD not working, A sensing ok, RV sensing OK since beginning\n of . Magnet to bedside in case of inappropriate shock. If VF/VT\n manage medically.\n fi02 weaned from 70 to 50, borderlien ABGs, back to 60, RISBI deferred.\n OGT with high bile output 350cc, ? whipple. Ok to hold tube feeds\n for 1-2 days. nutrition consult, gave tube feed recs (Isosource 1.5 at\n 15m;/hr, goal 55cc/hr with 14g beneprotein. OGT output 350 cc bile.?\n coz of whipple? Holding pancreatic enzyme. -consider pressidex if\n agitated for extubation.\n -changed to cefepime per I.D\n Sputum GS: >25 PMNs, no organisms\n UCx neg\n -decreased coumadin to 1mg given on levo\n Levo weaned down from 0.08 to 0.04mcg/kg/min maintain MAPs in 60s.\n .\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Meropenem - 12:44 AM\n Vancomycin - 08:30 PM\n Cefipime - 12:31 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 63 (53 - 67) bpm\n BP: 76/47(53) {0/0(0) - 0/0(0)} mmHg\n RR: 22 (20 - 23) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 6 (5 - 15)mmHg\n Total In:\n 1,968 mL\n 129 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 129 mL\n Blood products:\n Total out:\n 1,340 mL\n 110 mL\n Urine:\n 965 mL\n 110 mL\n NG:\n 375 mL\n Stool:\n Drains:\n Balance:\n 628 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 488 (488 - 488) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n Compliance: 44.6 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/44/137/28/4\n Ve: 10.8 L/min\n PaO2 / FiO2: 228\n Physical Examination\n GENERAL: intubated, sedated, unresponsive.\n NECK: Unable to appreciate JVP.\n CARDIAC: Quiet heart sounds. Difficult to hear over breath sounds; No\n m/r/g appreciated.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness noted.\n EXTREMITIES: No significant LE edema noted. Extremities warm and\n well-perfused.\n Labs / Radiology\n 197 K/uL\n 10.0 g/dL\n 109 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.6 %\n 6.6 K/uL\n [image002.jpg]\n 09:17 PM\n 11:16 PM\n 04:44 AM\n 04:55 AM\n 09:20 AM\n 01:51 PM\n 06:28 PM\n 04:26 AM\n 04:40 AM\n 07:02 AM\n WBC\n 7.5\n 6.6\n Hct\n 31.5\n 30.6\n Plt\n 172\n 197\n Cr\n 0.9\n 0.8\n TCO2\n 27\n 26\n 30\n 26\n 26\n 29\n 28\n 30\n Glucose\n 140\n 134\n 109\n Other labs: PT / PTT / INR:25.9/32.9/2.5, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:81.8 %, Lymph:8.5 %,\n Mono:5.6 %, Eos:3.9 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. have superimposed component\n of heart failure as well. On vancomycin, cefepime, azithromycin for\n broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation with CMV 500/22/0.7/8. Wean FiO2,\n peep as tolerated.\n - continue vancomycin, cefepime, azithromycin. Gram stain no growth\n prelim\n - f/u pending cultures\n .\n # Hypotension/sepsis: BPs high 90s to low 100s. Likely pneumonia.\n On levophed for pressor support. CVP 6-9 suggesting not volume up.\n Wean levo as tolerated.\n - holding metoprolol\n - holding diuresis\n - IV fluids PRN\n - norepinephrine\n ..\n # Chronic systolic heart failure: Patient with EF 20-25%. CVP suggests\n CHF contributing less than other factors. UOP 40cc/hr with pt net +ve\n 628, -ve 1.3L. On norepinephrine.\n - continue norepinephrine, wean as tolerated/\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension\n - continue Coumadin at 1mg/day , with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # s/p ICD: high impedance, unclear why.\n -pacer revison in future.\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple: NGT output bilous. Did not initiate tube feeds.\n - holding pancreatic enzyme repletion\n ICU Care\n Nutrition: consult nutrition for tube feeds\n Glycemic Control: none\n Lines:\n 20 Gauge - 12:58 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:39 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526406, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526712, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - weaned FiO2 to 40%\n - started tube feeds\n - weaned sedation from 50&4 to 25&2\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Meropenem - 12:44 AM\n Vancomycin - 08:48 PM\n Cefipime - 12:48 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:13 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.3\n HR: 65 (59 - 78) bpm\n BP: 76/47(53) {0/0(0) - 0/0(0)} mmHg\n RR: 22 (20 - 22) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 8 (5 - 12)mmHg\n Total In:\n 1,778 mL\n 440 mL\n PO:\n TF:\n 145 mL\n 179 mL\n IVF:\n 1,453 mL\n 161 mL\n Blood products:\n Total out:\n 590 mL\n 240 mL\n Urine:\n 590 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,188 mL\n 200 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 58.8 cmH2O/mL\n SpO2: 95%\n ABG: 7.47/41/84./26/5\n Ve: 10.3 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GENERAL: Intubated, sedated, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Labs / Radiology\n 205 K/uL\n 9.6 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.5 %\n 6.4 K/uL\n [image002.jpg]\n 04:55 AM\n 09:20 AM\n 01:51 PM\n 06:28 PM\n 04:26 AM\n 04:40 AM\n 07:02 AM\n 09:35 PM\n 04:35 AM\n 04:52 AM\n WBC\n 6.6\n 6.4\n Hct\n 30.6\n 28.5\n Plt\n 197\n 205\n Cr\n 0.8\n 0.7\n TCO2\n 30\n 26\n 26\n 29\n 28\n 30\n 30\n 31\n Glucose\n 109\n 132\n Other labs: PT / PTT / INR:31.1/42.8/3.1, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:81.8 %, Lymph:8.5 %,\n Mono:5.6 %, Eos:3.9 %, Lactic Acid:0.9 mmol/L, Ca++:7.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. On vancomycin, cefepime,\n azithromycin for broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation. Consider trial on pressure support\n if patient becomes more alert.\n - continue vancomycin, cefepime, azithromycin.\n - f/u pending cultures (no positive micro data to date)\n - chest CT to better evaluate lung fields\n .\n # Hypotension/sepsis: Off pressors since 2 a.m. with SBP around 110.\n - holding metoprolol\n - holding diuresis\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - holding diuresis\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension; consider restarting if\n BP stable off pressors\n - holding Coumadin in setting of supratherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: NGT output bilous. Did not initiate tube feeds.\n - holding pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:37 PM 25 mL/hour\n Glycemic Control: none\n Lines:\n Arterial Line - 09:13 PM\n 20 Gauge - 12:58 AM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: supratherapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528347, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on TuesdayPt is NPO for\n this procedure. Sedation dc\nd (yesterday) at 9:30am. Pt more\n awake over the course of the evening. Now rare movement\n of right upper extremitie, moves feet wiggles in bed. Opens eyes,\n appears nods head to question, resists mouth care. Wrist restraints in\n place as pt did raise up right arm toward tube.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Remains on ac 500x14, 8 peep. 40%. Minimal ETT secretions but clear to\n white oral secretion in moderate amounts. . Bs dim with a few crackles\n and clear anterior.\n Action:\n RSBI done even though pt on 8 PEEP. And pt passed with 55. pt more\n awake also, follows commands on rare occasions.\n Response:\n More awake, RSBI is good. No fever today and WBC down\n Plan:\n Follow sats. Assess mental status, safety precautions, ? extubate later\n today after TEE?\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Started on heparin at 1650units. Also cont on warfarin. PTT >150 at 7pm\n and again at 0200. Pt was given lasix yesterday and was neg 618 at\n midnight, despite pt rec D5w 2L 125 cc per hour for high sodium.\n Action:\n Heparin drip off x 2 and now at 950 units per hour. Pt continues to\n have good urine output but will be positive.\n A CXR was ordered for the AM\n Response:\n Pt continues to have good urine output but will be fluid balance\n positive likely due to D5\n Plan:\n Resumed heparin at 950 units at 05 AM, next PTT at 11 am, ? lasix in\n the AM\n Weight today\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this shift. Cont on meropenum. Cultures ntd. Cards Will do\n TEE tomorrow. To rule out intra cardiac infection. Poss resite central\n line today as well.\n Peripheral line placed on right arm by IV team. ? if pt needs centeral\n acess at this time?\n Discussed patient\ns status and plan with , HCP, and other. She\n is anxious about pt\ns course,.\n Dtr to visit tomorrow.\n Tubefeed was resumed at 5:30pm at 55cc/hr(goal). Abd soft. Hold at mn\n as pt is npo for tee tomorrow\n Action:\n Follow temp, follow culture data , If pt having stooll send for cdiff.\n Response:\n Afebrile\n Plan:\n Provide support to patient and family. Consult SW for support. CXR in\n AM\n" }, { "category": "Physician ", "chartdate": "2141-03-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528481, "text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - PM sodium 152, free water deficit of 3.2L. Ordered for 2L D5W at 125\n cc/hr.\n - TBB -500-1000 at 8pm\n - ID recs: continue meropenem, TEE if feasible, C. diff if diarrhea,\n consider cycling lines\n - Was afebrile over the course of the day, so held off on re-siting CVL\n for now.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 04:00 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 53 (48 - 67) bpm\n BP: 106/52(66) {99/46(60) - 129/60(78)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 9 (3 - 13)mmHg\n Total In:\n 1,514 mL\n 973 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,044 mL\n 973 mL\n Blood products:\n Total out:\n 2,132 mL\n 467 mL\n Urine:\n 2,130 mL\n 465 mL\n NG:\n 2 mL\n 2 mL\n Stool:\n Drains:\n Balance:\n -618 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/48/112/35/11\n Ve: 6.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n GENERAL: Intubated, alert, responding to / following commands.\n CARDIAC: RRR. ?1/6 systolic murmur, heard best at the apex.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Alert, following commands, able to move all 4 extremities on\n command; PERRL\n Labs / Radiology\n 371 K/uL\n 9.5 g/dL\n 198 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 106 mEq/L\n 147 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n WBC\n 3.7\n 12.4\n 10.4\n 9.2\n Hct\n 32.6\n 31.9\n 30.7\n 30.4\n Plt\n 343\n 439\n 386\n 371\n Cr\n 1.0\n 1.3\n 1.3\n 1.2\n 0.9\n TropT\n 0.03\n 0.10\n TCO2\n 29\n 33\n 35\n 37\n 37\n Glucose\n 196\n 178\n 130\n 164\n 130\n 198\n Other labs: PT / PTT / INR:21.5/137.9/2.0, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:84.9 %, Lymph:9.3 %, Mono:4.5 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:7.8 mg/dL,\n Mg++:3.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n continued to spike high fevers in spite of Tylenol, antibiotics, and\n improvement in respiratory status. CT abd/pelvis and CT sinuses were\n neg. Pt has been afebrile over 24 hours at this point. However, he did\n have a positive blood cx (GPC\ns) this am. This could represent true\n infection versus contaminant.\n - continue meropenem; adding vanc in the setting of positive blood cx\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - will need to pull CVL in setting of positive blood cx; d/w team\n whether we should place another CVL versus try to obtain peripheral\n access until patient is able to get a PICC\n - if above is negative and pt continues to spike fevers, will need to\n consider other causes, such as CNS infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Mental status greatly improved this\n morning; RSBI in the 30\n - attempt extubation after TEE\n - f/u pending cultures\n - f/u bronch data\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L; will give 60 mg IV lasix now\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -TEE to look for lead endocarditis, as above\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt; Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526409, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T 100.6, SAT 97 0N 60/500/22/8 .BS DIM ,MIN SECRETIONS VERY SEDATED ON\n VERSED 4MG/FENTANYL 50 MIC .BP 90 T0 100 SYSTOLIC ON LEVOPHED .04\n MIC/KG ,CVP 6 TO 8 .HUO 20 TO 50 CC/HR .MOD AMT BILIOUS FROM OG\n TUBE,ABD SOFT C BS\n Action:\n SX FOR MIN ,VAP PROTOCOL\n CONTINUE ANTIBX\n WEAN SEDATION ,LEVOPHED AS TOL\n FAMILY UPDATED\n TUBE FEEDINGS STARTED\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2141-03-07 00:00:00.000", "description": "Generic Note", "row_id": 526678, "text": "TITLE:\n CCU Attending progress note: Course reviewed and patient examined with\n housestaff on rounds\n 60 minutes\n Remains intubated and sedated. Responding to stimuation\n Being treated for left lower lobe pneumonia as well as chf\n Will try to extubate if possible today once sedation is reduced\n ICD is pacing appropriately however cannot rely on tachy therapies\n Volume status looks stable\n No diuresis unless oxygen requirements increase\n" }, { "category": "Nursing", "chartdate": "2141-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526768, "text": "71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated and sedated.\n Vent A/C 40% 500 X22 5.\n RR 22-24.\n Suctioned for thick tan sputum.\n Lungs diminished.\n Versed at 2mg/hr & Fentanyl at 25mcgs/hr.\n TF of Isosource with Benepro at 25cc/hr with minimal residuals.\n Pt arouses to painful stimuli.\n Does not follow commands.\n Does not tolerate repositioning and ADL\ns without getting agitated.\n Action:\n Chest CT done.\n Conts on Vancomycin and Cefepime.\n Given 500cc NS bolus.\n TF advanced to GR with minimal residuals\n Response:\n Chest CT shows bilateral LL infiltrates with pleural effusions.\n ^ In sputum production.\n Plan:\n Cont with antibiotics & pulmonary toilet. Vancomycin dose ^\nd to 1250mg\n .\n Wean sedation in am for pressure support trial.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced.\n Levophed remains off.\n SBP 90\ns-110\n INR 3.1 this am.\n Action:\n Lopressor remains on hold.\n Coumadin dc\n Response:\n Hemodynamcially stable.\n Plan:\n Cont to monitor.\n ? lasix vs further fluid boluses.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526830, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 26 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: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\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 Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Recruitment Maneuvers Done\n CPAP pressure used: 35 cm H2O\n Duration: 45 sec\n Times per shift: 2\n Comments: Patient tolerated first recruitment manuver, but forcefully\n coughing on the second.\n" }, { "category": "Physician ", "chartdate": "2141-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526382, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 10:00 AM\n central line placed, CVP 9-15, EP interogated, found that LV pacer not\n working, ICD not working, A sensing ok, RV sensing OK since beginning\n of . Magnet to bedside in case of inappropriate shock. If VF/VT\n manage medically.\n fi02 weaned from 70 to 50, borderlien ABGs, back to 60, RISBI deferred.\n OGT with high bile output 350cc, ? whipple. Ok to hold tube feeds\n for 1-2 days. nutrition consult, gave tube feed recs (Isosource 1.5 at\n 15m;/hr, goal 55cc/hr with 14g beneprotein. OGT output 350 cc bile.?\n coz of whipple? Holding pancreatic enzyme. -consider pressidex if\n agitated for extubation.\n -changed to cefepime per I.D\n Sputum GS: >25 PMNs, no organisms\n UCx neg\n -decreased coumadin to 1mg given on levo\n Levo weaned down from 0.08 to 0.04mcg/kg/min maintain MAPs in 60s.\n .\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Meropenem - 12:44 AM\n Vancomycin - 08:30 PM\n Cefipime - 12:31 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 63 (53 - 67) bpm\n BP: 76/47(53) {0/0(0) - 0/0(0)} mmHg\n RR: 22 (20 - 23) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 6 (5 - 15)mmHg\n Total In:\n 1,968 mL\n 129 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 129 mL\n Blood products:\n Total out:\n 1,340 mL\n 110 mL\n Urine:\n 965 mL\n 110 mL\n NG:\n 375 mL\n Stool:\n Drains:\n Balance:\n 628 mL\n 19 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 488 (488 - 488) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n Compliance: 44.6 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/44/137/28/4\n Ve: 10.8 L/min\n PaO2 / FiO2: 228\n Physical Examination\n GENERAL: intubated, sedated, unresponsive.\n NECK: Unable to appreciate JVP.\n CARDIAC: Quiet heart sounds. Difficult to hear over breath sounds; No\n m/r/g appreciated.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness noted.\n EXTREMITIES: No significant LE edema noted. Extremities warm and\n well-perfused.\n Labs / Radiology\n 197 K/uL\n 10.0 g/dL\n 109 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.6 %\n 6.6 K/uL\n [image002.jpg]\n 09:17 PM\n 11:16 PM\n 04:44 AM\n 04:55 AM\n 09:20 AM\n 01:51 PM\n 06:28 PM\n 04:26 AM\n 04:40 AM\n 07:02 AM\n WBC\n 7.5\n 6.6\n Hct\n 31.5\n 30.6\n Plt\n 172\n 197\n Cr\n 0.9\n 0.8\n TCO2\n 27\n 26\n 30\n 26\n 26\n 29\n 28\n 30\n Glucose\n 140\n 134\n 109\n Other labs: PT / PTT / INR:25.9/32.9/2.5, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:81.8 %, Lymph:8.5 %,\n Mono:5.6 %, Eos:3.9 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. have superimposed component\n of heart failure as well. On vancomycin, cefepime, azithromycin for\n broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation with CMV 500/22/0.7/8. Wean FiO2,\n peep as tolerated.\n - continue vancomycin, cefepime, azithromycin. Gram stain no growth\n prelim\n - f/u pending cultures\n .\n # Hypotension/sepsis: BPs high 90s to low 100s. Likely pneumonia.\n On levophed for pressor support. CVP 6-9 suggesting not volume up.\n Wean levo as tolerated.\n - holding metoprolol\n - holding diuresis\n - IV fluids PRN\n - norepinephrine\n ..\n # Chronic systolic heart failure: Patient with EF 20-25%. CVP suggests\n CHF contributing less than other factors. UOP 40cc/hr with pt net +ve\n 628, -ve 1.3L. On norepinephrine.\n - continue norepinephrine, wean as tolerated/\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension\n - continue Coumadin at 1mg/day , with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # s/p ICD: high impedance, unclear why.\n -pacer revison in future.\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple: NGT output bilous. Did not initiate tube feeds.\n - holding pancreatic enzyme repletion\n ICU Care\n Nutrition: consult nutrition for tube feeds\n Glycemic Control: none\n Lines:\n 20 Gauge - 12:58 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528637, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway. CT head, chest, & pelvis-without noted infectious\n process.\n" }, { "category": "Physician ", "chartdate": "2141-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527722, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - bolused Lasix 60 mg IV once in a.m. and once in p.m.\n - bronchoscopy done: mild mucus plugging, did not look purulent, labs\n sent\n - ID recs: 1. continue meropenem. 2. f/u respiratory virus screen.3.\n trend CK. 4. consider bronch\n - ID attending recs: ? splinter hemorrhage\n - pulm recs: 1. will do BAL LLL. 2. consider CT abd/pelvis if ?\n (illegible). 3. favor antipsychotics for delirium over opioids/benzos.\n 4. CHF contributes.\n - decreasing sedation overnight\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 03:52 PM\n Furosemide (Lasix) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.5\nC (101.3\n HR: 50 (50 - 54) bpm\n BP: 120/58(73) {104/49(64) - 138/67(84)} mmHg\n RR: 13 (9 - 18) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 102.2 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 12 (9 - 22)mmHg\n Total In:\n 2,723 mL\n 696 mL\n PO:\n TF:\n 1,068 mL\n 384 mL\n IVF:\n 1,235 mL\n 212 mL\n Blood products:\n Total out:\n 2,198 mL\n 840 mL\n Urine:\n 2,198 mL\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 525 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 641 (294 - 1,200) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/55/172/31/9\n Ve: 5.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n GENERAL: Intubated, sedated, responds to commands to open eyes and move\n extremities.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. Hands warm.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 175 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 45 mg/dL\n 105 mEq/L\n 146 mEq/L\n 32.6 %\n 11.4 K/uL\n [image002.jpg]\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n WBC\n 11.4\n Hct\n 30.8\n 32.6\n Plt\n 345\n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 27\n 27\n 29\n 30\n 36\n 37\n Glucose\n 157\n 167\n 175\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:1312/3/0.02, ALT / AST:237/329, Alk Phos / T Bili:93/0.8,\n Differential-Neuts:86.5 %, Lymph:7.5 %, Mono:4.7 %, Eos:1.1 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:474 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials, including this p.m.\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following.\n - CT abd/pelvis and CT sinuses\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - holding diuresis today\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:11 AM 55 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin; Coumadin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527723, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - bolused Lasix 60 mg IV once in a.m. and once in p.m.\n - bronchoscopy done: mild mucus plugging, did not look purulent, labs\n sent\n - ID recs: 1. continue meropenem. 2. f/u respiratory virus screen.3.\n trend CK. 4. consider bronch\n - ID attending recs: ? splinter hemorrhage\n - pulm recs: 1. will do BAL LLL. 2. consider CT abd/pelvis if ?\n (illegible). 3. favor antipsychotics for delirium over opioids/benzos.\n 4. CHF contributes.\n - decreasing sedation overnight\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 03:52 PM\n Furosemide (Lasix) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.5\nC (101.3\n HR: 50 (50 - 54) bpm\n BP: 120/58(73) {104/49(64) - 138/67(84)} mmHg\n RR: 13 (9 - 18) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 102.2 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 12 (9 - 22)mmHg\n Total In:\n 2,723 mL\n 696 mL\n PO:\n TF:\n 1,068 mL\n 384 mL\n IVF:\n 1,235 mL\n 212 mL\n Blood products:\n Total out:\n 2,198 mL\n 840 mL\n Urine:\n 2,198 mL\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 525 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 641 (294 - 1,200) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/55/172/31/9\n Ve: 5.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n GENERAL: Intubated, sedated, responds to commands to open eyes and move\n extremities.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. Hands warm.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 175 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 45 mg/dL\n 105 mEq/L\n 146 mEq/L\n 32.6 %\n 11.4 K/uL\n [image002.jpg]\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n WBC\n 11.4\n Hct\n 30.8\n 32.6\n Plt\n 345\n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 27\n 27\n 29\n 30\n 36\n 37\n Glucose\n 157\n 167\n 175\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:1312/3/0.02, ALT / AST:237/329, Alk Phos / T Bili:93/0.8,\n Differential-Neuts:86.5 %, Lymph:7.5 %, Mono:4.7 %, Eos:1.1 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:474 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials, including this p.m.\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following.\n - CT abd/pelvis and CT sinuses\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - holding diuresis today\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:11 AM 55 mL/hour\n Glycemic Control: Lantus + Humalog insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin; Coumadin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526816, "text": "2. Subtotal atelectasis of the lower lobes, with air-bronchogram. Focal\n consolidation in the left uppper lobe, could also represent\n atelectasis, less\n likely PNA.\n 3. Bilateral pleural effusions, small-to-moderate, non-hemorrhagic.\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526818, "text": "CCU Nursing Progess Note.\n 71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Chest CT:\n Subtotal atelectasis of the lower lobes, with air-bronchogram. Focal\n consolidation in the left uppper lobe,\n could also represent atelectasis, less likely PNA. Bilateral pleural\n effusions, small-to-moderate, non-hemorrhagic.\n Pneumonia\n Assessment:\n Intubated . On broad coverage abx. Continued low grade temp.\n Cultures pending. Responds to stimuli with\n restlessness/agitation-presently not following commands or purposeful\n movements. Tolerating tf-minimal residuals.\n Action:\n Weaning vent as tolerated. Attempted recruitment breaths. Peep\n increased to 10. VAP protocol. Abx as ordered. Sedation remains\n unchged.\n Response:\n Borderline abg/sats.\n Plan:\n Continue present management. ?d/c abx. ?brochoscopy.\n Heart Failure (CHF), Systolic, Acute\n Assessment:\n Borderline uo. ?sl volume overloaded.\n Action:\n Lasix 60mg iv.\n Response:\n Excellent response to lasix. Slightly improving abg.\n Plan:\n Continue present management\n" }, { "category": "Respiratory ", "chartdate": "2141-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526983, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\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: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Underlying illness not\n resolved\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527052, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated on 50%/500/15/10peep w/ O2 sats 95%. LS\n diminished/ bronchial @ bases.\n Pt has been off sedation since 0730 . MAE to painful stimuli and\n appears restless, kicking at pillows under legs. Eyes are slightly\n open, although pt does not track or appear to focus.\n T max 101.4 po at midnight.\n Pt receiving TF Isosource at goal rate of 55cc/ht\n Action:\n Pulmonary toileting q2hrs.\n VAP care per protocol.\n Abx Vancomycin, Cefepime and Flagyl continue\n Tylenol 650 q6hrs.\n Response:\n Producing thick tan/yellow secretions.\n Sedation remains off w/ no change in neuro status.\n Temp\n Plan:\n Attempt PS wean in am as tolerated, continue aggressive pulmonary\n toileting, abx and Tylenol. Check pnd cultures ()\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n BP 130-140/50-60.\n Rec\nd pt 40cc negative for the day.\n Action:\n Lopressor parameters discussed w/ MD. Lopressor has been held d/t HR\n parameter of 50. Parameter changed to 50.\n Given lasix 60mg IV at and 2230 in order to reach goal of 1.5\n liter neg for day. .\n Response:\n Good diuresis from lasix w/ midnight i/o negative 950cc.\n Plan:\n Consider lasix gtt as intake is approx 3000cc per day.\n Social\n HCP/ has called multiple times this shift and has\n been updated by this RN. would like to be called if for any\n reason medical service is to be changed (i.e pt is changed from CCU to\n MICU service).\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529864, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Better day yesterday and o.k. night tonight. He is Ox2-3, appropriate\n most of the time. Follows direction and commands. Not trying to get\n OOB but at times restless.\n Awake much of the night. Eyes would be closed but open as soon as RN\n walks into room. Always asking for something to drink.\n Asking for water and coke.\n Action:\n Taking meds crushed with applesause well. Liquids thickened to nectar\n consistency.\n Aspiration precautions.\n Trazadone 50mg at HS\n Response:\n Slept on and off. Incontinent x2 stool- unable to tell RN he had to\n go.\n Plan:\n Safety precautions, OOB to chair 2 assist.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . external defib pads\n dated .\n Heparin drip at 1850/hr. PTT >150\n - total 600cc u/o response from lasix given 1800.\n - D5W x total 2L completed for elevated Na+\n Action:\n Heparin on hold x1 hour and decresed to 1500units/hr at\n 0130.\n Repeat lasix 20mg at 0230\n Po lopressor and amio as ordered.\n Monitored sat, u/o\n KCL repletion on \n IVF completed.\n Response:\n HR 70-80 Vpaced with rare PVC. BP 94-99/60\ns MAP 70\n u/o 60-80cc/hr.\n 800cc response to IV lasix over 3 hours. Negative 300cc\n since MN.\n positive 800cc for .\n Plan:\n Check PTT at 0700.\n Monitor lytes with diuresis.\n" }, { "category": "Nutrition", "chartdate": "2141-03-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 530012, "text": "Subjective\n Patient just returned from video swallow evaluation. RN, patient\n failed study.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 99.6 kg ( 06:00 AM)\n 31.3\n Pertinent medications: Glargine 4 units, RISS, Furosemide , Potassium\n Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 103 mg/dL\n 06:30 AM\n Glucose Finger Stick\n 130\n 12:00 PM\n BUN\n 29 mg/dL\n 06:30 AM\n Creatinine\n 0.9 mg/dL\n 06:30 AM\n Sodium\n 145 mEq/L\n 06:30 AM\n Potassium\n 3.7 mEq/L\n 06:30 AM\n Chloride\n 107 mEq/L\n 06:30 AM\n TCO2\n 30 mEq/L\n 06:30 AM\n PO2 (arterial)\n 163 mm Hg\n 05:15 AM\n PCO2 (arterial)\n 39 mm Hg\n 05:15 AM\n pH (arterial)\n 7.49 units\n 05:15 AM\n pH (urine)\n 7.0 units\n 08:29 PM\n CO2 (Calc) arterial\n 31 mEq/L\n 05:15 AM\n Albumin\n 3.3 g/dL\n 01:07 AM\n Calcium non-ionized\n 8.3 mg/dL\n 06:30 AM\n Phosphorus\n 2.9 mg/dL\n 06:30 AM\n Ionized Calcium\n 1.10 mmol/L\n 08:00 AM\n Magnesium\n 2.3 mg/dL\n 06:30 AM\n ALT\n 224 IU/L\n 03:36 AM\n Alkaline Phosphate\n 92 IU/L\n 03:36 AM\n AST\n 204 IU/L\n 03:36 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:36 AM\n WBC\n 7.8 K/uL\n 06:30 AM\n Hgb\n 10.0 g/dL\n 06:30 AM\n Hematocrit\n 32.2 %\n 06:30 AM\n Current diet order / nutrition support: Fluid restriction: 1500ml\n NPO as Diet except Meds, may take ice chips ; meds whole or crushed in\n puree\n GI: soft, NBS\n Assessment of Nutritional Status\n 71 year old male admitted with ICD malfunction, VT/VF arrest requiring\n debrillation now extubated pending ICD revision this week. Patient\n previously on tube feed, feed discontinued since extubation, patient\n failed beside and video swallow evalution, recommend NGT replacement\n and restart tube feed as temporary nutrition support.\n Noted patient with hypernatremia, likely related to altered mental\n status/inability to take adequate PO.\n Medical Nutrition Therapy Plan - Recommend the Following\n NPO\n Tube feeding : replace NGT, restart tube feed : Isosource\n 1.5 goal 55ml/hr + 14g Beneprotein to provide 2029kcal/102g protein,\n monitor tube feed tolerance\n Check chemistry 10 panel daily\n Continue BS management\n Other: \n 15:28\n" }, { "category": "Rehab Services", "chartdate": "2141-03-20 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 530016, "text": "TITLE:\n OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION\n EVALUATION:\n An oral and pharyngeal swallowing videofluoroscopy was performed today\n in collaboration with Radiology. Thin liquid, Nectar-thick liquid, and\n pureed consistency barium were administered. Results follow:\n ORAL PHASE:\n Did not test bolus formation/mastication due to edentulous status.\n Bolus control was moderately impaired with premature spillover of thin\n and nectar thick liquids to the pharynx/larynx prior to the swallow.\n Anterior to posterior tongue movement remarkable for pumping, weakness,\n and piecemeal deglutition. Oral transit time for individual swallows\n was mildly prolonged. There was mild oral cavity residue across\n consistencies which only fully cleared with oropharyngeal suctioning.\n PHARYNGEAL PHASE:\n Pharyngeal phase was initiated in a timely manner, however at the\n height of the swallow, hyolaryngeal excursion, laryngeal valve closure,\n and epiglottic deflection were mildly impaired. Bolus propulsion\n moderately impaired. Deficits, in combination with oral deficits,\n resulted in moderate-severe valleculae residue (which overfilled\n valleculae and coated pharyngeal walls with puree) and moderate\n pyriform sinus residue across consistencies. Repeat swallows were only\n partially effective at clearing pharyngeal residue. Pt had to be\n suctioned via yankauer x2 at the end of today's evaluation to fully\n clear the oropharynx.\n ASPIRATION/PENETRATION:\n Pt presented with mild penetration of thin, nectar, and purees, all\n during follow up swallows, due to pharyngeal residue. He was not\n sensate to penetrated material consistently (only had spontanous cough\n x1) and cued cough was only partially effective at clearing the airway.\n Pt presented with mild aspiration of thin liquids before the swallow\n secondary to premature spillover. There was no spontaneous cough and\n cued cough was only partially effective at clearing the airway.\n TREATMENT TECHNIQUES:\n Pt cannot currently consistently follow commands to attempt treatment\n strategies.\n SUMMARY:\n Pt presents with oropharyngeal dysphagia as described above. While the\n volume of aspiration was small, the severity of the dysphagia is more\n severe, specifically due to risk for aspiration of pharyngeal residue\n that pt is not sensate to, as well as the fact that his cough is not\n effective at clearing aspirated material when it occurs. Deficits are\n suggestive of weakness in the setting of prolonged hospitalization,\n however baseline oropharyngeal dysphagia cannot be ruled out as a\n contributor.\n Pt is recommended to be strictly NPO at this time with nutrition,\n hydration, and medication via alternative means. Given the severity of\n deficits appreciated today, I do have concerns that after repeat\n intubation/return trip to OR later this week and further\n deconditioning, pt may not return to a PO diet prior to d/c from this\n facility. Would recommend leaving NGT in after extubation and team may\n wish to consider discussing pt/family's wishes regarding PEG.\n He'll likely benefit from intensive swallowing tx in a rehab setting\n once medically stable to maximize strength and return to PO intake.\n Please page or reconsult when pt is awake/alert and appropriate for\n repeat swallowing evaluation after extubation and we'll be happy to\n reassess and update recommendations.\n RECOMMENDATIONS:\n 1. NPO including no ice chips.\n 2. If there is a delay in NGT placement, can take essential meds\n crushed in puree, though this is not without aspiration risk. Would\n encourage alternative means of medication if possible.\n 3. Q4 oral care while NPO\n 4. Encourage alternative means of nutrition, hydration, and medication\n both now and following ICD revision pending repeat swallowing\n evaluation.\n 5. Team may consider discussion of PEG placement with pt/family, as\n above.\n 6. Swallow tx at this facility if medically appropriate after ICD\n revision and more intensively upon d/c to rehab.\n 7. Page/reconsult if there are further questions.\n These recommendations were shared with the patient, the nurse and the\n medical team.\n ___________________________________\n M.S., CCC-SLP\n Pager # \n Face time: 14:20-14:50\n Total time: 120 minutes\n" }, { "category": "Physician ", "chartdate": "2141-03-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 530098, "text": "TITLE: PHYSICIAN INTERN PROGRESS NOTE\n Chief Complaint:\n Dyspnea and leg swelling\n HPI:\n 24 Hour Events:\n - Mental status dramatically improved. Allowed patient to take some PO\n with close nursing supervision. Will get formal speech and swallow\n evaluation on Monday.\n - Dr. now favoring doing lead extraction/revision on Thursday\n - did not respond to Lasix 40 mg PO, but responded well to Lasix 20 mg\n IV\n - started heparin gtt for subtherapeutic INR\n - repleted free water deficit with D5W\n - this morning pateint states he has been coughing up soe brown sputum\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium - 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 83) bpm\n BP: 85/53(61) {84/42(50) - 157/141(144)} mmHg\n RR: 14 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,514 mL\n 943 mL\n PO:\n 960 mL\n 340 mL\n TF:\n IVF:\n 1,554 mL\n 603 mL\n Blood products:\n Total out:\n 1,695 mL\n 1,100 mL\n Urine:\n 1,695 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 819 mL\n -157 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2 L\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema. Feet erythematous, capilary changes on skin\n Neuro: Alert, orientation waxing and . Initially oriented to\n hospital () and year. However, repeat questioning later\n during rounds pt was unable to state location at . Able to state\n why he is the hospital. Asking to see various equipment/machines in the\n room and not making sense with what he wants it for.\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: Maculopapular erythematous rash on upper shoulders and chest\n consistent with resolving stages of rash.\n Neurologic: Responds to verbal commands, answers questions:\n Labs / Radiology\n 10.0 g/dL\n 478 K/uL\n 103 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.2 %\n 7.8 K/uL\n [image002.jpg]\n INR 1.2\n PTT 94.9\n PT 14.3\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n WBC\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 23\n Cr\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n 428\n 126\n 118\n Other labs: PT / PTT / INR:15.9/150.0/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.7 mg/dL\n Imagine: no new images\n Microbiology: Urine culture final \n no growth\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday pending patient and\n family are in agreement\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. This is still above\n baseline as he does not usually use supplemental oxygen. Heart failure\n less likely etiology of hypoxia and received home dose PO lasix this\n am. Speech and swallow evaluated this am and recommend PNO for now\n except meds with repeat video swallow study.\n -aspiration precautions\n -Video swallow study\n - F/u speech and swallow recs based on results of video, but for now\n NPO except meds\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n -check PM Is/Os\n if not 1 to 1.5 L negative will give one dose IV 40\n mg lasix as yesterday pt required extra IV dose\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile status post completed course of\n antibiotics. Previously, patient was spiking high fevers in spite of\n Tylenol, antibiotics, and improvement of pneumonia. This led to concern\n about an occult infection or non-infectious cause of fever. CT\n abd/pelvis and CT sinuses were negative. TEE showed no vegetation.\n There was one positive blood cx (coag neg staph), thought to be a\n contaminant. Patient was afebrile from , but spiked one fever\n to 101.8 thought to be related to possible aspiration pneumonitis in\n setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies which currently show no growth.\n Urine cultuire negative\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - will check Is/Os and if not 1-1.5 L negative will give extra 40 mg IV\n lasix\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - patient was given free water with D5W last night and sodium slightly\n improved, however pt more volume up\n - will consider giving free water if pm labs show worsening\n hypernatremia (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n - recheck Ck\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, this monring there was concern for aspiration so\n speech and swallow consulted\n - video swallow this afternoon\n - NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt, pnuemoboots\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition : call out to floor today\n Total time spent:\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 have also reviewed the note by Dr. today.\n I would add the following remarks:\n History\n Mental status markedly improved\n up in chair this AM\n No additional V Tach after pacemaker reprogrammed.\n Medical Decision Making\n Will plan lead extraction on Thursday given marked recovery of his\n sensorium.\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 20:58 ------\n" }, { "category": "Respiratory ", "chartdate": "2141-03-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528028, "text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n 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: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\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 Comments: Pt did SBT and tolerated well, team waiting for mental status\n to improve to possibly extubate in the evening. At1440 pt went into\n pulseless , pt then placed on AC, unable to wean FiO2 back to 50%\n patient desating to 87%, PEEP increased to 12 and 100% FiO2, currently\n 87%.\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, High min.\n ventilation)\n Plan\n Reason for continuing current ventilatory support: Hemodynamically\n unstable\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "EP Device Interrogation", "row_id": 528029, "text": "TITLE: EP Fellow\n Called by CCU team due to epidose of VF not appropriately treated by\n ICD, requiring external shock.\n Mr. is 72 years old with the following cardiovascular and\n device history:\n 1. IMI with recurrent VT\n 2. VT ablation \n 3. Single chamber ICD implant \n 4. Atrial lead implant \n 5. Biventricular upgrade \n 6. Suspected ICD lead infection requiring chronic suppressive\n antibiotic therapy\n 7. 6949 Sprint Fidelis pace/sense lead malfunction\n 8. Implantation of new R axillary 5076 RV pace/sense lead tunneled\n from right to left side\n Interrogation of his device was performed by Dr. on \n and found to have severe malfunction.\n In summary:\n 1. High voltage defibrillation lead impedances are >200 ohms (RV and\n SVC)\n 2. Atrial lead impedance >2500 ohms\n 3. LV lead impedance >2500 ohms without capture in all configurations\n Mr. \ns pacemaker continues to work, but his defibrillator is\n malfunctioning. Any further VT or VF episodes will require external\n defibrillation.\n Discussed with wife and CCU team.\n MD\n EP Fellow\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "EP Device Interrogation", "row_id": 528032, "text": "TITLE: EP Fellow\n Called by CCU team due to epidose of VF not appropriately treated by\n ICD, requiring external shock.\n Mr. is 72 years old with the following cardiovascular and\n device history:\n 1. IMI with recurrent VT\n 2. VT ablation \n 3. Single chamber ICD implant \n 4. Atrial lead implant \n 5. Biventricular upgrade \n 6. Suspected ICD lead infection requiring chronic suppressive\n antibiotic therapy\n 7. 6949 Sprint Fidelis pace/sense lead malfunction\n 8. Implantation of new R axillary 5076 RV pace/sense lead tunneled\n from right to left side\n Interrogation of his device was performed by Dr. on \n and found to have severe malfunction.\n In summary:\n 1. High voltage defibrillation lead impedances are >200 ohms (RV and\n SVC)\n 2. Atrial lead impedance >2500 ohms\n 3. LV lead impedance >2500 ohms without capture in all configurations\n Mr. \ns pacemaker continues to work, but his defibrillator is\n malfunctioning. Any further VT or VF episodes will require external\n defibrillation.\n Discussed with wife and CCU team.\n MD\n EP Fellow\n ------ Protected Section ------\n Attending\ns Note.\n Agree with Dr.\ns note.reviewed data and ICD status.\n ICD only functions as a DDD Pacer.Thus will not treat VT/VF.\n Treat VF externally. For now.\n \n ------ Protected Section Addendum Entered By: ,MD\n on: 17:35 ------\n" }, { "category": "Social Work", "chartdate": "2141-03-20 00:00:00.000", "description": "Social Work Progress Note", "row_id": 530071, "text": "SOCIAL WORK: Case discussed with RN. Pt more alert today, sitting up\n in bed, responding to commands, but confused. SW met with his partner\n for emotional support. She reports feeling some relief with pt\n progress, and feels there is a more concrete plan of care in place this\n week. SW met with at length to process her feelings. Pt\n \n arrived from FL over weekend and is staying with , which\n she finds as supportive and a healthy distraction.\n SW will continue to provide frequent support to partner family,\n and to pt when mental status improves.\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530081, "text": "Delirium / confusion\n Assessment:\n Pt remains very confused. Only occasionally pt will answer questions\n appropriately. Waxes and wanes.\n Action:\n Bed alarm on. OOB to chair this morning\n poor weight bearing\n requiring nurses for transfer. Pt incontinent large amt stool in\n chair. To Commode with no further results.\n Response:\n Pt more agitated this evening now that dobhoff tube placed\ngive me a\n knife\ncall the police\n Significant other in room with patient,\n assisting with distraction. Bilat wrist restraints on. Pt stooled\n large amt liquid stool this evening.\n Plan:\n Fall precautions, wrist restraints to prevent pt from pulling out\n dobhoff feeding tube. Bed alarms on. Bed low and locked. SR up x 4.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . external defib pads.\n Heparin gtt @ 1500units/hr.\n Action:\n Tolerating po lopressor and amio.\n Response:\n Pt remains Vpaced. Afternoon PTT WNL.\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Con\nt lopressor and amio po.\n Defibrillator at bedside.\n Dysphagia\n Assessment:\n Pt made NPO after noting delayed coughing after taking po meds in apple\n sauce.\n Action:\n Video swallow ordered after pt failed bedside speech swallow exam.\n Response:\n Pt failed video swallow. Pt made fully NPO. No ice chips. No meds in\n puree. Aspiriation precautions. Dobhoff placed at bedside, placement\n confirmed by xray\n started TF. Bilat wrist restraints placed to\n prevent pt from pulling out tube\n family aware and at bedside.\n Plan:\n Advance TF as tolerated. Bilat wrist restraints to prevent pt from\n pulling out dobhoff.\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528792, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. CT head, chest, & pelvis-without noted\n infectious process.\n vf arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n HCP: significant other , 2 daughter\n and live out of\n state.\n Pneumonia, Bacterial, Community Acquired (CAP)\n Assessment:\n Received on 50% shovel mask, with sats >95% when mask on, desatting to\n 88% when he removed mask. Lungs with crackles L base, bronchial at L\n base, few rhonchi.\n Action:\n * Rare, strong cough\n thick brown sputum (like a small ball). Dr.\n notified\n * O2 weaned to 2 L NP maintaining sats\n * Turned s\nS, enc to c & db, he is not cognitively ready for inc\n .\n * OOB to stretcher chair.\n Response:\n Maintained saturations throughout the day on L np.\n Plan:\n Heart Failure (CHF)/VT\n Assessment:\n Remains V paced, rate 50\ns, underlying rhythm AF. Rare to occ PVC.\n SBP 106-132. A-line d/c\n Action/Response:\n * Monitored u/o. No diuretic so far today and is 650 cc\ns negative.\n Goal for today is 1L negative.\n * Coumadin on hold pending EP\ns recs re: ICD replacement.\n * IV heparin gtt begun, 1400 unit/hour\n * K 3.8\n20 meq po.\n * Hands off defib pads in place,\n Plan:\n Monitor I/O, daily weights. Follow BP. Monitor HR/RHythm\n Delirium\n Assessment:\n Oriented x1 only\nself and family. At times thought he was in a Hotel\n Action:\n * Bed low/locked position\n * Frequent re-orientation\n * Hearing aides in\n * A-line removed.\n Response:\n Remains oriented x1 only.\n Plan:\n Continue present management. Frequent reorientation. Appropriate safety\n measures.\n Dysphagia\n Assessment:\n Pulled out his NGT at the end of night shift. Speech and swallow in to\n evaluate patient. Coughing with thin liqs and nectar thick. Able to\n swallow pills whole with applesauce without difficulty\n Action:\n * Plan of care discussed with S&S re: ? to replace NGT or whether\n this would slow down his swallow recovery process. They recommend\n keeping NGT out today. Give pills whole in applesauce, but no\n other po\ns. They will re-evaluate patient in 24 hours as they\n anticipate his swallow to come back as he was able to have regular\n diet pre-intubation.\n * HOB ^ 90 degrees with po\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527884, "text": "CCU Nursing Progress Note.\n 71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway. CT head, chest, & pelvis-without noted infectious\n process.\n Fever of Unknown Origin\n Assessment:\n Continued febrile. Cooling blanket, tylenol, & ibuprofen not breaking\n temp.Off droplet precautions.\n Action:\n ID following. IV meropenem q 8 hours. Tylenol/ibuprofen prn for pt\n comfort. Intermittent cooling blanket. Off droplet.\n Response:\n Temp down 100 range pr with cooling blanket in place and other above\n interventions.\n Plan:\n Continue to closely monitor temp/ wbc. Follow up results of culture\n data. Abx as ordered. Tylenol/ibuprofen & cooling blanket prn for pt\n comfort.\n Pneumonia, Bacterial, Community Acquired (CAP)\n Assessment:\n Intubate/vented. Off sedation. Appears more awake, but not following\n commands.\n Action:\n Abx as ordered. TF stopped @ 0400-?extubation. CPAP/PS @ 0430.\n Response:\n Stable sats.\n Plan:\n Continue to monitor resp status. VAP care/ pulm toileting. Abx as\n ordered. ?extubation.\n Heart Failure (CHF), Systolic, Acute\n Assessment:\n Breath sounds=clear/diminished. Hemodynamically stable.\n Action:\n Cardiac meds as ordered.\n Response:\n Tolerating meds. Without evidence of failure.\n Plan:\n Continue to monitor resp status/ volume status. Daily wts/ 1500ml\n fluid restriction\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528152, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet in\n room. CT head, chest, & pelvis-without noted infectious process.\n Of note, pt sustained a VF arrest on days, responded to 1 200j\n shock with return of spontaneous circulation and paced HR. No further\n arrythmias o/n. cpk\ns are being cycled. Plan is to do TEE today.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n initial vent settings A/C 500 x 14/peep12/1.0, overbreathing to total\n 16-18x/min. PO2 >200, so fio2 weaned to 70%, with abg7.45/52/260/37.\n LS with crackles L base. cxr from pm shows multifocal alveolar\n consolidations in upper lobes c/w edema vs infection. Remains on\n Meropenum. Sputum ngtd except for yeast. Sx for small amts beige\n secretions o/n. Given lasix overnight for +fluid balance.\n Action:\n fio2 weaned further to 40%. O2 sat 97%.\n Response:\n tolerated wean of fio2 overnight.\n Plan:\n Continue abx, diuresis, frequent turn and reposition, VAP preventative\n care. CXR repeated this am. f/u.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n tmax 101.4. med x 1 with Tylenol and given tepid bath. Temp this am is\n 100 by esophageal probe. AM wbc 10.4 (12).\n Action:\n Blood and urine cx sent. Needs sputum cx. Last sputum sent on \n during a bronch, shows some yeast.\n Response:\n Temp currently low grade on ATC Tylenol. Did not receive motrin o/n as\n is NPO, to avoid stomach upset.\n Plan:\n Follow cx, sent sputum when able. f/u with results cx . Continue\n Tylenol atc.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n cxr from yesterday afternoon still c/w ? pulmonary edema.. fluid\n balance +700 at midnight despite 20mg iv lasix given in evening. Pt\n then treated with 60mg iv lasix, await results. CVP 10-14 after pm dose\n lasix, down from 17. Vigileo hooked up, revealed CI 1.7-2.2, SVR\n 800-1200, SVV 6. Pt Continues with mottled feet , team aware.\n Action:\n Lasix given as noted. Further hemodynamic information obtained from\n Vigileo.\n Response:\n Await effect from repeat Lasix dose.\n Plan:\n f/u results am cxr. Follow fluid balance, cvp. Plan is for TEE today.\n No time as of yet.\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530150, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be oriented back to time and\n place. He has reached towards his feeding tube when unrestrained.\n Action:\n Oriented to time and place. Bed in locked and low position and exit\n alarm is on. Bilateral wrist restrains on to keep patient from\n pulling out feeding tube. Posey off. Given 50mg Trazodone for sleep at\n midnight with poor effect on sleep. Closely supervising patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up\n x4, bed low and locked, and bilateral wrist restraints on. Fall risk\n precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . External defib pads on.\n Heparin gtt @ 1500units/hr. Systolic BP dropping as low as 70s post\n metropolol dose. Rechecked and verified with doppler. Lung sounds\n diminished at bases. Chest xray showed no cardiopulmonary\n process. Pt. was saturating 100% on 2L nc. removed O2 and patient\n currently saturating 95-97% on room air. Patient tolerating Room air\n and denies feeling short of breath. Urine output between\n 20-65mLs/hour. Weight loss of 8kg since admission date .\n Action:\n MD updated low BP ? pt dry now. Hold metoprolol for now. Team to\n discuss fluid balance in the am.\n Response:\n SBP 80s. Pt mentating, alert , adequate urine output O2 sat 95-97% on\n room air, no s+S of CHF\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Defibrillator at bedside. Hold\n metoprolol. ? patient dry. Has been receiving lasix Q day and weight\n is down. Team to discuss fluid balance in am rounds\n Dysphagia\n Assessment:\n Patient is currently strict NPO & no ice chips after failing swallow\n study. On tube feeding Isosource 1.5 cal Full strength. Abdomen\n distended, but soft. Bowel sounds positive x4 quadrants.\n Action:\n Tube feeding: Starting rate at 25ml/hour. Currently at 35 ml/hour.\n Advance rate by 10ml every 6 hours. Until goal of 55 cc . Bilateral\n wrist restraints placed to prevent pt from pulling out tube\n family\n aware and at bedside.\n Response:\n Tolerating tube feedings well.\n Plan:\n Hold feeding if residual greater than or equal to 200mL. Flush with\n 30mLs water every four hours\n Titrate to goal of 55 cc by noon today\n" }, { "category": "Nursing", "chartdate": "2141-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528055, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet in\n room. CT head, chest, & pelvis-without noted infectious process.\n Full code\n Allergies: Bactrim, ambient\n According to IP- ICD will not detect VT/VF or shock for VT/VF. Magnet\n not necessary for ICD during incident but may require external\n pacing/defibrillation.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp 102.3 PO. Skin flushed.\n Action:\n Cooling blanket restarted. Skin assessed frequently. Given Tylenol and\n ibuprofen PO. ID following. Continued on meropenum.\n Response:\n Tcurrent 102.9 PO.\n Plan:\n Monitor temp curve. Cooling blanket continued. Continue Tylenol and\n ibuprofen PRN. Continue antibiotics. F/U ID rec\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received on PSV 5/5, 40%. O2 sats 97-100%. ABG 7.51/44/96/36. LS\n diminished throughout. RR 14-24. ET tube secretions-moderate amt of\n thick, tan/slightly red. Awake, not following commands, agitated. No\n sedation running. Restraints on and ordered.\n Action:\n Suctioned PRN. After cardiac arrest, o2 sats decreased to 87-92%. ABG\n 7.49/37/68/29- while on AC 10/500/5 PEEP/100%. Sedation initiated and\n vent settings changed to AC 14/500/12 PEEP/100%. Repeat ABG pending.\n Response:\n O2 sats increased to 95%. Continues to require PRN suctioning. Less\n agitated. Continues to not follow commands.\n Plan:\n Suction PRN. Continue sedation. Wean vent as tolerated. F/U ABG.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n V Paced (ICD). HR 50 but occasionally increased to low 100s. BP\n 120s-130s/50s-60s. Feet slightly mottled. Palpable DPs/PTs. Continues\n on amiodarone and Lopressor PO. At ~ 1440, rhythm changed to v-fib.\n A-line flat. Patient unresponsive to pain. CPR initiated. One shock\n given @ 200J. Amiodarone bolus given and gtt started. CXR done. 2gm\n magnesium IV given. Labs drawn.\n Action:\n Code as above. Amiodarone gtt continued @ 1mg/hr. IP assessed and\n recommendations as above. Vitals monitored.\n Response:\n Heart rhythm returned paced, SR. HR 80s. BP 120s-130/50s-70s. MS\n returned to above stated status. Continued to not follow commands. No\n significant change to labs from morning labs. Vitals continue to be\n stable s/p arrest.\n Plan:\n Monitor vitals. Monitor labs. Treat heart rhythm with\n pacing/defibrillation as needed. Continue amiodarone gtt. Code cart\n outside room. TEE tomorrow.\n" }, { "category": "Physician ", "chartdate": "2141-03-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528141, "text": "Chief Complaint:\n 24 Hour Events:\n CARDIAC ARREST - At 02:40 PM\n FEVER - 102.9\nF - 05:00 PM\n Overnight Events:\n - CODE BLUE: went into VF arrest, ICD did not shock him out of it,\n received approx. 2 minutes of CPR and 1 external defibrillation with\n return of a perfusing rhythm\n - was on amio gtt after code, stopped in evening\n - was desat'ing on , went up on FiO2 and PEEP\n - also increased sedation because he was fighting the \n - got 80 IV lasix total\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 01:24 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Amiodarone - 02:50 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 106) bpm\n BP: 114/53(68) {95/29(62) - 144/81(95)} mmHg\n RR: 16 (14 - 28) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 16 (9 - 24)mmHg\n Total In:\n 1,875 mL\n 283 mL\n PO:\n TF:\n 225 mL\n IVF:\n 1,650 mL\n 283 mL\n Blood products:\n Total out:\n 1,195 mL\n 160 mL\n Urine:\n 1,195 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 680 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 330 (330 - 864) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.45/52/262/34/10\n Ve: 8.1 L/min\n PaO2 / FiO2: 655\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 386 K/uL\n 10.0 g/dL\n 130 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 107 mEq/L\n 148 mEq/L\n 30.7 %\n 10.4 K/uL\n [image002.jpg]\n 03:36 AM\n 04:12 AM\n 08:00 AM\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n WBC\n 9.5\n 3.7\n 12.4\n 10.4\n Hct\n 32.0\n 32.6\n 31.9\n 30.7\n Plt\n 372\n 343\n 439\n 386\n Cr\n 0.9\n 1.0\n 1.3\n 1.3\n TropT\n 0.03\n 0.10\n TCO2\n 40\n 36\n 29\n 33\n 35\n 37\n Glucose\n 171\n 196\n 178\n 130\n Other labs: PT / PTT / INR:17.7/32.1/1.6, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:3.3 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528143, "text": "Chief Complaint:\n 24 Hour Events:\n CARDIAC ARREST - At 02:40 PM\n FEVER - 102.9\nF - 05:00 PM\n Overnight Events:\n - CODE BLUE: went into VF arrest, ICD did not shock him out of it,\n received approx. 2 minutes of CPR and 1 external defibrillation with\n return of a perfusing rhythm\n - was on amio gtt after code, stopped in evening\n - was desat'ing on , went up on FiO2 and PEEP\n - also increased sedation because he was fighting the \n - got 80 IV lasix total\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 01:24 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Amiodarone - 02:50 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 106) bpm\n BP: 114/53(68) {95/29(62) - 144/81(95)} mmHg\n RR: 16 (14 - 28) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 16 (9 - 24)mmHg\n Total In:\n 1,875 mL\n 283 mL\n PO:\n TF:\n 225 mL\n IVF:\n 1,650 mL\n 283 mL\n Blood products:\n Total out:\n 1,195 mL\n 160 mL\n Urine:\n 1,195 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 680 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 330 (330 - 864) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.45/52/262/34/10\n Ve: 8.1 L/min\n PaO2 / FiO2: 655\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 386 K/uL\n 10.0 g/dL\n 130 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 107 mEq/L\n 148 mEq/L\n 30.7 %\n 10.4 K/uL\n [image002.jpg]\n 03:36 AM\n 04:12 AM\n 08:00 AM\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n WBC\n 9.5\n 3.7\n 12.4\n 10.4\n Hct\n 32.0\n 32.6\n 31.9\n 30.7\n Plt\n 372\n 343\n 439\n 386\n Cr\n 0.9\n 1.0\n 1.3\n 1.3\n TropT\n 0.03\n 0.10\n TCO2\n 40\n 36\n 29\n 33\n 35\n 37\n Glucose\n 171\n 196\n 178\n 130\n Other labs: PT / PTT / INR:17.7/32.1/1.6, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:3.3 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - too sedated on exam this morning, will defer extubation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528145, "text": "Chief Complaint:\n 24 Hour Events:\n CARDIAC ARREST - At 02:40 PM\n FEVER - 102.9\nF - 05:00 PM\n Overnight Events:\n - CODE BLUE: went into VF arrest, ICD did not shock him out of it,\n received approx. 2 minutes of CPR and 1 external defibrillation with\n return of a perfusing rhythm\n - was on amio gtt after code, stopped in evening\n - was desat'ing on , went up on FiO2 and PEEP\n - also increased sedation because he was fighting the \n - got 80 IV lasix total\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 01:24 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Amiodarone - 02:50 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 106) bpm\n BP: 114/53(68) {95/29(62) - 144/81(95)} mmHg\n RR: 16 (14 - 28) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 16 (9 - 24)mmHg\n Total In:\n 1,875 mL\n 283 mL\n PO:\n TF:\n 225 mL\n IVF:\n 1,650 mL\n 283 mL\n Blood products:\n Total out:\n 1,195 mL\n 160 mL\n Urine:\n 1,195 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 680 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 330 (330 - 864) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.45/52/262/34/10\n Ve: 8.1 L/min\n PaO2 / FiO2: 655\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. 2/6 systolic murmur at the apex.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. No significant pitting edema noted.\n Labs / Radiology\n 386 K/uL\n 10.0 g/dL\n 130 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 107 mEq/L\n 148 mEq/L\n 30.7 %\n 10.4 K/uL\n [image002.jpg]\n 03:36 AM\n 04:12 AM\n 08:00 AM\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n WBC\n 9.5\n 3.7\n 12.4\n 10.4\n Hct\n 32.0\n 32.6\n 31.9\n 30.7\n Plt\n 372\n 343\n 439\n 386\n Cr\n 0.9\n 1.0\n 1.3\n 1.3\n TropT\n 0.03\n 0.10\n TCO2\n 40\n 36\n 29\n 33\n 35\n 37\n Glucose\n 171\n 196\n 178\n 130\n Other labs: PT / PTT / INR:17.7/32.1/1.6, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:3.3 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - too sedated on exam this morning, will defer extubation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528150, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n initial vent settings A/C 500 x 14/peep12/1.0, overbreathing to total\n 16-18x/min. PO2 >200, so fio2 weaned to 70%, with abg7.45/52/260/37.\n LS with crackles L base. cxr from pm shows multifocal alveolar\n consolidations in upper lobes c/w edema vs infection. Remains on\n Meropenum. Sputum ngtd except for yeast. Sx for small amts beige\n secretions o/n. Given lasix overnight for +fluid balance.\n Action:\n fio2 weaned further to 40%. O2 sat 97%.\n Response:\n tolerated wean of fio2 overnight.\n Plan:\n Continue abx, diuresis, frequent turn and reposition, VAP preventative\n care. CXR repeated this am. f/u.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n tmax 101.4. med x 1 with Tylenol and given tepid bath. Temp this am is\n 100 by esophageal probe. AM wbc 10.4 (12).\n Action:\n Blood and urine cx sent. Needs sputum cx. Last sputum sent on \n during a bronch, shows some yeast.\n Response:\n Temp currently low grade on ATC Tylenol. Did not receive motrin o/n as\n is NPO, to avoid stomach upset.\n Plan:\n Follow cx, sent sputum when able. f/u with results cx . Continue\n Tylenol atc.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n cxr from yesterday afternoon still c/w ? pulmonary edema.. fluid\n balance +700 at midnight despite 20mg iv lasix given in evening. Pt\n then treated with 60mg iv lasix, await results. CVP 10-14 after pm dose\n lasix, down from 17. Vigileo hooked up, revealed CI 1.7-2.2, SVR\n 800-1200, SVV 6. Pt Continues with mottled feet , team aware.\n Action:\n Lasix given as noted. Further hemodynamic information obtained from\n Vigileo.\n Response:\n Await effect from repeat Lasix dose.\n Plan:\n f/u results am cxr. Follow fluid balance, cvp. Plan is for TEE today.\n No time as of yet.\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528067, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.2\nC - 08:00 AM\n Overnight Events:\n - Brief trial of 0/5 with RISBI 50-60S, will stay on MMV (5L) on \n overnight with plan for pressure support trial in am.\n - Added on LFTs, elevated (CK's now trending down)\n - Fentanyl stopped at 4pm after CT scan.\n - Ready to extubate in am.\n - BAL- -ve PCP, stuff pending.\n - DFA negative, resp precautions dc'd.\n - Having Fevers through out day. I.D recommended imaging. Head/Torso CT\n negative. Will need TEE on Monday to eval leads ? endocarditis\n (ordered)\n - Defervesced with ibuprofen.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.7\nC (99.9\n HR: 52 (50 - 52) bpm\n BP: 126/55(73) {89/50(67) - 136/80(299)} mmHg\n RR: 17 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 23 (10 - 24)mmHg\n Total In:\n 2,474 mL\n 392 mL\n PO:\n TF:\n 1,104 mL\n 225 mL\n IVF:\n 610 mL\n 167 mL\n Blood products:\n Total out:\n 1,780 mL\n 395 mL\n Urine:\n 1,780 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 694 mL\n -3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 471 (456 - 859) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.47/54/175/34/14\n Ve: 15.2 L/min\n PaO2 / FiO2: 438\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. 2/6 systolic murmur at the apex.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. No significant pitting edema noted.\n Labs / Radiology\n 372 K/uL\n 10.2 g/dL\n 171 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 104 mEq/L\n 145 mEq/L\n 32.0 %\n 9.5 K/uL\n [image002.jpg]\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n 06:14 AM\n 06:58 AM\n 03:36 AM\n 04:12 AM\n WBC\n 11.4\n 10.1\n 9.5\n Hct\n 30.8\n 32.6\n 31.2\n 32.0\n Plt\n \n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 0.9\n TropT\n 0.02\n TCO2\n 36\n 37\n 35\n 40\n Glucose\n 157\n 167\n 175\n 170\n 171\n Other labs: PT / PTT / INR:15.7/27.9/1.4, CK / CKMB /\n Troponin-T:434/3/0.02, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - too sedated on exam this morning, will defer extubation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528068, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.2\nC - 08:00 AM\n Overnight Events:\n - Brief trial of 0/5 with RISBI 50-60S, will stay on MMV (5L) on \n overnight with plan for pressure support trial in am.\n - Added on LFTs, elevated (CK's now trending down)\n - Fentanyl stopped at 4pm after CT scan.\n - Ready to extubate in am.\n - BAL- -ve PCP, stuff pending.\n - DFA negative, resp precautions dc'd.\n - Having Fevers through out day. I.D recommended imaging. Head/Torso CT\n negative. Will need TEE on Monday to eval leads ? endocarditis\n (ordered)\n - Defervesced with ibuprofen.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.7\nC (99.9\n HR: 52 (50 - 52) bpm\n BP: 126/55(73) {89/50(67) - 136/80(299)} mmHg\n RR: 17 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 23 (10 - 24)mmHg\n Total In:\n 2,474 mL\n 392 mL\n PO:\n TF:\n 1,104 mL\n 225 mL\n IVF:\n 610 mL\n 167 mL\n Blood products:\n Total out:\n 1,780 mL\n 395 mL\n Urine:\n 1,780 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 694 mL\n -3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 471 (456 - 859) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.47/54/175/34/14\n Ve: 15.2 L/min\n PaO2 / FiO2: 438\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. 2/6 systolic murmur at the apex.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. No significant pitting edema noted.\n Labs / Radiology\n 372 K/uL\n 10.2 g/dL\n 171 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 104 mEq/L\n 145 mEq/L\n 32.0 %\n 9.5 K/uL\n [image002.jpg]\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n 06:14 AM\n 06:58 AM\n 03:36 AM\n 04:12 AM\n WBC\n 11.4\n 10.1\n 9.5\n Hct\n 30.8\n 32.6\n 31.2\n 32.0\n Plt\n \n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 0.9\n TropT\n 0.02\n TCO2\n 36\n 37\n 35\n 40\n Glucose\n 157\n 167\n 175\n 170\n 171\n Other labs: PT / PTT / INR:15.7/27.9/1.4, CK / CKMB /\n Troponin-T:434/3/0.02, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - too sedated on exam this morning, will defer extubation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n Addendum: CODE BLUE called for patient at 1:45pm when pt went into\n pulseless VF arrest. Etiology of arrest not clear. ICD did not shock\n patient. However, pt did have a return of a perfusable rhythm within\n approximately 2 minutes of arrest. CPR and 1 external shock were given.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:25 ------\n" }, { "category": "Respiratory ", "chartdate": "2141-03-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528134, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: wean PEEP and FiO2 as indicated\n" }, { "category": "Physician ", "chartdate": "2141-03-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528264, "text": "Chief Complaint:\n 24 Hour Events:\n CARDIAC ARREST - At 02:40 PM\n FEVER - 102.9\nF - 05:00 PM\n Overnight Events:\n - CODE BLUE: went into VF arrest, ICD did not shock him out of it,\n received approx. 2 minutes of CPR and 1 external defibrillation with\n return of a perfusing rhythm\n - was on amio gtt after code, stopped in evening\n - was desat'ing on , went up on FiO2 and PEEP\n - also increased sedation because he was fighting the \n - got 80 IV lasix total\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 01:24 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Amiodarone - 02:50 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 106) bpm\n BP: 114/53(68) {95/29(62) - 144/81(95)} mmHg\n RR: 16 (14 - 28) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 16 (9 - 24)mmHg\n Total In:\n 1,875 mL\n 283 mL\n PO:\n TF:\n 225 mL\n IVF:\n 1,650 mL\n 283 mL\n Blood products:\n Total out:\n 1,195 mL\n 160 mL\n Urine:\n 1,195 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 680 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 330 (330 - 864) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.45/52/262/34/10\n Ve: 8.1 L/min\n PaO2 / FiO2: 655\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. No m/r/g appreciated.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n Labs / Radiology\n 386 K/uL\n 10.0 g/dL\n 130 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 107 mEq/L\n 148 mEq/L\n 30.7 %\n 10.4 K/uL\n [image002.jpg]\n 03:36 AM\n 04:12 AM\n 08:00 AM\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n WBC\n 9.5\n 3.7\n 12.4\n 10.4\n Hct\n 32.0\n 32.6\n 31.9\n 30.7\n Plt\n 372\n 343\n 439\n 386\n Cr\n 0.9\n 1.0\n 1.3\n 1.3\n TropT\n 0.03\n 0.10\n TCO2\n 40\n 36\n 29\n 33\n 35\n 37\n Glucose\n 171\n 196\n 178\n 130\n Other labs: PT / PTT / INR:17.7/32.1/1.6, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:3.3 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - if above is negative, will need to consider other causes, such as CNS\n infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation has been\n sedation.\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - wean sedation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I have also reviewed the notes of Dr(s). dated .\n I would add the following remarks:\n Status post VF not terminated by ICD. Persistent fevers. Plan for TEE\n to identify if there is an intracardiac source of infection. Continue\n secondary prevention CAD and CHF. Patient care time 40 minutes\n critical care for management of malignant ventricular arrhythmia.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:42 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530145, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on to keep patient from\n pulling out feeding tube. Posey off. Given 50mg Trazodone for sleep at\n midnight with poor effect on sleep. Closely supervising patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up\n x4, bed low and locked, and bilateral wrist restraints on. Fall risk\n precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . External defib pads.\n Heparin gtt @ 1500units/hr. Systolic BP trailing in the low 70s\n questionably from metroprolol. Rechecked and verified with doppler.\n Lung sounds diminished at bases. Chest xray showed no\n cardiopulmonary process. Pt. was saturating 100% on 2L nc. removed O2\n and patient currently saturating 100% on RA. Patient tolerating well\n and denies feeling short of breath. Urine output between\n 20-65mLs/hour. Weight loss of 8kg since admission date .\n Action:\n ? fluid to increase BP\n Response:\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Defibrillator at bedside. Monitor\n Dysphagia\n Assessment:\n Patient is currently strict NPO & no ice chips after failing swallow\n study. On tube feeding Isosource 1.5 cal Full strength. Abdomen\n distended, but soft. Bowel sounds positive x4 quadrants.\n Action:\n Tube feeding: Starting rate at 25ml/hour. Currently at 35 ml/hour.\n Advance rate by 10ml every 6 hours. Bilateral wrist restraints placed\n to prevent pt from pulling out tube\n family aware and at bedside.\n Response:\n Tolerating tube feedings well.\n Plan:\n Hold feeding if residual greater than or equal to 200mL. Flush with\n 30mLs water every four hours\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530147, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on to keep patient from\n pulling out feeding tube. Posey off. Given 50mg Trazodone for sleep at\n midnight with poor effect on sleep. Closely supervising patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up\n x4, bed low and locked, and bilateral wrist restraints on. Fall risk\n precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . External defib pads.\n Heparin gtt @ 1500units/hr. Systolic BP trailing in the low 70s\n questionably from metroprolol. Rechecked and verified with doppler.\n Lung sounds diminished at bases. Chest xray showed no\n cardiopulmonary process. Pt. was saturating 100% on 2L nc. removed O2\n and patient currently saturating 95-97% on room air. Patient tolerating\n well and denies feeling short of breath. Urine output between\n 20-65mLs/hour. Weight loss of 8kg since admission date .\n Action:\n MD updated. Hold metoprolol for now. Team to discuss fluid balance in\n the am.\n Response:\n BP 80s. O2 sat 95-97% on room air\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Defibrillator at bedside. Hold\n metoprolol. Question patient dry. Team to discuss fluid balance in am\n rounds\n Dysphagia\n Assessment:\n Patient is currently strict NPO & no ice chips after failing swallow\n study. On tube feeding Isosource 1.5 cal Full strength. Abdomen\n distended, but soft. Bowel sounds positive x4 quadrants.\n Action:\n Tube feeding: Starting rate at 25ml/hour. Currently at 35 ml/hour.\n Advance rate by 10ml every 6 hours. Bilateral wrist restraints placed\n to prevent pt from pulling out tube\n family aware and at bedside.\n Response:\n Tolerating tube feedings well.\n Plan:\n Hold feeding if residual greater than or equal to 200mL. Flush with\n 30mLs water every four hours\n" }, { "category": "Social Work", "chartdate": "2141-03-16 00:00:00.000", "description": "Social Work Progress Note", "row_id": 529025, "text": "SOCIAL WORK: SW continuing to meet with family daily to support\n coping. SW met briefly with who is returning home to VT this\n evening. She continues to offer support to pt\ns partner , and\n offers to help with practical things to minimize stress for her. SW\n provided empathic listening. SW met separately with pt\ns partner\n . She reports pt was able to recognize his today, but\n continues to have significantly altered mental status. vented\n her feelings of loss, and anticipatory loss in regard to pt\n condition. She expresses awareness pt\ns condition may improve, and team\n offers reassuring information about his condition, but she finds it\n difficult to have hope, given pt\ns slow progress. SW assisted in\n planning activities for self care to help her pace self in coping with\n pt\ns long hospitalization and recovery.\n SW will continue to follow with team to support pt and family coping.\n is very open to and seeks out ongoing SW support.\n" }, { "category": "Physician ", "chartdate": "2141-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529032, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - EP recs: to come and interrogate whether there is a problem\n with the generator; timing of change of ICD and/or leads depends on\n when PICC is removed and on course of abx; if can't be done during this\n hospitalization, pt will need lifevest at d/c\n - d/c'ed coumadin; restarted heparin IV\n - d/c'ed Aline\n - Blood cx growing coag negative staph; d/c'ed vanc\n - ID says we can stop meropenem; when we stop meropenem, need to\n restart outpt cefpodoxime therapy\n - put in PT consult\n - gave 60 mg IV lasix; put out a lot of urine to that\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin Sodium - 1,400 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.7\nC (98.1\n HR: 51 (51 - 62) bpm\n BP: 122/58(73) {98/51(62) - 132/69(82)} mmHg\n RR: 18 (10 - 26) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 978 mL\n 365 mL\n PO:\n TF:\n IVF:\n 978 mL\n 365 mL\n Blood products:\n Total out:\n 1,545 mL\n 3,025 mL\n Urine:\n 1,545 mL\n 3,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -567 mL\n -2,660 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///34/\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 464 K/uL\n 10.6 g/dL\n 152 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 103 mEq/L\n 145 mEq/L\n 33.0 %\n 8.4 K/uL\n [image002.jpg]\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n WBC\n 9.2\n 9.3\n 8.4\n Hct\n 30.4\n 31.8\n 33.0\n Plt\n 371\n 468\n 464\n Cr\n 1.2\n 0.9\n 0.7\n 0.7\n 0.8\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 164\n 130\n 198\n 151\n 137\n 122\n 152\n Other labs: PT / PTT / INR:30.7/48.8/3.1, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # s/p VT/VF arrest/ICD dysfunction: Patient had VT/VF arrest on \n during which ICD failed to defibrillate him and he required external\n therapy. High impedance. LV lead dysfunction.\n - f/u EP recs\n - pads in place\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxemic respiratory failure: Now s/p extubation and satting well on\n room air. Was intubated on for hypoxemic respiratory failure.\n Etiology likely pneumonia + heart failure.\n - f/u pending cultures\n - treat pneumonia as above and heart failure as below\n .\n # Fever/Pneumonia: Now afebrile x 72 hours. Previously, patient was\n spiking high fevers in spite of Tylenol, antibiotics, and improvement\n of pneumonia. This led to concern about an occult infection or\n non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue meropenem for now. Will change to cefpodoxime once patient\n can take PO\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses. Had very strong diuresis overnight to\n Lasix 60 mg IV. Can be more gentle with diuresis in future.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 2.5 L today (already negative 2.5 L)\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528857, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs,\n BP\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day\n Response:\n Excellent response to IV Lasix\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c,\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Oriented x1 only,\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528133, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528327, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on Tuesday\n Pt is NPO for this procedure.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Remains on ac 500x14, 8 peep. 40%. Minimal secretions. Bs dim and cta.\n Sedation dc\nd at 9:30am. Pt more awake over the course of the evening.\n No spon movement of upper extremities, moves feet in bed. Opens eyes,\n nods head, resists mouth care. Wrist restraints in place.\n Action:\n ? to PSV after TEE tomorrow\n Response:\n Plan:\n Follow sats. Assess mental status, safety precautions\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Started on heparin at 1650units. Also cont on warfarin. PTT >150 at 7pm\n gtt on hold.\n Action:\n Response:\n Plan:\n Resume heparin at 1300units at 8pm.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this shift. Cont on meropenum. Cultures ntd. Will do TEE\n tomorrow. Poss resite line this eve.\n Peripheral line placed on r by IV team.\n Discussed patient\ns status and plan with , HCP, and other. She\n is anxious about pt\ns course, particularly about move to MICU and\n return. Explained and answered questions.\n Dtr to visit tomorrow.\n Tubefeed resumed at 5:30pm at 55cc/hr(goal). Abd soft. Hold at mn as pt\n is npo for tee tomorrow\n Action:\n Follow temp\n Response:\n Plan:\n Provide support to patient and family. Consult SW for support.\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528896, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs, BP\n 90\ns-130\ns/50-60\ns. IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n given 40meq IV KCL with rapid diuresis labs sent , cardiac meds given\n Response:\n Excellent response to IV Lasix, PTT 85 on Heparin at 1400units/hour\n Plan:\n Cont to monitor hemodynamics, follow up with am labs, awaiting\n interrogation of ICD by EPS\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem, frequent turning,\n encouraged TCDB\n Response:\n Stable sats with less oxygen requirement\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n HOB>45 degrees, NPO, Pt. requesting tea or Coke, stating he is thirsty\n Action:\n Pills given in whole in applesauce with HOB at 90degrees, given 80% of\n usual dose Glargine at 2200, no regular insulin required\n Response:\n Tolerated meds whole in applesauce, requires multiple mouthfuls to\n swallow pills but no choking noted\n Plan:\n Aspiration precautions, Speech and swallow to reevaluate in am\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, then requesting to go to\n as he stated\nI am the Vice President of the United\n States\n, doesn\nt answer to month/year, asking for something to drink,\n follows simple commands, cooperative with care, MAE, able to lift and\n hold right arm, left arm lifts but falls back, left hand more edematous\n than right, moves lower extremities on bed constantly, family states he\n has restless leg syndrome, restless most of night, turning self\n frequently in bed, slept poorly, only in very short intervals\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up\n Response:\n Confused and disoriented, safety maintained\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures,\n discuss with team need for sleep med\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529098, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, freq. runs PVCs, self\n limiting runs of VT 6-10sec long\n strips printed and placed in chart.\n 2 episodes of long runs VT witnessed by EP fellow who happened to be at\n bedside this afternoon with patient. BP100-130\ns/50-60\ns. IV Heparin\n at 1400units/hour. Pt on Amiodarone 100mg po daily.\n Action:\n No diuresis given today. Heparin gtt increased to 1600units/hr, no\n bolus. ICD/pacer interrogated by EPS and rep. runs of \n sec of VT\n strips placed in chart.\n Response:\n afternoon PTT WNL. Repeat PTT due this evening. EP increased Amiodarone\n to 400mg po BID\n started. Pt continues to have short runs of VT and\n frequent Ectopy.\n Plan:\n PTT due 8pm. con\nt Amiodarone.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Abx meropenum IV q8H. pt too lethargic and confused this morning for\n speech and swallow eval.\n Response:\n Stable sats with less oxygen requirement , remains afebrile\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n HOB>45 degrees, NPO, Pt. requesting food this afternoon.\n Action:\n Pills given crushed in applesauce. HOB 90\n. FS QID with regular insulin\n coverage.\n Response:\n Tolerated meds whole in applesauce, requires multiple mouthfuls to\n swallow pills but no choking noted.\n Plan:\n Aspiration precautions, Speech and swallow to reevaluate in am.\n Delirium / confusion\n Assessment:\n Pt oriented x 1, doesn\nt answer to month/year, asking for something to\n eat, follows simple commands, cooperative with care, MAE, able to lift\n and hold right arm, left arm lifts but falls back, left hand more\n edematous than right, moves lower extremities on bed constantly, family\n states he has restless leg syndrome, restless most of night, turning\n self frequently in bed, constantly being repositioned in bed.\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up. Bed low to ground. Pt seemed to be more\n Response:\n Pt remains confused\n slightly better than this morning.\n Pt did manage to get himself between siderails and slide to floor in\n sitting position (leaning on side of bed). No signs of injury to torso\n or head\n pt denying pain or discomfort when assessed later by nursing\n and CCU team. Total lift with 4 staff back into bed. No abrasions or\n contusions noted. Lines in place. Bed alarm reset on bed. SR up. Bed\n low. Attemped reorientation. Significant other called and\n notified by nursing.\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures.\n Fall precautions.\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528231, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet in\n room. CT head, chest, & pelvis-without noted infectious process.\n Of note, pt sustained a VF arrest on days, responded to 1 200j\n shock with return of spontaneous circulation and paced HR. No further\n arrythmias o/n. cpk\ns are being cycled. Plan is to do TEE today.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n initial vent settings A/C 500 x 14/peep12/1.0, 40% overbreathing to\n total 16-18x/min. PO2 >200, LS clear w/ dim bases.. Remains on\n Meropenum. Sputum ngtd except for yeast. Sx for small amts beige\n secretions o/n. Given lasix overnight for +fluid balance. ABG this am\n 7.45/52/262\n Action:\n PEEP weaned to 10, suctioned for sm amt thick tan secretions.\n Response:\n ABG after wean 7.43/52/115, PEEP decreased to 8.\n Plan:\n Continue abx, diuresis, frequent turn and reposition, VAP preventative\n care. CXR repeated this am. f/u.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n tmax 101.4.overnight, rec\nd afebrile Blood and urine cx sent. Needs\n sputum cx. Last sputum sent on during a bronch, shows some yeast.\n Action:\n Tylenol held as pt afebrile. TEE pending\n Response:\n Pt remans afebrile.\n Plan:\n Follow cx, sent sputum when able. f/u with results cx .\n Heart failure (CHF), Systolic, Acute\n Assessment:\n cxr from yesterday afternoon still c/w ? pulmonary edema.. fluid\n balance +700 at midnight despite 20mg iv lasix given in evening. Pt\n then treated with 60mg iv lasix, await results. CVP 10-14 after pm dose\n lasix, down from 17. Vigileo hooked up, revealed CI 1.7-2.2, SVR\n 800-1200, SVV 6. Pt Continues with mottled feet , team aware.\n Action:\n Vigileo disconnected. Lasix as needed\n Response:\n UOP cont 100-150ml/hr\n Plan:\n f/u results am cxr. Follow fluid balance, cvp. Plan is for TEE today.\n No time as of yet.\n Of note, pt\ns INR subtheraputic at 1.6, coumadin increased to 3mg, and\n heparin gtt started at 1650units/hr at 12:00 a/o.\n" }, { "category": "Nursing", "chartdate": "2141-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528232, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet in\n room. CT head, chest, & pelvis-without noted infectious process.\n Of note, pt sustained a VF arrest on days, responded to 1 200j\n shock with return of spontaneous circulation and paced HR. No further\n arrythmias o/n. cpk\ns are being cycled. Plan is to do TEE today.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n initial vent settings A/C 500 x 14/peep12/1.0, 40% overbreathing to\n total 16-18x/min. PO2 >200, LS clear w/ dim bases.. Remains on\n Meropenum. Sputum ngtd except for yeast. Sx for small amts beige\n secretions o/n. Given lasix overnight for +fluid balance. ABG this am\n 7.45/52/262\n Action:\n PEEP weaned to 10, suctioned for sm amt thick tan secretions.\n Response:\n ABG after wean 7.43/52/115, PEEP decreased to 8.\n Plan:\n Continue abx, diuresis, frequent turn and reposition, VAP preventative\n care. CXR repeated this am. f/u.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n tmax 101.4.overnight, rec\nd afebrile Blood and urine cx sent. Needs\n sputum cx. Last sputum sent on during a bronch, shows some yeast.\n Action:\n Tylenol held as pt afebrile. TEE pending\n Response:\n Pt remans afebrile.\n Plan:\n Follow cx, sent sputum when able. f/u with results cx .\n Heart failure (CHF), Systolic, Acute\n Assessment:\n cxr from yesterday afternoon still c/w ? pulmonary edema.. fluid\n balance +700 at midnight despite 20mg iv lasix given in evening. Pt\n then treated with 60mg iv lasix, await results. CVP 10-14 after pm dose\n lasix, down from 17. Vigileo hooked up, revealed CI 1.7-2.2, SVR\n 800-1200, SVV 6. Pt Continues with mottled feet , team aware.\n Action:\n Vigileo disconnected. Lasix as needed\n Response:\n UOP cont 100-150ml/hr\n Plan:\n f/u results am cxr. Follow fluid balance, cvp. Plan is for TEE today.\n No time as of yet.\n Of note, pt\ns INR subtheraputic at 1.6, coumadin increased to 3mg, and\n heparin gtt started at 1650units/hr at 12:00 a/o.\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528396, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on TuesdayPt is NPO for\n this procedure. Sedation dc\nd (yesterday) at 9:30am. Pt more\n awake over the course of the evening. Now rare movement\n of right upper extremitie, moves feet wiggles in bed. Opens eyes,\n appears nods head to question, resists mouth care. Wrist restraints in\n place as pt did raise up right arm toward tube.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Remains on ac 500x14, 8 peep. 40%. Minimal ETT secretions but clear to\n white oral secretion in moderate amounts. . Bs dim with a few crackles\n and clear anterior.\n Action:\n RSBI done even though pt on 8 PEEP. And pt passed with 55. pt more\n awake also, follows commands on rare occasions.\n Response:\n More awake, RSBI is good. No fever today and WBC down\n Plan:\n Follow sats. Assess mental status, safety precautions, ? extubate later\n today after TEE?\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Started on heparin at 1650units. Also cont on warfarin. PTT >150 at\n 7pm and again at 0200. Pt was given lasix yesterday and was neg 618 at\n midnight, despite pt rec D5w 2L 125 cc per hour for high sodium.\n Action:\n Heparin drip off x 2 and now at 950 units per hour. Pt continues to\n have good urine output but will be positive.\n A CXR was ordered for the AM\n Response:\n Pt continues to have good urine output but will be fluid balance\n positive likely due to D5\n Plan:\n Resumed heparin at 950 units at 05 AM, next PTT at 11 am, ? lasix in\n the AM\n Weight today\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this shift. Cont on meropenum. Cultures ntd. Cards Will do\n TEE tomorrow. To rule out intra cardiac infection. Poss resite\n central line today as well.\n Peripheral line placed on right arm by IV team. ? if pt needs centeral\n acess at this time?\n Discussed patient\ns status and plan with , HCP, and other. She\n is anxious about pt\ns course,.\n Dtr to visit tomorrow.\n Tubefeed was resumed at 5:30pm at 55cc/hr(goal). Abd soft. Hold at mn\n as pt is npo for tee tomorrow\n Action:\n Follow temp, follow culture data , If pt having stooll send for cdiff.\n Response:\n Afebrile\n Plan:\n Provide support to patient and family. Consult SW for support. CXR in\n AM\n" }, { "category": "Physician ", "chartdate": "2141-03-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528398, "text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - PM sodium 152, free water deficit of 3.2L. Ordered for 2L D5W at 125\n cc/hr.\n - TBB -500-1000 at 8pm\n - ID recs: continue meropenem, TEE if feasible, C. diff if diarrhea,\n consider cycling lines\n - Was afebrile over the course of the day, so held off on re-siting CVL\n for now.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 04:00 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 53 (48 - 67) bpm\n BP: 106/52(66) {99/46(60) - 129/60(78)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 9 (3 - 13)mmHg\n Total In:\n 1,514 mL\n 973 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,044 mL\n 973 mL\n Blood products:\n Total out:\n 2,132 mL\n 467 mL\n Urine:\n 2,130 mL\n 465 mL\n NG:\n 2 mL\n 2 mL\n Stool:\n Drains:\n Balance:\n -618 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/48/112/35/11\n Ve: 6.5 L/min\n PaO2 / FiO2: 280\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 371 K/uL\n 9.5 g/dL\n 198 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 106 mEq/L\n 147 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n WBC\n 3.7\n 12.4\n 10.4\n 9.2\n Hct\n 32.6\n 31.9\n 30.7\n 30.4\n Plt\n 343\n 439\n 386\n 371\n Cr\n 1.0\n 1.3\n 1.3\n 1.2\n 0.9\n TropT\n 0.03\n 0.10\n TCO2\n 29\n 33\n 35\n 37\n 37\n Glucose\n 196\n 178\n 130\n 164\n 130\n 198\n Other labs: PT / PTT / INR:21.5/137.9/2.0, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:84.9 %, Lymph:9.3 %, Mono:4.5 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:7.8 mg/dL,\n Mg++:3.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt; Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528399, "text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - PM sodium 152, free water deficit of 3.2L. Ordered for 2L D5W at 125\n cc/hr.\n - TBB -500-1000 at 8pm\n - ID recs: continue meropenem, TEE if feasible, C. diff if diarrhea,\n consider cycling lines\n - Was afebrile over the course of the day, so held off on re-siting CVL\n for now.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 04:00 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 53 (48 - 67) bpm\n BP: 106/52(66) {99/46(60) - 129/60(78)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 9 (3 - 13)mmHg\n Total In:\n 1,514 mL\n 973 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,044 mL\n 973 mL\n Blood products:\n Total out:\n 2,132 mL\n 467 mL\n Urine:\n 2,130 mL\n 465 mL\n NG:\n 2 mL\n 2 mL\n Stool:\n Drains:\n Balance:\n -618 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/48/112/35/11\n Ve: 6.5 L/min\n PaO2 / FiO2: 280\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 371 K/uL\n 9.5 g/dL\n 198 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 106 mEq/L\n 147 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n WBC\n 3.7\n 12.4\n 10.4\n 9.2\n Hct\n 32.6\n 31.9\n 30.7\n 30.4\n Plt\n 343\n 439\n 386\n 371\n Cr\n 1.0\n 1.3\n 1.3\n 1.2\n 0.9\n TropT\n 0.03\n 0.10\n TCO2\n 29\n 33\n 35\n 37\n 37\n Glucose\n 196\n 178\n 130\n 164\n 130\n 198\n Other labs: PT / PTT / INR:21.5/137.9/2.0, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:84.9 %, Lymph:9.3 %, Mono:4.5 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:7.8 mg/dL,\n Mg++:3.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - if above is negative, will need to consider other causes, such as CNS\n infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation has been\n sedation.\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - wean sedation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt; Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528400, "text": "Chief Complaint:\n 24 Hour Events:\n Overnight Events:\n - PM sodium 152, free water deficit of 3.2L. Ordered for 2L D5W at 125\n cc/hr.\n - TBB -500-1000 at 8pm\n - ID recs: continue meropenem, TEE if feasible, C. diff if diarrhea,\n consider cycling lines\n - Was afebrile over the course of the day, so held off on re-siting CVL\n for now.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 04:00 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 53 (48 - 67) bpm\n BP: 106/52(66) {99/46(60) - 129/60(78)} mmHg\n RR: 14 (14 - 20) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 9 (3 - 13)mmHg\n Total In:\n 1,514 mL\n 973 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,044 mL\n 973 mL\n Blood products:\n Total out:\n 2,132 mL\n 467 mL\n Urine:\n 2,130 mL\n 465 mL\n NG:\n 2 mL\n 2 mL\n Stool:\n Drains:\n Balance:\n -618 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/48/112/35/11\n Ve: 6.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. No m/r/g appreciated.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted\n Labs / Radiology\n 371 K/uL\n 9.5 g/dL\n 198 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 49 mg/dL\n 106 mEq/L\n 147 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n WBC\n 3.7\n 12.4\n 10.4\n 9.2\n Hct\n 32.6\n 31.9\n 30.7\n 30.4\n Plt\n 343\n 439\n 386\n 371\n Cr\n 1.0\n 1.3\n 1.3\n 1.2\n 0.9\n TropT\n 0.03\n 0.10\n TCO2\n 29\n 33\n 35\n 37\n 37\n Glucose\n 196\n 178\n 130\n 164\n 130\n 198\n Other labs: PT / PTT / INR:21.5/137.9/2.0, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:84.9 %, Lymph:9.3 %, Mono:4.5 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:7.8 mg/dL,\n Mg++:3.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - if above is negative, will need to consider other causes, such as CNS\n infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation has been\n sedation.\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - wean sedation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt; Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529091, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -extubated 4PM\n -left PICC placed by IR\n -left IJ pulled, tip sent for culture\n -TEE: Severe (4+ MR). No vegetations seen on the right atrial leads\n (four identified) or on mitral, aortic, tricuspid or pulmonic valves.\n Severely depressed left ventricular function with septal, inferoseptal\n and inferior wall hypokinesis. Moderate tricuspid regurgitation. At\n least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n Echo in 09 - 2+ MR - possibility endocarditis.\n -Ucx negative, blood cx pending.\n -GPC in clusters. f/u cx data - no s/s yet. Possible contaminant.\n -started vanc\n -Got lasix 60 IV x 1 with UOP ***, likely need to repeat 9pm (got lasix\n late )goal negative 1L\n -3pm crit/lytes\n -heparin discontinued\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 08:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:05 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 52 (50 - 59) bpm\n BP: 105/45(62) {101/42(56) - 127/60(76)} mmHg\n RR: 16 (7 - 18) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 10 (9 - 10)mmHg\n Total In:\n 2,770 mL\n 67 mL\n PO:\n TF:\n IVF:\n 2,380 mL\n 67 mL\n Blood products:\n Total out:\n 3,972 mL\n 580 mL\n Urine:\n 3,970 mL\n 580 mL\n NG:\n 2 mL\n Stool:\n Drains:\n Balance:\n -1,202 mL\n -513 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 630 (630 - 630) mL\n RR (Set): 0\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SpO2: 99%\n ABG: 7.50/52/67/34/14\n Ve: 8.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 468 K/uL\n 10.4 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 30 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 9.3 K/uL\n [image002.jpg]\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n WBC\n 10.4\n 9.2\n 9.3\n Hct\n 30.7\n 30.4\n 31.8\n Plt\n \n Cr\n 1.3\n 1.2\n 0.9\n 0.7\n 0.7\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 130\n 164\n 130\n 198\n 151\n 137\n 122\n Other labs: PT / PTT / INR:19.5/29.4/1.8, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.6 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever/Pneumonia: Now afebrile x 48 hours. Previously, patient was\n spiking high fevers in spite of Tylenol, antibiotics, and improvement\n of pneumonia. This led to concern about an occult infection or\n non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue meropenem/vanc\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Hypoxemic respiratory failure: Now s/p extubation. Was intubated on\n for hypoxemic respiratory failure. Etiology likely pneumonia\n + heart failure.\n - f/u pending cultures\n - treat pneumonia as above\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during VT/VF arrest.\n -f/u EP recs\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Pulled NG tube yesterday. Will under repeat speech and\n swallow evaluation tomorrow, as mental status is rapidly improving.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n PICC\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On I saw, examined and was physically present with the resident\n / fellow for the key portions of the services provided. I agree with\n the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:42 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529093, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - EP recs: to come and interrogate whether there is a problem\n with the generator; timing of change of ICD and/or leads depends on\n when PICC is removed and on course of abx; if can't be done during this\n hospitalization, pt will need lifevest at d/c\n - d/c'ed coumadin; restarted heparin IV\n - d/c'ed Aline\n - Blood cx growing coag negative staph; d/c'ed vanc\n - ID says we can stop meropenem; when we stop meropenem, need to\n restart outpt cefpodoxime therapy\n - put in PT consult\n - gave 60 mg IV lasix; put out a lot of urine to that\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin Sodium - 1,400 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.7\nC (98.1\n HR: 51 (51 - 62) bpm\n BP: 122/58(73) {98/51(62) - 132/69(82)} mmHg\n RR: 18 (10 - 26) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 978 mL\n 365 mL\n PO:\n TF:\n IVF:\n 978 mL\n 365 mL\n Blood products:\n Total out:\n 1,545 mL\n 3,025 mL\n Urine:\n 1,545 mL\n 3,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -567 mL\n -2,660 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///34/\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 464 K/uL\n 10.6 g/dL\n 152 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 103 mEq/L\n 145 mEq/L\n 33.0 %\n 8.4 K/uL\n [image002.jpg]\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n WBC\n 9.2\n 9.3\n 8.4\n Hct\n 30.4\n 31.8\n 33.0\n Plt\n 371\n 468\n 464\n Cr\n 1.2\n 0.9\n 0.7\n 0.7\n 0.8\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 164\n 130\n 198\n 151\n 137\n 122\n 152\n Other labs: PT / PTT / INR:30.7/48.8/3.1, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # s/p VT/VF arrest/ICD dysfunction: Patient had VT/VF arrest on \n during which ICD failed to defibrillate him and he required external\n therapy. High impedance. LV lead dysfunction.\n - f/u EP recs\n - pads in place\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxemic respiratory failure: Now s/p extubation and satting well on\n room air. Was intubated on for hypoxemic respiratory failure.\n Etiology likely pneumonia + heart failure.\n - f/u pending cultures\n - treat pneumonia as above and heart failure as below\n .\n # Fever/Pneumonia: Now afebrile x 72 hours. Previously, patient was\n spiking high fevers in spite of Tylenol, antibiotics, and improvement\n of pneumonia. This led to concern about an occult infection or\n non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue meropenem for now. Will change to cefpodoxime once patient\n can take PO\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses. Had very strong diuresis overnight to\n Lasix 60 mg IV. Can be more gentle with diuresis in future.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 2.5 L today (already negative 2.5 L)\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:43 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-17 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 529173, "text": "TITLE: EP Follow-up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -VT requriing shock externally x\n 1, ATP failed\n -Amiodarone drip started\n Medications\n Changed\n Amio IV added\n Metoprolol 12.5 \n IV heparin\n Physical Exam\n General appearance: Confused, arousable\n BP: 114 / 75 mmHg\n HR: 96 bpm\n RR: 29 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 37.3 C\n T current F: 99.1 F\n O2 sat: 97 % on Supplemental oxygen: NC\n Previous day:\n Weight: 99.6 kg\n Intake: 927 mL\n Output: 3,280 mL\n Fluid balance: -2,353 mL\n Today:\n Intake: 227 mL\n Output: 235 mL\n Fluid balance: -8 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND)\n Neurological: (Orientation: confused, arousable)\n Extremities:\n Right: (Edema: 1+)\n Left: (Edema: 1+)\n Labs\n 426\n 9.6\n 201\n 1.2\n 29\n 4.1\n 36\n 103\n 142\n 31.0\n 9.1\n [image002.jpg]\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 10:30 PM\n 05:45 AM\n 01:44 PM\n 08:23 PM\n 05:02 AM\n 05:15 AM\n WBC\n 9.3\n 8.4\n 9.1\n Hgb\n 10.4\n 10.6\n 9.6\n Hct (Serum)\n 31.8\n 33.0\n 31.0\n Plt\n 468\n 464\n 426\n INR\n 1.8\n 3.1\n 3.9\n PTT\n 29.4\n 85.1\n 48.8\n 77.8\n 110.5\n Na+\n 145\n 143\n 145\n 145\n 142\n K + (Serum)\n 3.5\n 3.8\n 4.2\n 4.5\n 4.3\n 4.0\n K + (Whole blood)\n 4.1\n Cl\n 102\n 104\n 103\n 104\n 103\n HCO3\n 38\n 34\n 34\n 32\n 29\n BUN\n 33\n 30\n 25\n 25\n 36\n Creatinine\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n Glucose\n 151\n 137\n 122\n 152\n 131\n 201\n O2 sat (arterial)\n 97\n 92\n ABG: 7.49 / 39 / 163 / / 6 Values as of 05:15 AM\n Tests\n Telemetry: MMVT episodes x 2, one requiring external shock\n Assessment and Plan\n 72 yo M with CAD, infarct related cardiomyopathy, h/o VT s/p ICD with\n multiple leads due to revision p/w sepsis, now hemodynamically improved\n with RV coil fracture and non-functioning device and VT storm.\n 1. VT:\n -Agree with IV amio load, lidocaine can be added if incessant VT\n -Increase Metoprolol to 25 \n -If continues, will consider ablation next week\n 2. RV coil fracture on Fidelis lead:\n -External defibrillation necessary, ICD unable to deliver therapy\n -Will d/w Dr. re: lead extraction/revision possibilities for\n next week.\n Will d/w Dr. today.\n" }, { "category": "Nursing", "chartdate": "2141-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529176, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Pt will\n have to be Externally defibrillated. CT head, chest, &\n pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic,\n defib x 1 back to paced rhythm\n Brief CPR x 30 seconds.\n Dysrhythmia: VT\n Assessment:\n Pt was having some runs yesterday Amiodarone was increased to 400 po\n BID, then at 8 pm pt again had 10-20 seconds VT, self terminated. Was\n started on Amio drip at that time after bolus dose 150 mg. The again at\n 0445 AM this morning pt went into sustained VT, rate 200-220 ,\n appeared unresponsive, agonal breathing, was shocked x 1 back into V\n paced rhythm, 30 seconds CPR as pt was agonal breathing but pulse did\n return and pt started breathing on his own, o2 sats 87-100 percent\n after non rebreather was placed.\n Action:\n Team paged, 12 lead ekg was done, CXR, pt was very restless all night\n right up until he went into VT and then was unresponsive, then post\n defib very lethargic but arousable . Labs were sent lactate 3.5 k 4.1\n Team spoke with cards fellow.\n Response:\n One hour later pt now more awake and back to his baseline, he is\n restless, following some commands more, restleless, tossing and\n turning, pulling off o2 mask\n Plan:\n Lidocaine in the room., continue amiodarone, external pads on, full\n code.\n Delirium / confusion\n Assessment:\n Pt restless all night. At times verbal, states\n I just want to go\n home\n and\n Thank you very much\n you are such a nice doctor\n slept and was calm early in shift when family was here. But by 9 pm pt\n was restless again put leg over side rail setting off bed alarm.\n Removing his clothing, Bp cuff, o2 sat probes and ekg leads.\n Action:\n Reoriented and reassured pt, frequently. vest on for safety as pt\n fell earlier, team ordered 4 side rails as well. Trazadone given at two\n am when pt complained\n I can not sleep\n poor effect.\n Response:\n Pt at times following commands but continues to be confused, responds\n to is name will hold up right arm and falls back, left arm weaker but\n will Lift both arms to put his hands behind his head, lifts both legs\n and falls back. PERL.\n Plan:\n Continue reorient and reassure pt, vest 4 side rails bed alarm\n and chair alarm.\n" }, { "category": "Physician ", "chartdate": "2141-03-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528223, "text": "Chief Complaint:\n 24 Hour Events:\n CARDIAC ARREST - At 02:40 PM\n FEVER - 102.9\nF - 05:00 PM\n Overnight Events:\n - CODE BLUE: went into VF arrest, ICD did not shock him out of it,\n received approx. 2 minutes of CPR and 1 external defibrillation with\n return of a perfusing rhythm\n - was on amio gtt after code, stopped in evening\n - was desat'ing on , went up on FiO2 and PEEP\n - also increased sedation because he was fighting the \n - got 80 IV lasix total\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 01:24 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Amiodarone - 02:50 PM\n Midazolam (Versed) - 05:15 PM\n Fentanyl - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.4\nC (102.9\n Tcurrent: 37.2\nC (99\n HR: 58 (50 - 106) bpm\n BP: 114/53(68) {95/29(62) - 144/81(95)} mmHg\n RR: 16 (14 - 28) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 16 (9 - 24)mmHg\n Total In:\n 1,875 mL\n 283 mL\n PO:\n TF:\n 225 mL\n IVF:\n 1,650 mL\n 283 mL\n Blood products:\n Total out:\n 1,195 mL\n 160 mL\n Urine:\n 1,195 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 680 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 330 (330 - 864) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.45/52/262/34/10\n Ve: 8.1 L/min\n PaO2 / FiO2: 655\n Physical Examination\n GENERAL: Intubated, sedated, not responding to stimuli.\n CARDIAC: RRR. No m/r/g appreciated.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n Labs / Radiology\n 386 K/uL\n 10.0 g/dL\n 130 mg/dL\n 1.3 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 107 mEq/L\n 148 mEq/L\n 30.7 %\n 10.4 K/uL\n [image002.jpg]\n 03:36 AM\n 04:12 AM\n 08:00 AM\n 02:53 PM\n 04:37 PM\n 06:56 PM\n 08:48 PM\n 09:00 PM\n 04:26 AM\n 04:32 AM\n WBC\n 9.5\n 3.7\n 12.4\n 10.4\n Hct\n 32.0\n 32.6\n 31.9\n 30.7\n Plt\n 372\n 343\n 439\n 386\n Cr\n 0.9\n 1.0\n 1.3\n 1.3\n TropT\n 0.03\n 0.10\n TCO2\n 40\n 36\n 29\n 33\n 35\n 37\n Glucose\n 171\n 196\n 178\n 130\n Other labs: PT / PTT / INR:17.7/32.1/1.6, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:3.3 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following. CT abd/pelvis and\n CT sinuses were negative by prelim read.\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - if above is negative, will need to consider other causes, such as CNS\n infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation has been\n sedation.\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - wean sedation\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2141-03-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528390, "text": "Demographics\n Day of intubation: 11\n Day of mechanical ventilation: 11\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 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 Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n" }, { "category": "Nursing", "chartdate": "2141-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529154, "text": "Dysrhythmia: VT\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529164, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -ID recs: stop vanc and meropenem; restart cefpodoxime; no objection to\n PICC removal or device replacement during this admission from ID\n perspective\n -EP recs: Device interrogated with representative. RV coil\n fractured, leading to high impedence and inability to defibrillate.\n Since SVC coil impedence is calculated using RV coil, this appears\n elevated. LV coil is unipolar, with impedence calculated to RV coil,\n making is also appear elevated. A lead impedence is elevated, but still\n functional and may be due to scar or tissue impedence problem. \n discuss with Dr. re: extraction vs. new lead. Keep\n defibrillator at bedside. Increase amiodarone to 400 mg for VT. If\n VT continues, consider ablation next week.\n -increased amiodarone to 400 mg \n -looked into history of lead infection. Per clinic notes, TEE on\n showed mobile echodensities on both pacer leads\n -had runs of VT lasting as long as 30 seconds. Gave amiodarone 150 mg\n IV, followed by 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours\n -changed meropenem to cefpodoxime\n -will need to be NPO after midnight on Sunday for possible EP procedure\n -4:30 a.m. Had 30 seconds of VT with HR 200. Unclear if patient had\n pulse. RN, patient was exhibiting agonal breathing, so he was\n defibrillated. Following defibrillation, patient received approximately\n 1 minute of CPR.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 08:30 AM\n Infusions:\n Heparin Sodium - 1,400 units/hour\n Amiodarone - 1 mg/min\n Other ICU medications:\n Amiodarone - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 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: 73 (51 - 220) bpm\n BP: 120/66(78) {88/37(44) - 142/76(87)} mmHg\n RR: 25 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 927 mL\n 246 mL\n PO:\n TF:\n IVF:\n 927 mL\n 246 mL\n Blood products:\n Total out:\n 3,280 mL\n 135 mL\n Urine:\n 3,280 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,353 mL\n 111 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: 7.49/39/163/29/6\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 426 K/uL\n 9.6 g/dL\n 201 mg/dL\n 1.2 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 36 mg/dL\n 103 mEq/L\n 142 mEq/L\n 31.0 %\n 9.1 K/uL\n [image002.jpg]\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n WBC\n 9.2\n 9.3\n 8.4\n 9.1\n Hct\n 30.4\n 31.8\n 33.0\n 31.0\n Plt\n 371\n 468\n 464\n 426\n Cr\n 0.9\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n TCO2\n 37\n 39\n 42\n 31\n Glucose\n 198\n 151\n 137\n 122\n 152\n 131\n 201\n Other labs: PT / PTT / INR:37.4/110.5/3.9, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:3.5 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # s/p VT/VF arrest/ICD dysfunction: Patient had VT/VF arrest on \n during which ICD failed to defibrillate him and he required external\n therapy. High impedance. LV lead dysfunction.\n - f/u EP recs\n - pads in place\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxemic respiratory failure: Now s/p extubation and satting well on\n room air. Was intubated on for hypoxemic respiratory failure.\n Etiology likely pneumonia + heart failure.\n - f/u pending cultures\n - treat pneumonia as above and heart failure as below\n .\n # Fever/Pneumonia: Now afebrile x 72 hours. Previously, patient was\n spiking high fevers in spite of Tylenol, antibiotics, and improvement\n of pneumonia. This led to concern about an occult infection or\n non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue meropenem for now. Will change to cefpodoxime once patient\n can take PO\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses. Had very strong diuresis overnight to\n Lasix 60 mg IV. Can be more gentle with diuresis in future.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 2.5 L today (already negative 2.5 L)\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529290, "text": "Delirium / confusion\n Assessment:\n Pt remains confused. Pt restless and moving all over bed all day, legs\n over side rails, shifting self. Posey restraint on. SR up x 4. Bilat\n wrist restraints applied to keep pt from pulling oxygen off face.\n Family aware. Bed alarm on and chair alarm also behind patients back.\n Action:\n Continuing frequent repositioning, reorienting and monitoring safety.\n Significant other in and out all day. Emotional support given to\n significant other. Pts daughters both called on phone and updated.\n Daughter from to fly in this evening.\n Response:\n Pt remains confused. No changes.\n Plan:\n SR up x 4, posey, bed alarms, chair alarm, bil wrist restraints for\n confusion and treatment interference.\n Dysphagia\n Assessment:\n Speech and swallow eval today\n Action:\n Pt failed all liquids.\n Response:\n Pt NPO except for meds in pureed (apple sauce or custard only.).\n Continue to maintain aspiration precautions.\n Plan:\n NPO except for meds. Asp prec.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Desaturating this morning.\n Action:\n Placed on high flow 95% plus 5L n/c w/ improvement in sats to mid 90s.\n attempted diuresis 20mg IVP.\n Response:\n BUN/CR elevated 42/1.3. diuresis minimal. Continues >30cc/hr.\n Plan:\n Monitor resp status. Pt remains FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529376, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n. Continuously restless and moving legs\n and arms all over and off to the side of the bed. Oxygen mask and nc\n frequently removed due patient shifting all over bed.\n Action:\n Continuous orienting. Posey restraint on. Side rails up x 4. Bilateral\n wrist restraints applied to keep patient from removing oxygen off face.\n Family is aware. Bed alarm activated, locked and low. Frequent\n repositioning. Given 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, disoriented, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, bilateral wrist\n restraints and posey restraint on for patient safety.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour. BUN\n elevated\n46. Creatinine 1.1. Hct 31.4 Hgb 10.4. Na slightly elevated at\n 149.\n Action:\n Continuous monitoring of hemodynamic status.\n Response:\n Plan:\n Continue to monitor hemodynamic status. Monitor BUN and Creatinine.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at 1900.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2200 for fever with good effect and at 0230 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Sats lower 90s. Patient afebrile with temp down to 98.5.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Need to\n continuously awaken/stimulate patient and remind to swallow.\n Response:\n When reminded, patient swallowed all PO meds.\n Plan:\n NPO except for meds. Aspiration precautions.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 528499, "text": "Comments: Patient extubated and placed on 50% cool mist (open face\n mask) alert with acceptable hemodynamics.Has mild metabolic\n acidosis,period of apnea may need to use CPAP machine.\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528751, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway. CT head, chest, & pelvis-without\n noted infectious process.\n vf arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n Pneumonia, Bacterial, Community Acquired (CAP)\n Assessment:\n Received on 50% shovel mask, with sats >95% when mask on, desatting to\n 88% when he removed mask. Lungs with crackles L base, bronchial at L\n base, few rhonchi.\n Action:\n * Rare, strong cough\n thick brown sputum (like a small ball)\n * O2 weaned to 2 L NP maintaining sats\n * Turned s\nS, enc to c & db, he is not cognitively ready for inc\n .\n Response:\n Plan:\n Heart Failure (CHF)/VT\n Assessment:\n Remains V paced.\n Action:\n Response:\n Plan:\n Delirium\n Assessment:\n Oriented x1 only\nself and family. At times thought he was in a Hotel\n Action:\n * Bed low/locked position\n * Frequent re-orientation\n * Hearing aides in\n * A-line removed.\n Response:\n Remains oriented x1 only.\n Plan:\n Continue present management. Frequent reorientation. Appropriate safety\n measures.\n Dysphagia\n Assessment:\n Speech and swallow in to evaluate. Coughing with thin liqs and nectar\n thick. Able to swallow pills whole with applesauce without difficulty\n Action:\n * Plan of care discussed with S&S re: ? to replace NGT or whether\n this would slow down his swallow recovery process. They recommend\n keeping NGT out today. Give pills whole in applesauce, but no\n other po\ns. They will re-evaluate patient in 24 hours as they\n anticipate his swallow to come back as he was able to have regular\n diet pre-intubation.\n * HOB ^ 90 degrees with po\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529159, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Pt will\n have to be Externally defibrillated. CT head, chest, &\n pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic,\n defib x 1 back to paced rhythm\n Brief CPR x 30 seconds.\n Dysrhythmia: VT\n Assessment:\n Pt was having some runs yesterday Amiodarone was increased to 400 po\n BID, then at 8 pm pt had 10-20 seconds VT, self terminated. Was\n started on Amio drip at that time after bolus dose 150 mg. The again at\n 0445 AM pt went into sustained VT, rate 200-220 , appeared\n unresponsive, agonal breathing, was shocked x 1 back into V paced\n rhythm, 30 seconds CPR as pt was agonal breathing but pulse did mreturn\n and pt started breathing on hisown, o2 sats 87-100 percent after non\n rebrether was placed.\n Action:\n Team paged 12 lead ekg was done CXR, pt was very restless all night\n right up until he went into VT and then was unresponsive, then post\n defib very lethargic but arousable post. Labs were sent lactate 3.5 k\n 4.1\n Team spoke with cards fellow.\n Response:\n One hour later pt now more awake and back to his baseline, he is\n following commans more, restleless, pulling off o2 mask\n Plan:\n Lidocaine in the room., continue amiodarone, external pads on, full\n code.\n Delirium / confusion\n Assessment:\n Pt reswtless all night. At times verbal, states\n I just want to go\n home\n and\n Thank you very much\n you are such a nice doctor\n slept and was calm early in shift when family was here. But by 9 pm pt\n was restless again put leg over side rail setting off bed alarm.\n Removing his clothing Bp cuff o2 sat probes and ekg leads.\n Action:\n Reoriented and reassured pt, frequently. Posey vest on for safety as pt\n fell earler, team ordered 4 side rails as well. Trazadone given at two\n am when pt complained\n I can not sleep\n Response:\n Pt at times following commands but continues to be confused, responds\n to is name will hold up right arm and falls back, left arm wreaker.\n Lifts both arms to put his hands behind his head, lifyts both legs and\n falls back. PERL.\n Plan:\n Continue reorient and reassure pt, posey vest 4 side rails bed alarm\n and chair alarm.\n" }, { "category": "Social Work", "chartdate": "2141-03-17 00:00:00.000", "description": "Social Work Progress Note", "row_id": 529283, "text": "SOCIAL WORK: Case discussed with team, patient had VT overnight, was\n defribillated and had 1 minute of CPR. Per team, pt\ns partner was very\n distressed today, using pastoral care and other providers for support.\n SW met with partner this afternoon to provide counseling re: coping\n with stress of pt\ns hospitalization and empathic support. SW\n continuing to educate partner re: self care strategies to help her\n manage long course of pt\ns hospitalization. Per partner, pt\ns brother\n to visit from NY tonight, and is returning from FL late\n tonight.\n SW will continue to follow with CCU team. Please contact weekend SW\n on-call if needed.\n" }, { "category": "Nursing", "chartdate": "2141-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529289, "text": "Delirium / confusion\n Assessment:\n Pt remains confused. Pt restless and moving all over bed all day, legs\n over side rails, shifting self. Posey restraint on. SR up x 4. Bilat\n wrist restraints applied to keep pt from pulling oxygen off face.\n Family aware. Bed alarm on and chair alarm also behind patients back.\n Action:\n Continuing frequent repositioning, reorienting and monitoring safety.\n Significant other in and out all day. Emotional support given to\n significant other. Pts daughters both called on phone and updated.\n Daughter from to fly in this evening.\n Response:\n Pt remains confused. No changes.\n Plan:\n SR up x 4, posey, bed alarms, chair alarm, bil wrist restraints for\n confusion and treatment interference.\n Dysphagia\n Assessment:\n Speech and swallow eval today\n Action:\n Pt failed all liquids.\n Response:\n Pt NPO except for meds in pureed (apple sauce or custard only.).\n Continue to maintain aspiration precautions.\n Plan:\n NPO except for meds. Asp prec.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Desaturating this morning.\n Action:\n Placed on high flow 95% plus 5L n/c w/ improvement in sats to mid 90s.\n attempted diuresis 20mg IVP.\n Response:\n BUN/CR elevated 42/1.3. diuresis minimal. Continues >30cc/hr.\n Plan:\n Monitor resp status. Pt remains FULL CODE.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529360, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n. Continuously restless and moving legs\n and arms all over and off to the side of the bed. Oxygen mask and nc\n frequently removed due patient shifting all over bed.\n Action:\n Continuous orienting. Posey restraint on. Side rails up x 4. Bilateral\n wrist restraints applied to keep patient from removing oxygen off face.\n Family is aware. Bed alarm activated, locked and low. Frequent\n repositioning. Given 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, disoriented, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, bilateral wrist\n restraints and posey restraint on for patient safety.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529363, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n. Continuously restless and moving legs\n and arms all over and off to the side of the bed. Oxygen mask and nc\n frequently removed due patient shifting all over bed.\n Action:\n Continuous orienting. Posey restraint on. Side rails up x 4. Bilateral\n wrist restraints applied to keep patient from removing oxygen off face.\n Family is aware. Bed alarm activated, locked and low. Frequent\n repositioning. Given 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, disoriented, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, bilateral wrist\n restraints and posey restraint on for patient safety.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529369, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n. Continuously restless and moving legs\n and arms all over and off to the side of the bed. Oxygen mask and nc\n frequently removed due patient shifting all over bed.\n Action:\n Continuous orienting. Posey restraint on. Side rails up x 4. Bilateral\n wrist restraints applied to keep patient from removing oxygen off face.\n Family is aware. Bed alarm activated, locked and low. Frequent\n repositioning. Given 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, disoriented, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, bilateral wrist\n restraints and posey restraint on for patient safety.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour. BUN 46\n and Creatinine 1.2. PTT Pt INR Lactic Acid\n Action:\n Continuous monitoring of hemodynamic status\n Response:\n Plan:\n Continue to monitor hemodynamic status. Monitor BUN and Creatinine.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with bibasilar rales. Patient febrile at 1900.\n Action:\n Abx meropenum IV q8H. pt too lethargic and confused this morning for\n speech and swallow eval.\n Response:\n Stable sats with less oxygen requirement , remains afebrile\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529489, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Rec\nd w/ bilat soft wrist\n restraints and posey belt. Stating\nI need to see the president of\n Denmarkl\n. When asked where he was he stated\n\n, but will\n sometimes say the hospital. Continuously restless and moving legs and\n arms all over and off to the side of the bed. Oxygen mask and NC\n frequently removed due patient shifting all over bed. PICC dsg\n non-occlusive-> dsg changed when pt calm and pt suddenly agitated,\n pulling out PICC line inches. CCU team and IV team alerted. OK to\n use as a midline- signage changed at bedside. Pt w/ sudden increase in\n agitation after AM care- kicking legs over side rail, swearing at staff\n and his family.\n Action:\n Continuous reorienting. Side rails up x 4. Bilateral wrist restraints\n maintained when alone, but removed when family/RN at bedside. Posey\n restraint removed. Bed alarm activated, close supervision, bed locked\n and low. Frequent repositioning. Tubing/lines concealed.\n Response:\n Patient remains confused, oriented x1, and restless. Posey back on as\n pt was found again with leg over the side rail.\n Plan:\n Continue to reorient patient. Keep side rails up x4, may use bilateral\n wrist restraints if pt pulls off mask, and pt requires posey\n restraint as he has slid between the side rails before.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: rales at bases. SPO2 100% on highflow neb mask as 95% and 5LNC. RR\n 20s. Trace LE edema. HR 70s V-paced. BP 110s-120s/70s.\n Action:\n *20mg IV lasix x one\n *Weaned O2 as noted below\n Response:\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient rec\nd on 5L n/c and high flow neb FiO2 95%. Lungs with lower\n bilateral crackles. Last Temp spike 20:00- pan cultured. Likely\n r/t aspiration pneumonitis that occurred during time of VT arrest. T\n max today 99.8 PR. Pt w/ rare, non-productive cough. WBC 11.\n Action:\n Weaned O2 to 5LNC. Resumed pt\ns home dose of PO cefpodoxime Q 12 hrs.\n Trended Temp/ WBC. Encouraged C&DB. OOB->chair x __ hrs.\n Response:\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating at times\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528504, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on TuesdayPt is NPO for\n this procedure. Sedation dc\nd (yesterday) at 9:30am. Pt more\n awake over the course of the evening. Now rare movement\n of right upper extremitie, moves feet wiggles in bed. Opens eyes,\n appears nods head to question, resists mouth care. Wrist restraints in\n place as pt did raise up right arm toward tube.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient placed on CPAP 5/5 40%- lung sounds clear- suctioned small amt\n thick tan\n Action:\n RSBI 55 this am- ABG on CPAP\n Response:\n More awake, RSBI is good. No fever today and WBC down\n Plan:\n Follow sats. Assess mental status, safety precautions, ? extubate later\n today after TEE?\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Started on heparin at 1650units. Also cont on warfarin. PTT >150 at\n 7pm and again at 0200. Pt was given lasix yesterday and was neg 618 at\n midnight, despite pt rec D5w 2L 125 cc per hour for high sodium.\n Action:\n Heparin drip off x 2 and now at 950 units per hour. Pt continues to\n have good urine output but will be positive.\n A CXR was ordered for the AM\n Response:\n Pt continues to have good urine output but will be fluid balance\n positive likely due to D5\n Plan:\n Resumed heparin at 950 units at 05 AM, next PTT at 11 am, ? lasix in\n the AM\n Weight today\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528505, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on TuesdayPt is NPO for\n this procedure. Sedation dc\nd (yesterday) at 9:30am. Pt more\n awake over the course of the evening. Now rare movement\n of right upper extremitie, moves feet wiggles in bed. Opens eyes,\n appears nods head to question, resists mouth care. Wrist restraints in\n place as pt did raise up right arm toward tube.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient placed on CPAP 5/5 40%- lung sounds clear- suctioned small amt\n thick tan.\n Action:\n RSBI 55 this am- ABG on CPAP 7.50-48-115-39 sat 97%- successfully\n extubated @ 1600.\n Response:\n More awake- no resp distress.\n Plan:\n Monitor resp status- follow ABG\ns- encourage coughing and deep\n breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n D5W 2L 125 cc per hour for high sodium- D/C\nd after 1500cc.\n Action:\n TEE done this am- lasix 60mg IV given- heparin gtt D/C\nd @ 1400- INR\n 2.0 this am- repeat 1.8-\n Response:\n Diuresed well- hemodynamically stable.\n Plan:\n Follow U/O- con\nt cardiac meds as ordered- keep family updated on plan\n of care.\n" }, { "category": "Nursing", "chartdate": "2141-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528508, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. IACD will act as a pacer but not able to detect or\n convert VT/VF so pt will have to be externally defibrillated. CT\n head, chest, & pelvis-without noted infectious process.\n PT sustained a VF arrest on on days, rec\nd 2min CPR. Externally\n defib x 1 200 J shock with return of spontaneous circulation and paced\n HR. No further arrhythmias. Plan is to do TEE on TuesdayPt is NPO for\n this procedure. Sedation dc\nd (yesterday) at 9:30am. Pt more\n awake over the course of the evening. Now rare movement\n of right upper extremitie, moves feet wiggles in bed. Opens eyes,\n appears nods head to question, resists mouth care. Wrist restraints in\n place as pt did raise up right arm toward tube.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient placed on CPAP 5/5 40%- lung sounds clear- suctioned small amt\n thick tan.\n Action:\n RSBI 55 this am- ABG on CPAP 7.50-48-115-39 sat 97%- successfully\n extubated @ 1600.\n Response:\n More awake- no resp distress.\n Plan:\n Monitor resp status- follow ABG\ns- encourage coughing and deep\n breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n D5W 2L 125 cc per hour for high sodium- D/C\nd after 1500cc.\n Action:\n TEE done this am- lasix 60mg IV given- heparin gtt D/C\nd @ 1400- INR\n 2.0 this am- repeat 1.8- Coumadin given @ 1600.\n Response:\n Diuresed well- hemodynamically stable.\n Plan:\n Follow U/O- con\nt cardiac meds as ordered- keep family updated on plan\n of care.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n 1 blood culture from taken from CL growning gm (+) cocci. WBC 6.0\n today- afebrile.\n Action:\n Awaiting PICC line inserted @ IR- TLCL R IJ to be D/C\nd once PICC is\n placed- Pt recultured- meropenum given as ordered- vanco restarted.\n Response:\n Remains afebrile.\n Plan:\n D/C TL tonight- follow temps and culture results- reculture if patient\n spikes- con\nt ABX.\n" }, { "category": "Social Work", "chartdate": "2141-03-14 00:00:00.000", "description": "Social Work Progress Note", "row_id": 528515, "text": "SOCIAL WORK: Case discussed with RN, pt remains on CCU with plans to\n be extubated today. SW met with pt\ns partner to support her\n coping with pt\ns illness. SW also met with , who returned\n from her home in VT. Pt\ns partner vented her fears and worries about\n pt\ns illness and fears he may die, or have dramatically impaired\n quality of life. She reports feeling significant distress around pt\n lack of progress, and general uncertainty about outcomes. SW provided\n empathic listening and discussed strategies for self care. Pt\n \n returned to to attend to pt and to his partner, stating\n she has been a strong support through pt\ns turbulent illness for many\n years.\n SW will continue to follow with team to support family coping.\n" }, { "category": "Rehab Services", "chartdate": "2141-03-15 00:00:00.000", "description": "Repeat Bedside Swallowing Evaluation", "row_id": 528714, "text": "TITLE:\n REPEAT BEDSIDE SWALLOWING EVALUATION:\n HISTORY:\n Thank you for reconsulting on this 71 year old man initially admitted\n on with a week of cough productive of dark beige sputum x 1\n week with progressive dyspnea. His respiratory failure progressed, and\n was intuated on . Initially symptoms were thought to be due to CHF\n exacerbation with infiltrate, fever, white count consistent with PNA.\n Bronch on notable for normal airways. Recently underwent TEE to\n evaluate for endocarditis. He was extubated on and has been\n asking for breakfast this morning. We were consulted to evaluate oral\n and pharyngeal swallow function to determine the safest diet.\n Pt is known to our department from a bedside swallow eval on the day of\n admission . At that time he had no overt signs of aspiration or\n other odynophagia except for difficulty chewing with edentulous\n status. We recommended diet of regular solids and thin liquids with\n videoswallow study only if there remained concern for aspiration on\n that diet.\n PAST MEDICAL/SURGICAL HISTORY:\n - CAD s/p Anterior wall myocardial infarction in with\n ventricular tachycardia and complete heart block requiring\n pacemaker\n - CHF Systolic heart failure (EF 20-25%)\n - Atrial fibrillation\n - Hypertension.\n - Hypothyroidism.\n - Anemia.\n - Irritable bowel syndrome.\n - Constipation.\n - Obesity.\n - Hearing loss, requiring bilateral hearing aids.\n - Squamous cell carcinoma of the left lower eyelid.\n - Cerebral infarct.\n - History of Whipple operation, with subsequent E. coli and\n Klebsiella bacteremia, on chronic suppression with cefpodoxime\n - History of possible C3-C4 osteomyelitis\n s/p:\n 1. Placement of pacemaker and ICD.\n 2. Knee surgery.\n 3. Removal of squamous cell carcinoma of his left lower eyelid.\n 4. Recent Whipple's procedure for which he was diagnosed with\n dysplasia.\n .\n SOCIAL HISTORY:\n Teaches history at .\n Divorced, 2 children. Lives in , but is staying intermittently\n in with his companion. Former pipe and cigarette smoker\n (quit >10 years ago). Used to smoke 1ppd X 30 yrs. Drinks \n glasses of wine/day. No drugs.\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the bed in CCU.\n Cognition, language, speech, voice:\n Awake but intattentive, keeps eyes closed through much of the\n evaluation. Oriented to self only. Answers 50% of y/n questions,\n follows 50% of one step commands. Expressive language fluent but\n limited with phrases of 5+ words without overt word finding or\n paraphasias. Speech and voice are clear without overt dysarthria.\n Teeth: edentulous\n Secretions: dry oral cavity\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Tongue protrudes midline with reduced ROM\n and strength in formal eval, though appears functional with PO trials.\n Palatal elevation symmetrical. Labial seal intact.\n SWALLOWING ASSESSMENT:\n Pt offered ice chips, thin liquid (tspn, cup), nectar thick liquids\n (tspn, cup), puree, and meds whole in puree provided by RN. Oral phase\n functional for the limited consistencies assessed, occasionally\n swallows puree and leaves pill in mouth, but can be cued to swallow\n pill with f/u bite of puree. No other overt oral cavity residue.\n Laryngeal elevation delayed but adequate in height to palpation. Pt\n had consistent throat clearing and prolonged cough with thin liquid and\n nectar thick liquids only. No throat clearing, coughing, or choking\n with puree or pills whole in puree. O2 sats stable throughout eval at\n 99-100%. Pt endorsed possible aspiration of liquids, denied sensation\n of aspiration or pharyngeal residue of purees.\n SUMMARY / IMPRESSION:\n Pt presents with s/sx of aspiration of thin liquids and nectar thick\n liquids today, however appears to tolerate small volumes of puree and\n meds whole in puree. Would keep primarily NPO at this time with meds\n whole or crushed in puree only. Would not recommend diet of pureed\n solids only with no liquids, given risk for increased pharyngeal\n residue without liquid wash down available. We will return tomorrow to\n reassess and hopefully initiate a diet. If pt continues to require NPO\n at that time, team should consider replacing non-oral means of\n nutrition (e.g., Dobbhoff).\n This swallowing pattern correlates to a Functional Oral Intake Scale\n (FOIS) rating of 1 out of 7, NPO.\n RECOMMENDATIONS:\n 1. NPO except meds whole or crushed in puree\n 2. Q4 oral care while NPO\n 3. If providing whole meds, please check oral cavity to ensure the pill\n was swallowed prior to laying back.\n 4. Repeat swallowing evaluation tomrrow \n 5. Consider NGT/Dobbhoff if pt requires NPO for >24 hours.\n These recommendations were shared with the patient, nurse and medical\n team.\n ____________________________________\n M.S., CCC-SLP\n Pager # \n Face time: 8:50-9:05\n Total time: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529473, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by\n antitachycardia pacing pacer set at higher rate of 75 -100 A to avoid\n fast-slow-fast sequences that may have precipitated episode of\n ventricular tachycardia (note in chart). ATP were added in a FVT zone\n of 260-300 and ? DVT zone 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n GENERAL: Oriented to person, able to follow commands, improved from\n y/d\n CARDIAC: RRR. II/VI HSM at apex.\n LUNGS: Diffuse rales.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE.\n .\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA initially on\n meropenem for concern resistant klebsiella who has been cx negative,\n narrowed to suppressive cefpodoxime regimen now spiking temp with\n meropenem restarted. Pt also had VT thought fast/short sequences\n due to pacer setting.\n .\n # s/p VT/VF arrest/ICD dysfunction: LV lead not pacing, only RV\n (). PMR programmed to DDD\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Patient had\n multiple runs of VT, including second VT arrest 2 nites ago requiring\n defibrillation. Etiology of recently increased ectopy thought \n fast/short sequences, pacer settings. A sensed V paced.\n . Device may not be able to detect VT/VF. Pt will have to be\n Externally defibrillated\n -Unlikely to need ablation as previously thought when etiology VT\n unclear.\n -continue current amnio dose 200mg daily, metoprololl 25mg \n monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n Possible lead extraction next week for RV coil fracture.\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to VT arrest, patient was satting well on 2L NC . Has had increased O2\n requirement since, requiring face mask and desating when not on it,\n possibly related to aspiration, less likely worsening heart failure.\n Spiked temp last night, most likely asp pneumonitis, mild\n leukocytosis. Heart failure lesser contributor, diuresed well to 20 IV\n lasix but no frther given, given bump in Cr. Not grossly volume\n overloaded on exam.\n Given prior hx, broadened to meropenem but can consider narrowing if\n remains afebrile, pending Cx data\n -aspiration precautions\n -allow to autodiurese today, if later in day appears positive, consider\n lasix bolus,\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has intermittent periods of lucidity, over\n general course slightl improved. MS currently limiting ability to take\n p.o . Plan currently to keep NPO except meds, repeat swallow eval early\n next week.\n - continue to follow clinically\n - minimize sedating medications\n .\n Acute renal failure: hypernatremia, Cr increased y/d in setting lasix\n IV. need to give free H20 to correct free h20 deficit today. Cr\n increased to 1.3 yesterday. Now 1.1\n Continue to trend Cr\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amnio.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ------ Protected Section ------\n TITLE:\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n History\n Spike to 101 today without obvious source.\n Mental status is improved\n oriented to person and place.\n Diuresis of 700 cc with furosemide 20 mg with improvement in the CXR\n and oxygenation.\n Medical Decision Making\n Pacemaker reprogrammed.\n EP procedure Thurs with possible lead extraction and ICD replacement.\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:45 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529474, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Rec\nd w/ bilat soft wrist\n restraints and posey belt. Stating\nI need to see the president of\n Denmarkl\n. When asked where he was he stated\n\n, but will\n sometimes say the hospital. Continuously restless and moving legs and\n arms all over and off to the side of the bed. Oxygen mask and NC\n frequently removed due patient shifting all over bed. PICC dsg\n non-occlusive-> dsg changed when pt calm and pt suddenly agitated,\n pulling out PICC line inches. CCU team and IV team alerted. OK to\n use as a midline- signage changed at bedside. Pt w/ sudden increase in\n agitation after AM care- kicking legs over side rail, swearing at staff\n and his family.\n Action:\n Continuous reorienting. Side rails up x 4. Bilateral wrist restraints\n maintained when alone, but removed when family/RN at bedside. Posey\n restraint removed. Bed alarm activated, close supervision, bed locked\n and low. Frequent repositioning. Tubing/lines concealed.\n Response:\n Patient remains confused, oriented x1, and restless. Posey back on as\n pt was found again with leg over the side rail.\n Plan:\n Continue to reorient patient. Keep side rails up x4, may use bilateral\n wrist restraints if pt pulls off mask, and pt requires posey\n restraint as he has slid between the side rails before.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: rales at bases. SPO2 100% on highflow neb mask as 95% and 5LNC. RR\n 20s. Trace LE edema. HR 70s V-paced. BP 110s-120s/70s.\n Action:\n *20mg IV lasix x one\n Response:\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at last\n night.\n Action:\n Response:\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating at times\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529497, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Patient is alert, oriented x 1 only. Rec\nd w/ bilat soft wrist\n restraints and posey belt in place. Stating\nI need to see the\n president of Denmarkl\n. When asked where he was he stated\n\n or\nNew Yorl\n, but will sometimes say the hospital. Continuously\n restless and moving legs and arms all over and off to the side of the\n bed. Oxygen mask and NC frequently removed due patient shifting all\n over bed.\n PICC dsg non-occlusive-> dsg changed when pt calm and pt suddenly\n agitated, pulling out PICC line inches. CCU team and IV team\n alerted. OK to use as a midline- signage changed at bedside.\n Pt w/ sudden increase in agitation after AM care- kicking legs over\n side rail, swearing at staff and his family.\n Action:\n Continuous reorienting. Side rails up x 4. Bilateral wrist restraints\n maintained when alone, but removed when family/RN at bedside. Posey\n restraint removed. Bed alarm activated, close supervision, bed locked\n and low. Frequent repositioning. OOB->chair w/ chair alarm in place.\n Tubing/lines concealed.\n Response:\n Patient remains confused, oriented x1, and restless. Pt does seem to\n calm down after repositioning when more comfortable in bed. Pt calm\n while OOB to chair.\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced, no\n ectopy noted; no runs VT since PCM settings changed->PCM set DDD @ 70.\n As noted above, pt w/ fractured LV lead on ICD. K= 4.3/ magnesium 2.6/\n Na elevated at 149. INR 2.2 (had been on Coumadin).\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads on . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia.\n Response:\n PM lytes-> _____.\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: rales at bases. SPO2 100% on highflow neb mask as 95% and 5LNC. RR\n 20s. Trace LE edema. HR 70s V-paced. BP 110s-120s/70s.\n Action:\n *20mg IV lasix x one for goal diuresis neg 1 Liter\n *Weaned O2 as noted below\n Response:\n Plan:\n Pneumonia, Aspiration/ Bacterial/ FEVERS\n Assessment:\n Patient rec\nd on 5L n/c and high flow neb FiO2 95%. Lungs with lower\n bilateral crackles. Last Temp spike 20:00- pan cultured. Likely\n r/t aspiration pneumonitis that occurred during time of VT arrest. T\n max today 99.8 PR. Pt w/ rare, non-productive cough. WBC 11.\n Action:\n Weaned O2 to 5LNC. Resumed pt\ns home dose of PO cefpodoxime Q 12 hrs.\n Trended Temp/ WBC. Encouraged C&DB. OOB->chair x __ hrs. Followed by\n ID team.\n Response:\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528650, "text": "CCU Nursing Progress Note.\n 71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway. CT head, chest, & pelvis-without\n noted infectious process.\n vf arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n Pneumonia, Bacterial, Community Acquired (CAP)\n Assessment:\n Tolerating extubation. O2 via aerosol fm @ 40%. Upper airway\n congestion. Afebrile.\n Action:\n Requiring oral sxing intermittently. Encouraged to c&bd. Frequent\n postion chgs. Abx as ordered. BCx2 sent with am labs.\n Response:\n Stable sats-desats with o2 off.\n Plan:\n Continue present management.\n Heart Failure (CHF)\n Assessment:\n Excellent response to am lasix.\n Action:\n Cardiac meds as ordered-down ogt.\n Response:\n Tolerating meds. Without further diuresis. Hemodynamically stable.\n Plan:\n Continue present management. Support pt/family as indicated (being\n followed by ss).\n Altered Mental Status\n Assessment:\n Oriented x1 only. Wanting to get up & dressed.\ns breakfast time!\n Action:\n Appropriate safety measures. Frequent reorientation.\n Response:\n Remains oriented x1 only.\n Plan:\n Continue present management. Frequent reorientation. Appropriate safety\n measures.\n" }, { "category": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527563, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT partly; RN was able to push back in; good placement on\n repeat CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting LE edema noted.\n Neuro: Normal lower extremity tone. No hyperreflexia noted. PERRL.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Elevated CK: Pt noted to have an elevated in CK on labwork yesterday.\n Not likely cardiac in nature, as MB is normal. Serotonin syndrome is a\n possibility in this patient on fentanyl and with high fevers. However,\n physical exam not consistent with serotonin syndrome. Also, the patient\n has been on fentanyl for some time, and you would expect this to have\n shown up sooner. Likely this is mild rhabdomyolysis in the setting of\n prolonged hospitalization and sedation. Pt was given 500 cc overnight\n to help prevent renal damage from the elevated CK. CK trending down\n this morning.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically as of yesterday. Suspect multifactorial etiology of\n CHF + pneumonia. Of note, pt spiked high temperatures yesterday despite\n being on vanc/cefepime/flagyl. Started on a cooling blanket and\n switched to meropenem\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n - consider bronch today\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. After spike to\n 103.8 yesterday, ID was consulted. One concern would be for empyema,\n although lack of pleural enhancement of chest CT argues against this.\n - continue meropenem monotherapy, per ID recs\n - f/u respiratory viral screen\n - f/u repeat CXR this AM\n - consider bronch\n - continue cooling blanket PRN\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic. Was being diuresed with goal negative 1-2 L. However,\n ended up getting some fluid overnight elevated CK.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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 ------ Protected Section ------\n CCU Attending\n I agree with the detailed note by Dr. delineated in his note on\n .\n History and Physical. I agree with the history and physical\n examination. I concur with the treatment plan outlined above. Still\n have variable orientation\n Medical Decision Making. Mr. is a 72 year old man with a LVEF\n 20-30% who has continued to have acute respiratory failure and is now\n spiking temperatures to > 103. Bronchoscopy today failed to show an\n obvious source. The spectrum of antimicrobial coverage has been\n expanded and cultures are pending. In the interim, we will continue\n ventilatory support and maintaining his volume status.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 19:21 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529431, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by\n antitachycardia pacing pacer set at higher rate of 75 -100 A to avoid\n fast-slow-fast sequences that may have precipitated episode of\n ventricular tachycardia (note in chart). ATP were added in a FVT zone\n of 260-300 and ? DVT zone 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n GENERAL: Oriented to person, able to follow commands, improved from\n y/d\n CARDIAC: RRR. II/VI HSM at apex.\n LUNGS: Diffuse rales.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE.\n .\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA initially on\n meropenem for concern resistant klebsiella who has been cx negative,\n narrowed to suppressive cefpodoxime regimen now spiking temp with\n meropenem restarted. Pt also had VT thought fast/short sequences\n due to pacer setting.\n .\n # s/p VT/VF arrest/ICD dysfunction: LV lead not pacing, only RV\n (). PMR programmed to DDD\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Patient had\n multiple runs of VT, including second VT arrest 2 nites ago requiring\n defibrillation. Etiology of recently increased ectopy thought \n fast/short sequences, pacer settings. A sensed V paced.\n . Device may not be able to detect VT/VF. Pt will have to be\n Externally defibrillated\n -Unlikely to need ablation as previously thought when etiology VT\n unclear.\n -continue current amnio dose 200mg daily, metoprololl 25mg \n monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n Possible lead extraction next week for RV coil fracture.\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to VT arrest, patient was satting well on 2L NC . Has had increased O2\n requirement since, requiring face mask and desating when not on it,\n possibly related to aspiration, less likely worsening heart failure.\n Spiked temp last night, most likely asp pneumonitis, mild leukocytosis.\n Heart failure lesser contributor, diuresed well to 20 IV lasix but no\n frther given, given bump in Cr. Not grossly volume overloaded on exam.\n Given prior hx, broadened to meropenem but can consider narrowing if\n remains afebrile, pending Cx data\n -aspiration precautions\n -allow to autodiurese today, if later in day appears positive, consider\n lasix bolus,\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has intermittent periods of lucidity, over\n general course slightl improved. MS currently limiting ability to take\n p.o . Plan currently to keep NPO except meds, repeat swallow eval early\n next week.\n - continue to follow clinically\n - minimize sedating medications\n .\n Acute renal failure: hypernatremia, Cr increased y/d in setting lasix\n IV. need to give free H20 to correct free h20 deficit today. Cr\n increased to 1.3 yesterday. Now 1.1\n Continue to trend Cr\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amnio.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 529461, "text": "TITLE: EP Follow-up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness:\n -No VT; ICD settings adjusted to include increased ATP therapy from\n functioning P/S lead and increase lower rate to prevent long-short\n pacing intervals that may pro-arrhythmmic\n -Still confused, febrile to 101 ? worsened aspiration\n Medications\n Unchanged\n IV Heparin\n Amiodarone 200 mg po daily\n Meropenem resumed\n Physical Exam\n General appearance: Confused, somnolent but arousable\n BP: 140 / 73 mmHg\n HR: 78 bpm\n RR: 26 insp/min\n Tmax C last 24 hours: 38.8 C\n Tmax F last 24 hours: 101.8 F\n T current C: 37.6 C\n T current F: 99.6 F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 400 mL\n Output: 1,140 mL\n Fluid balance: -740 mL\n Today:\n Intake: 93 mL\n Output: 420 mL\n Fluid balance: -327 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR, nml S1 and S2)\n Respiratory: (Auscultation: Course BS B/L)\n Abdomen: (Palpation: Soft, NTND)\n Neurological: (Orientation: confused)\n Labs\n 521\n 10.4\n 130\n 1.1\n 30\n 4.3\n 46\n 110\n 149\n 31.4\n 11.0\n [image002.jpg]\n 10:30 PM\n 05:45 AM\n 01:44 PM\n 08:23 PM\n 05:02 AM\n 05:15 AM\n 06:21 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 8.4\n 9.1\n 11.0\n Hgb\n 10.6\n 9.6\n 10.4\n Hct (Serum)\n 33.0\n 31.0\n 31.4\n Plt\n \n INR\n 3.1\n 3.9\n 7.8\n 5.3\n 2.2\n PTT\n 85.1\n 48.8\n 77.8\n 110.5\n 75.1\n 37.6\n 33.1\n Na+\n 145\n 145\n 142\n 146\n 148\n 149\n K + (Serum)\n 4.2\n 4.5\n 4.3\n 4.0\n 5.2\n 4.5\n 4.3\n K + (Whole blood)\n 4.1\n Cl\n 103\n 104\n 103\n 105\n 107\n 110\n HCO3\n 34\n 32\n 29\n 31\n 30\n 30\n BUN\n 25\n 25\n 36\n 42\n 46\n 46\n Creatinine\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n ABG: / / / 30 / Values as of 03:46 AM\n Tests\n Telemetry: No VT; no events\n Assessment and Plan\n 72 year old with h/o VTdue to infarct related cardiomyopathy, complex\n ICD history with multiple access issues and capped leads p/w fever c/b\n RV coil fracture on Fidelis lead and ICD malfunction. Has had\n recurrent VT, now improving. Case now complicated by recurrent fever, ?\n aspiration and antibiotics restarted.\n 1. ICD malfunction:\n -Will need attempt at Fidelis lead extraction in OR with general\n anesthesia + new lead placement as able with access issues\n -This cannot be addressed until infectious issues cleared; please\n review with ID\n -Will need GA and intubation for procedure, tentaive Thursday if\n clinically improves\n 2. VT:\n -Improved with increased pacing rate\n -Continue amio at 200 daily\n D/W Dr. and housestaff.\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 529464, "text": "TITLE: EP Follow-up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness:\n -No VT; ICD settings adjusted to include increased ATP therapy from\n functioning P/S lead and increase lower rate to prevent long-short\n pacing intervals that may pro-arrhythmmic\n -Still confused, febrile to 101 ? worsened aspiration\n Medications\n Unchanged\n IV Heparin\n Amiodarone 200 mg po daily\n Meropenem resumed\n Physical Exam\n General appearance: Confused, somnolent but arousable\n BP: 140 / 73 mmHg\n HR: 78 bpm\n RR: 26 insp/min\n Tmax C last 24 hours: 38.8 C\n Tmax F last 24 hours: 101.8 F\n T current C: 37.6 C\n T current F: 99.6 F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 400 mL\n Output: 1,140 mL\n Fluid balance: -740 mL\n Today:\n Intake: 93 mL\n Output: 420 mL\n Fluid balance: -327 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR, nml S1 and S2)\n Respiratory: (Auscultation: Course BS B/L)\n Abdomen: (Palpation: Soft, NTND)\n Neurological: (Orientation: confused)\n Labs\n 521\n 10.4\n 130\n 1.1\n 30\n 4.3\n 46\n 110\n 149\n 31.4\n 11.0\n [image002.jpg]\n 10:30 PM\n 05:45 AM\n 01:44 PM\n 08:23 PM\n 05:02 AM\n 05:15 AM\n 06:21 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 8.4\n 9.1\n 11.0\n Hgb\n 10.6\n 9.6\n 10.4\n Hct (Serum)\n 33.0\n 31.0\n 31.4\n Plt\n \n INR\n 3.1\n 3.9\n 7.8\n 5.3\n 2.2\n PTT\n 85.1\n 48.8\n 77.8\n 110.5\n 75.1\n 37.6\n 33.1\n Na+\n 145\n 145\n 142\n 146\n 148\n 149\n K + (Serum)\n 4.2\n 4.5\n 4.3\n 4.0\n 5.2\n 4.5\n 4.3\n K + (Whole blood)\n 4.1\n Cl\n 103\n 104\n 103\n 105\n 107\n 110\n HCO3\n 34\n 32\n 29\n 31\n 30\n 30\n BUN\n 25\n 25\n 36\n 42\n 46\n 46\n Creatinine\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n ABG: / / / 30 / Values as of 03:46 AM\n Tests\n Telemetry: No VT; no events\n Assessment and Plan\n 72 year old with h/o VTdue to infarct related cardiomyopathy, complex\n ICD history with multiple access issues and capped leads p/w fever c/b\n RV coil fracture on Fidelis lead and ICD malfunction. Has had\n recurrent VT, now improving. Case now complicated by recurrent fever, ?\n aspiration and antibiotics restarted.\n 1. ICD malfunction:\n -Will need attempt at Fidelis lead extraction in OR with general\n anesthesia + new lead placement as able with access issues\n -This cannot be addressed until infectious issues cleared; please\n review with ID\n -Will need GA and intubation for procedure, tentaive Thursday if\n clinically improves\n 2. VT:\n -Improved with increased pacing rate\n -Continue amio at 200 daily\n D/W Dr. and housestaff.\n ------ Protected Section ------\n Patient seen, discussed, examined with Dr. ; agree witth\n assessment and plans. Mr. is doing poorly : respiratory failure\n with desaturation probably due to aspiration pneumonia. His BUN/CR is\n rising. The only positive is that he is pacing without VT. House staff\n needs to address DNR status. Clearly no ablation in near future. 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 09:45 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528657, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -extubated 4PM\n -left PICC placed by IR\n -left IJ pulled, tip sent for culture\n -TEE: Severe (4+ MR). No vegetations seen on the right atrial leads\n (four identified) or on mitral, aortic, tricuspid or pulmonic valves.\n Severely depressed left ventricular function with septal, inferoseptal\n and inferior wall hypokinesis. Moderate tricuspid regurgitation. At\n least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n Echo in 09 - 2+ MR - possibility endocarditis.\n -Ucx negative, blood cx pending.\n -GPC in clusters. f/u cx data - no s/s yet. Possible contaminant.\n -started vanc\n -Got lasix 60 IV x 1 with UOP ***, likely need to repeat 9pm (got lasix\n late )goal negative 1L\n -3pm crit/lytes\n -heparin discontinued\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 08:00 AM\n Vancomycin - 11:30 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:05 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 52 (50 - 59) bpm\n BP: 105/45(62) {101/42(56) - 127/60(76)} mmHg\n RR: 16 (7 - 18) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 10 (9 - 10)mmHg\n Total In:\n 2,770 mL\n 67 mL\n PO:\n TF:\n IVF:\n 2,380 mL\n 67 mL\n Blood products:\n Total out:\n 3,972 mL\n 580 mL\n Urine:\n 3,970 mL\n 580 mL\n NG:\n 2 mL\n Stool:\n Drains:\n Balance:\n -1,202 mL\n -513 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 630 (630 - 630) mL\n RR (Set): 0\n RR (Spontaneous): 9\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n SpO2: 99%\n ABG: 7.50/52/67/34/14\n Ve: 8.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GENERAL: Intubated, alert, responding to / following commands.\n CARDIAC: RRR. ?1/6 systolic murmur, heard best at the apex.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Alert, following commands, able to move all 4 extremities on\n command; PERRL\n Labs / Radiology\n 468 K/uL\n 10.4 g/dL\n 122 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 30 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 9.3 K/uL\n [image002.jpg]\n 04:26 AM\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n WBC\n 10.4\n 9.2\n 9.3\n Hct\n 30.7\n 30.4\n 31.8\n Plt\n \n Cr\n 1.3\n 1.2\n 0.9\n 0.7\n 0.7\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 130\n 164\n 130\n 198\n 151\n 137\n 122\n Other labs: PT / PTT / INR:19.5/29.4/1.8, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.6 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n continued to spike high fevers in spite of Tylenol, antibiotics, and\n improvement in respiratory status. CT abd/pelvis and CT sinuses were\n neg. Pt has been afebrile over 24 hours at this point. However, he did\n have a positive blood cx (GPC\ns) this am. This could represent true\n infection versus contaminant.\n - continue meropenem; adding vanc in the setting of positive blood cx\n - f/u ID recs\n - f/u pending microbiological studies\n - TEE to look for ? lead endocarditis\n - will need to pull CVL in setting of positive blood cx; d/w team\n whether we should place another CVL versus try to obtain peripheral\n access until patient is able to get a PICC\n - if above is negative and pt continues to spike fevers, will need to\n consider other causes, such as CNS infx or drug fever\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Mental status greatly improved this\n morning; RSBI in the 30\n - attempt extubation after TEE\n - f/u pending cultures\n - f/u bronch data\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L; will give 60 mg IV lasix now\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - increase Coumadin; trend INR\n - starting heparin gtt bridge while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during code blue yesterday.\n -pacer revision in future\n -TEE to look for lead endocarditis, as above\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: subtherapeutic INR\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527658, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - bolused Lasix 60 mg IV once in a.m. and once in p.m.\n - bronchoscopy done: mild mucus plugging, did not look purulent, labs\n sent\n - ID recs: 1. continue meropenem. 2. f/u respiratory virus screen.3.\n trend CK. 4. consider bronch\n - ID attending recs: ? splinter hemorrhage\n - pulm recs: 1. will do BAL LLL. 2. consider CT abd/pelvis if ?\n (illegible). 3. favor antipsychotics for delirium over opioids/benzos.\n 4. CHF contributes.\n - decreasing sedation overnight\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 03:52 PM\n Furosemide (Lasix) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.5\nC (101.3\n HR: 50 (50 - 54) bpm\n BP: 120/58(73) {104/49(64) - 138/67(84)} mmHg\n RR: 13 (9 - 18) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 102.2 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 12 (9 - 22)mmHg\n Total In:\n 2,723 mL\n 696 mL\n PO:\n TF:\n 1,068 mL\n 384 mL\n IVF:\n 1,235 mL\n 212 mL\n Blood products:\n Total out:\n 2,198 mL\n 840 mL\n Urine:\n 2,198 mL\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 525 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 641 (294 - 1,200) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/55/172/31/9\n Ve: 5.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting LE edema noted.\n Neuro: Normal lower extremity tone. No hyperreflexia noted. PERRL.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 175 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 45 mg/dL\n 105 mEq/L\n 146 mEq/L\n 32.6 %\n 11.4 K/uL\n [image002.jpg]\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n WBC\n 11.4\n Hct\n 30.8\n 32.6\n Plt\n 345\n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 27\n 27\n 29\n 30\n 36\n 37\n Glucose\n 157\n 167\n 175\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:1312/3/0.02, ALT / AST:237/329, Alk Phos / T Bili:93/0.8,\n Differential-Neuts:86.5 %, Lymph:7.5 %, Mono:4.7 %, Eos:1.1 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:474 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Elevated CK: Pt noted to have an elevated in CK on labwork yesterday.\n Not likely cardiac in nature, as MB is normal. Serotonin syndrome is a\n possibility in this patient on fentanyl and with high fevers. However,\n physical exam not consistent with serotonin syndrome. Also, the patient\n has been on fentanyl for some time, and you would expect this to have\n shown up sooner. Likely this is mild rhabdomyolysis in the setting of\n prolonged hospitalization and sedation. Pt was given 500 cc overnight\n to help prevent renal damage from the elevated CK. CK trending down\n this morning.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically as of yesterday. Suspect multifactorial etiology of\n CHF + pneumonia. Of note, pt spiked high temperatures yesterday despite\n being on vanc/cefepime/flagyl. Started on a cooling blanket and\n switched to meropenem\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n - consider bronch today\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. After spike to\n 103.8 yesterday, ID was consulted. One concern would be for empyema,\n although lack of pleural enhancement of chest CT argues against this.\n - continue meropenem monotherapy, per ID recs\n - f/u respiratory viral screen\n - f/u repeat CXR this AM\n - consider bronch\n - continue cooling blanket PRN\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic. Was being diuresed with goal negative 1-2 L. However,\n ended up getting some fluid overnight elevated CK.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:11 AM 55 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin; Coumadin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527661, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt tolerated PSV /.40 o/n with MMV rate set at 10 d/t sedation.\n O2 sats 97-100%. Remains on Meropenum. Tmax 101.4. Cx pending from\n bronch yesterday. Sx q 3-4 hours for small amts beige secretions,\n thick.\n Action:\n Fentanyl decreased to 25mcg/hr at 4am. Vent settings changed to 8/8/.40\n with O2 sats 99%. MV unchanged\n Response:\n ABG pending on decreased peep/psv. Await effects of Fentanyl to wear\n off.\n Plan:\n F/u abg. need to shut off fent to awaken pt sufficiently for SBT.\n f/u results of cx data.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Cooling blanket removed at onset of shift, as temp 99.6. Temp climbed\n up to 101.4 max this am.\n Action:\n Tepid bath x 1, Tylenol x 1.\n Response:\n Continues to spike fevers.\n Plan:\n Sputum cx pending. If pt is not to be extubated today, ? moving NGT to\n OGt would help to decrease risk of sinusitis.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Initial cvp 18, fluid balance +500. per HO cxr shows worsening chf\n yesterday\n Action:\n 60mg iv lasix repeated o/n. excellent response.\n Response:\n Am CVP ranging from . Fluid balance -600 for past 24 hrs, and -140\n cc\ns since midnight.\n Plan:\n Plan is to trial daily w/u and SBT this am. Follow fluid balance, f/u\n with team r/e fluid goals for today.\n" }, { "category": "Nursing", "chartdate": "2141-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527666, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt tolerated PSV /.40 o/n with MMV rate set at 10 d/t sedation.\n O2 sats 97-100%. Remains on Meropenum. Tmax 101.4. Cx pending from\n bronch yesterday. Sx q 3-4 hours for small amts beige secretions,\n thick.\n Action:\n Fentanyl decreased to 25mcg/hr at 4am. Vent settings changed to 8/8/.40\n with O2 sats 99%. MV unchanged\n Response:\n ABG pending on decreased peep/psv. Await effects of Fentanyl to wear\n off.\n Plan:\n F/u abg. need to shut off fent to awaken pt sufficiently for SBT.\n f/u results of cx data.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Cooling blanket removed at onset of shift, as temp 99.6. Temp climbed\n up to 101.4 max this am.\n Action:\n Tepid bath x 1, Tylenol x 1.\n Response:\n Continues to spike fevers.\n Plan:\n Sputum cx pending. If pt is not to be extubated today, ? moving NGT to\n OGt would help to decrease risk of sinusitis.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Initial cvp 18, fluid balance +500. per HO cxr shows worsening chf\n yesterday\n Action:\n 60mg iv lasix repeated o/n. excellent response.\n Response:\n Am CVP ranging from . Fluid balance -600 for past 24 hrs, and -140\n cc\ns since midnight.\n Plan:\n Plan is to trial daily w/u and SBT this am. Follow fluid balance, f/u\n with team r/e fluid goals for today.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529557, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529560, "text": "Delirium / confusion\n Assessment:\n Pt. able to state name,\nhospital\n and\n\n initially but then not\n able to repeat place or year. Talking to himself and having\n conversation with self. Thirsty , asking for diet coke. Able to take\n meds crushed with custard sitting up in bed.\n - follows commands, turns side to side with assist and by himself.\n Very active/restless in bed.\n Action:\n Trazadone 50mg at 2200. freq. mouth swabs/VAP.\n Oriented freq. as needed. Bed alarm on. Side rails up. Close\n observation by RNs.\n Response:\n Pt. fell asleep ~ 2300.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Negative 500cc at 2200. LS crackles right base. Sats 97-98% on 4lnc.\n Action:\n IVF stopped early\n Na+ normalized at 140.\n NPO with any po liquids d/t failed swallow study.\n - Lopressor .\n Response:\n Ended up negative 800cc for . sats dipping to low 90\ns when\n asleep. Increased to 5lnc when sleeping.\n HR Vpaced 70-80\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 529659, "text": "TITLE: EP Follow-up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -No events, afebrile\n -Mildly improving mental status\n Medications\n Unchanged\n No antibiotics\n IV Heparin\n Physical Exam\n General appearance: NAD, sitting up in chair\n BP: 123 / 64 mmHg\n HR: 75 bpm\n RR: 21 insp/min\n Tmax C last 24 hours: 37.7 C\n Tmax F last 24 hours: 99.8 F\n T current C: 36.1 C\n T current F: 97 F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 956 mL\n Output: 1,820 mL\n Fluid balance: -864 mL\n Today:\n Output: 340 mL\n Fluid balance: -340 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR; HSM)\n Respiratory: (Auscultation: Course BS B/L)\n Abdomen: (Palpation: Soft, NTND)\n Neurological: (Orientation: alert, arousable)\n Extremities:\n Right: (Edema: trace)\n Left: (Edema: trace)\n Labs\n 523\n 10.6\n 126\n 0.9\n 31\n 3.7\n 40\n 113\n 150\n 33.3\n 10.9\n [image002.jpg]\n 01:44 PM\n 08:23 PM\n 05:02 AM\n 05:15 AM\n 06:21 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.1\n 11.0\n 10.9\n Hgb\n 9.6\n 10.4\n 10.6\n Hct (Serum)\n 31.0\n 31.4\n 33.3\n Plt\n 426\n 521\n 523\n INR\n 3.9\n 7.8\n 5.3\n 2.2\n 1.4\n PTT\n 77.8\n 110.5\n 75.1\n 37.6\n 33.1\n 28.1\n Na+\n 145\n 142\n 146\n 148\n 149\n 140\n 150\n K + (Serum)\n 4.5\n 4.3\n 4.0\n 5.2\n 4.5\n 4.3\n 3.5\n 3.7\n K + (Whole blood)\n 4.1\n Cl\n 104\n 103\n 105\n 107\n 110\n 102\n 113\n HCO3\n 32\n 29\n 31\n 30\n 30\n 31\n 31\n BUN\n 25\n 36\n 42\n 46\n 46\n 40\n 40\n Creatinine\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n Glucose\n 131\n 201\n 124\n 126\n 130\n 428\n 126\n ABG: / / / 31 / Values as of 05:06 AM\n Tests\n Telemetry: V paced, no events\n Assessment and Plan\n 72 yo M with complicated cardiac history, CAD with myopathy s/p VT and\n VF in past and ICD with multiple lead revisions, access issues p/w\n sepsis and RV coil fracture leading to ICD malfunction.\n Plan tentatively for ICD lead extraction, new lead placement on\n Thursday under GA. Procedure is high risk, and does require\n re-intubation.\n 1. ICD malfunction: RV coil fracture\n -Tentative lead extraction and new laed placement Thursday with Dr.\n if family agrees to degree of risk, re-intubation and GA\n -External defibrillation needed if VT\n 2. VT:\n -No events on current amio dose\n -Continue higher pacing rate\n D/W Dr. who agrees.\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529671, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n .\n Action:\n *Continuous reorienting. Bed alarm activated, close supervision, bed\n locked and low. *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place and family at bedside.\n Response:\n Patient remains confused, oriented x1, and restless. Pt does seem to\n calm down after repositioning when more comfortable in bed. Pt calm\n while OOB to chair.\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Reassess need for restraints for safety, currently off since 1400.\n Trazadone at bedtime for sleep (home regimen).\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced, no\n ectopy noted; no runs VT since PCM settings changed->PCM set DDD @ 70.\n As noted above, pt w/ fractured LV lead on ICD. K= 4.3/ magnesium 2.6/\n Na elevated at 149. INR 2.2 (had been on Coumadin).\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads on . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia.\n Response:\n PM lytes-> Na improved to 140, K down 3.5.\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: rales at bases. SPO2 100% on highflow neb mask as 95% and 5LNC. RR\n 20s. Trace LE edema. HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *20mg IV lasix x one for goal diuresis neg 1 liter\n *Weaned O2 as noted below.\n Response:\n Negative 700ml at 1900.\n Plan:\n Continue to monitor fluid/volume status. Wean O2 as able.\n Pneumonia, Aspiration/ Bacterial/ FEVERS\n Assessment:\n Patient rec\nd on 5L n/c and high flow neb FiO2 95%. Lungs with lower\n bilateral crackles. Last Temp spike 20:00- pan cultured. Likely\n r/t aspiration pneumonitis that occurred during time of VT arrest. T\n max today 99.8 PR. Pt w/ rare, non-productive cough. WBC 11.\n Action:\n Weaned O2 to 5LNC. Resumed pt\ns home dose of PO cefpodoxime Q 12 hrs.\n Tylenol PRN. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x 4 hrs.\n Followed by ID team.\n Response:\n Afebrile this shift. No sputum production noted.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Tylenol PRN.\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527548, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp slowly rising since cooling blanket DC\nd 0100. Tmax 102.2 PR. WBC=\n 11.4. AM lactate 1.6. Remains on droplet precautions while ruling out\n influenza.\n Action:\n *ID following- unclear if PNA is source of temp spike as CXR w/\n improvement\n *Intermittent ice packs to bilat groin sites/ axilla (monitored skin\n closely)/ tepid baths to help decrease temp\n *IV meropenem q 8 hours\n *Tylenol ATC q 6 hrs for pt comfort\n *Pt pan cultured \n *Flu specimen resent per lab request\n Response:\n *Temp down 100 range PR w/ cooling blanket in place and other above\n interventions. PM lactate 1.4.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated MMV: PSV 10/ 10 Peep, FiO2 40%. LS diminished/\n bronchial @ bases. Mod amts thick/ yellow secretions via ETT. SPO2\n >95%. Sedation w/ IV fentanyl @ 100mcg/min. Pt w/ open opening to\n speech, though no eye contact. Not following commands but moving all\n extremities in bed, non-purposeful. Restless legs in bed (present on\n admission).\n Action:\n * Fiberoptic bronchoscopy by pulmonary @ 1500y-> cultures\n obtained/sent.\n *IV meropenem q 8 hours.\n *Nutrition w/ tubefeeds via NGT.\n *Sedation weaned to fentanyl 50 mcg/min after bronch\n Response:\n *PM ABG: 7.42/55/172/37\n Plan:\n Continue to monitor resp status. Daily RSBI/SBT, wean vent as\n tolerated. IV fentanyl for comfort. VAP care/ pulm toileting. IV\n meropenem Q 8 hrs.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/crackes at bases. SPO2 mainly>95%. Bilat LE edema. HR\n paced at 50. Underlying rhythm appears to be aflutter. NIBP\n 120s-150s/60s-70s. CVP 18-20.\n Action:\n *IV lasix 60mg x one at noon\n *Lopressor \n *E-lytes monitored- re-sent at 1800\n Response:\n *Pt positive 1liter at 1600, CVP unchanged 18-20. Given additional\n 60mg IV lasix at 1800.\n Plan:\n *Continue to monitor resp status/ volume status.\n *Daily wts/ 1500ml fluid restriction\n *Follow up results of PM lytes\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529627, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - INR still therapeutic; consider starting heparin gtt in AM\n - gave 20 IV lasix\n - restarted cefpodoxime\n - gave 1 L D5W for hypernatremia\n - ID: signed off\n - no new positive cx data\n - EP: can attempt lead extraction in OR but risky, should readdress\n goals of care\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:50 AM\n Furosemide (Lasix) - 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 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 77 (75 - 82) bpm\n BP: 117/67(80) {61/27(35) - 142/80(91)} mmHg\n RR: 21 (15 - 30) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 956 mL\n PO:\n TF:\n IVF:\n 956 mL\n Blood products:\n Total out:\n 1,820 mL\n 340 mL\n Urine:\n 1,820 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -864 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\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 523 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 113 mEq/L\n 150 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 468\n 464\n 426\n 521\n 523\n Cr\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n TCO2\n 31\n Glucose\n 122\n 152\n 131\n \n 130\n 428\n 126\n Other labs: PT / PTT / INR:15.9/28.1/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.6 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA initially on\n meropenem for concern resistant klebsiella who has been cx negative,\n narrowed to suppressive cefpodoxime regimen now spiking temp with\n meropenem restarted. Pt also had VT thought fast/short sequences\n due to pacer setting.\n .\n # s/p VT/VF arrest/ICD dysfunction: LV lead not pacing, only RV\n (). PMR programmed to DDD\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Patient had\n multiple runs of VT, including second VT arrest 2 nites ago requiring\n defibrillation. Etiology of recently increased ectopy thought \n fast/short sequences, pacer settings. A sensed V paced.\n . Device may not be able to detect VT/VF. Pt will have to be\n Externally defibrillated\n -Unlikely to need ablation as previously thought when etiology VT\n unclear.\n -continue current amnio dose 200mg daily, metoprololl 25mg \n monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n Possible lead extraction next week for RV coil fracture.\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to VT arrest, patient was satting well on 2L NC . Has had increased O2\n requirement since, requiring face mask and desating when not on it,\n possibly related to aspiration, less likely worsening heart failure.\n Spiked temp last night, most likely asp pneumonitis, mild\n leukocytosis. Heart failure lesser contributor, diuresed well to 20 IV\n lasix but no frther given, given bump in Cr. Not grossly volume\n overloaded on exam.\n Given prior hx, broadened to meropenem but can consider narrowing if\n remains afebrile, pending Cx data\n -aspiration precautions\n -allow to autodiurese today, if later in day appears positive, consider\n lasix bolus,\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has intermittent periods of lucidity, over\n general course slightl improved. MS currently limiting ability to take\n p.o . Plan currently to keep NPO except meds, repeat swallow eval early\n next week.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Acute renal failure: hypernatremia, Cr increased y/d in setting lasix\n IV. need to give free H20 to correct free h20 deficit today. Cr\n increased to 1.3 yesterday. Now 1.1\n Continue to trend Cr\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amio\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529634, "text": "Delirium / confusion\n Assessment:\n Pt. able to state name,\nhospital\n and\n\n initially but then not\n able to repeat place or year. Talking to himself and having\n conversation with self. Thirsty , asking for diet coke. Able to take\n meds crushed with custard sitting up in bed.\n - follows commands, turns side to side with assist and by himself.\n Very active/restless in bed, turning side to side by himself. Follow\n commands.\n Action:\n Trazadone 50mg at 2200. freq. mouth swabs/VAP.\n Oriented freq. as needed. Bed alarm on. Side rails up. Close\n observation by RNs.\n Response:\n Pt. fell asleep ~ 2300. slept for ~ 3 hours- 4 hours. Woke ~ 0400,\n laying quiet in bed. Asking for something to eat or drink.\nwhen do I\n get breakfast?\n Plan:\n OOB to chair again today. Orient as needed. Safety precautions.\n Aspiration precautions: no thin liquids. ? rescreen Speech/swallow\n Monday.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n ICD malfunction:\n -Will need attempt at Fidelis lead extraction in OR with general\n anesthesia + new lead placement as able with access issues\n No VT overnight. K+ 3.5 at 1700\n Negative 500cc at 2200. LS crackles right base. Sats 97-98% on 4lnc.\n Action:\n IVF stopped early\n Na+ normalized at 140.\n NPO with no po liquids d/t failed swallow study.\n - Lopressor . Amio QD.\n - KCL repleted po.\n - Pacer pads replaced.\n Response:\n Ended up negative 800cc for . sats dipping to low 90\ns when\n asleep. Increased to 5lnc when sleeping.\n HR Vpaced 70-80\ns. BP 90\ns-111/.\n Plan:\n ? thurs. for lead extraction under GA\n now with recent fever and\n worsening aspiration PNA.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afeb. No cough. Laying flat to 30degrees with no distress.\n Action:\n VAP care q2-4hours.\n Response:\n Cultures pnd from (last spike)\n Plan:\n Follow temp, cultures. VAP care, aspiration precautions\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529754, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Pt w/ much improved MS today compared to yesterday. Alert, oriented to\n . At times very clear, stating he\ns at in , stating\n year as , month as or . Other times, asking if we are in\n , or if he has been nominated to receive a heroic medal. Still w/\n some periods of agitation/ restlessness in bed, and rare attempt to get\n OOB w/out assist. No need for restraints today.\n Action:\n *Continuous reorienting. Bed alarm or chair alarm activated; close\n supervision, bed locked and low.\n *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place\n Response:\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Trazadone at bedtime for sleep (home regimen).\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced,\n occasional PVCs noted; no runs VT since PCM settings changed->PCM set\n DDD @ 70. As noted above, pt w/ fractured LV lead on ICD. K= 3.7/\n magnesium 2.6/ Na elevated at 150. INR down today 1.4.\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads, . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia. K repleted w/ 40mEq PO. Heparin\n gtt restarted for INR 1.4- 1500unit/shr up at 10:50.\n Response:\n PM lytes 1700->\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 95-100% 5LNC. RR 20s. Trace LE edema.\n HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *Resumed pt\ns home dose of lasix PO 40mg- goal even I/Os\n *Weaned O2 to 2LNC\n Response:\n Plan:\n Continue to monitor fluid/volume status. Wean O2 as able.\n Pneumonia, Aspiration\n Assessment:\n Likely r/t aspiration pneumonitis that occurred during time of VT\n arrest. T max 98.6po. Pt w/ rare, non-productive cough. WBC 10.\n Action:\n *Weaned O2 to 2LNC. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x\n 5.5 hrs. Followed by ID team.\n *Aspiration Risk- given pt\ns improved mental status, trial of nectar\n thick liquid attempted while pt completely awake and sitting in chair\n with no overt signs of aspiration. Team notified. Diet changed to\n Nectar liqs/ pureed solids w/ strict 1:1 supervision until S&S can\n reevaluate tomorrow. Ate ~ 50% of lunch.\n Response:\n Afebrile this shift. No sputum production noted. Aspiration\n Precautions.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529756, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Pt w/ much improved MS today compared to yesterday. Alert, oriented to\n . At times very clear, stating he\ns at in , stating\n year as , month as or . Other times, asking if we are in\n , or if he has been nominated to receive a heroic medal. Still w/\n some periods of agitation/ restlessness in bed, and rare attempt to get\n OOB w/out assist. No need for restraints today.\n Action:\n *Continuous reorienting. Bed alarm or chair alarm activated; close\n supervision, bed locked and low.\n *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place\n Response:\n Still w/ periods of confusion though much improved. One attempt to get\n OOB without assist- bed alarms activated.\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Trazadone at bedtime for sleep.\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced,\n occasional PVCs noted; no runs VT since PCM settings changed->PCM set\n DDD @ 70. As noted above, pt w/ fractured LV lead on ICD. K= 3.7/\n magnesium 2.6/ Na elevated at 150. INR down today 1.4.\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads, . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia. K repleted w/ 40mEq PO. Heparin\n gtt restarted for INR 1.4- 1500unit/shr up at 10:50.\n Response:\n PM lytes 1700-> Na down 147. K 4.2. No VT noted this shift. PM PTT 37.\n Heparin bolused 3000 units and gtt increased to 1850 units/hr at 18:00.\n Plan:\n Continue to monitor HR and rhythm. Next PTT due 24:00. Continue D5W @\n 100ml/hr x total of 2 liters- #1 up.\n Will need external defibrillation in the event of further VT.\n Possible lead removal and/or VT ablation next week, awaiting further\n imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 95-100% 5LNC. RR 20s. Trace LE edema.\n HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *Resumed pt\ns home dose of lasix PO 40mg- goal even I/Os\n *Weaned O2 to 2LNC\n Response:\n Fluid balance +640 ml at 1800. Given 20mg IV lasix w/ results PND.\n Plan:\n Continue to monitor fluid/volume status. Goal even to slightly\n negative. Wean O2 as able.\n Pneumonia, Aspiration\n Assessment:\n Likely r/t aspiration pneumonitis that occurred during time of VT\n arrest. T max 98.6po. Pt w/ rare, non-productive cough. WBC 10.\n Action:\n *Weaned O2 to 2LNC. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x\n 5.5 hrs. Followed by ID team.\n *Aspiration Risk- given pt\ns improved mental status, trial of nectar\n thick liquid attempted while pt completely awake and sitting in chair\n with no overt signs of aspiration. Team notified. Diet changed to\n Nectar liqs/ pureed solids w/ strict 1:1 supervision until S&S can\n reevaluate tomorrow. Ate ~ 50% of lunch.\n Response:\n Afebrile this shift. No sputum production noted. Aspiration\n Precautions.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527551, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp slowly rising since cooling blanket DC\nd 0100. Tmax 102.2 PR. WBC=\n 11.4. AM lactate 1.6. Remains on droplet precautions while ruling out\n influenza.\n Action:\n *ID following- unclear if PNA is source of temp spike as CXR w/\n improvement\n *Intermittent ice packs to bilat groin sites/ axilla (monitored skin\n closely)/ tepid baths to help decrease temp\n *IV meropenem q 8 hours\n *Tylenol ATC q 6 hrs for pt comfort\n *Pt pan cultured \n *Flu specimen resent per lab request\n Response:\n *Temp down 100 range PR w/ cooling blanket in place and other above\n interventions. PM lactate 1.4.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated MMV: PSV 10/ 10 Peep, FiO2 40%. LS diminished/\n bronchial @ bases. Mod amts thick/ yellow secretions via ETT. SPO2\n >95%. Sedation w/ IV fentanyl @ 100mcg/min. Pt w/ open opening to\n speech, though no eye contact. Not following commands but moving all\n extremities in bed, non-purposeful. Restless legs in bed (present on\n admission).\n Action:\n * Fiberoptic bronchoscopy by pulmonary @ 1500y-> cultures\n obtained/sent.\n *IV meropenem q 8 hours.\n *Nutrition w/ tubefeeds via NGT.\n *Sedation weaned to fentanyl 50 mcg/min after bronch\n Response:\n *PM ABG: 7.42/55/172/37\n Plan:\n Continue to monitor resp status. Daily RSBI/SBT, wean vent as\n tolerated. IV fentanyl for comfort. VAP care/ pulm toileting. IV\n meropenem Q 8 hrs.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/crackes at bases. SPO2 mainly>95%. Bilat LE edema. HR\n paced at 50. Underlying rhythm appears to be aflutter. NIBP\n 120s-150s/60s-70s. CVP 18-20.\n Action:\n *IV lasix 60mg x one at noon\n *Lopressor \n *E-lytes monitored- re-sent at 1800\n Response:\n *Pt positive 1liter at 1600, CVP unchanged 18-20. Given additional\n 60mg IV lasix at 1800- awaiting results. Decreased response to lasix\n today comparted to yesterday.\n Plan:\n *Continue to monitor resp status/ volume status.\n *Follow results of 18:00 lasix dosing. Goal 1-2 L neg at midnight,\n currently running positive.\n *Daily wts/ 1500ml fluid restriction\n *Follow up results of PM lytes\n" }, { "category": "Physician ", "chartdate": "2141-03-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527749, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - bolused Lasix 60 mg IV once in a.m. and once in p.m.\n - bronchoscopy done: mild mucus plugging, did not look purulent, labs\n sent\n - ID recs: 1. continue meropenem. 2. f/u respiratory virus screen.3.\n trend CK. 4. consider bronch\n - ID attending recs: ? splinter hemorrhage\n - pulm recs: 1. will do BAL LLL. 2. consider CT abd/pelvis if ?\n (illegible). 3. favor antipsychotics for delirium over opioids/benzos.\n 4. CHF contributes.\n - decreasing sedation overnight\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 03:52 PM\n Furosemide (Lasix) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.5\nC (101.3\n HR: 50 (50 - 54) bpm\n BP: 120/58(73) {104/49(64) - 138/67(84)} mmHg\n RR: 13 (9 - 18) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 102.2 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 12 (9 - 22)mmHg\n Total In:\n 2,723 mL\n 696 mL\n PO:\n TF:\n 1,068 mL\n 384 mL\n IVF:\n 1,235 mL\n 212 mL\n Blood products:\n Total out:\n 2,198 mL\n 840 mL\n Urine:\n 2,198 mL\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 525 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 641 (294 - 1,200) mL\n PS : 8 cmH2O\n RR (Set): 10\n RR (Spontaneous): 4\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/55/172/31/9\n Ve: 5.2 L/min\n PaO2 / FiO2: 430\n Physical Examination\n GENERAL: Intubated, sedated, responds to commands to open eyes and move\n extremities.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. Hands warm.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 175 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 45 mg/dL\n 105 mEq/L\n 146 mEq/L\n 32.6 %\n 11.4 K/uL\n [image002.jpg]\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n WBC\n 11.4\n Hct\n 30.8\n 32.6\n Plt\n 345\n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n TropT\n 0.02\n TCO2\n 27\n 27\n 29\n 30\n 36\n 37\n Glucose\n 157\n 167\n 175\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:1312/3/0.02, ALT / AST:237/329, Alk Phos / T Bili:93/0.8,\n Differential-Neuts:86.5 %, Lymph:7.5 %, Mono:4.7 %, Eos:1.1 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:474 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials, including this p.m.\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following.\n - CT abd/pelvis and CT sinuses\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - holding diuresis today\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:11 AM 55 mL/hour\n Glycemic Control: Lantus + Humalog insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin; Coumadin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n CCU Attending\n I agree with the detailed note by Dr. delineated in his note on\n .\n History and Physical. I agree with the documentation of the history\n and physical examination. I concur with the treatment plan outlined\n above.\n Medical Decision Making. Mr. is a 72 year old man with a LVEF\n 20-30% who has continued to have acute respiratory failure and elevated\n temperatures. Bronchoscopy today failed to show an obvious source,\n and a CT abdomen-CT sinuses (r/o sinusitis) will be obtained. We will\n continue ventilatory support and maintaining his volume status.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 15:51 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527807, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remains vented on PS 40% with MMV rate set at 10. O2 sats\n 97-100%. Remains on Meropenum IVPB q8h. Tmax 102.2 via rectal\n thermometer. Cx pending from bronch . Fentanyl gtt @ 25cmg/hr.\n Droplet precautions to rule out flu.\n Action:\n Sx small amts thick tan/yellow secretions.\n Response:\n Await effects of Fentanyl to wear off\n gtt turned off at 1800hrs after\n CT scan completed.\n Plan:\n awaiting results of cx data and CT scan. Con\nt vent wean ?extubate in\n am. Con\nt abx.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.2 at 0800hrs (cooling blanket placed over patient as pt seemed\n to have skin compromise when cooling blanket under back\n now resolved)\n .\n Action:\n Tylenol 650mg x2 today. Temp down to 101.7. To CT scan of head,\n sinuses and abd/pelvis this afternoon.\n Response:\n Continues to spike fevers. Awaiting results of CT scans and culture\n data. started Ibuprofin 800mg given this evening\n so far temp\n increasing not decreasing- 101.8.\n Plan:\n Sputum cx pending. If pt is not to be extubated today, ? moving NGT to\n OGt would help to decrease risk of sinusitis. Tylenol and ibuprofen for\n fever\n con\nt cooling blanket. Con\nt abx.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Am CXR shows improvement. CVP 10-14.\n Action:\n No diuresis planned for today.\n Response:\n No diuretics.\n Plan:\n Daily weights. Daily CXR.\n" }, { "category": "Respiratory ", "chartdate": "2141-03-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527621, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n 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: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Having periods of apnea. Sedation being weaned.\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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Cont to wean peep/sedation for SBT this AM.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: MDI\nS given. Still not waking from sedation.\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527922, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.2\nC - 08:00 AM\n Overnight Events:\n - Brief trial of 0/5 with RISBI 50-60S, will stay on MMV (5L) on \n overnight with plan for pressure support trial in am.\n - Added on LFTs, elevated (CK's now trending down)\n - Fentanyl stopped at 4pm after CT scan.\n - Ready to extubate in am.\n - BAL- -ve PCP, stuff pending.\n - DFA negative, resp precautions dc'd.\n - Having Fevers through out day. I.D recommended imaging. Head/Torso CT\n negative. Will need TEE on Monday to eval leads ? endocarditis\n (ordered)\n - Defervesced with ibuprofen.\n - Goal I/O even\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.7\nC (99.9\n HR: 52 (50 - 52) bpm\n BP: 126/55(73) {89/50(67) - 136/80(299)} mmHg\n RR: 17 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 23 (10 - 24)mmHg\n Total In:\n 2,474 mL\n 392 mL\n PO:\n TF:\n 1,104 mL\n 225 mL\n IVF:\n 610 mL\n 167 mL\n Blood products:\n Total out:\n 1,780 mL\n 395 mL\n Urine:\n 1,780 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 694 mL\n -3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 471 (456 - 859) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.47/54/175/34/14\n Ve: 15.2 L/min\n PaO2 / FiO2: 438\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 372 K/uL\n 10.2 g/dL\n 171 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 104 mEq/L\n 145 mEq/L\n 32.0 %\n 9.5 K/uL\n [image002.jpg]\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n 06:14 AM\n 06:58 AM\n 03:36 AM\n 04:12 AM\n WBC\n 11.4\n 10.1\n 9.5\n Hct\n 30.8\n 32.6\n 31.2\n 32.0\n Plt\n \n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 0.9\n TropT\n 0.02\n TCO2\n 36\n 37\n 35\n 40\n Glucose\n 157\n 167\n 175\n 170\n 171\n Other labs: PT / PTT / INR:15.7/27.9/1.4, CK / CKMB /\n Troponin-T:434/3/0.02, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527923, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.2\nC - 08:00 AM\n Overnight Events:\n - Brief trial of 0/5 with RISBI 50-60S, will stay on MMV (5L) on \n overnight with plan for pressure support trial in am.\n - Added on LFTs, elevated (CK's now trending down)\n - Fentanyl stopped at 4pm after CT scan.\n - Ready to extubate in am.\n - BAL- -ve PCP, stuff pending.\n - DFA negative, resp precautions dc'd.\n - Having Fevers through out day. I.D recommended imaging. Head/Torso CT\n negative. Will need TEE on Monday to eval leads ? endocarditis\n (ordered)\n - Defervesced with ibuprofen.\n - Goal I/O even\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.7\nC (99.9\n HR: 52 (50 - 52) bpm\n BP: 126/55(73) {89/50(67) - 136/80(299)} mmHg\n RR: 17 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 23 (10 - 24)mmHg\n Total In:\n 2,474 mL\n 392 mL\n PO:\n TF:\n 1,104 mL\n 225 mL\n IVF:\n 610 mL\n 167 mL\n Blood products:\n Total out:\n 1,780 mL\n 395 mL\n Urine:\n 1,780 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 694 mL\n -3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 471 (456 - 859) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.47/54/175/34/14\n Ve: 15.2 L/min\n PaO2 / FiO2: 438\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 372 K/uL\n 10.2 g/dL\n 171 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 104 mEq/L\n 145 mEq/L\n 32.0 %\n 9.5 K/uL\n [image002.jpg]\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n 06:14 AM\n 06:58 AM\n 03:36 AM\n 04:12 AM\n WBC\n 11.4\n 10.1\n 9.5\n Hct\n 30.8\n 32.6\n 31.2\n 32.0\n Plt\n \n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 0.9\n TropT\n 0.02\n TCO2\n 36\n 37\n 35\n 40\n Glucose\n 157\n 167\n 175\n 170\n 171\n Other labs: PT / PTT / INR:15.7/27.9/1.4, CK / CKMB /\n Troponin-T:434/3/0.02, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials, including this p.m.\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following.\n - CT abd/pelvis and CT sinuses\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - holding diuresis today\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527925, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.2\nC - 08:00 AM\n Overnight Events:\n - Brief trial of 0/5 with RISBI 50-60S, will stay on MMV (5L) on \n overnight with plan for pressure support trial in am.\n - Added on LFTs, elevated (CK's now trending down)\n - Fentanyl stopped at 4pm after CT scan.\n - Ready to extubate in am.\n - BAL- -ve PCP, stuff pending.\n - DFA negative, resp precautions dc'd.\n - Having Fevers through out day. I.D recommended imaging. Head/Torso CT\n negative. Will need TEE on Monday to eval leads ? endocarditis\n (ordered)\n - Defervesced with ibuprofen.\n - Goal I/O even\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:03 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:04 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39\nC (102.2\n Tcurrent: 37.7\nC (99.9\n HR: 52 (50 - 52) bpm\n BP: 126/55(73) {89/50(67) - 136/80(299)} mmHg\n RR: 17 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 23 (10 - 24)mmHg\n Total In:\n 2,474 mL\n 392 mL\n PO:\n TF:\n 1,104 mL\n 225 mL\n IVF:\n 610 mL\n 167 mL\n Blood products:\n Total out:\n 1,780 mL\n 395 mL\n Urine:\n 1,780 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n 694 mL\n -3 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 471 (456 - 859) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.47/54/175/34/14\n Ve: 15.2 L/min\n PaO2 / FiO2: 438\n Physical Examination\n GENERAL: Intubated, sedated, responds to commands to open eyes and move\n extremities.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: Feet cool and mottled. Hands warm.\n Labs / Radiology\n 372 K/uL\n 10.2 g/dL\n 171 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 45 mg/dL\n 104 mEq/L\n 145 mEq/L\n 32.0 %\n 9.5 K/uL\n [image002.jpg]\n 03:51 PM\n 04:50 AM\n 04:55 AM\n 05:46 PM\n 05:59 PM\n 01:07 AM\n 06:14 AM\n 06:58 AM\n 03:36 AM\n 04:12 AM\n WBC\n 11.4\n 10.1\n 9.5\n Hct\n 30.8\n 32.6\n 31.2\n 32.0\n Plt\n \n Cr\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 0.9\n TropT\n 0.02\n TCO2\n 36\n 37\n 35\n 40\n Glucose\n 157\n 167\n 175\n 170\n 171\n Other labs: PT / PTT / INR:15.7/27.9/1.4, CK / CKMB /\n Troponin-T:434/3/0.02, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:83.5 %, Lymph:8.9 %, Mono:6.1 %, Eos:1.2 %, Lactic\n Acid:1.4 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Etiology likely pneumonia + heart failure. Respiratory status improving\n clinically and radiographically. Main barrier to extubation is\n sedation. s/p bronchoscopy/BAL .\n - continue mechanical ventilation, with daily spontaneous breathing\n trials, including this p.m.\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n .\n # Fever: Source unclear. Initially attributed to pneumonia, but patient\n has continued to spike high fevers in spite of Tylenol, antibiotics,\n and improvement in respiratory status. ID following.\n - CT abd/pelvis and CT sinuses\n - continue meropenem monotherapy\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic to hypovolemic.\n - continue to monitor fluid status\n - continue metoprolol \n - holding diuresis today\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hyperglycemia: No known history of diabetes. Contributing factors\n include stress response to infection, h/o pancreatic resection,\n infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n 20 Gauge - 01:32 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527742, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remains vented on PS 40% with MMV rate set at 10. O2 sats\n 97-100%. Remains on Meropenum IVPB q8h. Tmax 102.2 via rectal\n thermometer. Cx pending from bronch . Fentanyl gtt @ 25cmg/hr.\n Droplet precautions to rule out flu.\n Action:\n Sx small amts thick tan/yellow secretions.\n Response:\n ABG pending on decreased peep/psv. Await effects of Fentanyl to wear\n off.\n Plan:\n awaiting results of cx data.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.2 at 0800hrs (cooling blanket placed over patient as pt seemed\n to have skin compromise when cooling blanket under back\n now resolved)\n .\n Action:\n Tylenol 650mg x2 today. Temp down to 101.7. To CT scan of head,\n sinuses and abd/pelvis this afternoon.\n Response:\n Continues to spike fevers. Awaiting results of CT scans and culture\n data.\n Plan:\n Sputum cx pending. If pt is not to be extubated today, ? moving NGT to\n OGt would help to decrease risk of sinusitis.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Am CXR shows improvement. CVP 10-14.\n Action:\n No diuresis planned for today.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527788, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt remains vented on PS 40% with MMV rate set at 10. O2 sats\n 97-100%. Remains on Meropenum IVPB q8h. Tmax 102.2 via rectal\n thermometer. Cx pending from bronch . Fentanyl gtt @ 25cmg/hr.\n Droplet precautions to rule out flu.\n Action:\n Sx small amts thick tan/yellow secretions.\n Response:\n Await effects of Fentanyl to wear off\n gtt turned off at 1800hrs after\n CT scan completed.\n Plan:\n awaiting results of cx data and CT scan. Con\nt vent wean ?extubate in\n am. Con\nt abx.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.2 at 0800hrs (cooling blanket placed over patient as pt seemed\n to have skin compromise when cooling blanket under back\n now resolved)\n .\n Action:\n Tylenol 650mg x2 today. Temp down to 101.7. To CT scan of head,\n sinuses and abd/pelvis this afternoon.\n Response:\n Continues to spike fevers. Awaiting results of CT scans and culture\n data. Ibuprofin 800mg given this evening\n awaiting results if temp\n decreases.\n Plan:\n Sputum cx pending. If pt is not to be extubated today, ? moving NGT to\n OGt would help to decrease risk of sinusitis. Tylenol and ibuprofen for\n fever. Con\nt abx.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Am CXR shows improvement. CVP 10-14.\n Action:\n No diuresis planned for today.\n Response:\n No diuretics.\n Plan:\n Daily weights. Daily CXR.\n" }, { "category": "Nursing", "chartdate": "2141-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528036, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526020, "text": "Chief Complaint:\n 24 Hour Events:\n - developed more dyspnea and had to be placed back in BiPAP, improved\n after\n - CXR with ?infiltrate on L\n - given cefepime (had already gotten vanc/levo in ED)\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Vancomycin - 09:28 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:10 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 C/o some diaphoresis and lightheadedness; No CP\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100.1\n HR: 93 (70 - 98) bpm\n BP: 104/61(71) {84/26(53) - 127/84(89)} mmHg\n RR: 25 (18 - 27) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 980 mL\n 80 mL\n PO:\n 480 mL\n 80 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 3,500 mL\n 200 mL\n Urine:\n 2,650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,520 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 541 (541 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 19 cmH2O\n SpO2: 95%\n ABG: 7.48/37/80./27/3\n Ve: 9.3 L/min\n PaO2 / FiO2: 80\n Physical Examination\n GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.\n High-flow O2 mask on.\n HEENT: NC/AT.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: Difficult to hear over breath sounds; No m/r/g appreciated.\n LUNGS: Resp slightly labored; bilateral crackles and coarse breath\n sounds.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain.\n Labs / Radiology\n 174 K/uL\n 11.5 g/dL\n 131 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 98 mEq/L\n 137 mEq/L\n 33.9 %\n 7.4 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n WBC\n 7.4\n Hct\n 33.9\n Plt\n 174\n Cr\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 28\n Glucose\n 134\n 131\n Other labs: CK / CKMB / Troponin-T:232/3/<0.01, Lactic Acid:1.4 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but now\n suspicious for pneumonia.\n .\n # Dyspnea: Overnight, the patient had recurrent of dyspnea. Repeat CXR\n showed a more clear left-sided infiltrate. Also, of note, pt had fevers\n overnight. This presentation now more consistent with pneumonia, with a\n possible superimposed CHF component. Pt given\n vanc/cefepime/levofloxacin yesterday evening.\n - vanc/cefepime/azithromycin for broad coverage for pneumonia at this\n point\n - attempt to get sputum cultures\n - restarting Lasix 60 mg PO daily to prevent CHF exacerbation on top of\n PNA\n - continue metoprolol 12.5 mg daily, per home med list\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first 2 sets of CE's was\n negative. Of note, the patient did report some chest pressure\n previously, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3 on presentation. Telemetry\n currently showing v-paced rhythm.\n - continue coumadin, with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix as above\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n NOTE: On review of ECG, seems that PM LV lead is not pacing as before.\n Pt will need to have PM interrogated while he is in the CCU.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:41 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526021, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526229, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526230, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526017, "text": "Chief Complaint:\n 24 Hour Events:\n - developed more dyspnea and had to be placed back in BiPAP, improved\n after\n - CXR with ?infiltrate on L\n - given cefepime (had already gotten vanc/levo in ED)\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Vancomycin - 09:28 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:10 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 C/o some diaphoresis and lightheadedness; No CP\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100.1\n HR: 93 (70 - 98) bpm\n BP: 104/61(71) {84/26(53) - 127/84(89)} mmHg\n RR: 25 (18 - 27) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 980 mL\n 80 mL\n PO:\n 480 mL\n 80 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 3,500 mL\n 200 mL\n Urine:\n 2,650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,520 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 541 (541 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 19 cmH2O\n SpO2: 95%\n ABG: 7.48/37/80./27/3\n Ve: 9.3 L/min\n PaO2 / FiO2: 80\n Physical Examination\n GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.\n High-flow O2 mask on.\n HEENT: NC/AT.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: Difficult to hear over breath sounds; No m/r/g appreciated.\n LUNGS: Resp slightly labored; bilateral crackles and coarse breath\n sounds.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain.\n Labs / Radiology\n 174 K/uL\n 11.5 g/dL\n 131 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 98 mEq/L\n 137 mEq/L\n 33.9 %\n 7.4 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n WBC\n 7.4\n Hct\n 33.9\n Plt\n 174\n Cr\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 28\n Glucose\n 134\n 131\n Other labs: CK / CKMB / Troponin-T:232/3/<0.01, Lactic Acid:1.4 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but now\n suspicious for pneumonia.\n .\n # Dyspnea: Overnight, the patient had recurrent of dyspnea. Repeat CXR\n showed a more clear left-sided infiltrate. Also, of note, pt had fevers\n overnight. This presentation now more consistent with pneumonia, with a\n possible superimposed CHF component. Pt given\n vanc/cefepime/levofloxacin yesterday evening.\n - vanc/cefepime/azithromycin for broad coverage for pneumonia\n -\n - holding on further antibiotics at this time, as pt does not\n clinically appear to have a pneumonia\n - continue metoprolol 12.5 mg daily\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first set of CE's was negative.\n Of note, the patient did report some chest pressure last night and in\n the ED this morning, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3. Telemetry currently showing\n v-paced rhythm.\n - continue coumadin, with goal INR of 2.3\n - need to closely monitor INR, as it may change at patient received\n levofloxacin in the ED\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix bolus PRN\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - continue cefpodoxime\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526018, "text": "Chief Complaint:\n 24 Hour Events:\n - developed more dyspnea and had to be placed back in BiPAP, improved\n after\n - CXR with ?infiltrate on L\n - given cefepime (had already gotten vanc/levo in ED)\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Vancomycin - 09:28 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:10 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 C/o some diaphoresis and lightheadedness; No CP\n Flowsheet Data as of 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100.1\n HR: 93 (70 - 98) bpm\n BP: 104/61(71) {84/26(53) - 127/84(89)} mmHg\n RR: 25 (18 - 27) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 980 mL\n 80 mL\n PO:\n 480 mL\n 80 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 3,500 mL\n 200 mL\n Urine:\n 2,650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,520 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 541 (541 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 19 cmH2O\n SpO2: 95%\n ABG: 7.48/37/80./27/3\n Ve: 9.3 L/min\n PaO2 / FiO2: 80\n Physical Examination\n GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.\n High-flow O2 mask on.\n HEENT: NC/AT.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: Difficult to hear over breath sounds; No m/r/g appreciated.\n LUNGS: Resp slightly labored; bilateral crackles and coarse breath\n sounds.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain.\n Labs / Radiology\n 174 K/uL\n 11.5 g/dL\n 131 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 98 mEq/L\n 137 mEq/L\n 33.9 %\n 7.4 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n WBC\n 7.4\n Hct\n 33.9\n Plt\n 174\n Cr\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 28\n Glucose\n 134\n 131\n Other labs: CK / CKMB / Troponin-T:232/3/<0.01, Lactic Acid:1.4 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but now\n suspicious for pneumonia.\n .\n # Dyspnea: Overnight, the patient had recurrent of dyspnea. Repeat CXR\n showed a more clear left-sided infiltrate. Also, of note, pt had fevers\n overnight. This presentation now more consistent with pneumonia, with a\n possible superimposed CHF component. Pt given\n vanc/cefepime/levofloxacin yesterday evening.\n - vanc/cefepime/azithromycin for broad coverage for pneumonia at this\n point\n - attempt to get sputum cultures\n - restarting Lasix 60 mg PO daily to prevent CHF exacerbation on top of\n PNA\n - continue metoprolol 12.5 mg daily, per home med list\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first 2 sets of CE's was\n negative. Of note, the patient did report some chest pressure\n previously, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3 on presentation. Telemetry\n currently showing v-paced rhythm.\n - continue coumadin, with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix as above\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "General", "chartdate": "2141-03-05 00:00:00.000", "description": "Generic Note", "row_id": 526205, "text": "TITLE:\n CCU Attending progress note\n Course reviewed and patient examined on ccu rounds\n 60 minutes of critical care time due to ventilatory failure and\n cardiomyopathy/chf\n Respiratory decompensation in setting of progressive hypoxia felt to be\n due to left lower lobe pneumonia\n Diuresed\n Expanded antibiotic coverage to cover klebsiella in the setting of\n chronic cefapexime\n Plan to decrease fio2 to 0.6\n Will try to decrease norepinephrine as tolerated\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526214, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2141-03-05 00:00:00.000", "description": "Generic Note", "row_id": 526225, "text": "TITLE:\n Central line procedure note:\n Right IJ vein identified by US. Site prepped with chlorhexidine. Full\n body drape placed, time out performed, gown, mask, sterile gloves\n utilized. IJ cannulated, guide wire used to place triple lumen. No\n immediate complications. Catheder sutured and X-Ray ordered.\n" }, { "category": "Physician ", "chartdate": "2141-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526227, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -started meropenem and discontinued ceftriaxone\n -consulted EP, will check ICD tomorrow\n -6 p.m., noted to be more hypoxemic, blood gas 7.50/37/50\n -gave Lasix and placed on non-rebreather without improvement\n -7 p.m. intubated for hypoxemic respiratory failure\n -8 p.m. A-line placed\n -febrile, pan-cultured\n -9 p.m. bolused 500 cc NS for SBP 70s\n -10 p.m. started levophed for SBP 70s\n -11 p.m. bolused additional 500 cc NS for SBP 70s\n -2 a.m. ET tube advanced 2 cm.\n -4 a.m. bolused with 500 cc NS for low urine output\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Azithromycin - 09:30 AM\n Ceftriaxone - 03:00 PM\n Vancomycin - 11:16 PM\n Meropenem - 12:44 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100\n HR: 60 (60 - 103) bpm\n BP: 76/47(53) {76/47(53) - 124/83(96)} mmHg\n RR: 22 (16 - 25) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,049 mL\n 712 mL\n PO:\n 560 mL\n TF:\n IVF:\n 1,489 mL\n 712 mL\n Blood products:\n Total out:\n 1,610 mL\n 145 mL\n Urine:\n 1,610 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n 439 mL\n 567 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%, Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n Compliance: 51.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.42/44/117/27/3\n Ve: 10.7 L/min\n PaO2 / FiO2: 167\n Physical Examination\n GENERAL: Alert; Oriented x3. Uncomfortable; fidgety. Diaphoretic.\n High-flow O2 mask on.\n HEENT: NC/AT.\n NECK: Unable to appreciate JVP.\n CARDIAC: Quiet heart sounds. Difficult to hear over breath sounds; No\n m/r/g appreciated.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness noted.\n EXTREMITIES: No significant LE edema noted. Extremities warm and\n well-perfused.\n Labs / Radiology\n 172 K/uL\n 10.6 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 31.5 %\n 7.5 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n 10:00 AM\n 03:08 PM\n 06:29 PM\n 09:17 PM\n 11:16 PM\n 04:44 AM\n 04:55 AM\n WBC\n 7.4\n 7.5\n Hct\n 33.9\n 31.5\n Plt\n 174\n 172\n Cr\n 1.2\n 1.1\n 0.9\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 28\n 30\n 30\n 27\n 26\n 30\n Glucose\n 134\n 131\n 140\n 134\n Other labs: PT / PTT / INR:24.2/34.4/2.3, CK / CKMB /\n Troponin-T:374/4/<0.01, Lactic Acid:0.9 mmol/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but now more\n consistent with pneumonia.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. have superimposed component\n of heart failure as well. On vancomycin, meropenem, azithromycin for\n broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation with CMV 500/22/0.7/5. Wean FiO2 as\n tolerated.\n - continue vancomycin, meropenem, azithromycin\n - f/u pending cultures\n .\n # Hypotension/sepsis: Likely pneumonia.\n - holding metoprolol\n - holding diuresis\n - IV fluids PRN\n - norepinephrine\n - place central venous line given pressor requirement\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Heart failure\n may be contributing to patient\ns dyspnea, on top of pneumonia. Has\n required fluids overnight for low urine output. On norepinephrine.\n - continue norepinephrine\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension\n - continue coumadin, with goal INR of \n - need to closely monitor INR, as it may change with pt on abx\n .\n # s/p ICD: Based on EKG, left ventricular lead may not be functioning\n properly.\n - EP consulted\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia.\n - holding cefpodoxime while on broad spectrum abx as above\n - touch base with outpt ID doc\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition: consult nutrition for tube feeds\n Glycemic Control: none\n Lines:\n 20 Gauge - 12:58 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526299, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated. A/C 70% 500 22 8.\n Lungs diminished.\n Low grade fever.\n Suctioned for minimal sputum.\n Sedated with versed & fentanyl drips.\n Pt agitated with minimal stimulation.\n Not able to follow commands.\n Responsive to some verbal stimulation.\n Pt is NPO.\n Action:\n Sedation not lightened today d/t agitation.\n FIO2 weaned to 50%.\n Restarted on Cefepime per ID.\n Meropenem dc\n Response:\n Improved abg\n Plan:\n Pt to remain sedated overnight.\n Cont with antibiotics.\n To hold off on TF until am.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced 50\ns-60\n SBP 100\ns-120\n Lungs diminished.\n Levophed at .08mcgs/kg/min.\n Action:\n Lopressor & lasix held.\n Device interrogated by EP fellow.\n Levophed weaned to .05mcgs/kg/min.\n Given 500cc\ns NS x\ns 1.\n Response:\n CVP 5-14.\n Only RV lead is functional.\n Hemodynamically stable with wean of Levo\n Plan:\n Cont to monitor I&O.\n Cont to hold lasix.\n" }, { "category": "Nursing", "chartdate": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525932, "text": "72 y/o M with PMHx significant for systolic HF (EF 20-25%), MI,\n arrhythmias, s/p BiV ICD implantation with subsequent revisions due to\n the presence of malfunctioning lead, who presented to the ED this\n morning with a chief complaint of dyspnea and chest pressure. CXR LLL\n opacity and fluid overload. Started Abx and diuresed. Admitted to CCU.\n Pan cultured. Need sputum sample.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n *1500ml fluid restriction* Vpaced 80s w/ occ PVCs. SBP 110s.\n Action:\n high flow/cool neb, FiO2 60% - pt very restless at beginning of shift\n ?resp distress -switched to BiPap for an hour then back to high flow\n cool neb facemask with 3L nasal cannula for sats 92-97%. Pt constantly\n moving around in bed, picking at things, taking off O2 sat probe, so\n sat probe now on toe.\n LS crackles bases. Non productive cough.\n Response:\n Breathing fine overnite. Sats 94-97%.\n Plan:\n Continue to closely monitor resp status/ diuresis/ O2 requirement.\n Follow up results PM lytes in setting of diuresis.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n *Of note, patient on chornic abx: cefpodoxime at home for ongoing\n suppression after high-grade viridans streptococcal bacteremia in the\n setting of pacer/defibrillator wires and to continue intended life-long\n suppression for suspected Klebsiella pneumoniae lead endocarditis\n during a prior bacteremia. *\n Action:\n Tmax 100.7. given Tylenol. CXR done. Vanco increased to q12h. Started\n on Cefepime.\n Response:\n Am temp 100.3. am WBC pnd.\n Plan:\n Awaiting blood culture results sent . UA and C+S from . no\n results yet. Con\nt to monitor temps and white count. Con\nt ABX.\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526351, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Received patient on Levophed at .08 mcgs. V ( RV ) paced in the mid\n 50\ns to low 60\ns. SBP hovering in the low 90\ns. Withdrawng to oral\n care, ett suctioning. Pupils pinpoint but reactive. Moving lower\n extremities.\n Action:\n Slow wean of levophed attempted. Lasix and fluid challenge on hold\n Response:\n Unsuccessful as SBP dropping into the mid 70\ns. Urine output 20-40\n cc/hr .. urine dark amber in appearance\n Plan:\n Per EP note .. No Capture of LV lead. Device reprogrammed to DDD\n 50/125and LV pacing lead turned off by EP.. Underlying SR with long AV\n delay. Magnet at door way in case of complete RV lead failure..\n Monitor electrolytes.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received patient orally intubated and sedated. Lungs diminished at\n the bases. Resp rate in sync with vent .Vent settings 50%/AC 22/peep\n 8/TV 500\n Action:\n Suction q3 with instillation with ett secretions minimal . Noted\n sudden trend down in 02 sat . ABG 7.44/40/62/2/96. Suction for a large\n tan clot\n Response:\n Although 02 sats not improved. Fi02 increased to 60\n Plan:\n Monitor ABG .. Continue ABXs . Defer wake-up as patient with borderline\n ABG\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526481, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n , EP interogated, found that LV pacer not working, ICD not working, A\n sensing ok, RV sensing OK since beginning of . Magnet to bedside\n in case of inappropriate shock. If VF/VT manage medically.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T 100.6 max , SAT 97 0N 60/500/22/8 .BS DIM ,MIN SECRETIONS VERY\n SEDATED ON VERSED 4MG/FENTANYL 50 MIC. V PACED HR 60 TO 70 .BP 90 T0\n 100 SYSTOLIC ON LEVOPHED .04 MIC/KG ,CVP 6 TO 8 .HUO 20 TO 30 CC/HR\n neg 900cc.MOD AMT BILIOUS FROM OG TUBE,ABD SOFT C BS\n Action:\n SX FOR MIN ,VAP PROTOCOL\n CONTINUE ANTIBX\n WEAN SEDATION ,LEVOPHED AS TOL\n ATTEMPTING TO WEAN FIO2,PEEP\n FAMILY UPDATED\n TUBE FEEDINGS STARTED\n Response:\n TOL SLOW WEAN LEVOPHED ,BEGINNING TO RESPOND ON LESS SEDATION\n Plan:\n CONTINUE SLOW WEAN LEVOPHED,MAINTAIN MINIMAL SEDATION\n WEAN FIO2,PEEP AS TOL\n INCREASE TF AS TOL\n FOLLOW TEMP\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526477, "text": "This is a 72 yr old male with a significant cardiac history including\n systolic HF ( EF ~ 20% ), Ant MI in 96\nparoxysmal AV block , afib,\n h/o v tach and v fib , s/p ICD placement . He is on chronic\n cefpodoxime for on suppression after high grade viridans strept\n bacteremai in the setting of pacer/defib wires and continued life long\n suppression for suspected Klebsiella PNA lead encocarditis during a\n prior bacteremia admission. Presented to EW on for worsening\n SOB. CXR with LLL infiltrate and CHF exacerbation. High 02\n requirements since admit to the CCU. Intubated on for increased\n work of breathing.\n , EP interogated, found that LV pacer not working, ICD not working, A\n sensing ok, RV sensing OK since beginning of . Magnet to bedside\n in case of inappropriate shock. If VF/VT manage medically.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n T 100.6 max , SAT 97 0N 60/500/22/8 .BS DIM ,MIN SECRETIONS VERY\n SEDATED ON VERSED 4MG/FENTANYL 50 MIC .BP 90 T0 100 SYSTOLIC ON\n LEVOPHED .04 MIC/KG ,CVP 6 TO 8 .HUO 20 TO 50 CC/HR .MOD AMT BILIOUS\n FROM OG TUBE,ABD SOFT C BS\n Action:\n SX FOR MIN ,VAP PROTOCOL\n CONTINUE ANTIBX\n WEAN SEDATION ,LEVOPHED AS TOL\n ATTEMPTING TO WEAN FIO2,PEEP\n FAMILY UPDATED\n TUBE FEEDINGS STARTED\n Response:\n Plan:\n CONTINUE SLOW WEAN LEVOPHED,MAINTAIN MINIMAL SEDATION\n WEAN FIO2,PEEP AS TOL\n INCREASE TF AS TOL\n FOLLOW TEMP\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2141-03-04 00:00:00.000", "description": "Generic Note", "row_id": 526004, "text": "TITLE:\n Cardiology CCU attending Note: Addendum to Dr \ns progress note\n Reviewed Admission notes from Dr on ;/10\n Interviewed and examined on CCU rounds with housestaff\n 60 minutes of critical care time for congestive heart failure\n management.\n Admitted with progressive subacute systolic congestive heart failure in\n setting of known coronary artery disease associated cardiomyopathy.\n Also history of complete heart block, VT and BIV icd\n Chronic suppression with antibiotics for osteomyelitis and concern for\n ICD infection\n Exacerbation of heart failure felt due to volume overload from dietary\n indiscretion\n Diuresed well with Lasix with signicant improvement in heart failure\n initially\n Over night fevers to 100.7\n started cefapine. CXR is suggestive of\n left sided pneumonia\n likely a culprit as well. Need to follow blood\n cultures\n Not LV pacing at this point\n only RV pacing. Need to interrogate the\n ICD to evaluate CS lead function.\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526536, "text": "71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Pneumonia-\n Assessment:\n Intubated . On broad coverage abx-vanco, azithromycin,\n ceftriaxone, & cefepime. Continued low grade temp. Cltures pending.\n Continues on low dose pressor ( norepinephrine) with maps >50\ns to 60.\n Responds to stimuli with restlessness/agitation-presently not following\n commands or purposeful movements.\n Action:\n Weaning vent as tolerated. VAP protocol. Abx as ordered.\n Response:\n Plan:\n Continue present management.\n Heart Failure (CHF), Systolic, Acute\n Assessment:\n Overall LOS i&o slightly negative. Borderline uo. Requiring pressor\n (low dose) to maintain adequate maps.\n Action:\n Titrating pressor as indicated.\n Response:\n Plan:\n Continue present management. Wean pressor as tolerated.\n Chronic Antibiotic Use\n Assessment:\n On abx for ongoing suppression of high-grade viridans streptococcal\n bacteremia & for life-long suppression of suspected klebsiella\n pneumonia lead endocarditis.\n Action:\n Holding cefpodoxime while on broad spectum abx.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526537, "text": "CCU Nursing Progess Note.\n 71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Pneumonia\n Assessment:\n Intubated . On broad coverage abx-vanco, azithromycin,\n ceftriaxone, & cefepime. Continued low grade temp. Cltures pending.\n Continues on low dose pressor ( norepinephrine) with maps >50\ns to 60.\n Responds to stimuli with restlessness/agitation-presently not following\n commands or purposeful movements.\n Action:\n Weaning vent as tolerated. VAP protocol. Abx as ordered.\n Response:\n Plan:\n Continue present management.\n Heart Failure (CHF), Systolic, Acute\n Assessment:\n Overall LOS i&o slightly negative. Borderline uo. Requiring pressor\n (low dose) to maintain adequate maps.\n Action:\n Titrating pressor as indicated.\n Response:\n Plan:\n Continue present management. Wean pressor as tolerated.\n Chronic Antibiotic Use\n Assessment:\n On abx for ongoing suppression of high-grade viridans streptococcal\n bacteremia & for life-long suppression of suspected klebsiella\n pneumonia lead endocarditis.\n Action:\n Holding cefpodoxime while on broad spectum abx.\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2141-03-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526614, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 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 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, Cannot protect airway, Hemodynimic instability\n" }, { "category": "Respiratory ", "chartdate": "2141-03-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 526738, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / 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 Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean to PSV as tol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1130\n Uneventful\n" }, { "category": "Social Work", "chartdate": "2141-03-07 00:00:00.000", "description": "Social Work Progress Note", "row_id": 526730, "text": "SOCIAL WORK: Pt referred to SW in POE to support pt and family\n coping. Case discussed with resident, Dr , and \n RN. Pt has complex medical history including heart disease and\n recent Whipple surgery, currently intubated and sedated on CCU with\n diagnosis of pneumonia. SW reviewed SW notes from pt\ns previous\n admissions. SW and Dr and met with family\n today, (HCP) and pt\ns 2 daughters were\n present. Dr provided a medical update. Family asked\n appropriate questions. Pt\ns 2 daughters are from out of state and\n contemplating return home tomorrow evening, but ambivalent, given\n uncertainty of pt\ns illness. After meeting, SW explained role and\n availability. \ns requesting SW act as liaison for them when they\n return home as pt\ns partner is supportive and well intentioned, but\n they believe she tends to listen for, and perseverate on, the worst\n case scenario.\n SW will meet again with family tomorrow. Will develop rapport with\n pt\ns partner to provide supportive counseling.\n" }, { "category": "Nursing", "chartdate": "2141-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 526734, "text": "Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525921, "text": "72 y/o M with PMHx significant for systolic HF (EF 20-25%), MI,\n arrhythmias, s/p BiV ICD implantation with subsequent revisions due to\n the presence of malfunctioning lead, who presented to the ED this\n morning with a chief complaint of dyspnea and chest pressure. CXR LLL\n opacity and fluid overload. Started Abx and diuresed. Admitted to CCU.\n Pan cultured. Need sputum sample.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/ diffuse crackles/ exp wheezes throughout. SPO2 97% on\n NIMV/BiPap. RR teens. Speaking in full sentences, no s/s resp distress.\n +Orthopnea, +DOE. Bilat LE edema 2+. Wt on bedscale 105kg. BNP 3057.\n NIBP 100s-110s/ 60s-70s. HR 70s-80s V-paced w/ PVCs.\n Action:\n *Monitored resp status. Weaned NIMV to high flow/cool neb, FiO2 60%.\n *CXR in ED c/w volume overload\n *Diuresing large amts to 40 lasix given in ED\n *Home dose lopressor\n *1500ml fluid restriction\n Response:\n SPO2 mainly >90% on above O2 requirement. Does desat to mid 80s when on\n 5L NC for eating, recovers when mask re-applied. Pt without SOB w/\n desaturating. VSS. Net negative 2200ml at 18:30.\n Plan:\n Continue to closely monitor resp status/ diuresis/ O2 requirement.\n Follow up results PM lytes in setting of diuresis.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n *Pt and significant other reporting unspecified dysphagia. Seen by our\n S&S this afternoon- please see note in metavision. No major deficits\n noted. Able to resume regular diet and swallow pills whole w/ water.\n *Pt w/ Temp 100.3 PO at 1800. Blood cxs sent x 2 and UA/ C&S sent in\n ED. Already rec\nd IV levaquin and IV Vanco today.\n *Of note, patient on chornic abx: cefpodoxime at home for ongoing\n suppression after high-grade viridans streptococcal bacteremia in the\n setting of pacer/defibrillator wires and to continue intended life-long\n suppression for suspected Klebsiella pneumoniae lead endocarditis\n during a prior bacteremia. Followed closely by out-pt ID team who has\n seen him here since arrival.\n" }, { "category": "Nursing", "chartdate": "2141-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525991, "text": "72 y/o M with PMHx significant for systolic HF (EF 20-25%), MI,\n arrhythmias, s/p BiV ICD implantation with subsequent revisions due to\n the presence of malfunctioning lead, who presented to the ED this\n morning with a chief complaint of dyspnea and chest pressure. CXR LLL\n opacity and fluid overload. Started Abx and diuresed. Admitted to CCU.\n Pan cultured. Need sputum sample.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n *1500ml fluid restriction* Vpaced 80s w/ occ PVCs. SBP 110s.\n Action:\n high flow/cool neb, FiO2 60% - pt very restless at beginning of shift\n ?resp distress -switched to BiPap for an hour then back to high flow\n cool neb facemask with 3L nasal cannula for sats 92-97%. Pt constantly\n moving around in bed, picking at things, taking off O2 sat probe, so\n sat probe now on toe.\n LS crackles bases. Non productive cough.\n Response:\n Breathing fine overnite. Sats 94-97%.\n Plan:\n Continue to closely monitor resp status/ diuresis/ O2 requirement.\n Follow up results PM lytes in setting of diuresis.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n *Of note, patient on chornic abx: cefpodoxime at home for ongoing\n suppression after high-grade viridans streptococcal bacteremia in the\n setting of pacer/defibrillator wires and to continue intended life-long\n suppression for suspected Klebsiella pneumoniae lead endocarditis\n during a prior bacteremia. *\n Action:\n Tmax 100.7. given Tylenol. CXR done. Vanco increased to q12h. Started\n on Cefepime.\n Response:\n Am temp 100.3 decreasing to 99.9 without Tylenol. am WBC 7.4.\n Plan:\n Awaiting blood culture results sent . UA and C+S from . no\n results yet. Con\nt to monitor temps and white count. Con\nt ABX.\n Awaiting cefepime to be approved by ID, and to given vanco q12h.\n" }, { "category": "General", "chartdate": "2141-03-08 00:00:00.000", "description": "Generic Note", "row_id": 526891, "text": "TITLE:\n CCU attending progress note: Addendum to Dr \ns note\n Patient examined and plan reviewed and agreed upon with housestaff on\n rounds\n 60 minutes\n CT scan yesterday did not suggest pneumonia. Likely all CHF and\n atelectasis. Diuresed over night\n No evidence of interstitial lung disease (given amiodarone) or focal\n infiltrates\n Today chest x ray is improved\n Mental status is decreased but neuro exam is non focal. Moving all\n extremities. Will not pursue CT scan unless status worsens\n Continue antiobitics, continue diuresis\n Consider pulmonary consultation to help with decisions for best\n mechanism to recruit more lung volume.\n" }, { "category": "Physician ", "chartdate": "2141-03-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 526854, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - increased vancomycin to 1250 mg IV Q12H\n - held Coumadin for supratherapeutic INR\n - Chest CT was initially read as pneumonia, then reread as follow:\n 1. No intrathoracic abscess. Bilateral non-hemorrhagic\n small-to-moderate pleural effusions, minimally loculated, if at all, on\n the right.\n 2. Severe lower lobe and moderate upper lobe atelectasis. Minimal\n pneumonia cannot be excluded.\n 3. Mediastinal lymphadenopathy, likely reactive.\n - bolused 500 cc for low urine output, without improvement in urine\n output\n - ordered Lasix 60 mg IV x 1. Put out almost 2 L of urine overnight\n - did recruitment maneuvers and increased PEEP\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 12:00 PM\n Vancomycin - 09:00 PM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 78 (50 - 83) bpm\n BP: 106/58(70) {92/47(60) - 127/71(84)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 104 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 12 (5 - 15)mmHg\n Total In:\n 2,565 mL\n 326 mL\n PO:\n TF:\n 884 mL\n 309 mL\n IVF:\n 1,201 mL\n 17 mL\n Blood products:\n Total out:\n 1,580 mL\n 850 mL\n Urine:\n 1,580 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 985 mL\n -524 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): 313 (313 - 313) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 88\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 95%\n ABG: 7.44/40/107/27/2\n Ve: 9.2 L/min\n PaO2 / FiO2: 214\n Physical Examination\n GENERAL: Intubated, sedated, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse ventilated breath sounds bilaterally.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Labs / Radiology\n 258 K/uL\n 10.6 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 105 mEq/L\n 139 mEq/L\n 31.5 %\n 7.2 K/uL\n [image002.jpg]\n 04:26 AM\n 04:40 AM\n 07:02 AM\n 09:35 PM\n 04:35 AM\n 04:52 AM\n 05:51 PM\n 11:27 PM\n 03:41 AM\n 04:21 AM\n WBC\n 6.6\n 6.4\n 7.2\n Hct\n 30.6\n 28.5\n 31.5\n Plt\n 197\n 205\n 258\n Cr\n 0.8\n 0.7\n 0.9\n TCO2\n 28\n 30\n 30\n 31\n 22\n 29\n 28\n Glucose\n 109\n 132\n 191\n Other labs: PT / PTT / INR:22.8/32.4/2.2, CK / CKMB /\n Troponin-T:374/4/<0.01, Differential-Neuts:83.3 %, Lymph:6.5 %,\n Mono:6.5 %, Eos:3.5 %, Lactic Acid:0.9 mmol/L, Ca++:8.3 mg/dL, Mg++:2.2\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure/Pneumonia: Patient with fever, cough,\n dyspnea, left-sided infiltrate on CXR. On vancomycin, cefepime,\n azithromycin for broad coverage. Was intubated on for hypoxemia.\n - continue mechanical ventilation. Consider trial on pressure support\n if patient becomes more alert.\n - continue vancomycin, cefepime, azithromycin.\n - f/u pending cultures (no positive micro data to date)\n - chest CT to better evaluate lung fields\n .\n # Hypotension/sepsis: Off pressors since 2 a.m. with SBP around 110.\n - holding metoprolol\n - holding diuresis\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - holding diuresis\n - holding metoprolol in setting of hypotension\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin 81 mg daily\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently therapeutic at 2.3 on presentation.\n Telemetry currently showing v-paced rhythm.\n - holding metoprolol in setting of hypotension; consider restarting if\n BP stable off pressors\n - holding Coumadin in setting of supratherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds. Holding pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:35 AM 45 mL/hour\n Glycemic Control: none\n Lines:\n Arterial Line - 09:13 PM\n 20 Gauge - 12:58 AM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: supratherapeutic INR\n Stress ulcer: lansoprazole\n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527026, "text": "71 year old male with pmx significant for systolic hf ( ef 20-25%), mi\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation. Admitted with sob/dyspna-due to chf exacerbation & pna.\n Chest CT:\n Subtotal atelectasis of the lower lobes, with air-bronchogram. Focal\n consolidation in the left uppper lobe,\n could also represent atelectasis, less likely PNA. Bilateral pleural\n effusions, small-to-moderate, non-hemorrhagic\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated and sedated.\n Versed at 2mg/hr & Fentanyl at 25mcgs/hr.\n Vent settings SMV .\n Suctioned for thick tan sputum.\n Lungs diminished in bases otherwise clear.\n Action:\n Sedation dc\nd at 0730.\n Vent settings changed to CPAP/PS \n Conts on Vancomycin & Cefepime.\n Response:\n Unable to tolerate PS.\n Having long periods of apnea with low TV & MV\ns alternating with ^\nd RR\n and TV 800\n Sedation remains off.\n Placed back on A/C with RR of 14. overbreathing x\ns /min.\n Plan:\n Cont A/C overnite until pt more awake.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n TM 101.4 WBC\ns wnl.\n Action:\n Bld cultures x\n Urine & sputum cultures sent.\n 650mg Tylenol x\ns 2.\n Flagyl 500mg IV Q8hrs.\n Response:\n Pt conts with fever\n Plan:\n Check cultures. Prn Tylenol.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V paced with periods of AF. HR mostly in 50\n Action:\n Lopressor remains on hold.\n Given lasix 60mg IV x\ns 1.\n Response:\n Good diuresis from lasix.\n Improved abg\n Plan:\n Lasix as needed.\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527239, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 103.8 PR. WBC=_____. AM lactate 2.1.\n Action:\n *ID following- unclear in PNA is source of temp spike as CXR w/\n improvement\n *Triple IV anbx- cefepime/ flagyl/ vanco\n *Tylenol ATC for pt comfort\n *Ice packs to groin/ armpits\n *Pt pan cultured \n Response:\n Temp remained elevated despite above interventions. Ice packs removed\n and cooling blanket applied at 13:00 w/ Temp down 98-99 F range.\n Continuous rectal temp probe placed for better monitoring. Afternoon\n lactate 1.6.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated PSV 12/ 10 Peep. LS diminished/ bronchial @\n bases. Small amts thick/ yellow tan secretions via ETT. SPO2 >94%.\n Pt has been off sedation since 0730 - Upon initial exam, pt w/\n occasional eye opening, no tracking. No response to verbal stimuli/\n nail bed pressure/ sternal rub. MAE, non-purposeful.\n Action:\n *Per resp therapy- PS trial . Pt w/ SPO2 down 89%, RR >35, SBP\n 180s. Discussed w/ team-> No plans to extubate today given pt\ns mental\n status and need to further diurese. Vent settings changed back to 10\n PSV/ 10 Peep w/ ABG:________.\n *Pulmonary toileting q2hrs. VAP care per protocol.\n *Abx Vancomycin, Cefepime and Flagyl continue\n Tylenol 650 q6hrs.\n Response:\n Producing thick tan/yellow secretions.\n Plan:\n Attempt PS wean in am as tolerated, continue aggressive pulmonary\n toileting, abx and Tylenol. Check pnd cultures ()\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2141-03-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527105, "text": "Demographics\n Day of intubation: 6\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 26 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: Tan / 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, High\n flow demand\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 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" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527092, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated on 50%/500/15/10peep w/ O2 sats 95%. LS\n diminished/ bronchial @ bases.\n Pt has been off sedation since 0730 . MAE to painful stimuli and\n appears restless, kicking at pillows under legs. Eyes are slightly\n open, although pt does not track or appear to focus.\n T max 101.4 po at midnight.\n Pt receiving TF Isosource at goal rate of 55cc/ht\n Action:\n Pulmonary toileting q2hrs.\n VAP care per protocol.\n Abx Vancomycin, Cefepime and Flagyl continue\n Tylenol 650 q6hrs.\n Response:\n Producing thick tan/yellow secretions.\n Sedation remains off w/ no change in neuro status.\n Temp continues elevated 101.8po\n Plan:\n Attempt PS wean in am as tolerated, continue aggressive pulmonary\n toileting, abx and Tylenol. Check pnd cultures ()\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n BP 130-140/50-60.\n Rec\nd pt at 8pm, 40cc negative for the day.\n Action:\n Lopressor parameters discussed w/ MD. Lopressor has been held d/t HR\n parameter of 50. Parameter changed to 50.\n Given lasix 60mg IV at and 2230 in order to reach goal of 1.5\n liter neg for day. .\n Response:\n Good diuresis from lasix w/ midnight i/o negative 950cc.\n Only 200cc negative at 6am.\n Plan:\n Consider lasix gtt as intake is approx 3000cc per day.\n Social\n HCP/ has called multiple times this shift and has\n been updated by this RN. would like to be called if for any\n reason medical service is to be changed (i.e pt is changed from CCU to\n MICU service).\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527095, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated on 50%/500/15/10peep w/ O2 sats 95%. LS\n diminished/ bronchial @ bases.\n Pt has been off sedation since 0730 . MAE to painful stimuli and\n appears restless, kicking at pillows under legs. Eyes are slightly\n open, although pt does not track or appear to focus.\n T max 101.4 po at midnight.\n Pt receiving TF Isosource at goal rate of 55cc/ht\n Action:\n Pulmonary toileting q2hrs.\n VAP care per protocol.\n Abx Vancomycin, Cefepime and Flagyl continue\n Tylenol 650 q6hrs.\n Response:\n Producing thick tan/yellow secretions.\n Sedation remains off w/ no change in neuro status.\n Temp continues elevated 101.8po\n Plan:\n Attempt PS wean in am as tolerated, continue aggressive pulmonary\n toileting, abx and Tylenol. Check pnd cultures ()\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Rec\nd pt w/ HR paced at 50. Underlying rythum appears to be aflutter.\n BP 130-140/50-60.\n Rec\nd pt at 8pm, 40cc negative for the day.\n Action:\n Lopressor parameters discussed w/ MD. Lopressor has been held d/t HR\n parameter of 50. Parameter changed to 50.\n Given lasix 60mg IV at and 2230 in order to reach goal of 1.5\n liter neg for day. .\n Response:\n Good diuresis from lasix w/ midnight i/o negative 950cc.\n Only 200cc negative at 6am.\n Plan:\n Consider lasix gtt as intake is approx 3000cc per day.\n Social\n HCP/ has called multiple times this shift and has\n been updated by this RN. would like to be called if for any\n reason medical service is to be changed (i.e pt is changed from CCU to\n MICU service).\n ------ Protected Section ------\n Per resp, unable to do RSBI as pt tachypnic. Placed on PS12/peep10.\n ABG pnd.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:22 ------\n" }, { "category": "Rehab Services", "chartdate": "2141-03-03 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 525834, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 72 y/o male CAD s/p MI, VT/VF\ns/p ICD, AF who presentedto on dyspnea. Patient\nwas found with volume overload c/w CHF exacerbation. Patient was\nrecently seen by his PCP worsening cough for ~ 10\ndays. Patient reported difficulty swallowing (symptoms unclear)\nand his PCP ordered CXR to r/o aspiration pna. CXR on \nrevealed \"No pneumonia\". We were consulted to evaluate patient's\noral and pharyngeal swallowing function and r/o aspiration while\neating and drinking.\nPatient reported that since he had his whipple surgery and an\ninfection post-procedure he noticed that when swallowing hard\nsolid foods (i.e. cookie) he would feel the sensation of \"some\nleft over\" in his throat. He stated that he usually takes a sip a\nwater and the sensation goes away. He also reported this\nsensation may happen when he eats too fast or does not drink\nenough during a meal. He otherwise tolerates regular solid foods\n(mostly soft foods when eating without dentures), thin liquids,\nand pills whole with water without reported difficulty at home.\nPAST MEDICAL HISTORY:\n1. Myocardial infarction in with ventricular tachycardia\nand complete heart block requiring pacemaker.\n2. Hypertension.\n3. Hypothyroidism.\n4. Anemia.\n5. Irritable bowel syndrome.\n6. Constipation.\n7. Obesity.\n8. Hearing loss, requiring bilateral hearing aids.\n9. Squamous cell carcinoma of the left lower eyelid.\n10. Vitamin D deficiency.\n11. Cerebral infarct.\n12. Falls.\n13. Compression fractures.\nPAST SURGICAL HISTORY: Significant for:\n1. Placement of pacemaker and ICD.\n2. Knee surgery.\n3. Removal of squamous cell carcinoma of his left lower eyelid.\n4. Recent Whipple's procedure for which he was diagnosed with\ndysplasia.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the CCU with full face mask.\nCognition, language, speech, voice: Grossly wfl. Hard of hearing.\nTeeth: edentulous, dentures not present\nSecretions: normal oral secretions\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual strength,\nROM, and buccal tone. Palatal elevation was symmetrical. Gag\ndeferred.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp/straw), bites of\npuree, and a bite of cracker coated with applesauce for\nsoftening. Oral phase grossly wfl with normal oral residue\nremaining. Laryngeal elevation felt adequate to palpation. No\novert change in vocal quality. No throat clearing, coughing, or\nchoking noted. Patient denied the sensation of food or liquid\nstuck in his throat or going down the wrong way. O2 sats remained\nstable at 91%/92%.\nSUMMARY / IMPRESSION:\nDr. appeared to tolerate today's PO trials without overt\ns/sx of aspiration or complaint of pharyngeal residue. Patient\nreportedly already compensating for occasional sensation of\npharyngeal residue (when eating hard solids or eating too fast)\nby using a liquid wash. Recommend he continue baseline diet of\nthin liquids and regular solids, encourage soft foods while\ndentures are not present. Recommend patient keep solid foods\nmoist and alternate bites and sips. If there are further concerns\nfor aspiration on this diet, we will be happy to perform a video\nswallow.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 6 out of 7.\nRECOMMENDATIONS:\n1. PO diet of thin liquids and regular solids, soft foods while\nedentulous.\n2. Pills whole with water as tolerated.\n3. Q8 oral care.\n4. Alternate bites and sips.\n5. Keep hard solid foods moist with extra butter, gravy, sauce,\nor condiments.\n6. If there are further concerns for aspiration on this diet, we\nwill be happy to perform a video swallow.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1515-1530\nTotal time: 45 minutes\n" }, { "category": "Respiratory ", "chartdate": "2141-03-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 527223, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\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 Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes, Tachypneic (RR> 35 b/min); Comments: Pt\n has complex breathing disorder. OSA and respirations.\n Ordered for Bipap 14/9 02 bled in @12 lpm. Uses his own full face mask.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Tolerated well\n" }, { "category": "Nursing", "chartdate": "2141-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527236, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 103.8 PR. WBC=_____. AM lactate 2.1.\n Action:\n *ID following- unclear in PNA is source of temp spike as CXR w/\n improvement\n *Triple IV anbx- cefepime/ flagyl/ vanco\n *Tylenol ATC for pt comfort\n *Ice packs to groin/ armpits\n *Pt pan cultured \n Response:\n Temp remained elevated despite above interventions. Ice packs removed\n and cooling blanket applied at 13:00 w/ Temp down 98-99 F range.\n Continuous rectal temp probe placed for better monitoring. Afternoon\n lactate 1.6.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n" }, { "category": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527353, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT; RN was able to push back in; good placement on repeat\n CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\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 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527354, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT partly; RN was able to push back in; good placement on\n repeat CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\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 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically. Suspect multifactorial etiology of CHF + pneumonia.\n - continue mechanical ventilation, with minimized sedation and daily\n spontaneous breathing trials\n - continue vancomycin, cefepime, Flagyl. Course of azithromycin is\n complete.\n - f/u pending cultures (no positive micro data to date)\n - appreciate pulmonary consult recs\n - diuresis as below\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic.\n - continue diuresis with goal negative 1-2 L today\n - uptitrate metoprolol to dosing\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. One concern would\n be for empyema, although lack of pleural enhancement of chest CT argues\n against this.\n - trend fever curves\n - Tylenol\n - antibiotics as above\n - consider ID consult\n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - add basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - uptitrate metoprolol to \n - continue Coumadin; trend INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527355, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT partly; RN was able to push back in; good placement on\n repeat CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales, wheezes, or\n rhonchi.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: WWP. Trace bilateral LE edema.\n Neuro: Normal lower extremity tone. Knee and ankle jerks absent\n bilaterally.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate,fever, white count consistent with PNA.\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically. Suspect multifactorial etiology of CHF + pneumonia.\n - continue mechanical ventilation, with minimized sedation and daily\n spontaneous breathing trials\n - continue vancomycin, cefepime, Flagyl. Course of azithromycin is\n complete.\n - f/u pending cultures (no positive micro data to date)\n - appreciate pulmonary consult recs\n - diuresis as below\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic.\n - continue diuresis with goal negative 1-2 L today\n - uptitrate metoprolol to dosing\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. One concern would\n be for empyema, although lack of pleural enhancement of chest CT argues\n against this.\n - trend fever curves\n - Tylenol\n - antibiotics as above\n - consider ID consult\n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - add basal insulin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - uptitrate metoprolol to \n - continue Coumadin; trend INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # Chronic antibiotic use: Per o/p ID notes, the patient is on chornic\n cefpodoxime for ongoing suppression after high-grade viridans\n streptococcal bacteremia in the setting of pacer/defibrillator wires\n and to continue intended life-long suppression for suspected Klebsiella\n pneumoniae lead endocarditis during a prior bacteremia. On cefepime per\n ID.\n - holding cefpodoxime while on broad spectrum abx as above\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527481, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp slowly rising since cooling blanket DC\nd 0100. Tmax_____. WBC=\n 11.4. AM lactate 1.6. Remains on droplet precautions while ruling out\n influenza.\n Action:\n *ID following- unclear if PNA is source of temp spike as CXR w/\n improvement\n *Intermittent ice packs to bilat groin sites/ axilla (monitored skin\n closely)/ tepid baths to help decrease temp\n *IV meropenem q 8 hours\n *Tylenol ATC q 6 hrs for pt comfort\n *Pt pan cultured \n Response:\n *Awaiting flu culture.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated MMV: PSV 10/ 10 Peep, FiO2 40%. LS diminished/\n bronchial @ bases. Mod amts thick/ yellow secretions via ETT. SPO2\n >95%. Sedation w/ IV fentanyl @ 100mcg/min. Pt w/ open opening to\n speech, though no eye contact. Not following commands but moving all\n extremities in bed, non-purposeful. Restless legs in bed (present on\n admission).\n Action:\n * Fiberoptic bronchoscopy by pulmonary->______.\n *IV meropenem q 8 hours.\n *Nutrition w/ tubefeeds via NGT.\n *\n Response:\n *\n Plan:\n Continue to monitor resp status. Daily RSBI/SBT, wean vent as\n tolerated. IV fentanyl for comfort. VAP care/ pulm toileting. IV\n meropenem Q 8 hrs.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/crackes at bases. SPO2 mainly>95%. Bilat LE edema. HR\n paced at 50. Underlying rhythm appears to be aflutter. NIBP\n 120s-150s/60s-70s.\n Action:\n *IV lasix 60mg x one at noon\n *Lopressor NGT \n *E-lytes monitored.\n Response:\n *Volume out to lasix_____\n Plan:\n *Continue to monitor resp status/ volume status.\n *\n *Daily wts/ 1500ml fluid restriction\n" }, { "category": "Nursing", "chartdate": "2141-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527475, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent Whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n AICD lead infections. He was admitted to CCU with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and BiPAP, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. Device may not be able to detect VT/VF. Magnet at\n doorway.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Temp slowly rising since cooling blanket DC\nd 0100. Tmax_____. WBC=\n 11.4. AM lactate 1.6. Remains on droplet precautions while ruling out\n influenza.\n Action:\n *ID following- unclear if PNA is source of temp spike as CXR w/\n improvement\n *Intermittent ice packs to bilat groin sites/ axilla (monitored skin\n closely) to help decrease temp\n *IV meropenem q 8 hours\n *Tylenol ATC q 6 hrs for pt comfort\n *Pt pan cultured \n Response:\n *Awaiting flu culture.\n Plan:\n Continue to closely monitor temp/ WBC. Follow up results of culture\n data. Anbx as ordered. Tylenol/ cooling blanket PRN for pt comfort.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt received intubated MMV: PSV 10/ 10 Peep, FiO2 40%. LS diminished/\n bronchial @ bases. Mod amts thick/ yellow secretions via ETT. SPO2\n >95%. Sedation w/ IV fentanyl @ 100mcg/min. Pt w/ open opening to\n speech, though no eye contact. Not following commands but moving all\n extremities in bed, non-purposeful. Restless legs in bed (present on\n admission).\n Action:\n * Fiberoptic bronchoscopy by pulmonary->______.\n *IV meropenem q 8 hours.\n *Nutrition w/ tubefeeds via NGT.\n *\n Response:\n *\n Plan:\n Continue to monitor resp status. Daily RSBI/SBT, wean vent as\n tolerated. IV fentanyl for comfort. VAP care/ pulm toileting. IV\n meropenem Q 8 hrs.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/crackes at bases. SPO2 mainly>95%. Bilat LE edema. HR\n paced at 50. Underlying rhythm appears to be aflutter. NIBP\n 120s-150s/60s-70s.\n Action:\n *IV lasix 60mg x one at noon\n *Lopressor NGT \n *E-lytes monitored.\n Response:\n *Volume out to lasix_____\n Plan:\n *Continue to monitor resp status/ volume status.\n *\n *Daily wts/ 1500ml fluid restriction\n" }, { "category": "Physician ", "chartdate": "2141-03-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 525861, "text": "Chief Complaint: Dyspnea\n HPI:\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum for the past week.\n He also had some low-grade temps at home (Tm 99.8) earlier this week.\n He called his cardiologist on , complaining of this cough and LE\n edema. He was told to increase his lasix to 60mg TIW and 40 mg daily\n the rest of the week. He then presented to gerontology clinic on\n with similar complaints. CXR and CBC done that day were\n unremarkable. He then developed dyspnea over the past 24-36 hours. He\n called cardiology clinic this morning and was instructed to present to\n the ED.\n .\n On arrival to the ED, the patient's VS were 97.1 80 100/60 22 96. He\n was noted to have crackles half-way up bilaterally. CXR reportedly\n showed changes c/w pulmonary edema as well as a ? LLL opacification. In\n the ED, he received Levofloxacin 750mg, Vancomycin 1g, Ondansetron\n 4mg, and Furosemide 40mg. He was admitted to the CCU for further\n management.\n .\n On arrival to the CCU, the patient's VS were T= 98.7 BP= 103/67 HR= 76\n RR= 21 O2 sat= 97% on BiPAP. He reported that his dyspnea was improved.\n He stated that the chest pressure that he experienced earlier had\n resolved. He endorses recent worsening DOE and PND. He also reports\n some chest pressure last night and this morning, which was located\n across his chest, did not radiate, and has since resolved. He reports\n recent 5-pound weight gain. He also reports recent loose stools and\n stable urinary frequency.\n .\n On review of systems, he denied any prior history of stroke. He did\n report a questionable history of TIA. He denied any history of deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, hemoptysis, black stools or red stools. He\n denied recent chills or rigors. He denied exertional buttock or calf\n pain. All of the other review of systems were negative.\n .\n Cardiac review of systems is notable for absence of palpitations or\n syncope.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n MEDICATIONS:\n AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a\n day\n CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily\n FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1\n Tablet(s) by mouth Tues//Sat/Sun and 1.2 tabs (60mg) on M/W/F\n LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by mouth\n once a day\n LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-,000\n unit-,000 unit Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by\n mouth 3x/day\n METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth\n once a day\n NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth \n times/day swish in mouth and swallow\n PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg\n Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth DAILY\n PAROXETINE HCL [PAXIL] - 30 mg Tablet - 1 (One) Tablet(s) by mouth once\n a day\n SIMVASTATIN [ZOCOR] - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a\n day\n TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime Start with\n pill. increase to 1 pill if needed; may increase to total of 2\n pills as needed\n WARFARIN - 1 mg Tablet - 1 (One)-3 Tablet(s) by mouth as directed by MD\n ACETAMINOPHEN - (OTC) - Dosage uncertain\n ASCORBIC ACID - (Prescribed by Other Provider) - 250 mg Tablet - 1\n Tablet(s) by mouth daily\n ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - 81 mg\n Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day\n FERROUS SULFATE [SLOW FE] - 142 mg (45 mg Iron) Tablet Sustained\n Release - 1 (One) Tablet(s) by mouth every other day\n LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (OTC) - Dosage uncertain\n MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1\n (One) Tablet(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n - Anterior wall myocardial infarction in with ventricular\n tachycardia and complete heart block requiring pacemaker\n - Systolic heart failure (EF 20-25%)\n - Atrial fibrillation\n 3. OTHER PAST MEDICAL HISTORY:\n PAST MEDICAL HISTORY:\n 1. Hypertension.\n 2. Hypothyroidism.\n 3. Anemia.\n 4. Irritable bowel syndrome.\n 5. Constipation.\n 6. Obesity.\n 7. Hearing loss, requiring bilateral hearing aids.\n 8. Squamous cell carcinoma of the left lower eyelid.\n 9. Vitamin D deficiency.\n 10. Cerebral infarct.\n 11. Falls.\n 12. Compression fractures.\n 13. History of Whipple operation, with subsequent E. coli and\n Klebsiella bacteremia\n 14. History of possible C3-C4 osteomyelitis\n PAST SURGICAL HISTORY:\n 1. Placement of pacemaker and ICD.\n 2. Knee surgery.\n 3. Removal of squamous cell carcinoma of his left lower eyelid.\n 4. Recent Whipple's procedure for which he was diagnosed with\n dysplasia.\n Strong family history of vascular disease with father deceased of CVA\n at 59, Mother with MI at 70, Brother with MI and CABG in 50's. Also\n reports a family history of diabetes.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Divorced, 2 children. Former pipe and cigarette smoker (quit in\n ). Used to smoke 1ppd X 30 yrs. Drinks glasses of wine/day. No\n illicit drugs.\n Review of systems:\n Flowsheet Data as of 05:21 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 80 (70 - 80) bpm\n BP: 84/71(74) {84/56(68) - 105/75(81)} mmHg\n RR: 21 (18 - 23) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 200 mL\n PO:\n TF:\n IVF:\n 200 mL\n Blood products:\n Total out:\n 0 mL\n 2,370 mL\n Urine:\n 1,520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -2,170 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 92%\n Physical Examination\n VS: T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP\n GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.\n LUNGS: Resp were unlabored, no accessory muscle use. Pt with high-flow\n neb O2 mask on. Crackles noted to of the way up bilaterally.\n Scattered wheezes as well.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain. DP pulses\n palpable bilaterally.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED this morning with a chief\n complaint of dyspnea, likely due to CHF exacerbation.\n .\n # Dyspnea: Likely related to CHF exacerbation. The patient reports\n recent dietary indiscretion; BNP is ~3000. He also reports increased\n leg edema, DOE, and PND recently. He self-increased his PO lasix dose\n this week with little effect. This could have been related to decreased\n absorption of PO lasix in the setting of gut edema. He does report a\n productive cough recently, and his CXR showed a potential LLL\n opacification. However, pneumonia seems unlikely, as he does not have a\n fever or leukocytosis.\n - pt put out very well to 40 mg IV lasix in the ED; will continue to\n monitor I/O and will re-bolus when UOP declines\n - holding on further antibiotics at this time, as pt does not\n clinically appear to have a pneumonia\n - continue metoprolol 12.5 mg daily\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first set of CE's was negative.\n Of note, the patient did report some chest pressure last night and in\n the ED this morning, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3. Telemetry currently showing\n v-paced rhythm.\n - continue coumadin, with goal INR of 2.3\n - need to closely monitor INR, as it may change at patient received\n levofloxacin in the ED\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix bolus PRN\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - continue cefpodoxime\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n .\n .\n FEN: passed speech and swallow eval; low sodium / HH diet\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with therapeutic INR on coumadin\n -Pain management with acetaminophen\n -Bowel regimen with colace/senna\n CODE: FULL CODE, confirmed with patient and his HCP\n : HCP is ()\n DISPO: CCU for now, transfer to floor tomorrow if respiratory status is\n improved\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 527462, "text": "Chief Complaint:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 103.8\nF - 12:00 PM\n Overnight Events:\n - spiked temp to 103; pan cultured, put on cooling blanket\n - consulted ID: recommended switch to meropenem, viral screen\n - pulm recs: rpt cxr in AM, daily SBT, consider bronch tomorrow\n - got lasix 60 mg IV x 2 (one in AM and one in PM)\n - d/c'ed pancreatic enzymes while pt is on TF's\n - increased metoprolol tartrate to \n - started glargine\n - started heparin SC while pt is suptherapeutic on INR\n - noted to have increased CK; d/c'ed simvastatin; did not show signs of\n serotonin syndrome on physical exam\n - pulled out NGT partly; RN was able to push back in; good placement on\n repeat CXR\n - I/O: -800mL at midnight\n - gave 500 cc over 120 mins for elevated CK\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 09:22 AM\n Cefipime - 12:00 PM\n Metronidazole - 04:00 PM\n Meropenem - 12:10 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Heparin Sodium (Prophylaxis) - 05:30 PM\n Furosemide (Lasix) - 08:24 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 37.8\nC (100\n HR: 50 (50 - 51) bpm\n BP: 115/60(73) {110/51(66) - 146/66(84)} mmHg\n RR: 12 (10 - 30) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 102.5 kg (admission): 105 kg\n Height: 72 Inch\n CVP: 17 (13 - 18)mmHg\n Total In:\n 3,244 mL\n 1,254 mL\n PO:\n TF:\n 1,220 mL\n 333 mL\n IVF:\n 1,254 mL\n 721 mL\n Blood products:\n Total out:\n 4,125 mL\n 453 mL\n Urine:\n 4,125 mL\n 453 mL\n NG:\n Stool:\n Drains:\n Balance:\n -881 mL\n 801 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 1,200 (471 - 1,300) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 77\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.42/53/141/30/8\n Ve: 13 L/min\n PaO2 / FiO2: 353\n Physical Examination\n GENERAL: Intubated, sedated, moving legs, does not respond to commands.\n CARDIAC: RRR. No M/G/R.\n LUNGS: Coarse breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting LE edema noted.\n Neuro: Normal lower extremity tone. No hyperreflexia noted. PERRL.\n Labs / Radiology\n 345 K/uL\n 10.2 g/dL\n 167 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.8 %\n 11.4 K/uL\n [image002.jpg]\n 05:10 PM\n 12:23 AM\n 04:48 AM\n 05:03 AM\n 06:50 AM\n 09:14 AM\n 01:02 PM\n 03:51 PM\n 04:50 AM\n 04:55 AM\n WBC\n 10.0\n 11.4\n Hct\n 32.6\n 30.8\n Plt\n 312\n 345\n Cr\n 1.0\n 1.0\n 1.0\n 0.9\n TCO2\n 23\n 27\n 27\n 29\n 30\n 36\n Glucose\n 191\n 170\n 157\n 167\n Other labs: PT / PTT / INR:18.4/30.6/1.7, CK / CKMB /\n Troponin-T:/<0.01, Differential-Neuts:86.5 %, Lymph:7.5 %,\n Mono:4.7 %, Eos:1.1 %, Lactic Acid:1.6 mmol/L, Ca++:7.6 mg/dL, Mg++:2.2\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Elevated CK: Pt noted to have an elevated in CK on labwork yesterday.\n Not likely cardiac in nature, as MB is normal. Serotonin syndrome is a\n possibility in this patient on fentanyl and with high fevers. However,\n physical exam not consistent with serotonin syndrome. Also, the patient\n has been on fentanyl for some time, and you would expect this to have\n shown up sooner. Likely this is mild rhabdomyolysis in the setting of\n prolonged hospitalization and sedation. Pt was given 500 cc overnight\n to help prevent renal damage from the elevated CK. CK trending down\n this morning.\n - continue to trend CK\n - no further IV fluids at this point, as CK not at a significant enough\n level to cause renal failure\n - holding statin\n .\n # Hypoxemic respiratory failure: Was intubated on for hypoxemia.\n Chest CT more consistent with atelectasis/effusion rather than\n pneumonia. Oxygenation improving. Right side clearing\n radiographically as of yesterday. Suspect multifactorial etiology of\n CHF + pneumonia. Of note, pt spiked high temperatures yesterday despite\n being on vanc/cefepime/flagyl. Started on a cooling blanket and\n switched to meropenem\n - continue mechanical ventilation, with daily spontaneous breathing\n trials\n - continue meropenem monotherapy\n - f/u pending cultures (no positive micro data to date)\n - consider bronch today\n .\n # Fever: Likely source is pneumonia, although differential includes\n worsening of known ICD infection. Unclear why patient is continuing to\n spike fevers in spite of broad spectrum antibiotics. After spike to\n 103.8 yesterday, ID was consulted. One concern would be for empyema,\n although lack of pleural enhancement of chest CT argues against this.\n - continue meropenem monotherapy, per ID recs\n - f/u respiratory viral screen\n - f/u repeat CXR this AM\n - consider bronch\n - continue cooling blanket PRN\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n hypervolemic. Was being diuresed with goal negative 1-2 L. However,\n ended up getting some fluid overnight elevated CK.\n - continue to monitor fluid status\n - continue metoprolol \n .\n # Hyperglycemia: No known history of diabetes. Infection is likely\n cause, although it is also possible that patient\ns hyperglycemic is\n related to infusion of meds in D5W.\n - insulin sliding scale\n - continue basal insulin that was added yesterday\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, simvastatin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently subtherapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - continue Coumadin; trend INR\n - heparin SQ for DVT ppx while subtherapeutic INR\n .\n # s/p ICD: high impedance. LV lead dysfunction\n -pacer revison in future\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation while on tube feeds.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:14 AM 55 mL/hour\n Glycemic Control: Comments: Insulin Sliding Scale\n Lines:\n Arterial Line - 09:13 PM\n Multi Lumen - 10:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Coumadin)\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": "Physician ", "chartdate": "2141-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 525957, "text": "Chief Complaint:\n 24 Hour Events:\n - developed more dyspnea and had to be placed back in BiPAP, improved\n after\n - CXR with ?infiltrate on L\n - given cefepime (had already gotten vanc/levo in ED)\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Vancomycin - 09:28 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:10 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 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100.1\n HR: 93 (70 - 98) bpm\n BP: 104/61(71) {84/26(53) - 127/84(89)} mmHg\n RR: 25 (18 - 27) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 980 mL\n 80 mL\n PO:\n 480 mL\n 80 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 3,500 mL\n 200 mL\n Urine:\n 2,650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,520 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 541 (541 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 19 cmH2O\n SpO2: 95%\n ABG: 7.48/37/80./27/3\n Ve: 9.3 L/min\n PaO2 / FiO2: 80\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 11.5 g/dL\n 131 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 98 mEq/L\n 137 mEq/L\n 33.9 %\n 7.4 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n WBC\n 7.4\n Hct\n 33.9\n Plt\n 174\n Cr\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 28\n Glucose\n 134\n 131\n Other labs: CK / CKMB / Troponin-T:232/*/***, Lactic Acid:1.4 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 525959, "text": "Chief Complaint:\n 24 Hour Events:\n - developed more dyspnea and had to be placed back in BiPAP, improved\n after\n - CXR with ?infiltrate on L\n - given cefepime (had already gotten vanc/levo in ED)\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Vancomycin - 09:28 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:10 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 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100.1\n HR: 93 (70 - 98) bpm\n BP: 104/61(71) {84/26(53) - 127/84(89)} mmHg\n RR: 25 (18 - 27) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 980 mL\n 80 mL\n PO:\n 480 mL\n 80 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 3,500 mL\n 200 mL\n Urine:\n 2,650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,520 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 541 (541 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 19 cmH2O\n SpO2: 95%\n ABG: 7.48/37/80./27/3\n Ve: 9.3 L/min\n PaO2 / FiO2: 80\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 11.5 g/dL\n 131 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 98 mEq/L\n 137 mEq/L\n 33.9 %\n 7.4 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n WBC\n 7.4\n Hct\n 33.9\n Plt\n 174\n Cr\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 28\n Glucose\n 134\n 131\n Other labs: CK / CKMB / Troponin-T:232/*/***, Lactic Acid:1.4 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED this morning with a chief\n complaint of dyspnea, likely due to CHF exacerbation.\n .\n # Dyspnea: Likely related to CHF exacerbation. The patient reports\n recent dietary indiscretion; BNP is ~3000. He also reports increased\n leg edema, DOE, and PND recently. He self-increased his PO lasix dose\n this week with little effect. This could have been related to decreased\n absorption of PO lasix in the setting of gut edema. He does report a\n productive cough recently, and his CXR showed a potential LLL\n opacification. However, pneumonia seems unlikely, as he does not have a\n fever or leukocytosis.\n - pt put out very well to 40 mg IV lasix in the ED; will continue to\n monitor I/O and will re-bolus when UOP declines\n - holding on further antibiotics at this time, as pt does not\n clinically appear to have a pneumonia\n - continue metoprolol 12.5 mg daily\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first set of CE's was negative.\n Of note, the patient did report some chest pressure last night and in\n the ED this morning, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3. Telemetry currently showing\n v-paced rhythm.\n - continue coumadin, with goal INR of 2.3\n - need to closely monitor INR, as it may change at patient received\n levofloxacin in the ED\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix bolus PRN\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - continue cefpodoxime\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 525961, "text": "Chief Complaint:\n 24 Hour Events:\n - developed more dyspnea and had to be placed back in BiPAP, improved\n after\n - CXR with ?infiltrate on L\n - given cefepime (had already gotten vanc/levo in ED)\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Cefipime - 08:15 PM\n Vancomycin - 09:28 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:10 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 05:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.8\nC (100.1\n HR: 93 (70 - 98) bpm\n BP: 104/61(71) {84/26(53) - 127/84(89)} mmHg\n RR: 25 (18 - 27) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Height: 72 Inch\n Total In:\n 980 mL\n 80 mL\n PO:\n 480 mL\n 80 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 3,500 mL\n 200 mL\n Urine:\n 2,650 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,520 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 541 (541 - 541) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 8 cmH2O\n FiO2: 100%\n PIP: 19 cmH2O\n SpO2: 95%\n ABG: 7.48/37/80./27/3\n Ve: 9.3 L/min\n PaO2 / FiO2: 80\n Physical Examination\n GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink.\n NECK: Supple. Unable to appreciate JVP.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.\n LUNGS: Resp were unlabored, no accessory muscle use. Pt with high-flow\n neb O2 mask on. Crackles noted to of the way up bilaterally.\n Scattered wheezes as well.\n ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia\n present.\n EXTREMITIES: No significant LE edema noted. No calf pain. DP pulses\n palpable bilaterally.\n Labs / Radiology\n 174 K/uL\n 11.5 g/dL\n 131 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 26 mg/dL\n 98 mEq/L\n 137 mEq/L\n 33.9 %\n 7.4 K/uL\n [image002.jpg]\n 05:38 PM\n 08:15 PM\n 04:30 AM\n WBC\n 7.4\n Hct\n 33.9\n Plt\n 174\n Cr\n 1.2\n 1.1\n TropT\n <0.01\n TCO2\n 28\n Glucose\n 134\n 131\n Other labs: CK / CKMB / Troponin-T:232/*/***, Lactic Acid:1.4 mmol/L,\n Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED this morning with a chief\n complaint of dyspnea, likely due to CHF exacerbation.\n .\n # Dyspnea: Likely related to CHF exacerbation. The patient reports\n recent dietary indiscretion; BNP is ~3000. He also reports increased\n leg edema, DOE, and PND recently. He self-increased his PO lasix dose\n this week with little effect. This could have been related to decreased\n absorption of PO lasix in the setting of gut edema. He does report a\n productive cough recently, and his CXR showed a potential LLL\n opacification. However, pneumonia seems unlikely, as he does not have a\n fever or leukocytosis.\n - pt put out very well to 40 mg IV lasix in the ED; will continue to\n monitor I/O and will re-bolus when UOP declines\n - holding on further antibiotics at this time, as pt does not\n clinically appear to have a pneumonia\n - continue metoprolol 12.5 mg daily\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Pt\n denies any current chest pain, and the first set of CE's was negative.\n Of note, the patient did report some chest pressure last night and in\n the ED this morning, but this has since resolved.\n - will continue to rule out MI with 3 sets of CE's\n - continue to monitor for any chest pain\n .\n # RHYTHM: Pt with a history of a.fib, for which he is on coumadin. His\n INR is currently therapeutic at 2.3. Telemetry currently showing\n v-paced rhythm.\n - continue coumadin, with goal INR of 2.3\n - need to closely monitor INR, as it may change at patient received\n levofloxacin in the ED\n .\n # Hypertension: Normotensive at this time.\n - continue metoprolol tartrate\n - lasix bolus PRN\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Pt currently near his baseline.\n - continue iron supplementation\n - continue to trend hct\n - bowel regimen with colace/senna\n .\n # ID: Per o/p ID notes, the patient is on chornic cefpodoxime for\n ongoing suppression after high-grade viridans streptococcal bacteremia\n in the setting of pacer/defibrillator wires and to continue intended\n life-long suppression for suspected Klebsiella pneumoniae lead\n endocarditis during a prior bacteremia.\n - continue cefpodoxime\n .\n # S/p Whipple:\n - continue pancreatic enzyme repletion\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2141-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525883, "text": "71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, s/p BiV\n ICD implantation with subsequent revisions due to the presence of\n malfunctioning lead, who presented to the ED this morning with a chief\n complaint of dyspnea. The patient reports that he began having a cough\n productive of dark beige sputum for the past week. He also had some\n low-grade temps at home (Tm 99.8) earlier this week. He called his\n cardiologist on , complaining of this cough and LE edema. He was\n told to increase his lasix to 60mg TIW and 40 mg daily the rest of the\n week. He then presented to gerontology clinic on with similar\n complaints. CXR and CBC done that day were unremarkable. He then\n developed dyspnea over the past 24-36 hours. He called cardiology\n clinic this morning who told him to come to ED- called EMS.\n .\n On arrival to the ED, the patient's VS were 97.1, 80, 100/60, 22, 96.\n He was noted to have crackles half-way up bilaterally. CXR reportedly\n showed changes c/w pulmonary edema as well as a ? LLL opacification. In\n the ED, he received Levofloxacin 750mg, Vancomycin 1g, Ondansetron\n 4mg, and Furosemide 40mg. He was admitted to the CCU for further\n management.\n .\n On arrival to the CCU, the patient's VS were T= 98.7 BP= 103/67 HR= 76\n RR= 21 O2 sat= 97% on BiPAP. He reported that his dyspnea was improved.\n He stated that the chest pressure that he experienced earlier had\n resolved. He endorses recent worsening DOE and PND. He also reports\n some chest pressure last night and this morning, which was located\n across his chest, did not radiate, and has since resolved. He reports\n recent 5-pound weight gain. He also reports recent loose stools and\n stable urinary frequency.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/ rhonchi/ exp wheezes throughout. SPO2 97% on\n NIMV/BiPap. RR teens. Speaking in full sentences, no s/s resp distress.\n +Orthopnea, +DOE. Bilat LE edema 2+. Wt on bedscale 105kg.\n Action:\n *1500ml fluid restriction\n *Diuresing large amts to 40 lasix given\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2141-03-03 00:00:00.000", "description": "CCU Fellow Admit Note", "row_id": 525815, "text": "TITLE: CCU Fellow Admit Note\n 72M CAD s/p anterior MI, VT/VF s/p ICD, CHF, AF admitted with dyspnea.\n Notes weight has been increasing over the past few weeks, gained 4 lb\n in the past 2 days. +orthopnea. Has been compliant with meds. Admits to\n dietary indiscretion. Chest discomfort initially but now chest pain\n free. +cough. Given abx for ?PNA in ED as well as IV lasix. Placed on\n BiPAP given O2 sat in 80s on NRB.\n VS: 98.7 105/55 70 18 89% on FM\n Pleasant male, NAD\n JVP difficult to assess\n S1/S2 II/VI HSM apex\n Crackles throughout lung fields\n Distended abd, soft NT, +BS, small ventral hernia\n No , cool extremities\n Labs:\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [1] 10:15AM\n 152*[1]\n 28*\n 1.1\n 135\n 4.4\n 99\n 25\n 15\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [2] 10:15AM\n 7.1\n 3.71*\n 11.9*\n 35.3*\n 95#[1]\n 32.0\n 33.7\n 14.4\n 166\n CPK ISOENZYMES\n CK-MB\n cTropnT\n proBNP\n [3] 10:15AM\n 4\n <0.01[1]\n 3057\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [4] 10:15AM\n 27\n 36\n 126[1]\n 139*\n 0.6\n CXR: mild vasc congestion\n TTE : , dilated LV with severe global HK (EF 20-25), mod MR,\n mild-mod TR, TR gradient 33\n A/P: 72M CAD s/p MI, VT/VF s/p ICD, AF admitted with dyspnea and volume\n overload c/w CHF exacerbation.\n -cycle cardiac biomarkers\n -lasix for diuresis -> excellent response to dose given in ED\n -cont cardiac regimen as bp tolerates\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_5%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_9%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_7%22);\n" }, { "category": "Nursing", "chartdate": "2141-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525888, "text": "71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, s/p BiV\n ICD implantation with subsequent revisions due to the presence of\n malfunctioning lead, who presented to the ED this morning with a chief\n complaint of dyspnea. The patient reports that he began having a cough\n productive of dark beige sputum for the past week. He also had some\n low-grade temps at home (Tm 99.8) earlier this week. He called his\n cardiologist on , complaining of this cough and LE edema. He was\n told to increase his lasix to 60mg TIW and 40 mg daily the rest of the\n week. He then presented to gerontology clinic on with similar\n complaints. CXR and CBC done that day were unremarkable. He then\n developed dyspnea over the past 24-36 hours. He called cardiology\n clinic this morning who told him to come to ED- called EMS.\n .\n On arrival to the ED, the patient's VS were 97.1, 80, 100/60, 22, 96.\n He was noted to have crackles half-way up bilaterally. CXR reportedly\n showed changes c/w pulmonary edema as well as a ? LLL opacification. In\n the ED, he received Levofloxacin 750mg, Vancomycin 1g, Ondansetron\n 4mg, and Furosemide 40mg. He was admitted to the CCU for further\n management.\n .\n On arrival to the CCU, the patient's VS were T= 98.7 BP= 103/67 HR= 76\n RR= 21 O2 sat= 97% on BiPAP. He reported that his dyspnea was improved.\n He stated that the chest pressure that he experienced earlier had\n resolved. He endorses recent worsening DOE and PND. He also reports\n some chest pressure last night and this morning, which was located\n across his chest, did not radiate, and has since resolved. He reports\n recent 5-pound weight gain. He also reports recent loose stools and\n stable urinary frequency.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/ diffuse crackles/ exp wheezes throughout. SPO2 97% on\n NIMV/BiPap. RR teens. Speaking in full sentences, no s/s resp distress.\n +Orthopnea, +DOE. Bilat LE edema 2+. Wt on bedscale 105kg. BNP 3057.\n NIBP 100s-110s/ 60s-70s. HR 70s-80s V-paced w/ PVCs.\n Action:\n *Monitored resp status. Weaned NIMV to high flow/cool neb, FiO2 60%.\n *CXR in ED c/w volume overload\n *Diuresing large amts to 40 lasix given in ED\n *Home dose lopressor\n *1500ml fluid restriction\n Response:\n SPO2 mainly >90% on above O2 requirement. Does desat to mid 80s when on\n 5L NC for eating, recovers when mask re-applied. Pt without SOB w/\n desaturating. VSS. Net negative 2200ml at 18:30.\n Plan:\n Continue to closely monitor resp status/ diuresis/ O2 requirement.\n Follow up results PM lytes in setting of diuresis.\n Pt and significant other reporting unspecified dysphagia.\n Fever->\n" }, { "category": "Nursing", "chartdate": "2141-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525889, "text": "71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, s/p BiV\n ICD implantation with subsequent revisions due to the presence of\n malfunctioning lead, who presented to the ED this morning with a chief\n complaint of dyspnea. The patient reports that he began having a cough\n productive of dark beige sputum for the past week. He also had some\n low-grade temps at home (Tm 99.8) earlier this week. He called his\n cardiologist on , complaining of this cough and LE edema. He was\n told to increase his lasix to 60mg TIW and 40 mg daily the rest of the\n week. He then presented to gerontology clinic on with similar\n complaints. CXR and CBC done that day were unremarkable. He then\n developed dyspnea over the past 24-36 hours. He called cardiology\n clinic this morning who told him to come to ED- called EMS.\n .\n On arrival to the ED, the patient's VS were 97.1, 80, 100/60, 22, 96.\n He was noted to have crackles half-way up bilaterally. CXR reportedly\n showed changes c/w pulmonary edema as well as a ? LLL opacification. In\n the ED, he received Levofloxacin 750mg, Vancomycin 1g, Ondansetron\n 4mg, and Furosemide 40mg. He was admitted to the CCU for further\n management.\n .\n On arrival to the CCU, the patient's VS were T= 98.7 BP= 103/67 HR= 76\n RR= 21 O2 sat= 97% on BiPAP. He reported that his dyspnea was improved.\n He stated that the chest pressure that he experienced earlier had\n resolved. He endorses recent worsening DOE and PND. He also reports\n some chest pressure last night and this morning, which was located\n across his chest, did not radiate, and has since resolved. He reports\n recent 5-pound weight gain. He also reports recent loose stools and\n stable urinary frequency.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/ diffuse crackles/ exp wheezes throughout. SPO2 97% on\n NIMV/BiPap. RR teens. Speaking in full sentences, no s/s resp distress.\n +Orthopnea, +DOE. Bilat LE edema 2+. Wt on bedscale 105kg. BNP 3057.\n NIBP 100s-110s/ 60s-70s. HR 70s-80s V-paced w/ PVCs.\n Action:\n *Monitored resp status. Weaned NIMV to high flow/cool neb, FiO2 60%.\n *CXR in ED c/w volume overload\n *Diuresing large amts to 40 lasix given in ED\n *Home dose lopressor\n *1500ml fluid restriction\n Response:\n SPO2 mainly >90% on above O2 requirement. Does desat to mid 80s when on\n 5L NC for eating, recovers when mask re-applied. Pt without SOB w/\n desaturating. VSS. Net negative 2200ml at 18:30.\n Plan:\n Continue to closely monitor resp status/ diuresis/ O2 requirement.\n Follow up results PM lytes in setting of diuresis.\n *Pt and significant other reporting unspecified dysphagia. Seen by our\n S&S this afternoon- please see note in metavision. No major deficits\n noted. Able to resume regular diet and swallow pills whole w/ water.\n *Pt w/ Temp 100.3 PO at 1800. Blood cxs sent x 2 and UA/ C&S sent in\n ED. Already rec\nd IV levaquin and IV Vanco today. Pt takes PO anbx at\n home for lifelong immunosuppression of klebsiella\n" }, { "category": "Nursing", "chartdate": "2141-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 525890, "text": "71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, s/p BiV\n ICD implantation with subsequent revisions due to the presence of\n malfunctioning lead, who presented to the ED this morning with a chief\n complaint of dyspnea. The patient reports that he began having a cough\n productive of dark beige sputum for the past week. He also had some\n low-grade temps at home (Tm 99.8) earlier this week. He called his\n cardiologist on , complaining of this cough and LE edema. He was\n told to increase his lasix to 60mg TIW and 40 mg daily the rest of the\n week. He then presented to gerontology clinic on with similar\n complaints. CXR and CBC done that day were unremarkable. He then\n developed dyspnea over the past 24-36 hours. He called cardiology\n clinic this morning who told him to come to ED- called EMS.\n .\n On arrival to the ED, the patient's VS were 97.1, 80, 100/60, 22, 96.\n He was noted to have crackles half-way up bilaterally. CXR reportedly\n showed changes c/w pulmonary edema as well as a ? LLL opacification. In\n the ED, he received Levofloxacin 750mg, Vancomycin 1g, Ondansetron\n 4mg, and Furosemide 40mg. He was admitted to the CCU for further\n management.\n .\n On arrival to the CCU, the patient's VS were T= 98.7 BP= 103/67 HR= 76\n RR= 21 O2 sat= 97% on BiPAP. He reported that his dyspnea was improved.\n He stated that the chest pressure that he experienced earlier had\n resolved. He endorses recent worsening DOE and PND. He also reports\n some chest pressure last night and this morning, which was located\n across his chest, did not radiate, and has since resolved. He reports\n recent 5-pound weight gain. He also reports recent loose stools and\n stable urinary frequency.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished/ diffuse crackles/ exp wheezes throughout. SPO2 97% on\n NIMV/BiPap. RR teens. Speaking in full sentences, no s/s resp distress.\n +Orthopnea, +DOE. Bilat LE edema 2+. Wt on bedscale 105kg. BNP 3057.\n NIBP 100s-110s/ 60s-70s. HR 70s-80s V-paced w/ PVCs.\n Action:\n *Monitored resp status. Weaned NIMV to high flow/cool neb, FiO2 60%.\n *CXR in ED c/w volume overload\n *Diuresing large amts to 40 lasix given in ED\n *Home dose lopressor\n *1500ml fluid restriction\n Response:\n SPO2 mainly >90% on above O2 requirement. Does desat to mid 80s when on\n 5L NC for eating, recovers when mask re-applied. Pt without SOB w/\n desaturating. VSS. Net negative 2200ml at 18:30.\n Plan:\n Continue to closely monitor resp status/ diuresis/ O2 requirement.\n Follow up results PM lytes in setting of diuresis.\n *Pt and significant other reporting unspecified dysphagia. Seen by our\n S&S this afternoon- please see note in metavision. No major deficits\n noted. Able to resume regular diet and swallow pills whole w/ water.\n *Pt w/ Temp 100.3 PO at 1800. Blood cxs sent x 2 and UA/ C&S sent in\n ED. Already rec\nd IV levaquin and IV Vanco today.\n *Of note, patient on chornic cefpodoxime for ongoing suppression after\n high-grade viridans streptococcal bacteremia in the setting of\n pacer/defibrillator wires and to continue intended life-long\n suppression for suspected Klebsiella pneumoniae lead endocarditis\n during a prior bacteremia. Followed closely by out-pt ID team who has\n seen him here since arrival.\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532324, "text": "Delirium / confusion\n Assessment:\n Needs frequent reorientation. Thinks he is leaving and needs to get\n dressed. Slept in short naps. Tried to climb oob once. Said\n the\n medicine makes me do funny things\n Action:\n Monitor, pt received 6.25 mg seroquel at HS. have it prn if\n agitation occurs\n Response:\n Delirium much improved on low dose seroquel\n Plan:\n Continue seroquel in eve, monitor, frequent re-orientation\n Dysphagia\n Assessment:\n Had been only on sm amts applesauce w/ meds\n Action:\n Speech/swallow study yesterday and has progressed to nectar thickened\n liquids and pureed solids with supervision/ aspiration precautions.\n Response:\n Enjoys cranberry juice. Tol po\ns well throughout the night. Now takes\n meds whole in teaspoon of pudding.\n Plan:\n Calorie counts\n Continue 1:1 supervision\n Aspiration precautions\n Heparin GTT restarted yesterday to keep INR therapeuticX 24 hours. PTT\n therapeutic at 2300 and 0500 on 950units/hr.. Receiving Coumadin\n daily. Plan: ? transfer to rehab today\n" }, { "category": "Physician ", "chartdate": "2141-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531860, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - evaluated by geriatrics yesterday who recommended serroquel for\n agitation\n - received seroquel + Zydis with improvement in delirium/agitation\n overnight, however quite somnolent in the am\n - able to take some applesauce last night\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98\n HR: 75 (73 - 77) bpm\n BP: 94/54(63) {91/44(58) - 123/80(84)} mmHg\n RR: 21 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 92.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,163 mL\n 98 mL\n PO:\n TF:\n 741 mL\n IVF:\n 422 mL\n 98 mL\n Blood products:\n Total out:\n 2,040 mL\n 145 mL\n Urine:\n 2,040 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n -877 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Somnolent, minimally responsive, pedaling movements of legs when\n in light sleep. Not alert and only oriented to self this a.m.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 319 K/uL\n 11.2 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 35.6 %\n 5.4 K/uL\n [image002.jpg] mg 2.1 ca 9.1 mg 2.1 INR 1.2 PTT\n 82.3\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n WBC\n 5.8\n 9.5\n 8.3\n 6.0\n 5.4\n Hct\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n Plt\n 69\n 319\n Cr\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 100\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n MICROBIOLOGY:\n Urine cx pending\n RADIOLOGY\n Chest X ray\n The position of the lines of the ICD device is unchanged. No\n pneumothorax is\n present. The lung fields are clear. The endotracheal tube has been\n removed.\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced on .\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG (avoid Haldol)\n #hypotension: This am pt noted to have hypotension with SBPs in the\n high 60\ns upon sitting in chair. Concern for tampenade given recent\n lead revision. However, pulsus was 10 mm hg which is baseline for the\n patient. STAT echo obtained showed no evidence of effusion. Pt given\n 250 cc NS and BP corrected to 90s. Likely etiology is intravascular\n depletion in setting of poor PO intake.\n - continue to monitor BP\n - small boluses PRN\n - hold lasix\n - BP holding parameters on metoprolol\n # Mental Status\n Delirium markedly exacerbated by many psychotropics and sedatives. D/w\n geriatrics and appreciate their recommendations. The patient likely\n had hypoxic injury, ICU delirium, with possible undderlying\n neurodegenerative disease. Given possibility of Body Disease, they\n recommended not using Haldol or ativan, but instead using Seroquel or,\n if this is not possible, then Zydis. Avoid Haldol because of likely\n underlying disease and arrhythmogenicity/prolonged QT. Also taper Paxil\n because of the anticholinergic properties. Last night the patient\n agitation was improved with seroquel, however he was heavily sedated\n this am. Of note, we should make sure not to score limb movements\n (restless legs) as agitation.\n - decrease Seroquel to 6.25 (if possible) for standing dose before\n bedtime with repeat x 1 if no result within 1 hour\n - if pt requires more sedation overnight may try PRN seroquel, or if\n unable to give may try zydis x 1 PRN\n - try to avoid sedation during the day to preserve better sleep/wake\n cycle\n - Taper paxil to 20 mg q day\n - Avoid Haldol and ativan\n # Dysphagia\n Failed video swallow on multiple occasions. Had NGT but removed\n several times by patient. Mental status improving and pt tolerated\n applesauce last night. However, failed repeat swallow study this am.\n - consider PEG tube for short term nutrition as pt has potential to\n improve with time once ICU delirium/mental status improves\n - NPO except meds\n # Hypoxia\n Resolving\n doing well on nasal canula. Patient was intubated from\n for hypoxemic respiratory failure from pneumonia + heart\n failure. Reintubated for pacemaker revision. Was on room air, but\n drifts down to high 80s while sleeping, possibly related to undiagnosed\n OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n - F/u Is/Os\n -no abx for now (except cefpodoxime for one week as above)\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Continue coumadin\n - continue heparin gtt until bridged (INR 1.2)\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic.\n - holding PO lasix given hypotension this am\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now, but may consider restarting different \n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition: NPO, except meds\n - considering PEG tube\n Glycemic Control: insulin SS\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: hep gtt, coumadin\n Stress ulcer:\n Communication: Comments: (HCP)\n status: full code\n Disposition: CCU for now, consider transfer to LTAC\n" }, { "category": "Nursing", "chartdate": "2141-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531746, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n Ventricular tachycardia, sustained\n Assessment:\n Pt 100% paced; no runs of v-tach observed this shift\n Action:\n Pt continuously monitored; received lopressor as ordered.\n Response:\n No v-tach this shift, 100% a-v paced;\n Plan:\n Continue cardiac monitoring\n Delirium / confusion\n Assessment:\n Pt putting legs over siderail;\n Pt pulled heparin off where plugged into PICC port;\n Though able to retain and repeat back later information from\n conversation w/ nurse;\n Pt rested w/ hs meds, until 3a, became restless/agitated again,\n medicated again as ordered, didn\nt settle into restfulness again until\n about 4:20 a.m.;\n Action:\n Heparin replaced with fresh cap; taped on;\n Pt requested sleeping pill at hs (21:00), received trazadone hs as\n ordered;\n Also received olanzapine at 23:30 d/t continued restlessness/agitation;\n Medicated again at 3a as stated above for return of\n restlessness/agitation;\n Response:\n Still occasionally calling out, did request and received bedpan, no\n stool (had large stool earlier in the day);\n Plan:\n Pt w/ prn anti-aggitation meds (seroquel, olanzapine);\n Next PTT with a.m. labs\n Dysphagia\n Assessment:\n Pt w/ hx having pulled out feeding tube x3;\n Pt reportedly with improved alertness today, via shift RN and via\n s.o. (who identified herself on phone as\nwife\n Action:\n put up to 80 degrees, pt given small amt of custard, swallowed\n without difficulty;\n Therefore received a few pills in teaspoon of custard.\n Response:\n Pt swallowed without any difficulty or coughing at all.\n Plan:\n Suggest repeat of swallow study as patient increases alertness.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Pt 100% paced so far this noc; vss;\n Action:\n Urine output continues to be followed closely via foley catheter\n Response:\n Very good urine output so far this shift\n Plan:\n Continue to follow\n Daily weights as ordered.\n Pt\ns s.o. called about 20:00; Pt\ns daughter called about 21:30.\n" }, { "category": "Physician ", "chartdate": "2141-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531840, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n \n - continued to have delirium, agitation, restlessness, worse at night\n - gave haldol to control agitation\n - unable to find sitter so kept him in CCU another night given concern\n for significant agitation\n - was negative 1200cc with just his home PO lasix dose (40mg)\n - per review of speech/swallow recs, he is unlikely to regain\n significant swallow function in a timely manner; possibility of PEG\n should be discussed w/ family\n - dc'd art line\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (72 - 78) bpm\n BP: 118/68(80) {97/42(57) - 152/68(80)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 981 mL\n 144 mL\n PO:\n TF:\n IVF:\n 681 mL\n 144 mL\n Blood products:\n Total out:\n 2,250 mL\n 100 mL\n Urine:\n 2,250 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,269 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Somnolent, minimally responsive, pedaling movements of legs when\n in light sleep. Not alert and only oriented to self this a.m.\n Labs / Radiology\n 269 K/uL\n 10.5 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 106 mEq/L\n 138 mEq/L\n 32.7 %\n 6.0 K/uL\n [image002.jpg]\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.5\n 5.8\n 9.5\n 8.3\n 6.0\n Hct\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 09\n 269\n Cr\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n TCO2\n 28\n 26\n Glucose\n 120\n 100\n 88\n 193\n 171\n 132\n 119\n Other labs: PT / PTT / INR:13.3/32.8/1.1, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR \n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Microbiology: Nothing since - coag. negative staph thought to be\n contaminant\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restarting Coumadin\n -heparin IV weight based protocol bridge to coumadin\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG (avoid Haldol)\n # Mental Status\n Delirium markedly exacerbated by many psychotropics and sedatives. D/w\n geriatrics today. They also feel that there is baseline hypoxic injury\n with likely superimposed neurodegenerative disease. Given possibility\n of Body Disease, they recommend not using Haldol or ativan, but\n instead using Seroquel or, if this is not possible, then Zydis. Avoid\n Haldol because of likely underlying disease and\n arrhythmogenicity/prolonged QT. Also taper Paxil because elderly and\n has significant RLS/PLMD.\n - per . Team\n Seroquel 12.5 mg QAM then 12.5 Q6H PRN agitation\n making sure not to score limb movements as agitation.\n - Taper Paxil once discussed why he is on this (there may be a good\n reason)\n - Avoid Haldol and ativan\n - Use Zydis 2.5 mg wafer if cannot given Serquel.\n # Hypoxia\n Resolving\n doing well on nasal canula. Patient was intubated from\n for hypoxemic respiratory failure. Etiology likely pneumonia\n + heart failure. Currently resolving, was on room air, but drifts down\n to high 80s while sleeping, possibly related to undiagnosed OSA. Got\n some 2L or so of fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow, but reevaluate given Dopoff removed again.\n -If delirium has not been cause of dysphagia then consider surgery\n consult for PEG (per Geriatrics)\n -wean O2 as tolerated\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n - Will need to consider PEG in future\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: FULL\n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 13:21 ------\n" }, { "category": "Rehab Services", "chartdate": "2141-03-27 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 531838, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 428.0 / CHF\n Reason of referral: Re-evaluation\n History of Present Illness / Subjective Complaint: 72yom with multiple\n vascular risks factors admitted with dyspnea thought to be\n due to CHF. Pt subsequently found to have PNA on CXR and RV ICD lead\n fracture. Pt currently in ICU and course has been complicated by\n fevers and VT arrest requiring external defibrillation. pt\n underwent RV/RA lead extractions and ICD exchange with EP service. Pt\n intubated for 24hrs post-procedure, now extubated and on RA. Course\n also complicated by persistent delirium for which geriatric service has\n been following patient.\n Past Medical / Surgical History:\n HTN\n Anterior MI\n Vtach\n CHB\n Pacemaker and ICD placement\n Afib\n sCHF EF 20-25%\n Hypothyroidism\n Anemia\n IBS/Constipation\n Obesity\n Hearing loss c B hearing aids\n Vit D deficiency\n Cerebral infarct\n Compression fractures\n Whipple Procedure\n Removal of L lower eyelid squamous cell CA\n C3-C4 osteomyelitis\n Knee surgery\n Medications:\n ASA\n Acetaminophen\n Ibuprofen\n Amiodarone\n Metoprolol\n Warfarin\n Radiology:\n CXR: lead position unchanged\n Labs:\n 35.6\n 11.2\n 319\n 5.4\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: Please see initial evaluation.\n Living Environment: Please see initial evaluation.\n Prior Functional Status / Activity Level: Please see initial\n evaluation.\n Objective Test\n Arousal / Attention / Cognition / Communication: A&Ox3 initially,\n cooperative with garbled speech. Over course of treatment pt's BP\n dropped 10mmHg and he became more somnolent, responding less\n consistently to commands, however still alert when cued. RN aware.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 80\n 86/57\n 17\n 99% RA\n Rest\n /\n Sit\n 90\n 78/40\n 99% RA\n Activity\n /\n Stand\n /\n Recovery\n 86\n 81/60\n 25\n 100% RA\n Total distance walked: NA\n Minutes:\n Pulmonary Status: NARD, sat well on RA.\n Integumentary / Vascular: R UE PICC line, foley catheter, telemetry, L\n upper chest wall dressing over incision C/D/I.\n Sensory Integrity: Intact to light touch B UEs/LEs, denies numbness and\n tingling throughout.\n Pain / Limiting Symptoms: Pt denies pain, evidence of fatigue\n throughout session limiting ability to fully cooperate with exam.\n Hypotension also limiting exam.\n Posture: Pt received in bed, formal postural assessment deferred until\n EOB sitting assessed.\n Range of Motion\n Muscle Performance\n WFL B UEs/ B shoulders assessed to 90degrees only precautions\n >/= B UEs/ B shoulder flexion 3-/5\n Motor Function: Coordination: +dysmetria with B FTN (? true\n coordinative deficit vs. strength deficit)\n Vision: acuity intact with glasses donned\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Mobility deferred hypotension and pt lethargy.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: NA\n Education / Communication:\n Ed: role of PT, benefit of participation, PT recs.\n c RN re: pt's status, level of A, VS, PT recs.\n Intervention: Impairment level assessment.\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Gait, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Transfers, Impaired\n 6.\n Cognition, Impaired\n Clinical impression / Prognosis: 72yom admitted with multiple medical\n problems, now s/p ICD lead exchange with persistent delirium. Pt at\n this time p/w above impairments c/w cardiovascular pump dysfunction and\n resultant deconditioning from prolonged hospital stay. Pt at this time\n is functioning significantly below baseline, limited by his cognitive\n and arousal deficits as well as his strength deficits and activity\n intolerance as evidenced by his postural and baseline hypotension.\n Given pt's age, PLOF and extensive cardiac history, pt had guarded\n rehab potential, however if acute medical issues such as delirium and\n cardiac instability resolve, then anticipate pt will make good\n functional gains and progress to independence with household level\n mobility. PT will continue to follow patient 2-4x/week to progress all\n mobility, however pt will require rehab once medically stable for d/c\n to maximize functional potential.\n Goals\n Time frame: <1 week\n 1.\n Eyes open 100% of treatment\n 2.\n Follows 100% of simple commands\n 3.\n modA to transition supine to sitting EOB\n 4.\n Tolerates EOB sitting x 5 minutes with modA\n 5.\n Tolerates Transfer assessment\n 6.\n Tolerates Sit to Stand assessment\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-4x/week x 1 week\n *Bed Mobility\n *EOB Sitting Balance\n *Sit to Stand Assessment\n *Transfer Assessment\n *Cognitive Re-evaluation\n *Pt Education\n *D/ Planning\n RN Recommendations:\n *OOB TID if VSS via Lift\n Time Frame: 12:15-12:50\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "General", "chartdate": "2141-03-27 00:00:00.000", "description": "Generic Note", "row_id": 531852, "text": "TITLE:\n Cardiology attending Note\n 45 minutes including meeting with health care proxy\n Remaining issue is delirium\n Minimize night time sedation\n Failed speech and swallow study\n need to consider peg in next few days\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531938, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n : extubated. Neo weaned off.\n : agitated and yelling .. haldol with no effect.\n : gerontology consult. Recommended seroquel. Pt. self d/c\n dobhoff again (5^th time).\n : was sleepy from seroquel 12.5mg, trazadone and zyprexa given\n night previous. BP down to 60-70\ns/ when sitting up. Gave total 1L NS\n during day. Lopressor was held.\n Delirium / confusion\n Assessment:\n Pt. able to state name only. Remains confused but not as restless.\n Staying in bed and no attemps to swing legs over bed rails. No\n agitation. Asking for something to drink/eat.\n Action:\n Seroquel 6.25mg at per gerontology recs.\n Pt. in low bed with pads on. Oriented as needed.\n Response:\n No restraints needed. Pt. slept for a lot of the night. Woke\n intermittently but would go back to sleep.\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n No VT. s/p ICD/pacer lead extraction with new leads and generator\n .\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532055, "text": "Chief Complaint: Dyspnea, decompensated heart failure\n 24 Hour Events:\n - had hypotension in morning tat responded to IV bolus, 250 cc NS\n - STAT echo obtained to r/o ventricular perforation --> no evidence\n - required PM bolus for hypotension to 60s, 500 cc NS\n - talked with geriatrics who recommend continue seroquel standing dose\n at night to promote sleep, and then PRN throughout the day. (both 6.25\n mg seroquel)\n - Also decreased paxil from 30 to 20\n - talked with surgery about a PEG, but they recommend a bridled DH tube\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (97\n HR: 76 (72 - 90) bpm\n BP: 82/49(58) {63/32(45) - 116/81(85)} mmHg\n RR: 13 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,540 mL\n 151 mL\n PO:\n TF:\n IVF:\n 1,540 mL\n 151 mL\n Blood products:\n Total out:\n 1,215 mL\n 220 mL\n Urine:\n 1,215 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 325 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: Arcus senilius, no icterus, MM dry.\n CV: R (occasional ectopy) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m. (improvement).\n Less sedated this a.m. Moving limbs purposively. Gait not evaluated.\n Labs / Radiology\n 306 K/uL\n 11.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 36.1 %\n 5.6 K/uL\n [image002.jpg]\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n Hct\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n Plt\n 19\n 306\n Cr\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: Echo \n IMPRESSION: Moderately dilated left ventricular cavity with severe\n global systolic dysfunction accompanied by thinning and akinesis of the\n basal and mid anteroseptal walls and an apical aneurysm. Biatrial\n enlargement. Mild mitral regurgtitation. Mild tricuspid regurgitation.\n Borderline pulmonary artery systolic hypertension. No echocardiographic\n evidence of pericardial tamponade.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Microbiology: No new growth (only growth is coag - staph on \n thought to be contaminant.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension and NPO\n - F/u Is/Os\n - Continue metoprolol \n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - cefpodoxime for one week from \n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarting Coumadin, bridged with heparin gtt\n # Mental Status\n Patient has evidence of ischemic injury on CT (white matter hypodense\n in watershed between ACA and MCA left posterior frontal. Some frontal\n release on exam (grasp). Some mild dysarthria with dysphagia, per S&S\n (see below). Delirium markedly exacerbated by many psychotropics and\n sedatives. D/w geriatrics and appreciated their recommendations. The\n patient likely had hypoxic injury, ICU delirium, with possible\n underlying neurodegenerative disease. Given possibility of Body\n Disease, they recommended not using Haldol or ativan, but instead using\n Seroquel or, if this is not possible, then Zydis. Avoid Haldol because\n of likely underlying disease and arrhythmogenicity/prolonged QT. Also\n taper Paxil because of its anticholinergic properties and exacerbation\n of akathisia. Initial dose of seroquel was very sedating (12.5) so\n halved and standing dose shifted from am to pm. Of note, we should\n make sure not to score limb movements (restless legs) as agitation.\n - Seroquel to 6.25 mg PO QPM with repeat x 1 if no result within 1 hour\n - if pt requires more sedation overnight may try PRN seroquel, or if\n unable to give may try zydis x 1 PRN\n - try to avoid sedation during the day to preserve better sleep/wake\n cycle\n - Taper paxil to 20 mg q day\n - Avoid Haldol and Ativan\n - Talk to Dr. about pre-admission mental status\n # Dysphagia and dysarthria\n Dysarthria may suggest that dysphagia likely to show little recovery.\n Failed video swallow on multiple occasions. Had NGT but removed five\n times by patient. Mental status improving and pt tolerated applesauce\n last night. However, failed repeat swallow study yesterday. Reluctant\n to place PEG, as not good long-term solution (aspiration risk just as\n high as swallowing), but will talk to electrophysiologist (Dr.\n who knows the patient well and can likely comment on\n neurologic function at baseline.\n - D/w Dr. \n - Consider PEG versus bridled NGT (depending on above concerns) for\n short term nutrition as pt has potential to improve with time once ICU\n delirium/mental status improves\n - NPO except meds\n .\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility\n" }, { "category": "Nursing", "chartdate": "2141-03-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532114, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531725, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n Ventricular tachycardia, sustained\n Assessment:\n Pt 100% paced; no runs of v-tach observed this shift\n Action:\n Pt continuously monitored; received lopressor as ordered.\n Response:\n No v-tach so far\n Plan:\n Continue cardiac monitoring\n Delirium / confusion\n Assessment:\n Pt putting legs over siderail;\n Pt pulled heparin off where plugged into PICC port\n Action:\n Heparin replaced with fresh cap; taped on\n Response:\n tbd\n Plan:\n Next PTT with a.m. labs\n Dysphagia\n Assessment:\n Pt w/ hx having pulled out feeding tube x3\n Pt reportedly with improved alertness today, via shift RN and via\n s.o. (who identified herself on phone as\nwife\n Action:\n put up to 80 degrees, pt given small amt of custard, swallowed\n without difficulty\n Therefore received a few pills in teaspoon of custard.\n Response:\n Pt swallowed without any difficulty or coughing at all.\n Plan:\n Suggest repeat of swallow study as patient increases alertness.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Pt 100% paced so far this noc; vss;\n Action:\n Urine output continues to be followed closely via foley catheter\n Response:\n Very good urine output so far this shift\n Plan:\n Continue to follow\n Daily weights as ordered.\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531726, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n Ventricular tachycardia, sustained\n Assessment:\n Pt 100% paced; no runs of v-tach observed this shift\n Action:\n Pt continuously monitored; received lopressor as ordered.\n Response:\n No v-tach so far\n Plan:\n Continue cardiac monitoring\n Delirium / confusion\n Assessment:\n Pt putting legs over siderail;\n Pt pulled heparin off where plugged into PICC port;\n Though able to retain and repeat back later information from\n conversation w/ nurse;\n Action:\n Heparin replaced with fresh cap; taped on;\n Pt requested sleeping pill, received trazadone hs as ordered;\n Response:\n Still occasionally calling out, did request and received bedpan, no\n stool (had large stool earlier in the day);\n Plan:\n Pt w/ prn anti-aggitation meds (seroquel, olanzapine);\n Next PTT with a.m. labs\n Dysphagia\n Assessment:\n Pt w/ hx having pulled out feeding tube x3;\n Pt reportedly with improved alertness today, via shift RN and via\n s.o. (who identified herself on phone as\nwife\n Action:\n put up to 80 degrees, pt given small amt of custard, swallowed\n without difficulty;\n Therefore received a few pills in teaspoon of custard.\n Response:\n Pt swallowed without any difficulty or coughing at all.\n Plan:\n Suggest repeat of swallow study as patient increases alertness.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Pt 100% paced so far this noc; vss;\n Action:\n Urine output continues to be followed closely via foley catheter\n Response:\n Very good urine output so far this shift\n Plan:\n Continue to follow\n Daily weights as ordered.\n" }, { "category": "Physician ", "chartdate": "2141-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531800, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - evaluated by geriatrics yesterday\n - received seroquel with improvement in delirium/agitation overnight\n - able to take some applesauce\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98\n HR: 75 (73 - 77) bpm\n BP: 94/54(63) {91/44(58) - 123/80(84)} mmHg\n RR: 21 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 92.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,163 mL\n 98 mL\n PO:\n TF:\n 741 mL\n IVF:\n 422 mL\n 98 mL\n Blood products:\n Total out:\n 2,040 mL\n 145 mL\n Urine:\n 2,040 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n -877 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Somnolent, minimally responsive, pedaling movements of legs when\n in light sleep. Not alert and only oriented to self this a.m.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 319 K/uL\n 11.2 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 35.6 %\n 5.4 K/uL\n [image002.jpg] mg 2.1 ca 9.1 mg 2.1 INR 1.2 PTT\n 82.3\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n WBC\n 5.8\n 9.5\n 8.3\n 6.0\n 5.4\n Hct\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n Plt\n 69\n 319\n Cr\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 100\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n MICROBIOLOGY:\n Urine cx pending\n RADIOLOGY\n Chest X ray\n The position of the lines of the ICD device is unchanged. No\n pneumothorax is\n present. The lung fields are clear. The endotracheal tube has been\n removed.\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG (avoid Haldol)\n # Mental Status\n Delirium markedly exacerbated by many psychotropics and sedatives. D/w\n geriatrics yesterday. They also feel that there is baseline hypoxic\n injury with likely superimposed neurodegenerative disease. Given\n possibility of Body Disease, they recommended not using Haldol or\n ativan, but instead using Seroquel or, if this is not possible, then\n Zydis. Avoid Haldol because of likely underlying disease and\n arrhythmogenicity/prolonged QT. Also taper Paxil because elderly and\n has significant RLS/PLMD. Last night the patient\ns agitation was\n improved with seroquel.\n - continu Seroquel 12.5 mg QAM then 12.5 Q6H PRN agitation\n making\n sure not to score limb movements as agitation.\n - Discuss Paxil use, then taper Paxil if possible\n - Avoid Haldol and ativan\n - Use Zydis 2.5 mg dissolving if cannot give Seroquel.\n # Dysphagia\n Failed video swallow. Had NGT but removed several times by patient.\n However, mental status improving and tolerated applesauce last night\n - reconsult S & S\n # Hypoxia\n Resolving\n doing well on nasal canula. Patient was intubated from\n for hypoxemic respiratory failure from pneumonia + heart\n failure. Reintubated for pacemaker revision. Was on room air, but\n drifts down to high 80s while sleeping, possibly related to undiagnosed\n OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow, but reevaluate today given Dopoff removed\n again.\n - F/u Is/Os\n -no abx for now (except cefpodoxime for one week as above)\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin\n - continue heparin gtt until bridged (INR 1.2)\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition: NPO, TF but will reassess\n Glycemic Control: insulin SS\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: hep gtt, coumadin\n Stress ulcer:\n Communication: Comments: (HCP)\n status: full code\n Disposition: call out to floor\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531928, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Echo", "chartdate": "2141-03-27 00:00:00.000", "description": "Report", "row_id": 62509, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. ?Tamponade.\nHeight: (in) 72\nWeight (lb): 231\nBSA (m2): 2.27 m2\nBP (mm Hg): 93/61\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:34\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: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Dynamic interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Apical\nLV aneurysm. Severe global LV hypokinesis. No LV mass/thrombus. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - akinetic; septal apex- akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\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. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor suprasternal views. Suboptimal image quality - patient\nunable to cooperate.\n\nConclusions:\nThe left atrium is elongated. The right atrium is markedly dilated. Left\nventricular posterior wall thickness is normal. The left ventricular cavity is\nmoderately dilated. There is severe global left ventricular hypokinesis (LVEF\n= 20 %). There is thinning and akinesis of the basal and mid anteroseptal left\nventricular walls. The apex is aneurysmal No masses or thrombi are seen in the\nleft ventricle. 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 aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is borderline pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Moderately dilated left ventricular cavity with severe global\nsystolic dysfunction accompanied by thinning and akinesis of the basal and mid\nanteroseptal walls and an apical aneurysm. Biatrial enlargement. Mild mitral\nregurgtitation. Mild tricuspid regurgitation. Borderline pulmonary artery\nsystolic hypertension. No echocardiographic evidence of pericardial tamponade.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2141-03-14 00:00:00.000", "description": "Report", "row_id": 62510, "text": "PATIENT/TEST INFORMATION:\nIndication: Fevers of unknown origin. ? Endocarditis. ? Device lead infection.\nHeight: (in) 72\nWeight (lb): 231\nBSA (m2): 2.27 m2\nBP (mm Hg): 107/52\nHR (bpm): 51\nStatus: Inpatient\nDate/Time: at 14:32\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nAORTA: No atheroma in aortic arch. Complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No AR.\n\nMITRAL VALVE: No mass or vegetation on mitral valve. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Moderate [2+] 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: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). No\nTEE related complications. Results were personally reviewed with the MD caring\nfor the patient. Results were reviewed with the Cardiology Fellow involved\nwith the patient's care. Echocardiographic results were reviewed with the\nhouseofficer caring for the patient. Left pleural effusion.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. There is moderate to\nsevere regional left ventricular systolic dysfunction with septal,\ninferoseptal and inferior hypokinesis. There are complex (>4mm) atheroma in\nthe descending thoracic aorta. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. No masses or vegetations are\nseen on the aortic valve. No aortic regurgitation is seen. No mass or\nvegetation is seen on the mitral valve. Moderate to severe (3+) mitral\nregurgitation is seen. Moderate to severe [2+] tricuspid regurgitation is\nseen. There is at least mild pulmonary artery systolic hypertension. No\nvegetation/mass is seen on the pulmonic valve. There is no pericardial\neffusion.\n\nIMPRESSION: No vegetations seen on the pacemaker/ICD leads (at least 4 wires\nidentified in the right atrium) or on the valves. Depressed left ventricular\nsystolic function. Moderate to severe mitral regurgitation. At least mild\npulmonary hypertension. Complex atheroma in descending aorta.\n\n\n" }, { "category": "Physician ", "chartdate": "2141-03-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532377, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - passed swallow eval, no PEG, outpt providers updated\n - coumadin restarted at 2 mg daily (home dose 2 mg daily; 4 mg QMon)\n - IVF bolus for SBP 80s\n - being screened for rehab\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98\n HR: 75 (72 - 86) bpm\n BP: 112/76(84) {74/10(28) - 130/76(84)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,814 mL\n 311 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 1,454 mL\n 71 mL\n Blood products:\n Total out:\n 500 mL\n 340 mL\n Urine:\n 500 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,314 mL\n -29 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: no icterus, MM dry.\n CV:) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m., states he is\n going to rehab.\n Labs / Radiology\n 294 K/uL\n 10.3 g/dL\n 124 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 108 mEq/L\n 141 mEq/L\n 32.2 %\n 5.9 K/uL\n [image002.jpg]\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n 05:20 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n 5.9\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n 32.2\n Plt\n \n 294\n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n 124\n Other labs: PT / PTT / INR:33.2/81.1/3.4, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension\n - F/u Is/Os\n - Continue metoprolol with holding parameters\n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n - Encourage POs\n # supratheraputic INR: Also on hep gtt. be from Amiodarone\n interaction. Pt also received 3 mg a day for 2 days which is above\n baseline regimen of 2 mg a day.\n - INR 3.4 today, unclear why so elevated. Possibly from poor\n nutrition.\n - Stop hep gtt\n - Decrease Coumadin to 2 mg q day\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - clarify length of cefpodoxime (for one week from vs life?)\n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarted Coumadin\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and thought PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed swallow\n -Pureed (dysphagia); Nectar prethickened liquids\n - calorie counts\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since resolved.\n MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - restarted diet\n - restart pancreatic enzyme supplementation\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: pureed diet and nectar thickened liquids\n Lines: PIV\n Prophylaxis:\n DVT: coumadin\n Communication: HCP\n status: full\n Disposition: D/.C to LTAC\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 15:37 ------\n" }, { "category": "Rehab Services", "chartdate": "2141-03-27 00:00:00.000", "description": "Repeat Bedside Swallow Evaluation", "row_id": 531816, "text": "TITLE:\nREPEAT BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nReturned today to reassess this 71 year old man initially\nadmitted on with a week of cough productive of dark beige\nsputum x 1 week with progressive dyspnea. His respiratory failure\nprogressed, and was intubated on . Initially symptoms were\nthought to be due to CHF exacerbation with infiltrate, fever,\nwhite count consistent with PNA. Bronch on notable for\nnormal airways. He was extubated on . Hospital course\ncomplicated by ICD malfunction, VT/VF arrest requiring\ndefibrillation and reintubation, and runs of VT, including one VT\narrest.\nHe has been followed by our service during his admission and was\nseen most recently for a video swallow on with aspiration\nof thin liquids before the swallow and aspiration of all other\nconsistencies after the swallow from residue. Aspiration was\nsilent and cued coughs were generally ineffective at clearing\naspirate material. It was suggested he remain NPO with continued\nalternate means of nutrition, hydration and medication. There was\nalso concern about his ability to return to POs before d/c and\nteam was made aware pt may need a PEG at some point before d/c.\nSince then, he went to the OR for ICD revision. We\nreturned to see him , but he remained intubated post-op. RN\nreported pt has been doing well and slept overnight. Evening RN\nreported pt took his pills whole with apple sauce without\ndifficulty.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair in the CCU.\nCognition, language, speech, voice:\nPt was lethargic, but able to stay awake for brief periods of\ntime with constant stimulation. He was not oriented to self,\nplace or time and spontaneous output was confused, off topic and\noften unintelligible. Speech was generally clear without\ndysarthria, but volume was moderately reduced. Pt followed ~25 Of\nbasic one step commands when fully awake.\nTeeth: edentulous\nSecretions: wfl in the oral cavity- oral care performed just\nprior to my arrival.\nORAL MOTOR EXAM:\nSymmetrical facial appearance, but pt was unable to follow\ncommands to assess further\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tps), nectar thick\nliquids (tsp), pureed solids and meds whole with puree.Pt's MS\nimproved somewhat when he started taking Pos, but he continued to\nfall asleep without stimulation. The oral phase was timely, but\nwith continued reduced control (occasional anterior spill and\nlikely pre-spill). NO oral residue was seen after the swallow. Pt\nhad immediate changes in vocal quality after thin liquids and had\ndelayed coughing and 4 point drop in O2 SATs after several sips\nof nectar thick liquids. Pt also noted to take swallows for\nall liquids, not seen with purees. Laryngeal elevation felt\ntimely, but mild-moderately reduced to palpation.\nSUMMARY / IMPRESSION:\nMr. continues to be lethargic with difficulty\nmaintaining alertness to take POs. He is also known to aspirate\nsilently from previous video swallows and did have signs c/w\naspiration with both thin and nectar thick liquids. I do not\nfeel there are consistencies safe enough to recommend a PO diet\nand his lethargy would prevent him from eating and drinking\nenough to maintain his nutrition even if he were to be safe for a\ndiet. He will continue to need alternate means of nutrition,\nhydration and medication and I discussed the possibility of a PEG\nwith his wife, RN and MDs, as pt has already self d/c'd 5 NG\ntubes and his recovery thus far has been slow,expecting he will\nrequire supplemental nutrition for some time. I do feel he can\ntake SMALL TRIALS of moist purees (apple sauce, yogurt ect) and\ntake essential meds whole with apple sauce until an alternate\nroute can be placed. We will continue to follow him and expect he\nwill require additional speech therapy services s/p d/c in rehab.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 1.\nRECOMMENDATIONS:\n1. Suggest pt remain NPO.\n2. Essential meds can be given with apple sauce until alternate\nmeans can be placed.\n3. Suggest discussion around PEG placement for alternate means of\nnutrition, hydration and medication, as pt remains unsafe for POs\nand I expect it will be some time before he would be able to meet\nhis nutritional needs via POs alone.\n4. Q4 oral care.\n5. Small trials of moist, pureed solids are OK when most awake\nand alert.\n6. We will continue to follow him during his admission and expect\nhe will require speech therapy services s/p d/c to rehab.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 9:20-9:40\n Total time: 50 minutes\n 10:18\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532109, "text": "Delirium / confusion\n Assessment:\n This am oriented x3, cooperative, following commands, able to carry on\n a simple conversation and ask appropriate questions.\n Late in afternoon, more confused, oriented to , self only\n Action:\n Monitor, frequent reorienting\n Response:\n Improved mental status\n Plan:\n Seroquel at \n Monitor\n OOB to chair w/ 2 assists, able to stand w/ assistance and reminders to\n stand up and not bend knees.\n Pt attempted to get up out of chair and fell to knees. Chair alarm on ,\n but did not alarm, ? batteries died, since worked again when batteries\n replaced.\n Takes pills very well with applesauce, has had 2 additional serving of\n applesauce today w/ no difficulty.\n" }, { "category": "Nursing", "chartdate": "2141-03-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532282, "text": "Delirium / confusion\n Assessment:\n Oriented x2, cooperative, able to carry on conversation.\n Verbalized that he had been\nseeing things\n and having\nfunny dreams\n Action:\n Monitor, pt received 6.25 mg seroquel last eve\n Response:\n Delirium much improved\n Plan:\n Continue seroquel in eve, monitor\n Dysphagia\n Assessment:\n Had been only on sm amts applesauce w/ meds\n Action:\n Speech/swallow study today\n Response:\n Did well, may now have pureed solids, thickened liquid, aspiration\n precautions, 1:1 supervision\n Tolerated very well,\n Plan:\n Calorie count\n Continue 1:1 supervision\n Aspiration precautions\n Pt has been screened for rehab, (signifigant other) went to\n visit today, may be ready tomorrow\n BP today occasionally low w/ sbp 70\ns, asymptomatic, but u/o `20cchr.\n Given total 750cc in ns bolus w/ good effect\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531927, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532368, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - passed swallow eval, no PEG, outpt providers updated\n - coumadin restarted at 2 mg daily (home dose 2 mg daily; 4 mg QMon)\n - IVF bolus for SBP 80s\n - being screened for rehab\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98\n HR: 75 (72 - 86) bpm\n BP: 112/76(84) {74/10(28) - 130/76(84)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,814 mL\n 311 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 1,454 mL\n 71 mL\n Blood products:\n Total out:\n 500 mL\n 340 mL\n Urine:\n 500 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,314 mL\n -29 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: no icterus, MM dry.\n CV:) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m., states he is\n going to rehab.\n Labs / Radiology\n 294 K/uL\n 10.3 g/dL\n 124 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 108 mEq/L\n 141 mEq/L\n 32.2 %\n 5.9 K/uL\n [image002.jpg]\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n 05:20 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n 5.9\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n 32.2\n Plt\n \n 294\n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n 124\n Other labs: PT / PTT / INR:33.2/81.1/3.4, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension\n - F/u Is/Os\n - Continue metoprolol with holding parameters\n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n - Encourage POs\n # supratheraputic INR: Also on hep gtt. be from Amiodarone\n interaction. Pt also received 3 mg a day for 2 days which is above\n baseline regimen of 2 mg a day.\n - INR 3.4 today, unclear why so elevated. Possibly from poor\n nutrition.\n - Stop hep gtt\n - Decrease Coumadin to 2 mg q day\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - clarify length of cefpodoxime (for one week from vs life?)\n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarted Coumadin\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and thought PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed swallow\n -Pureed (dysphagia); Nectar prethickened liquids\n - calorie counts\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - restarted diet\n - restart pancreatic enzyme supplementation\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: pureed diet and nectar thickened liquids\n Lines: PIV\n Prophylaxis:\n DVT: coumadin\n Communication: HCP\n status: full\n Disposition: D/.C to LTAC\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532374, "text": "72yom with multiple vascular risks factors admitted with\n dyspnea thought to be due to CHF. Pt subsequently found to have PNA on\n CXR and RV ICD lead fracture. Pt currently in ICU and course has been\n complicated by fevers and VT arrest requiring external defibrillation.\n pt underwent RV/ RA lead extractions and ICD exchange with EP\n service. Pt intubated for 24hrs post-procedure. Course also\n complicated by persistent delirium for which geriatric service has been\n following patient.\n Delirium / confusion\n Assessment:\n Pts MS much improved. Knows he\ns in & why he is here. Follows\n commands, makes needs known. No attempts to climb oob unassisted.\n Action:\n Rehab did not accept pt. sent screener to\n evaluate. Helped oob-> chair for breakfast, strength improved from\n yesterday. PT helped assist pt back to bed. Bed/ chair alarm in use for\n safety. INR 3.4\n Response:\n Acceptance to pending. Delirium much improved since on\n low dose seroquel at HS.\n Plan:\n Pt will hopefully get a bed tomorrow . Continue seroquel in\n eve, freq monitoring to keep pt safe.\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532375, "text": "72yom with multiple vascular risks factors admitted with\n dyspnea thought to be due to CHF. Pt subsequently found to have PNA on\n CXR and RV ICD lead fracture. Pt currently in ICU and course has been\n complicated by fevers and VT arrest requiring external defibrillation.\n pt underwent RV/ RA lead extractions and ICD exchange with EP\n service. Pt intubated for 24hrs post-procedure. Course also\n complicated by persistent delirium for which geriatric service has been\n following patient.\n Delirium / confusion\n Assessment:\n Pts MS much improved. Knows he\ns in & why he is here. Follows\n commands, makes needs known. No attempts to climb oob unassisted.\n Action:\n Rehab did not accept pt. sent screener to\n evaluate. Helped oob-> chair for breakfast, strength improved from\n yesterday. PT helped assist pt back to bed. Bed/ chair alarm in use for\n safety. INR 3.4, PT 33.2, PTT therapeutic 81.1 Heparin gtt stopped,\n remains on Coumadin.\n Response:\n Acceptance to pending. Delirium much improved since on\n low dose seroquel at HS.\n Plan:\n Pt will hopefully get a bed tomorrow . Continue seroquel in\n eve, freq monitoring to keep pt safe. Heparin gtt on hold until\n recheck coags in morning.\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532358, "text": "Delirium / confusion\n Assessment:\n Needs frequent reorientation. Thinks he is leaving and needs to get\n dressed. Slept in short naps. Tried to climb oob once. Said\n the\n medicine makes me do funny things\n Action:\n Monitor, pt received 6.25 mg seroquel at HS. have it prn if\n agitation occurs\n Response:\n Delirium much improved on low dose seroquel\n Plan:\n Continue seroquel in eve, monitor, frequent re-orientation\n Dysphagia\n Assessment:\n Had been only on sm amts applesauce w/ meds\n Action:\n Speech/swallow study yesterday and has progressed to nectar thickened\n liquids and pureed solids with supervision/ aspiration precautions.\n Response:\n Enjoys cranberry juice. Tol po\ns well throughout the night. Now takes\n meds whole in teaspoon of pudding.\n Plan:\n Calorie counts\n Continue 1:1 supervision\n Aspiration precautions\n" }, { "category": "Nursing", "chartdate": "2141-03-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532440, "text": "72yom with multiple vascular risks factors admitted with\n dyspnea thought to be due to CHF. Pt subsequently found to have PNA on\n CXR and RV ICD lead fracture. Pt currently in ICU and course has been\n complicated by fevers and VT arrest requiring external defibrillation.\n pt underwent RV/ RA lead extractions and ICD exchange with EP\n service. Pt intubated for 24hrs post-procedure. Course also\n complicated by persistent delirium for which geriatric service has been\n following patient.\n Delirium / confusion\n Assessment:\n Pt oriented to person only. Very restless overnight, not easily\n redirected over night. Slept for only about 2 hours. By 5am, pt\n oriented x3 and more appropriate, though still impulsive and attempting\n to get OOB without assistance. Pt has tolerated nectar thick liquids\n with supervision overnight.\n Action:\n Pt rec\nd dose of seroquel with repeated dose as ordered with little\n effect. Pt slept very little overnight. Pt in low bed, safety pads in\n placed.\n Response:\n Pt continues to be very confused through the night with improvement by\n day.\n Plan:\n Pt stable to be d/c\nd to this morning.\n" }, { "category": "Physician ", "chartdate": "2141-03-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532335, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - passed swallow eval, no PEG, outpt providers updated\n - coumadin restarted at 2 mg daily (home dose 2 mg daily; 4 mg QMon)\n - IVF bolus for SBP 80s\n - being screened for rehab\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98\n HR: 75 (72 - 86) bpm\n BP: 112/76(84) {74/10(28) - 130/76(84)} mmHg\n RR: 16 (11 - 22) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,814 mL\n 311 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 1,454 mL\n 71 mL\n Blood products:\n Total out:\n 500 mL\n 340 mL\n Urine:\n 500 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,314 mL\n -29 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: Arcus senilius, no icterus, MM dry.\n CV: R (occasional ectopy) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m. (improvement).\n Less sedated this a.m. Moving limbs purposively. Gait not evaluated.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 294 K/uL\n 10.3 g/dL\n 124 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 108 mEq/L\n 141 mEq/L\n 32.2 %\n 5.9 K/uL\n [image002.jpg]\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n 05:20 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n 5.9\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n 32.2\n Plt\n \n 294\n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n 124\n Other labs: PT / PTT / INR:33.2/81.1/3.4, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension\n - F/u Is/Os\n - Continue metoprolol \n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n - Encourage POs\n # supratheraputic INR: Also on hep gtt.\n - INR 3.4 today, unclear why so elevated. Possibly from poor\n nutrition.\n - Stop hep gtt\n - Decrease Coumadin to 1 mg q day\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - cefpodoxime for one week from \n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarted Coumadin\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and thought PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed \n -Pureed (dysphagia); Nectar prethickened liquids\n - calorie counts\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - restarted diet\n - restart pancreatic enzyme supplementation\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532359, "text": "72yom with multiple vascular risks factors admitted with\n dyspnea thought to be due to CHF. Pt subsequently found to have PNA on\n CXR and RV ICD lead fracture. Pt currently in ICU and course has been\n complicated by fevers and VT arrest requiring external defibrillation.\n pt underwent RV/ RA lead extractions and ICD exchange with EP\n service. Pt intubated for 24hrs post-procedure. Course also\n complicated by persistent delirium for which geriatric service has been\n following patient.\n Delirium / confusion\n Assessment:\n Needs frequent reorientation. Thinks he is leaving and needs to get\n dressed. Slept in short naps. Tried to climb oob once. Said\n the\n medicine makes me do funny things\n Action:\n Monitor, pt received 6.25 mg seroquel at HS. have it prn if\n agitation occurs\n Response:\n Delirium much improved on low dose seroquel\n Plan:\n Continue seroquel in eve, monitor, frequent re-orientation\n Dysphagia\n Assessment:\n Had been only on sm amts applesauce w/ meds\n Action:\n Speech/swallow study yesterday and has progressed to nectar thickened\n liquids and pureed solids with supervision/ aspiration precautions.\n Response:\n Enjoys cranberry juice. Tol po\ns well throughout the night. Now takes\n meds whole in teaspoon of pudding.\n Plan:\n Calorie counts\n Continue 1:1 supervision\n Aspiration precautions\n" }, { "category": "Rehab Services", "chartdate": "2141-03-30 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 532365, "text": "Subjective:\n Ok, I'm ready to go!\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education, other:\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n T\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n T\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 Sit\n 75\n 90/60\n Activity\n Stand\n 105\n *cuff malfunction/\n Recovery\n Sit\n 92\n 91/57\n Total distance walked: 15 feet\n Minutes:\n Gait: retropulsive, requiring Bue support for ambulation, short steps\n Balance: retropulsive with initial standing, mod A to recover. cga at\n eob\n Education / Communication: pt ed: role of rehab\n case discussed with RN and CM\n Other: mental status: A&Ox3, somewhat impulsive, very HOH, following\n 100% of commands\n goals x 1 week:1. amb 100 ft with min A and r. walker\n 2. no LOB with initial standing with r. walker\n Assessment: 72m s/p lead revision presents with improved hemodynamic\n tolerance to mobility. He is following all commands and appropriate to\n participate in rehab. Continue to recommend discharge to rehab once\n medically stable.\n Anticipated Discharge: Rehab\n Plan: gait training with r. walker\n balance training\n d/c planning\n time: 11:40-12:10\n" }, { "category": "Nutrition", "chartdate": "2141-03-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 532205, "text": "Subjective\n Just had repeated bedside swallow evaluation, okay for diet advance\n (per discussion with RN)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 89.9 kg ( 08:00 AM)\n 31.3\n Pertinent medications: Amiodarone, Glargine 4 Units, RISS, Heparin,\n Cefpodoxime Proxetil , others noted\n Labs:\n Value\n Date\n Glucose\n 96 mg/dL\n 05:07 AM\n Glucose Finger Stick\n 103\n 07:00 AM\n BUN\n 15 mg/dL\n 05:07 AM\n Creatinine\n 0.9 mg/dL\n 05:07 AM\n Sodium\n 142 mEq/L\n 05:07 AM\n Potassium\n 4.0 mEq/L\n 05:07 AM\n Chloride\n 109 mEq/L\n 05:07 AM\n TCO2\n 22 mEq/L\n 05:07 AM\n PO2 (arterial)\n 182 mm Hg\n 05:25 AM\n PCO2 (arterial)\n 41 mm Hg\n 05:25 AM\n pH (arterial)\n 7.39 units\n 05:25 AM\n pH (urine)\n 7.5 units\n 03:41 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 05:25 AM\n Albumin\n 3.0 g/dL\n 03:31 PM\n Calcium non-ionized\n 9.8 mg/dL\n 05:07 AM\n Phosphorus\n 3.2 mg/dL\n 05:07 AM\n Ionized Calcium\n 1.10 mmol/L\n 08:00 AM\n Magnesium\n 2.1 mg/dL\n 05:07 AM\n ALT\n 224 IU/L\n 03:36 AM\n Alkaline Phosphate\n 92 IU/L\n 03:36 AM\n AST\n 204 IU/L\n 03:36 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:36 AM\n WBC\n 5.5 K/uL\n 05:07 AM\n Hgb\n 10.7 g/dL\n 05:07 AM\n Hematocrit\n 32.6 %\n 05:07 AM\n Current diet order / nutrition support: Regular; Low sodium / Heart\n healthy Consistency: Pureed (dysphagia); Nectar prethickened liquids\n GI: NBS\n Assessment of Nutritional Status\n 72 year old male with prolonged ICU course, previously on tube feed due\n to altered mental status, failed bedside and video swallow\n evaluations. Patient been off tube feed since , s/p repeated\n evaluation this morning ( notes not yet available), but RN, patient\n passed evacuation and later had Ensure pudding, 2 apple sauce and some\n thicken cranberry juice for breakfast, RN to order lunch later. Will\n continue to follow up regarding adequacy of po intake.\n Noted diet order advanced and PEG placement on hold for now\n Medical Nutrition Therapy Plan - Recommend the Following\n Diet consisitecny per SLP\ns recommendation\n Oral supplements: 2 Ensure pudding at each meal\n Multivitamin / Mineral supplement: daily\n Tube feeding discontinue tube feed order\n Check chemistry 10 panel daily\n Continue blood sugar management\n Will monitor po and assess intake\n Other: \n 10:47\n" }, { "category": "Physician ", "chartdate": "2141-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530598, "text": "Chief Complaint: Dyspnea\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum, with some\n low-grade temps at home (Tm 99.8).\n 24 Hour Events:\n PICC LINE - STOP 09:02 AM\n PICC LINE - START 10:23 AM\n \n - NGT replaced\n then pulled by patient\n - Increased free water flushes\n - No Dopoff, but managed to give amiodarone and metoprolol. Gave Lasix\n 20 mg IV.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Changes to medical and family history:\n None.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 82) bpm\n BP: 119/62(75) {82/54(65) - 132/74(85)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,037 mL\n 432 mL\n PO:\n TF:\n 475 mL\n 228 mL\n IVF:\n 323 mL\n 104 mL\n Blood products:\n Total out:\n 925 mL\n 250 mL\n Urine:\n 925 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n 182 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 424 K/uL\n 10.7 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 142 mEq/L\n 32.5 %\n 5.5 K/uL\n [image002.jpg]\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n Plt\n 521\n 523\n 478\n 448\n 424\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n Other labs: PT / PTT / INR:13.9/111.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - dobhoff now in proximal stomach. no other interval\n chnage, though note that lateral left hemithorax is excluded from the\n film.\n Microbiology: 8:48 pm BLOOD CULTURE 1 OF 2.\n **FINAL REPORT **\n Blood Culture, Routine (Final ):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET\n ONLY.\n SENSITIVITIES PERFORMED ON REQUEST..\n Aerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n REPORTED BY PHONE TO DR. , PAGER @ 08:30\n .\n Subsequent blood cultures on ,26 - no growth so far.\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be after MN, and will have 4 units crossmatched for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n Diuresis gently continues, and likely to be safe.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531242, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n Delirium / confusion\n Assessment:\n Pt. has been confused and very restless past few days, requiring\n restraints to maintain safety. Self d/c\nd feeding tube 3 x\ns in past\n week.\n Received pt on propofol 10 mcg/kg/min\n Extreme. Warm.\n Action:\n Propofol d/c at 0800\n Response:\n Pt initially slow to wake up, by 1200 slightly restless, arousable to\n voice and following commands\n This afternoon pt confused. Rest;ess in bed\n Plan:\n Soft wrist restrainsts on to maintain pt safety, bed alarm on, locked,\n low position\n Family in during afternoon\n Ventricular tachycardia, sustained\n Assessment:\n Received pt intubated from procedure \n AV paced at 75, no ectopyt\n Neo at 1 mcg/kg/min to maintain sbp > 90\n Propofol at 10 mcg/kg/min\n Action:\n Propofol off at 0800\n Pt extubated at 1145 w/o difficulty\n Neo d/c at 1200\n Response:\n Remains av paced at 75\n Bp 100-125/50-70 off neo\n Dressing on left shoulder d/I no oozing\n Plan:\n Monitor rhythm, bp, dsg\n TF restarted at 1400, isosource 1.5 FS w/ 14 gm beneprotein at\n 25cc/hr, goal 55 cc/hr\n On occipital area of head, 1.5x2 cm area of hair loss, scalp pink,\n blanches. Head kept off pillow.\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531967, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n : extubated. Neo weaned off.\n : agitated and yelling .. haldol with no effect.\n : gerontology consult. Recommended seroquel. Pt. self d/c\n dobhoff again (5^th time).\n : was sleepy from seroquel 12.5mg, trazadone and zyprexa given\n night previous. BP down to 60-70\ns/ when sitting up. Gave total 1L NS\n during day. Lopressor was held.\n Delirium / confusion\n Assessment:\n Pt. able to state name only. Remains confused but not as restless.\n Staying in bed and no attemps to swing legs over bed rails. No\n agitation. Asking for something to drink/eat.\n Action:\n Seroquel 6.25mg at per gerontology recs.\n Pt. in low bed with pads on side rails.\n Response:\n No restraints needed. Pt. slept for most of the night. Woke\n intermittently but would go back to sleep.\n Turned and positioned and tolerated well. No restlessness or\n agitation.\n Plan:\n Monitor MS following this good night sleep. Follow w/gerontoloty for\n recs.\n Heart failure (CHF), Systolic, Acute\n s/p Pacer/ICD .\n Assessment:\n LS clear bilat. RA sats 99-100%.\n BP 90s-114/40-50\ns. HR 75 Vpaced.\n Had hypotension with sitting up in bed and/or chair rx with IVF\n boluses for total 1L.\n Action:\n Lopessor held at .\n Response:\n u/o 25-30cc/hr . neg. 5.8 L LOS.\n BP better 90\ns-114/40\n Plan:\n OOB to chair. Monitor u/o . check with team about giving po lasix as\n ordered.\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530666, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531964, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n : extubated. Neo weaned off.\n : agitated and yelling .. haldol with no effect.\n : gerontology consult. Recommended seroquel. Pt. self d/c\n dobhoff again (5^th time).\n : was sleepy from seroquel 12.5mg, trazadone and zyprexa given\n night previous. BP down to 60-70\ns/ when sitting up. Gave total 1L NS\n during day. Lopressor was held.\n Delirium / confusion\n Assessment:\n Pt. able to state name only. Remains confused but not as restless.\n Staying in bed and no attemps to swing legs over bed rails. No\n agitation. Asking for something to drink/eat.\n Action:\n Seroquel 6.25mg at per gerontology recs.\n Pt. in low bed with pads on. Oriented as needed.\n Response:\n No restraints needed. Pt. slept for a lot of the night. Woke\n intermittently but would go back to sleep.\n Turned and positioned and tolerated well. No restlessness or\n agitation.\n Plan:\n Heart failure (CHF), Systolic, Acute\n s/p Pacer/ICD .\n Assessment:\n LS clear bilat. RA sats 99-100%.\n BP 90s-114/40-50\ns. HR 75 Vpaced.\n Had hypotension with sitting up in bed and/or chair rx with IVF\n boluses for total 1L.\n Action:\n Lopessor held at .\n Response:\n u/o 25-30cc/hr . neg. 5.8 L LOS.\n BP better 90\ns-114/40\n Plan:\n" }, { "category": "Social Work", "chartdate": "2141-03-29 00:00:00.000", "description": "Social Work Progress Note", "row_id": 532264, "text": "SOCIAL WORK: Per team, pt is now being screened for rehab. SW met\n with pt\ns partner . reports feeling quite distressed\n anticipating pt\ns transition to rehab level of care. She states she\n has observed significant improvement in pt\ns mental status over the\n past day, and feels some relief. SW validated benefits of rehab such\n as structured daily activity to help improve pt\ns cognitive status and\n physical endurance. SW supported partner in processing her feelings.\n Advised partner about self care and encouraged her to plan for using\n time pt is engaged in treatment at rehab as respite for herself.\n SW will continue to follow with team to support pt/family coping and\n decision making as needed.\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531154, "text": "Chief Complaint: Dyspnea\n Worsened CHF\n VT/VF, found to have fractured ICD lead\n 24 Hour Events:\n CARDIAC CATH - At 02:20 PM\n To EPS.\n INVASIVE VENTILATION - START 03:00 PM\n ARTERIAL LINE - START 04:00 PM\n \n - two lead extractions (R ventricular and R atrial) and ICD implant\n without complications\n - returned to floor intubated on propofol\n - hematocrit was stable despite reported blood loss of 450 ccs\n - plan for extubation on \n - Blood pressure post-procedure 80/51 at 03:30, so gave 500 cc back,\n then another 500 cc\n - No pulsus physiology on arterial line wave-form\n EP recs\n - Start Coumadin today\n - Start IV heparin to bridge 24 hrs after procedure\n - Heparin 5000 U SC until IV starts\n - Make today d1 of cefpodoxime for 7 days post-procedure\n - Received 1.5 L fluid plus one unit blood in OR (lost about 1\n unit blood)\n Somewhat hypotensive overnight\n improved when propofol stopped.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 01:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 75 (75 - 84) bpm\n BP: 105/61(76) {71/46(55) - 107/67(82)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,439 mL\n 1,667 mL\n PO:\n TF:\n 205 mL\n 90 mL\n IVF:\n 2,054 mL\n 1,477 mL\n Blood products:\n Total out:\n 1,945 mL\n 320 mL\n Urine:\n 1,295 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 494 mL\n 1,347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 564 (553 - 564) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/41/182/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 455\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 315 K/uL\n 9.8 g/dL\n 171\n 0.8 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 110 mEq/L\n 138 mEq/L\n 31.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n Plt\n 448\n 424\n 407\n 315\n Cr\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 28\n 26\n Glucose\n 108\n 122\n 120\n 100\n 88\n 193\n 171\n Other labs: PT / PTT / INR:13.9/29.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - wet read\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly\n clear.\n heart remains enlarged. ? fullness of left hilum.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured.\n -restart Coumadin\n -heparin SC BID then IV 24hrs after procedure\n -cefpodoxime for one week from today\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Intubation: Pt intubed from procedure.\n - Extubate today, stop sedation prior, then afterward try to wean\n pressor\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA. Got some 2L or so of\n fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: Most likely propofol as has improved after weaning\n down propofol.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Full\n code, but was DNR in context of surgery.\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 531428, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Received patient awake and agitated, actively trying to get out of\n bed.. Oriented times one\nscreaming out.\n Action:\n 4 siderails in high position, wrists restrained. Occ wears mitt to\n right hand to preserve dobhoff and ICD dsg integrity.\n Response:\n Conts to be restless/ agitated. Family in room.\n Plan:\n ? Haldol vs Trazadone for sleep tonight.\n Dysphagia\n Assessment:\n Dobhoff remains in place. Failed video swallow study\n Action:\n Isosource advanced to 55 cc/hr . HOB greater than >45. Frequent mouth\n care\n Response:\n Patient unable to remember/ understand NPO status\n Plan:\n ? PEG in future. Aspiration Precautions\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 75 V paced . SBP 110\ns/50\ns via right radial aline\n Action:\n Tolerating lopressor. Heparin at 1500 u/hr\n Response:\n Hemodynamic stable following ICD replacement\n Plan:\n Call out to floor with sitter if available\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Height:\n 72 Inch\n Admission weight:\n 105 kg\n Daily weight:\n 96.8 kg\n Allergies/Reactions:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Angina, Arrhythmias, CAD, CHF, Hypertension, MI, Pacemaker\n Additional history: CHF EF 20-25%, ant wall MI c/b VT s/p PCM/ICD,\n hypothryoid, anemia, IBS, bilateral hearing loss, Vit D defiency,\n cerebral infarct, falls, whipple procedure, knee surgery, dysphagia, hx\n of osteomyelitis C3-C4\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:58\n Temperature:\n 98.9\n Arterial BP:\n S:104\n D:58\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 736 mL\n 24h total out:\n 1,380 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 05:31 AM\n Potassium:\n 3.7 mEq/L\n 05:31 AM\n Chloride:\n 107 mEq/L\n 05:31 AM\n CO2:\n 23 mEq/L\n 05:31 AM\n BUN:\n 12 mg/dL\n 05:31 AM\n Creatinine:\n 0.7 mg/dL\n 05:31 AM\n Glucose:\n 132 mg/dL\n 05:31 AM\n Hematocrit:\n 31.1 %\n 05:31 AM\n Finger Stick Glucose:\n 128\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: , 1400\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532307, "text": "Delirium / confusion\n Assessment:\n Needs frequent reorientation. Thinks he is leaving and needs to get\n dressed. Slept in short naps. Tried to climb oob once. Said\n the\n medicine makes me do funny things\n Action:\n Monitor, pt received 6.25 mg seroquel at HS. have it prn if\n agitation occurs\n Response:\n Delirium much improved on low dose seroquel\n Plan:\n Continue seroquel in eve, monitor, frequent re-orientation\n Dysphagia\n Assessment:\n Had been only on sm amts applesauce w/ meds\n Action:\n Speech/swallow study yesterday and has progressed to nectar thickened\n liquids and pureed solids with supervision/ aspiration precautions.\n Response:\n Enjoys cranberry juice. Tol po\ns well throughout the night.\n Plan:\n Calorie counts\n Continue 1:1 supervision\n Aspiration precautions\n Heparin GTT restarted yesterday to keep INR therapeuticX 24 hours. PTT\n therapeutic at 2300 on 950units/hr. AM labs pending. Receiving Coumadin\n daily. Plan: ? transfer to rehab today\n" }, { "category": "Nursing", "chartdate": "2141-03-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532416, "text": "72yom with multiple vascular risks factors admitted with\n dyspnea thought to be due to CHF. Pt subsequently found to have PNA on\n CXR and RV ICD lead fracture. Pt currently in ICU and course has been\n complicated by fevers and VT arrest requiring external defibrillation.\n pt underwent RV/ RA lead extractions and ICD exchange with EP\n service. Pt intubated for 24hrs post-procedure. Course also\n complicated by persistent delirium for which geriatric service has been\n following patient.\n Delirium / confusion\n Assessment:\n Pt oriented to person only. Very restless overnight, not easily\n redirected.\n Action:\n Pt rec\nd dose of seroquel as ordered with little effect. Pt did not\n sleep overnight. Pt in low bed, safety pads in placed.\n Response:\n Pt continues to be very confused.\n Plan:\n Pt hemodynamically stable to be d/c\nd to this morning.\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530936, "text": "Delirium / confusion\n Assessment:\n Pt remains confused Ox1-2. Family in early today at bedside (both\n daughters and significant other). Pt remains with SR up x 4, waist\n posey, bilat wrist restraints, bed low and locked and bed alarm on. Pt\n attempting to pull out NGT and to get out of bed. Pt constantly in\n motion, moving legs arms and sliding self down in bed. NPO. Dobhoff\n tube for feeding due to failing video swallow.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Bed alarm\n on. Family at bedside assisting with reorientation with minimal\n success.\n Response:\n To EPS at 1415hrs. Planned intubation and sedation for procedure.\n Plan:\n Fall precautions. Aspiration precautions. Restraints to prevent\n pulling out of lines/tubes.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n sBP 90-117/50\ns. HR 70-90s\ns vpaced. No VEA. Heparin 1300units/hr.\n Action:\n Heparin gtt stopped at noon for EPS. To EPS after 1400hrs for lead\n revisions.\n Response:\n EPS: Atrial and fractured RV leads extracted on Lt side. New RV and\n Atrial leads placed and new generator. On Neo during procedure for some\n hypotension. 1Gm Vanco given pre procedure. Rt radial Aline in place.\n Rt brachial PICC still intact. Received 1unit PRBCs for blood loss\n during procedure. Lt chest dsg over pacer site. Neo @ 1.5mcg/k/min.\n Plan:\n Sling Lt arm, keep Lt arm immobilized x 24hrs post pacer lead\n placement. Monitor dsg over site. Wean NEO as tolerated. Vent support\n with sedation overnite to help keep pt immobilized. Recheck HCT this\n evening\n post transfusion HCT. Post pacer placement CXR this evening.\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531654, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Received patient awake and agitated, actively trying to get out of\n bed.. Oriented times one\nscreaming out.\n Action:\n 4 siderails in high position, wrists restrained. Occ wears mitt to\n right hand to preserve dobhoff and ICD dsg integrity.\n Response:\n Conts to be restless/ agitated. Family in room.\n Plan:\n ? Haldol vs Trazadone for sleep tonight.\n Dysphagia\n Assessment:\n Dobhoff remains in place. Failed video swallow study\n Action:\n Isosource advanced to 55 cc/hr . HOB greater than >45. Frequent mouth\n care\n Response:\n Patient unable to remember/ understand NPO status\n Plan:\n ? PEG in future. Aspiration Precautions\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 75 V paced . SBP 110\ns/50\ns via right radial aline\n Action:\n Tolerating lopressor. Heparin at 1500 u/hr\n Response:\n Hemodynamic stable following ICD replacement\n Plan:\n Call out to floor with sitter if available\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531655, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n \n - continued to have delirium, agitation, restlessness, worse at night\n - gave haldol to control agitation\n - unable to find sitter so kept him in CCU another night given concern\n for significant agitation\n - was negative 1200cc with just his home PO lasix dose (40mg)\n - per review of speech/swallow recs, he is unlikely to regain\n significant swallow function in a timely manner; possibility of PEG\n should be discussed w/ family\n - dc'd art line\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (72 - 78) bpm\n BP: 118/68(80) {97/42(57) - 152/68(80)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 981 mL\n 144 mL\n PO:\n TF:\n IVF:\n 681 mL\n 144 mL\n Blood products:\n Total out:\n 2,250 mL\n 100 mL\n Urine:\n 2,250 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,269 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Somnolent, minimally responsive, pedaling movements of legs when\n in light sleep. Not alert and only oriented to self this a.m.\n Labs / Radiology\n 269 K/uL\n 10.5 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 106 mEq/L\n 138 mEq/L\n 32.7 %\n 6.0 K/uL\n [image002.jpg]\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.5\n 5.8\n 9.5\n 8.3\n 6.0\n Hct\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 09\n 269\n Cr\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n TCO2\n 28\n 26\n Glucose\n 120\n 100\n 88\n 193\n 171\n 132\n 119\n Other labs: PT / PTT / INR:13.3/32.8/1.1, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR \n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Microbiology: Nothing since - coag. negative staph thought to be\n contaminant\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restarting Coumadin\n -heparin IV weight based protocol bridge to coumadin\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG (avoid Haldol)\n # Mental Status\n Delirium markedly exacerbated by many psychotropics and sedatives. D/w\n geriatrics today. They also feel that there is baseline hypoxic injury\n with likely superimposed neurodegenerative disease. Given possibility\n of Body Disease, they recommend not using Haldol or ativan, but\n instead using Seroquel or, if this is not possible, then Zydis. Avoid\n Haldol because of likely underlying disease and\n arrhythmogenicity/prolonged QT. Also taper Paxil because elderly and\n has significant RLS/PLMD.\n - per . Team\n Seroquel 12.5 mg QAM then 12.5 Q6H PRN agitation\n making sure not to score limb movements as agitation.\n - Taper Paxil once discussed why he is on this (there may be a good\n reason)\n - Avoid Haldol and ativan\n - Use Zydis 2.5 mg wafer if cannot given Serquel.\n # Hypoxia\n Resolving\n doing well on nasal canula. Patient was intubated from\n for hypoxemic respiratory failure. Etiology likely pneumonia\n + heart failure. Currently resolving, was on room air, but drifts down\n to high 80s while sleeping, possibly related to undiagnosed OSA. Got\n some 2L or so of fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow, but reevaluate given Dopoff removed again.\n -If delirium has not been cause of dysphagia then consider surgery\n consult for PEG (per Geriatrics)\n -wean O2 as tolerated\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n - Will need to consider PEG in future\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: FULL\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532149, "text": "Delirium / confusion\n Assessment:\n Pt. able to state hospital and , name and year. Having\n periods of lucidity, asking approp. Questions etc. but then also with\n periods of confusion , asking nonsensical questions.\n No agitation or attempts to get OOB but asking when he could get OOB\n and what time it was.\n He required 2 assist to bed, stands up well but has difficulty with\n shuffling over to the bed. Pt. stating\n I need to learn how to work\n again\n - taking meds sitting upright whole with applesause.\n Action:\n Seraquel 6.25 at . safety precautions in place with padded bed\n rails etc.\n Response:\n Pt. did not sleep much tonight but was very calm -therefore did not\n repeat seraquel dose.\n Plan:\n OOB today. 2 moderate assist to bed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 70\ns Vpaced. BP 85-100/50\n u/o dropping 10-15cc/hr in eve.\n Sats 99% RA. LS clear. Denies SOB/CP.\n Heparin at 1150u/hr. PTT 90 in eve. Up to 108 AM labs.\n Action:\n 500cc fluid bolus at 0030.\n Gave lopressor 25mg as ordered at .\n Heparin decreased to 950/hr at 0600.\n Response:\n u/o increasing to 25-30cc/hr. BP stable.\n Plan:\n PTT at 12noon. Speech /swallow reeval. Needs PEG for feeding.\n Monitor u/o\n" }, { "category": "Physician ", "chartdate": "2141-03-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532493, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ***has bed at , needs to be discharged at 10 am***\n - got extra dose of seroquel overnight for agitation\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 74 (68 - 83) bpm\n BP: 82/50(57) {82/48(56) - 120/76(84)} mmHg\n RR: 13 (9 - 23) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,209 mL\n 480 mL\n PO:\n 1,120 mL\n 480 mL\n TF:\n IVF:\n 89 mL\n Blood products:\n Total out:\n 615 mL\n 0 mL\n Urine:\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 594 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n GEN: NAD. Elderly man.\n Oriented x 3 although confabulating\n HEENT: no icterus, MM dry.\n CV:) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Ext: WWP. No edema.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 9.8 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 104 mEq/L\n 137 mEq/L\n 30.1 %\n 10.0 K/uL\n [image002.jpg] ca 8.7 mg 2.0 p 2.0 INR 3.2\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n 05:20 AM\n 04:55 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n 5.9\n 10.0\n Hct\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n 32.2\n 30.1\n Plt\n 64\n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n 124\n 107\n Other labs: PT / PTT / INR:31.5/36.2/3.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension\n - F/u Is/Os\n - Continue metoprolol with holding parameters\n - will not restart ACEi due to hypotension. This may be restarted\n eventually by outpt cardiologist\n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO. Today blood pressure is in high 90s.\n - continue to monitor BP\n - hold lasix\n - BP holding parameters on metoprolol\n - Encourage POs\n # supratheraputic INR: be from Amiodarone interaction. Pt also\n received 3 mg a day for 2 days which is above baseline regimen of 2 mg\n a day. Held Coumadin last night\n - Decrease Coumadin to 2 mg q day and restart with rehab to\n follow INR\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - continue cefpodoxime for life\n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - Restarted Coumadin\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and thought PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed swallow\n -Pureed (dysphagia); Nectar prethickened liquids\n - calorie counts\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - restarted diet\n - restart pancreatic enzyme supplementation\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: pureed diet and nectar thickened liquids\n Lines: PIV\n Prophylaxis:\n DVT: coumadin\n Communication: HCP\n status: full\n Disposition: D/.C to LTAC\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531082, "text": "Chief Complaint: Dyspnea\n Worsened CHF\n VT/VF, found to have fractured ICD lead\n 24 Hour Events:\n CARDIAC CATH - At 02:20 PM\n To EPS.\n INVASIVE VENTILATION - START 03:00 PM\n ARTERIAL LINE - START 04:00 PM\n \n - two lead extractions (R ventricular and R atrial) and ICD implant\n without complications\n - returned to floor intubated on propofol\n - hematocrit was stable despite reported blood loss of 450 ccs\n - plan for extubation on \n - Blood pressure post-procedure 80/51 at 03:30, so gave 500 cc back,\n then another 500 cc\n - No pulsus physiology on arterial line wave-form\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 01:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 75 (75 - 84) bpm\n BP: 105/61(76) {71/46(55) - 107/67(82)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,439 mL\n 1,667 mL\n PO:\n TF:\n 205 mL\n 90 mL\n IVF:\n 2,054 mL\n 1,477 mL\n Blood products:\n Total out:\n 1,945 mL\n 320 mL\n Urine:\n 1,295 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 494 mL\n 1,347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 564 (553 - 564) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/41/182/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 455\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 315 K/uL\n 9.8 g/dL\n 171\n 0.8 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 110 mEq/L\n 138 mEq/L\n 31.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n Plt\n 448\n 424\n 407\n 315\n Cr\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 28\n 26\n Glucose\n 108\n 122\n 120\n 100\n 88\n 193\n 171\n Other labs: PT / PTT / INR:13.9/29.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - wet read\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly\n clear.\n heart remains enlarged. ? fullness of left hilum.\n Microbiology: No new.\n ECG: .\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Full\n code, but was DNR in context of surgery.\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531083, "text": "Chief Complaint: Dyspnea\n Worsened CHF\n VT/VF, found to have fractured ICD lead\n 24 Hour Events:\n CARDIAC CATH - At 02:20 PM\n To EPS.\n INVASIVE VENTILATION - START 03:00 PM\n ARTERIAL LINE - START 04:00 PM\n \n - two lead extractions (R ventricular and R atrial) and ICD implant\n without complications\n - returned to floor intubated on propofol\n - hematocrit was stable despite reported blood loss of 450 ccs\n - plan for extubation on \n - Blood pressure post-procedure 80/51 at 03:30, so gave 500 cc back,\n then another 500 cc\n - No pulsus physiology on arterial line wave-form\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 01:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 75 (75 - 84) bpm\n BP: 105/61(76) {71/46(55) - 107/67(82)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,439 mL\n 1,667 mL\n PO:\n TF:\n 205 mL\n 90 mL\n IVF:\n 2,054 mL\n 1,477 mL\n Blood products:\n Total out:\n 1,945 mL\n 320 mL\n Urine:\n 1,295 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 494 mL\n 1,347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 564 (553 - 564) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/41/182/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 455\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 315 K/uL\n 9.8 g/dL\n 171\n 0.8 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 110 mEq/L\n 138 mEq/L\n 31.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n Plt\n 448\n 424\n 407\n 315\n Cr\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 28\n 26\n Glucose\n 108\n 122\n 120\n 100\n 88\n 193\n 171\n Other labs: PT / PTT / INR:13.9/29.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - wet read\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly\n clear.\n heart remains enlarged. ? fullness of left hilum.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be after MN, and will have 4 units crossmatched for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n Diuresis gently continues, and likely to be safe.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Full\n code, but was DNR in context of surgery.\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531309, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Received patient awake and agitated ..\n kicking staff and actively\n trying to get out of bed.. Oriented times one\nscreaming out.\n Action:\n Patient unable to take zyprexa ..Ativan .5 mg if times 2 for acute\n agitation without effect. Trazadone 50 mg for sleep. 4 siderails in\n high position, wrists restrained.. mitt to right hand to preserve\n dobhoff and ICD dsg integrity.\n Response:\n Plan:\n Dysphagia\n Assessment:\n Dobhoff remains in place. Failed video swallow study\n Action:\n Isosource advanced to 55 cc/hr . HOB greater than >45. Frequent mouth\n care\n Response:\n Patient unable to remember/understand NPO status\n Plan:\n ? PEG in future. Aspiration Precautions\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 75 V paced . SBP 110\ns/50\ns via right radial aline\n Action:\n Tolerating lopressor. Heparin at 1500 u/hr\n Response:\n Hemodynamic stable following ICD replacement\n Plan:\n Call out to floor with sitter anticipated\n" }, { "category": "Social Work", "chartdate": "2141-03-27 00:00:00.000", "description": "Social Work Progress Note", "row_id": 531872, "text": "SOCIAL WORK: Case discussed with CCU team. Pt remains confused at\n times, more restless and agitated at night. Pt is now being followed\n by gerontology service. SW met with pt\ns partner, . She voiced\n distress re: perceived setback as pt is more somnolent/ sedated today.\n Partner somewhat overwhelmed as CCU team changed today, and worries\n about lack of continuity and potential impact on pt\ns care. \n reports she had been pleased that pt was more alert and interactive\n yesterday and last evening. She expressed concern that altered mental\n status would be most distressing for the pt, and for her. SW\n acknowledged her frustration and worry. SW counseled partner about\n sharing her objective observations with team to optimally help advocate\n for his needs.\n SW will continue to follow with team to support pt and family coping,\n and advise partner about self care to minimize risk of caregiver burn\n out.\n" }, { "category": "Nursing", "chartdate": "2141-03-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 532389, "text": "72yom with multiple vascular risks factors admitted with\n dyspnea thought to be due to CHF. Pt subsequently found to have PNA on\n CXR and RV ICD lead fracture. Pt currently in ICU and course has been\n complicated by fevers and VT arrest requiring external defibrillation.\n pt underwent RV/ RA lead extractions and ICD exchange with EP\n service. Pt intubated for 24hrs post-procedure. Course also\n complicated by persistent delirium for which geriatric service has been\n following patient.\n Delirium / confusion\n Assessment:\n Pts MS much improved. Knows he\ns in & why he is here. Follows\n commands, makes needs known. No attempts to climb oob unassisted.\n Action:\n Rehab did not accept pt. sent screener to\n evaluate. Helped oob-> chair for breakfast, strength improved from\n yesterday. PT helped assist pt back to bed. Bed/ chair alarm in use for\n safety. INR 3.4, PT 33.2, PTT therapeutic 81.1 Coumadin d/c\nd. Heparin\n gtt also stopped. Foley removed.\n Response:\n Accepted to , significant other would like pt tnsf\n tomorrow instead of today as offered. Incontinent of urine x1\n attempting to use urinal. Pts delirium much improved on low dose\n seroquel at HS.\n Plan:\n Transfer to at 10am. Continue seroquel in eve. Bed/ chair\n alarm & freq monitoring to keep pt safe. Coumadin/ Heparin gtt on hold\n pending morning coags .\n" }, { "category": "Nursing", "chartdate": "2141-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530991, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated defibrillated.\n Ventricular tachycardia, sustained\n Assessment:\n Went to EP/OR for lead extraction\n new leads and\n generator placed. Arrived back to CCU ~ 1900, intubated for overnight\n on proofol.\n Received pt. on phenylephrine 0.9mcq/k/min. BP\n 90\ns-110/50\ns. HR 75 AV paced. BP higher with stimulation.\n Left upper chest dsg is D/I. no bleeding noted. Left arm\n in sling.\n EBL of 500cc in OR . transfused 1UPC\ns in OR.\n K+ 3.6\n HCT 31.9\n Remains off heparin drip.\n Action:\n HCT sent on arrival\n Neo weaned for goal SBP 90/.\n KCL total 60meq repleted. HCT checked again at 0100\n SC heparin started.\n Vanco IV q12hr x2 doses post op. (also received one dose in OR)\n Loressor dose was held while on pressor.\n Response:\n HCT 32. u/o 50-100cc/hr.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Arrived on vent\n sats 100%. Initial ABG with PO2 >400.\n Action:\n FO2 weaned to 40%. Sats 95-97%. LS diminished bases. Suctioned for\n no to scant secretions.\n Response:\n Adequate u/o . no lasix needed. Check with team in AM regarding AM\n lasix dose (po/NG)\n Plan:\n Delirium / confusion\n Assessment:\n Arrived to CCU on propofol 50mcq/k/min. pt. with no spontaneous\n movement.\n Extreme. Warm.\n Action:\n Propofol weaned to 10mcq.\n Response:\n Pt. starting to move all extremeties on the bed to stimulation.\n Moving mouth , resisting VAP care.\n Occas. strong cough.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531085, "text": "Chief Complaint: Dyspnea\n Worsened CHF\n VT/VF, found to have fractured ICD lead\n 24 Hour Events:\n CARDIAC CATH - At 02:20 PM\n To EPS.\n INVASIVE VENTILATION - START 03:00 PM\n ARTERIAL LINE - START 04:00 PM\n \n - two lead extractions (R ventricular and R atrial) and ICD implant\n without complications\n - returned to floor intubated on propofol\n - hematocrit was stable despite reported blood loss of 450 ccs\n - plan for extubation on \n - Blood pressure post-procedure 80/51 at 03:30, so gave 500 cc back,\n then another 500 cc\n - No pulsus physiology on arterial line wave-form\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 01:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 75 (75 - 84) bpm\n BP: 105/61(76) {71/46(55) - 107/67(82)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,439 mL\n 1,667 mL\n PO:\n TF:\n 205 mL\n 90 mL\n IVF:\n 2,054 mL\n 1,477 mL\n Blood products:\n Total out:\n 1,945 mL\n 320 mL\n Urine:\n 1,295 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 494 mL\n 1,347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 564 (553 - 564) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/41/182/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 455\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 315 K/uL\n 9.8 g/dL\n 171\n 0.8 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 110 mEq/L\n 138 mEq/L\n 31.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n Plt\n 448\n 424\n 407\n 315\n Cr\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 28\n 26\n Glucose\n 108\n 122\n 120\n 100\n 88\n 193\n 171\n Other labs: PT / PTT / INR:13.9/29.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - wet read\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly\n clear.\n heart remains enlarged. ? fullness of left hilum.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be after MN, and will have 4 units crossmatched for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n Diuresis gently continues, and likely to be safe.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Full\n code, but was DNR in context of surgery.\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2141-03-24 00:00:00.000", "description": "Swallowing Follow-Up", "row_id": 531137, "text": "TITLE: SWALLOWING FOLLOW-UP\nWe returned to follow-up with patient regarding swallowing.\nPatient currently intubated following OR procedure yesterday.\nPatient with possible extubation today. Currently not appropriate\nfor PO trials at this time and based on recent prolonged hospital\ncourse and documented dysphagia, will likely not be ready for POs\nimmediately following extubation. Suggest continuing NPO status\nwith tube feeds over the weekend. We will follow-up early next\nweek to re-attempt PO trials pending status post-extubation.\n_______________________________\n , MS, CCC-SLP\nPager #\n" }, { "category": "Nutrition", "chartdate": "2141-03-24 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 531138, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 96.8 kg ( 02:00 AM)\n 31.3\n Pertinent medications: Glargine, RISS, Amiodarone, Docusate Sodium,\n Potassium Chloride, Phenylephrine, others noted\n Labs:\n Value\n Date\n Glucose\n 171\n 06:00 AM\n Glucose Finger Stick\n 109\n 10:00 PM\n BUN\n 16 mg/dL\n 05:15 AM\n Creatinine\n 0.8 mg/dL\n 05:15 AM\n Sodium\n 138 mEq/L\n 05:15 AM\n Potassium\n 4.4 mEq/L\n 05:15 AM\n Chloride\n 110 mEq/L\n 05:15 AM\n TCO2\n 23 mEq/L\n 05:15 AM\n PO2 (arterial)\n 182 mm Hg\n 05:25 AM\n PCO2 (arterial)\n 41 mm Hg\n 05:25 AM\n pH (arterial)\n 7.39 units\n 05:25 AM\n pH (urine)\n 7.0 units\n 08:29 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 05:25 AM\n Albumin\n 3.0 g/dL\n 03:31 PM\n Calcium non-ionized\n 7.7 mg/dL\n 07:23 PM\n Phosphorus\n 3.5 mg/dL\n 07:23 PM\n Ionized Calcium\n 1.10 mmol/L\n 08:00 AM\n Magnesium\n 2.0 mg/dL\n 07:23 PM\n ALT\n 224 IU/L\n 03:36 AM\n Alkaline Phosphate\n 92 IU/L\n 03:36 AM\n AST\n 204 IU/L\n 03:36 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:36 AM\n WBC\n 9.5 K/uL\n 05:15 AM\n Hgb\n 9.8 g/dL\n 05:15 AM\n Hematocrit\n 31.6 %\n 05:15 AM\n Current diet order / nutrition support: Isosource 1.5 Cal Full\n strength; Additives: Beneprotein, 14 gm/day\n Starting rate: 25 ml/hr; Advance rate by 10 ml q6h Goal rate: 55 ml/hr\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n Flush w/ 100 ml water q6h\n GI:\n Assessment of Nutritional Status\n Medical Nutrition Therapy Plan - Recommend the Following\n Restart tube feed once extubated, monitor tol tolerance\n Check chemistry 10 panel\n Start regular insulin sliding scale if serum glucose greater\n than 150 mg/dL\n Other: \n" }, { "category": "Nutrition", "chartdate": "2141-03-24 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 531141, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 96.8 kg ( 02:00 AM)\n 31.3\n Pertinent medications: Glargine, RISS, Amiodarone, Docusate Sodium,\n Potassium Chloride, Phenylephrine, others noted\n Labs:\n Value\n Date\n Glucose\n 171\n 06:00 AM\n Glucose Finger Stick\n 109\n 10:00 PM\n BUN\n 16 mg/dL\n 05:15 AM\n Creatinine\n 0.8 mg/dL\n 05:15 AM\n Sodium\n 138 mEq/L\n 05:15 AM\n Potassium\n 4.4 mEq/L\n 05:15 AM\n Chloride\n 110 mEq/L\n 05:15 AM\n TCO2\n 23 mEq/L\n 05:15 AM\n PO2 (arterial)\n 182 mm Hg\n 05:25 AM\n PCO2 (arterial)\n 41 mm Hg\n 05:25 AM\n pH (arterial)\n 7.39 units\n 05:25 AM\n pH (urine)\n 7.0 units\n 08:29 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 05:25 AM\n Albumin\n 3.0 g/dL\n 03:31 PM\n Calcium non-ionized\n 7.7 mg/dL\n 07:23 PM\n Phosphorus\n 3.5 mg/dL\n 07:23 PM\n Ionized Calcium\n 1.10 mmol/L\n 08:00 AM\n Magnesium\n 2.0 mg/dL\n 07:23 PM\n ALT\n 224 IU/L\n 03:36 AM\n Alkaline Phosphate\n 92 IU/L\n 03:36 AM\n AST\n 204 IU/L\n 03:36 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:36 AM\n WBC\n 9.5 K/uL\n 05:15 AM\n Hgb\n 9.8 g/dL\n 05:15 AM\n Hematocrit\n 31.6 %\n 05:15 AM\n Current diet order / nutrition support: Isosource 1.5 Cal Full\n strength; Additives: Beneprotein, 14 gm/day\n Starting rate: 25 ml/hr; Advance rate by 10 ml q6h Goal rate: 55 ml/hr\n ( 2029kcal/102g Protein)\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n Flush w/ 100 ml water q6h\n GI: NBS\n Assessment of Nutritional Status\n 71 year old male with prolonged hospital course, s/p ICD revision\n yesterday, patient remains intub after procedure, sedation off this\n morning with plan to extubate. Patient failed video swallow\n evaluation, was on tube feed via NGT, tolerated well. Noted patient\n self discontinued NGTx2 previously, question PEG placement for long\n term nutrition support if patient fails again.\n Resume tube feed as temporary nutrition support once extubate, strict\n NPO until reassess by SLP.\n Medical Nutrition Therapy Plan - Recommend the Following\n Restart tube feed once extubated, monitor tol tolerance\n Check chemistry 10 panel\n Start regular insulin sliding scale if serum glucose greater\n than 150 mg/dL\n Other: \n 11:06\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531145, "text": "Chief Complaint: Dyspnea\n Worsened CHF\n VT/VF, found to have fractured ICD lead\n 24 Hour Events:\n CARDIAC CATH - At 02:20 PM\n To EPS.\n INVASIVE VENTILATION - START 03:00 PM\n ARTERIAL LINE - START 04:00 PM\n \n - two lead extractions (R ventricular and R atrial) and ICD implant\n without complications\n - returned to floor intubated on propofol\n - hematocrit was stable despite reported blood loss of 450 ccs\n - plan for extubation on \n - Blood pressure post-procedure 80/51 at 03:30, so gave 500 cc back,\n then another 500 cc\n - No pulsus physiology on arterial line wave-form\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 01:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 75 (75 - 84) bpm\n BP: 105/61(76) {71/46(55) - 107/67(82)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,439 mL\n 1,667 mL\n PO:\n TF:\n 205 mL\n 90 mL\n IVF:\n 2,054 mL\n 1,477 mL\n Blood products:\n Total out:\n 1,945 mL\n 320 mL\n Urine:\n 1,295 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 494 mL\n 1,347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 564 (553 - 564) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/41/182/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 455\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 315 K/uL\n 9.8 g/dL\n 171\n 0.8 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 110 mEq/L\n 138 mEq/L\n 31.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n Plt\n 448\n 424\n 407\n 315\n Cr\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 28\n 26\n Glucose\n 108\n 122\n 120\n 100\n 88\n 193\n 171\n Other labs: PT / PTT / INR:13.9/29.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - wet read\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly\n clear.\n heart remains enlarged. ? fullness of left hilum.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured.\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -consider echo\n .\n # Intubation: Pt intubed from procedure.\n - Extubate today\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: Most likely propofol as has improved after weaning\n down propofol.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Full\n code, but was DNR in context of surgery.\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531954, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n : extubated. Neo weaned off.\n : agitated and yelling .. haldol with no effect.\n : gerontology consult. Recommended seroquel. Pt. self d/c\n dobhoff again (5^th time).\n : was sleepy from seroquel 12.5mg, trazadone and zyprexa given\n night previous. BP down to 60-70\ns/ when sitting up. Gave total 1L NS\n during day. Lopressor was held.\n Delirium / confusion\n Assessment:\n Pt. able to state name only. Remains confused but not as restless.\n Staying in bed and no attemps to swing legs over bed rails. No\n agitation. Asking for something to drink/eat.\n Action:\n Seroquel 6.25mg at per gerontology recs.\n Pt. in low bed with pads on. Oriented as needed.\n Response:\n No restraints needed. Pt. slept for a lot of the night. Woke\n intermittently but would go back to sleep.\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n No VT. s/p ICD/pacer lead extraction with new leads and generator\n .\n Heparin at 1500units/hr.\n Action:\n Left Chest Dsg D/I.\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS clear bilat. RA sats 99-100%.\n BP 90s-114/40-50\ns. HR 75 Vpaced.\n Action:\n Lopessor held at .\n Response:\n u/o 25-30cc/hr . neg. 5.8 L LOS.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530346, "text": "Delirium / confusion\n Assessment:\n PT ALERT,STATES HE IS IN HOSPITAL AT TIMES ,RECOGNIZES FAMILY\n .AGITATED AT TIMES . DID SELF DC FEEDING TUBE BUT R\n Action:\n ORIENTED PT FREQUENTLY\n FAMILY VISITING MOST OD DAY\n WRIST RESTRAINTS PER PROTOCOL\n SAFETY MEASURES\n PT OOB TO CHAIR\n Response:\n PT CALM OVERALL,SOME EPISODES OF AGITATION RESPONDING TO REPRIENTATION\n Plan:\n CONTINUE REORIENTATION,FALL RISK PREVENTION\n Heart failure (CHF), Systolic, Acute\n Assessment:\n NO VT,BP STABLE,SAT 98 AT 2LNP\n UNABLE TO GIVE MEDS,NO FEEDING TUBE\n PTT 79 ON HEPARIN DRIP\n Action:\n NEW PICC IN IR\n K REPLETED\n DEFIB PADS REPLACED\n NPO FOR THURSDAYS LEAD EXTRACTION,NEEDS TYPE AND CROSS C AM BLOODS\n Response:\n STABLE OOB C \n Plan:\n CONTINUE TO MONITOR\n Dysphagia\n Assessment:\n FAILED SWALLOW STUDY ,KEEP NPO\n Action:\n NEEDS FEEDING TUBE PLACED\n Response:\n UNCHANGED\n Plan:\n REPLACE FEEDING TUBE ,RESUME TF\n" }, { "category": "Physician ", "chartdate": "2141-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530505, "text": "Chief Complaint: Dyspnea\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum, with some\n low-grade temps at home (Tm 99.8).\n 24 Hour Events:\n PICC LINE - STOP 09:02 AM\n PICC LINE - START 10:23 AM\n \n NGT replaced\n increased free water flushes\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 82) bpm\n BP: 119/62(75) {82/54(65) - 132/74(85)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,037 mL\n 432 mL\n PO:\n TF:\n 475 mL\n 228 mL\n IVF:\n 323 mL\n 104 mL\n Blood products:\n Total out:\n 925 mL\n 250 mL\n Urine:\n 925 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n 182 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 424 K/uL\n 10.7 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 142 mEq/L\n 32.5 %\n 5.5 K/uL\n [image002.jpg]\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n Plt\n 521\n 523\n 478\n 448\n 424\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n Other labs: PT / PTT / INR:13.9/111.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - dobhoff now in proximal stomach. no other interval\n chnage, though note that lateral left hemithorax is excluded from the\n film.\n Microbiology: 8:48 pm BLOOD CULTURE 1 OF 2.\n **FINAL REPORT **\n Blood Culture, Routine (Final ):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET\n ONLY.\n SENSITIVITIES PERFORMED ON REQUEST..\n Aerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n REPORTED BY PHONE TO DR. , PAGER @ 08:30\n .\n Subsequent blood cultures on ,26 - no growth so far.\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530508, "text": "Chief Complaint: Dyspnea\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum, with some\n low-grade temps at home (Tm 99.8).\n 24 Hour Events:\n PICC LINE - STOP 09:02 AM\n PICC LINE - START 10:23 AM\n \n NGT replaced\n then pulled by patient\n Increased free water flushes\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 82) bpm\n BP: 119/62(75) {82/54(65) - 132/74(85)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,037 mL\n 432 mL\n PO:\n TF:\n 475 mL\n 228 mL\n IVF:\n 323 mL\n 104 mL\n Blood products:\n Total out:\n 925 mL\n 250 mL\n Urine:\n 925 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n 182 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 424 K/uL\n 10.7 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 142 mEq/L\n 32.5 %\n 5.5 K/uL\n [image002.jpg]\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n Plt\n 521\n 523\n 478\n 448\n 424\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n Other labs: PT / PTT / INR:13.9/111.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - dobhoff now in proximal stomach. no other interval\n chnage, though note that lateral left hemithorax is excluded from the\n film.\n Microbiology: 8:48 pm BLOOD CULTURE 1 OF 2.\n **FINAL REPORT **\n Blood Culture, Routine (Final ):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET\n ONLY.\n SENSITIVITIES PERFORMED ON REQUEST..\n Aerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n REPORTED BY PHONE TO DR. , PAGER @ 08:30\n .\n Subsequent blood cultures on ,26 - no growth so far.\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be NPO Wednesday after MN, and will have 4 units crossmatched\n for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Add Lasix 40mg IV ONCE today given no response to 40 PO + 20 IV\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "General", "chartdate": "2141-03-31 00:00:00.000", "description": "Generic Note", "row_id": 532482, "text": "TITLE:\n CCU attending\n Discharge Day >30 minutes. Plans for transfer to were in\n place for today but he is more confused but well within the realm of\n his variation during his delirium and may be related to his seroquel\n dose last night. Will communicate with the MDs caring for him at\n today before transfer. Open issues include initiation of low\n dose ACE, warfarin and his delirium which we think is related to ICU\n and sedating medications.\n" }, { "category": "Nursing", "chartdate": "2141-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531065, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated defibrillated.\n Ventricular tachycardia, sustained\n Assessment:\n Went to EP/OR for lead extraction\n new leads and\n generator placed. Arrived back to CCU ~ 1900, intubated for overnight\n on proofol.\n Received pt. on phenylephrine 0.9mcq/k/min. BP\n 90\ns-110/50\ns. HR 75 AV paced. BP higher with stimulation.\n Left upper chest dsg is D/I. no bleeding noted. Left arm\n in sling.\n EBL of 500cc in OR . transfused 1UPC\ns in OR in addition to\n 1.5L IVF.\n K+ 3.6\n HCT 31.9\n Heparin gtt off.\n TM 100.1 at 0330 , assoc. with BP 83/50 on neo .3mcq.\n Action:\n Tylenol x1, gave IVF bolus 500cc x2at 0345 and 0500. neo\n titrated up to 1.5mcq/k/min.\n KCL total 60meq repleted. HCT checked again at 0100\n SC heparin started.\n Vanco IV q12hr x2 doses post op. (also received one dose in OR)\n Loressor dose was held while on pressor.\n Response:\n HCT 32. u/o 30-100cc/hr.\n BP coming up to 90-100\ns/50\ns. MAP 60\ns. by 0530.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Arrived on vent\n sats 100%. Initial ABG with PO2 >400.\n Action:\n FO2 weaned to 40%. Sats 95-97%. LS diminished bases. Suctioned for\n no to scant secretions.\n Response:\n Adequate u/o . no lasix needed. Check with team in AM regarding AM\n lasix dose (po/NG)\n Stable on CMV 550x14 5peep. 40%.\n Plan:\n Extubate today. RSBI in AM.\n Delirium / confusion\n Assessment:\n Pt. has been confused and very restless past few days, requiring\n restraints to maintain safety. Self d/c\nd feeding tube 3 x\ns in past\n week.\n Arrived to CCU on propofol 50mcq/k/min. pt. with no spontaneous\n movement.\n Extreme. Warm.\n Action:\n Propofol weaned to 10mcq.\n Response:\n Pt. starting to move all extremeties on the bed to stimulation and\n spontaneously. Periods of restlessness bordering on agitation, -\n propofol increased to 15mcq at 0430.\n Moving mouth , resisting VAP care. Opening eyes slightly to\n stimulation.\n Occas. strong cough.\n Plan:\n After extubation, maintain restraints for safety.\n GI: TF was restarted after OR at goal 45cc/hr. NPO after 0200 for\n extubation today. No stool. Last stool was guiac negative.\n" }, { "category": "Nursing", "chartdate": "2141-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531301, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Received patient awake and agitated ..\n kicking staff and actively\n trying to get out of bed.. Oriented times one\nscreaming out.\n Action:\n Patient unable to take zyprexa ..Ativan .5 mg if times 2 for acute\n agitation without effect. Trazadone 50 mg for sleep. 4 siderails in\n high position, wrists restrained.. mitt to right hand to preserve\n dobhoff and ICD dsg integrity.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531499, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n" }, { "category": "Physician ", "chartdate": "2141-03-25 00:00:00.000", "description": "EP Note", "row_id": 531394, "text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Tele: no arrhythmias, mostly A-V\n paced.\n Episode of delerium last night and wanting to get out of bed.\n Medications\n Unchanged\n Physical Exam\n General appearance: pleasant. conversant\n BP: 120 / 68 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 37.3 C\n Tmax F last 24 hours: 99.2 F\n T current C: 37.2 C\n T current F: 98.9 F\n Previous day:\n Intake: 2,363 mL\n Output: 1,895 mL\n Fluid balance: 468 mL\n Today:\n Intake: 433 mL\n Output: 480 mL\n Fluid balance: -47 mL\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: name, year, place)\n Other: L chest ICD incision C/D/I\n Labs\n 309\n 10.3\n 132\n 0.7\n 23\n 3.7\n 12\n 107\n 136\n 31.1\n 8.3\n [image002.jpg]\n 12:58 PM\n 05:52 PM\n 03:38 AM\n 03:41 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 06:00 AM\n 05:31 AM\n WBC\n 5.8\n 9.5\n 8.3\n Hgb\n 10.5\n 9.8\n 10.3\n Hct (Serum)\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n Plt\n \n INR\n 1.2\n 1.2\n 1.2\n 1.2\n 1.3\n PTT\n 74.5\n 59.9\n 74.1\n 29.1\n 83.2\n Na+\n 143\n 143\n 138\n 136\n K + (Serum)\n 4.1\n 3.8\n 3.6\n 4.4\n 3.7\n Cl\n 109\n 111\n 110\n 107\n HCO3\n 27\n 24\n 23\n 23\n BUN\n 20\n 15\n 16\n 12\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n Glucose\n 100\n 88\n 193\n 171\n 132\n O2 sat (arterial)\n 99\n ABG: / / / 23 / Values as of 05:31 AM\n Assessment and Plan\n VT - s/p new BiV-ICD placed and functioning well. Amio 200mg daily.\n -V ICD - incision C/D/I. PA & Lat CXR when allowed. Pt on\n Cefpodoxime for chronic infectious suppression, continue indefinitely\n for now.\n Nutrition - feeding tube for now. Will reevaluate swallow study once\n pt more stable later in the week.\n PT/OT eval.\n pAF - on heparin to coumadin.\n Clinically stable for floor.\n" }, { "category": "Nursing", "chartdate": "2141-03-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531500, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Received patient awake and agitated, actively trying to get out of\n bed.. Oriented times one\nscreaming out.\n Action:\n 4 siderails in high position, wrists restrained. Occ wears mitt to\n right hand to preserve dobhoff and ICD dsg integrity.\n Response:\n Conts to be restless/ agitated. Family in room.\n Plan:\n ? Haldol vs Trazadone for sleep tonight.\n Dysphagia\n Assessment:\n Dobhoff remains in place. Failed video swallow study\n Action:\n Isosource advanced to 55 cc/hr . HOB greater than >45. Frequent mouth\n care\n Response:\n Patient unable to remember/ understand NPO status\n Plan:\n ? PEG in future. Aspiration Precautions\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 75 V paced . SBP 110\ns/50\ns via right radial aline\n Action:\n Tolerating lopressor. Heparin at 1500 u/hr\n Response:\n Hemodynamic stable following ICD replacement\n Plan:\n Call out to floor with sitter if available\n" }, { "category": "Rehab Services", "chartdate": "2141-03-21 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 530338, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 428 / CHF\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: 72 y.o. male admit\n with dyspnea, weight gain, and orthopnea. Reports med\n compliance but being liberal with his diet. Diagnosed with CHF and\n infiltrate and was being diuresed. Was intubated from / to \n due to respiratory failure and during that time required pressors. He\n was found to have an AICD lead malfxn and when the pt went into VT/VF\n arrest x 2 on this admit he required external defibrillation.\n Currently he's being treated for infection presumed to be from lead\n infection and is waiting for infection to clear in order to receive a\n new AICD. He was up to the chair with nursing via the lift\n yesterday and was noted to have difficulty bearing wt through his B LE\n when the PCTs attempted to stand him to clean him up.\n Past Medical / Surgical History: paroxysmal AV block, a fib,\n ventricular tachycardia, cent fib, s/p Biv ICD with mult revisions due\n to lead malfxns, HTN, hypothyroid, anemia, IBS, constipation, obesity,\n hearing loss requiring B aids, squamous cell carcinoma L eye lid,\n cerebral infarct, falls, compression fx, s/p Whipple, C3-C4\n osteomyelitis.\n Medications: albuterol, trazodone, amiodarone, metoprolol, furosemide\n Radiology: Chest x-ray shows pace device in place and stable\n cardiomegaly.\n Labs:\n 31.8\n 10.1\n 448\n 6.2\n [image002.jpg]\n Other labs:\n INR 1.2\n Activity Orders: OOB with assist\n Social / Occupational History: Divorced, retired professor.\n Living Environment: Lives with partner in an elevator\n building/apartment. Has to stairs to enter but can go around to the\n elevator.\n Prior Functional Status / Activity Level: Previously walking with SC\n and able to go up/down the stairs to get in the front door. Walks\n outside with his partner. Partner, , reports multiple near falls\n in doors and outdoors with pt being able to catch himself.\n Independent with ADLs although there to help if needed.\n Objective Test\n Arousal / Attention / Cognition / Communication: Drowsy, alert for\n short periods of time in supine and at edge of bed. Difficult to\n understand speech. Not oriented to place, self, or current medical\n condition. Follows 25% verbal commands and requires increased time for\n processing.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 76\n 121/68\n 13\n 100\n Sit\n /\n Activity\n 85\n /\n 24\n Stand\n /\n Recovery\n 75\n 110/66\n 97\n Total distance walked:\n Minutes:\n Pulmonary Status: Decreased breath sounds throughout due to pt not\n following commands for deep breaths. Weak cough. Non-labored\n breathing pattern\n Integumentary / Vascular: No edema noted in extremities, extremities\n cool to touch. Raised area noted back of head. Pt has external pacing\n pads/wires as back up, tele, PICC R UE, catheter\n Sensory Integrity: Appears intact to light touch, difficult to assess\n due to cognition. Does respond to pain throughout.\n Pain / Limiting Symptoms: Pt repeats during session that he is very\n tired. Answers no when questioned re pain.\n Posture: Difficult to assess as pt is not able to hold himself up at\n edge of bed.\n Range of Motion\n Muscle Performance\n WFL hips, knees, ankles, elbows, wrists\n Unable to follow commands for MMT. Noted to have at least 3/5 strength\n in all extremities during fxn'l mobility.\n Motor Function: Pt noted to have ridgidity in B UE vs pt resisting\n movement. Does move all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: TBA. Pt was unable to maintain balance seated at\n edge of bed and therefore sit <> stand was not attempted. Pt was\n transferred to chair via .\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n NT\n\n\n\n\n\n\n Ambulation:\n NT\n\n\n\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: Seated static balance is poor. Pt falling forward and to his\n L, requires mod to max A to maintain balance with visual, verbal, and\n tactile cues.\n Education / Communication: Pt, , and pt's brother re PT role,\n , recommendations. Communicated with RN re status.\n Intervention: EVAL, mobility.\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Gait, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Transfers, Impaired\n Clinical impression / Prognosis: 72 y.o. male presents with above\n impairments a/w cardiac pump failure and compounded by prolonged period\n of inactivity due to medical status. Pt is currently fxn'ing well\n below his baseline of being able to ambulate I with a cane. Pt will\n benefit from aggressive PT once he has received a new ICD. In the\n meantime, he will benefit from a more conservative approach to prevent\n further secondary effects of bed rest and inactivity. He will benefit\n from being OOB daily with nursing via the lift. Once medical\n plan has been solidified, he will likely require rehab. PT to continue\n to follow and make recommendations as appropriate.\n Goals\n Time frame: 1 week\n 1.\n Tolerate OOB in chair x 3 hours at a time\n 2.\n Able to sit at the edge of the bed with 1 UE support for 2 min in prep\n for UE ADL\n 3.\n Pt will participate in seated and/or supine LE AROM therex\n 4.\n Pt will be able to perform sit <> stand transfer with mod A of 2 people\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3 times per week until ICD/ x 1 wk\n Assess WB transfers\n Gently progress endurance and independence with mobility\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n TREATMENT TIME: 1440 to 1540\n" }, { "category": "Nursing", "chartdate": "2141-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530624, "text": "Delirium / confusion\n Assessment:\n Pt and at times Ox2 which is an improvement. States he is at the\n , remembered the year, the president. At other times Very\n angry and agitated. At 9 PM last night pt angry wanted a glass of\n wine, and\n Pt yelling out most of day\n Please help me!\n Cut this thing\n want to go home\n pulling off his gown and leads.\n Action:\n Posey restraints with SRx4 up, bed alarm on. Chair alarm on while in\n chair. Posey on while in chair. Slid out of bed to stretcher chair\n this afternoon.\n Response:\n New dobhoff placed this afternoon\n checked by xray and bilat wrist\n restraints back on. Pt more annoyed and yelling out more now that wrist\n restraints are on even while family in room.\nI want a coke\nLets\n get going!\n Pt seems to be more confused today (significant\n other). Frequent reorientation to patient and emotional support to\n patient and family members.\n :\n Family comes in during the day and they have calming influence. Fall\n risk. Requires frequent re orientation. Provide comfort with lines\n and tubes.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n NO VT,BP higher all day as he was off his metoprolol and lasix , but\n did recieive all his meds at 9 PM after dopoff was placed. BP did drop\n when pt was sleeping SBP 80-90 ( as he has been last 48 hours).\n PICC line Rt brachial. Heparin gtt @ 1300units/hr.\n Action:\n PT remains on room air, lungs are clear,dim bases, Denies SOB. PTT at\n 1pm WNL. Given lasix 20mg IVP with good effect this morning (not given\n po dose as pt NPO after pulling out NGT).\n Response:\n PT remains on room air, lungs are clear, Denies SOB, good u/o. Heparin\n gtt @ 1300units/hr.\n Plan:\n No evidence of CHF no Arrhythmias. Repeat PTT this evening. To EP for\n Lead placement and Battery change on ICD Thursday afternoon by Dr\n . Needs type and cross match with am blood draw.\n Dysphagia\n Assessment:\n FAILED Swallow study, strict NPO, Had feeding tube ( dopoff) placed\n but self d/c\nd at 430am. was on feeding overnight x 7 hours was at goal\n of 55 cc per hour and tolerating.\n Action:\n Pt given po lopressor and amiodarone this morning crushed in apple\n sauce sitting 90\n upright in bed\n seemed to tolerate\n per speech and\n swallow NPO as pt high aspiration risk per video swallow\n but in\n circumstances, when he pulls his tube out, can take crushed meds in\n puree with caution. New dobhoff tube placed this afternoon\n checked\n by CXR\n started on TF back to goal rate. Daily meds given this\n afternoon via tube.\n Response:\n Remains strict NPO. TF at 55cc/hr.\n Plan:\n Pt will be NPO after midnight. .\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530691, "text": "Delirium / confusion\n Assessment:\n Pt. initially was oriented to person and place but as night went on he\n became only Oriented to self. He was more calm in the eve, but\n becoming more restless and mildly agitated at times during the night.\n Calling out for , yelling\nhelp\n, talking to himself all night,\n mostly about getting out of this place and getting help. He was very\n confused and had difficulty responding approp. When spoken to.\n Moving legs all over the bed and at times over the siderails.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Trazadone\n 50mg at HS. Zyprexa 2.5 x2.\n Response:\n Appeared to have some effect- pt. appearing more sleepy , eyes half\n closed. But continued to talk and move in the bed.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n BP 87-117/50\ns. HR 70\ns vpaced. No VEA.\n Negative 1.4L for \n Heparin 1300units/hr. PTT 59.9\n Action:\n Lopressor held at for SBP<100 per order (87-90\ns/).\n Heparin increased to 1500units/hr.\n Response:\n u/o dropped to 25-30cc/hr rest of night.\n NPO after MN for cath lab procedure today.\n Plan:\n AM labs. Clot sent to BB.\n" }, { "category": "Rehab Services", "chartdate": "2141-03-29 00:00:00.000", "description": "Repeat Bedside Swallowing Evaluation", "row_id": 532233, "text": "TITLE: REPEAT BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nReturned today to reassess this 71 year old man initially\nadmitted on with a week of cough productive of dark beige\nsputum x 1 week with progressive dyspnea. His respiratory failure\nprogressed, and was intubated on . Initially symptoms were\nthought to be due to CHF exacerbation with infiltrate, fever,\nwhite count consistent with PNA. Bronch on notable for\nnormal airways. He was extubated on . Hospital course\ncomplicated by ICD malfunction, VT/VF arrest requiring\ndefibrillation and reintubation, and runs of VT, including one VT\narrest.\nHe has been followed by our service during his admission and was\nseen most recently for a video swallow on with aspiration\nof thin liquids before the swallow and aspiration of all other\nconsistencies after the swallow from residue. Aspiration was\nsilent and cued coughs were generally ineffective at clearing\naspirate material. It was suggested he remain NPO with continued\nalternate means of nutrition, hydration and medication. There was\nalso concern about his ability to return to POs before d/c and\nteam was made aware pt may need a PEG at some point before d/c.\nSince then, he went to the OR for ICD revision. We\nreturned to see him , but he remained intubated post-op. A\nrepeat bedside swallowing evaluation was performed on and\npatient was recommended to remain primarily NPO continued\nlethargy and s/sx of aspiration on nectar thick and thin liquid.\nHe was able to tolerate pills whole with puree and small amounts\nof moist puree during the day with 1:1 assistance.\nWe returned today to repeat the evaluation and determine\ncontinued need for G-tube placement. RN reported patient has been\ntolerating purees and pills whole with puree without difficulty.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair in the CCU.\nCognition, language, speech, voice:\nPatient was awake and alert, oriented to self, and made friendly\nconversation. Patient followed commands and participated in PO\ntrials. Speech was fluent and voice wfl.\nTeeth: edentulous\\s, dentures not present\nSecretions: wfl in the oral cavity\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual strength,\nROM, and buccal tone. Palatal elevation was symmetrical. Gag\ndeferred.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp, cup, straw),\nnectar thick liquid (straw/consecutive), bites of puree, and\nground solids. Oral phase was remarkable for mild oral residue\nwith ground solids, cleared with f/u sips of liquid. Laryngeal\nelevation was adequate to palpation. Patient was noted with\nslight wet change in vocal quality after several trials of thin\nliquids, primarily with straw sips. One small throat clear was\nnoted on thin liquids following ground solid trial. No further\nchanges in vocal quality, throat clearing, coughing, or choking\nwas noted with nectar thick liquids. O2 sats remained stable in\nthe upper 90s. Patient denied the sensation of food or liquid\nstuck in his throat or going down the wrong way.\nSUMMARY / IMPRESSION:\nMr. presents with much improved mental status and\nalertness as compared to previous evaluations. He was awake and\nalert and fully participated in PO trials and conversation. He\nwas noted with soft s/sx of aspiration on thin liquids with\nslight wet change in vocal quality and one mild throat clear. No\novert s/sx of aspiration were noted with nectar thick liquids and\nsolid trials. Recommend initiating a PO diet of nectar thick\nliquids and ground solids ( no dentures) with continued strict\naspiration precautions. Please give POs only when patient is most\nawake and alert. Hold off on G-tube for now and continue\nNutrition following to ensure adequate PO intake. If patient's\nstatus remains consistent with today's evaluation, he will likely\ntolerate adequate POs without alternative means of nutrition. We\nwill continue to follow to see how he is tolerating and if he may\nbe appropriate for a diet upgrade at the end of the week.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5 out of 7.\nRECOMMENDATIONS:\n1. PO diet of nectar thick liquids and ground solids.\n2. Pills whole or crushed with puree.\n3. Strict 1:1 supervision to assist with meals and monitor\nswallow safety.\n4. Give POs only when most awake and alert.\n5. Check oral cavity for residue throughout meal.\n6. Nutrition to monitor adequate caloric intake.\n7. Q8 oral care.\n8. We will continue to follow to see how he is tolerating and if\nhe may be appropriate for a diet upgrade at the end of the week.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 0930-0945\nTotal time: 50 minutes\n" }, { "category": "Physician ", "chartdate": "2141-03-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532235, "text": "Chief Complaint:\n 24 Hour Events:\n - \n - Emailed Drs. and about Neurologic status\n - Consensus is to try PEG tube. GI to see pt on . Holding\n warfarin in anticipation. Pt already NPO as no tube in place.\n - Taking pudding and apple sauce without difficulty.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.6\nC (97.9\n HR: 80 (69 - 111) bpm\n BP: 99/55(66) {74/49(44) - 121/83(76)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 875 mL\n 580 mL\n PO:\n TF:\n IVF:\n 875 mL\n 580 mL\n Blood products:\n Total out:\n 600 mL\n 195 mL\n Urine:\n 600 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 275 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: Arcus senilius, no icterus, MM dry.\n CV: R (occasional ectopy) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m. (improvement).\n Less sedated this a.m. Moving limbs purposively. Gait not evaluated.\n Labs / Radiology\n 320 K/uL\n 10.7 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.6 %\n 5.5 K/uL\n [image002.jpg]\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n Plt\n \n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n TCO2\n 28\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n Other labs: PT / PTT / INR:28.9/108.0/2.8, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: No new.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension and NPO\n - F/u Is/Os\n - Continue metoprolol \n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n - Restart POs\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - cefpodoxime for one week from \n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarting Coumadin, bridged with heparin gtt\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and though PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed today.\n - Ground and nectar thick liquids.\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility, likely\n tomorrow.\n" }, { "category": "Physician ", "chartdate": "2141-03-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532241, "text": "Chief Complaint:\n 24 Hour Events:\n - \n - Emailed Drs. and about Neurologic status\n - Consensus is to try PEG tube. GI to see pt on . Holding\n warfarin in anticipation. Pt already NPO as no tube in place.\n - Taking pudding and apple sauce without difficulty.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.6\nC (97.9\n HR: 80 (69 - 111) bpm\n BP: 99/55(66) {74/49(44) - 121/83(76)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 875 mL\n 580 mL\n PO:\n TF:\n IVF:\n 875 mL\n 580 mL\n Blood products:\n Total out:\n 600 mL\n 195 mL\n Urine:\n 600 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 275 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: Arcus senilius, no icterus, MM dry.\n CV: R (occasional ectopy) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m. (improvement).\n Less sedated this a.m. Moving limbs purposively. Gait not evaluated.\n Labs / Radiology\n 320 K/uL\n 10.7 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.6 %\n 5.5 K/uL\n [image002.jpg]\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n Plt\n \n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n TCO2\n 28\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n Other labs: PT / PTT / INR:28.9/108.0/2.8, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: No new.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension and NPO\n - F/u Is/Os\n - Continue metoprolol \n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n - Restart POs\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - cefpodoxime for one week from \n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarting Coumadin, bridged with heparin gtt\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and though PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed today.\n - Ground and nectar thick liquids.\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility, likely\n tomorrow.\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 14:45 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532243, "text": "Chief Complaint: Dyspnea, decompensated heart failure\n 24 Hour Events:\n - had hypotension in morning tat responded to IV bolus, 250 cc NS\n - STAT echo obtained to r/o ventricular perforation --> no evidence\n - required PM bolus for hypotension to 60s, 500 cc NS\n - talked with geriatrics who recommend continue seroquel standing dose\n at night to promote sleep, and then PRN throughout the day. (both 6.25\n mg seroquel)\n - Also decreased paxil from 30 to 20\n - talked with surgery about a PEG, but they recommend a bridled DH tube\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (97\n HR: 76 (72 - 90) bpm\n BP: 82/49(58) {63/32(45) - 116/81(85)} mmHg\n RR: 13 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,540 mL\n 151 mL\n PO:\n TF:\n IVF:\n 1,540 mL\n 151 mL\n Blood products:\n Total out:\n 1,215 mL\n 220 mL\n Urine:\n 1,215 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 325 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: Arcus senilius, no icterus, MM dry.\n CV: R (occasional ectopy) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m. (improvement).\n Less sedated this a.m. Moving limbs purposively. Gait not evaluated.\n Labs / Radiology\n 306 K/uL\n 11.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 36.1 %\n 5.6 K/uL\n [image002.jpg]\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n Hct\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n Plt\n 19\n 306\n Cr\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: Echo \n IMPRESSION: Moderately dilated left ventricular cavity with severe\n global systolic dysfunction accompanied by thinning and akinesis of the\n basal and mid anteroseptal walls and an apical aneurysm. Biatrial\n enlargement. Mild mitral regurgtitation. Mild tricuspid regurgitation.\n Borderline pulmonary artery systolic hypertension. No echocardiographic\n evidence of pericardial tamponade.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Microbiology: No new growth (only growth is coag - staph on \n thought to be contaminant.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension and NPO\n - F/u Is/Os\n - Continue metoprolol \n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - cefpodoxime for one week from \n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarting Coumadin, bridged with heparin gtt\n # Mental Status\n Patient has evidence of ischemic injury on CT (white matter hypodense\n in watershed between ACA and MCA left posterior frontal. Some frontal\n release on exam (grasp). Some mild dysarthria with dysphagia, per S&S\n (see below). Delirium markedly exacerbated by many psychotropics and\n sedatives. D/w geriatrics and appreciated their recommendations. The\n patient likely had hypoxic injury, ICU delirium, with possible\n underlying neurodegenerative disease. Given possibility of Body\n Disease, they recommended not using Haldol or ativan, but instead using\n Seroquel or, if this is not possible, then Zydis. Avoid Haldol because\n of likely underlying disease and arrhythmogenicity/prolonged QT. Also\n taper Paxil because of its anticholinergic properties and exacerbation\n of akathisia. Initial dose of seroquel was very sedating (12.5) so\n halved and standing dose shifted from am to pm. Of note, we should\n make sure not to score limb movements (restless legs) as agitation.\n - Seroquel to 6.25 mg PO QPM with repeat x 1 if no result within 1 hour\n - if pt requires more sedation overnight may try PRN seroquel, or if\n unable to give may try zydis x 1 PRN\n - try to avoid sedation during the day to preserve better sleep/wake\n cycle\n - Taper paxil to 20 mg q day\n - Avoid Haldol and Ativan\n - Talk to Dr. about pre-admission mental status\n # Dysphagia and dysarthria\n Dysarthria may suggest that dysphagia likely to show little recovery.\n Failed video swallow on multiple occasions. Had NGT but removed five\n times by patient. Mental status improving and pt tolerated applesauce\n last night. However, failed repeat swallow study yesterday. Reluctant\n to place PEG, as not good long-term solution (aspiration risk just as\n high as swallowing), but will talk to electrophysiologist (Dr.\n who knows the patient well and can likely comment on\n neurologic function at baseline.\n - D/w Dr. \n - Consider PEG versus bridled NGT (depending on above concerns) for\n short term nutrition as pt has potential to improve with time once ICU\n delirium/mental status improves\n - NPO except meds\n .\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 14:46 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532244, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - evaluated by geriatrics yesterday who recommended serroquel for\n agitation\n - received seroquel + Zydis with improvement in delirium/agitation\n overnight, however quite somnolent in the am\n - able to take some applesauce last night\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98\n HR: 75 (73 - 77) bpm\n BP: 94/54(63) {91/44(58) - 123/80(84)} mmHg\n RR: 21 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 92.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,163 mL\n 98 mL\n PO:\n TF:\n 741 mL\n IVF:\n 422 mL\n 98 mL\n Blood products:\n Total out:\n 2,040 mL\n 145 mL\n Urine:\n 2,040 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n -877 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Somnolent, minimally responsive, pedaling movements of legs when\n in light sleep. Not alert and only oriented to self this a.m.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 319 K/uL\n 11.2 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 35.6 %\n 5.4 K/uL\n [image002.jpg] mg 2.1 ca 9.1 mg 2.1 INR 1.2 PTT\n 82.3\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n WBC\n 5.8\n 9.5\n 8.3\n 6.0\n 5.4\n Hct\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n Plt\n 69\n 319\n Cr\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 100\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n MICROBIOLOGY:\n Urine cx pending\n RADIOLOGY\n Chest X ray\n The position of the lines of the ICD device is unchanged. No\n pneumothorax is\n present. The lung fields are clear. The endotracheal tube has been\n removed.\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced on .\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG (avoid Haldol)\n #hypotension: This am pt noted to have hypotension with SBPs in the\n high 60\ns upon sitting in chair. Concern for tampenade given recent\n lead revision. However, pulsus was 10 mm hg which is baseline for the\n patient. STAT echo obtained showed no evidence of effusion. Pt given\n 250 cc NS and BP corrected to 90s. Likely etiology is intravascular\n depletion in setting of poor PO intake.\n - continue to monitor BP\n - small boluses PRN\n - hold lasix\n - BP holding parameters on metoprolol\n # Mental Status\n Delirium markedly exacerbated by many psychotropics and sedatives. D/w\n geriatrics and appreciate their recommendations. The patient likely\n had hypoxic injury, ICU delirium, with possible undderlying\n neurodegenerative disease. Given possibility of Body Disease, they\n recommended not using Haldol or ativan, but instead using Seroquel or,\n if this is not possible, then Zydis. Avoid Haldol because of likely\n underlying disease and arrhythmogenicity/prolonged QT. Also taper Paxil\n because of the anticholinergic properties. Last night the patient\n agitation was improved with seroquel, however he was heavily sedated\n this am. Of note, we should make sure not to score limb movements\n (restless legs) as agitation.\n - decrease Seroquel to 6.25 (if possible) for standing dose before\n bedtime with repeat x 1 if no result within 1 hour\n - if pt requires more sedation overnight may try PRN seroquel, or if\n unable to give may try zydis x 1 PRN\n - try to avoid sedation during the day to preserve better sleep/wake\n cycle\n - Taper paxil to 20 mg q day\n - Avoid Haldol and ativan\n # Dysphagia\n Failed video swallow on multiple occasions. Had NGT but removed\n several times by patient. Mental status improving and pt tolerated\n applesauce last night. However, failed repeat swallow study this am.\n - consider PEG tube for short term nutrition as pt has potential to\n improve with time once ICU delirium/mental status improves\n - NPO except meds\n # Hypoxia\n Resolving\n doing well on nasal canula. Patient was intubated from\n for hypoxemic respiratory failure from pneumonia + heart\n failure. Reintubated for pacemaker revision. Was on room air, but\n drifts down to high 80s while sleeping, possibly related to undiagnosed\n OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n - F/u Is/Os\n -no abx for now (except cefpodoxime for one week as above)\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Continue coumadin\n - continue heparin gtt until bridged (INR 1.2)\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic.\n - holding PO lasix given hypotension this am\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now, but may consider restarting different \n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition: NPO, except meds\n - considering PEG tube\n Glycemic Control: insulin SS\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: hep gtt, coumadin\n Stress ulcer:\n Communication: Comments: (HCP)\n status: full code\n Disposition: CCU for now, consider transfer to LTAC\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 14:47 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532467, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ***has bed at , needs to be discharged at 10 am***\n - got extra dose of seroquel overnight for agitatio006E\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.4\nC (97.6\n HR: 74 (68 - 83) bpm\n BP: 82/50(57) {82/48(56) - 120/76(84)} mmHg\n RR: 13 (9 - 23) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,209 mL\n 480 mL\n PO:\n 1,120 mL\n 480 mL\n TF:\n IVF:\n 89 mL\n Blood products:\n Total out:\n 615 mL\n 0 mL\n Urine:\n 615 mL\n NG:\n Stool:\n Drains:\n Balance:\n 594 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: no icterus, MM dry.\n CV:) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m., states he is\n going to rehab.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 9.8 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 13 mg/dL\n 104 mEq/L\n 137 mEq/L\n 30.1 %\n 10.0 K/uL\n [image002.jpg]\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n 05:20 AM\n 04:55 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n 5.9\n 10.0\n Hct\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n 32.2\n 30.1\n Plt\n 64\n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n 124\n 107\n Other labs: PT / PTT / INR:31.5/36.2/3.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest. These issues are now resolved,\n with pacer wire replacement and no fevers for some time. He has pulled\n his NGT five times and we were considering PEG, but he fortunately\n passed speech and swallow this a.m. His mental status continues to\n improve, but while NPO had had some small amount of asymptomatic\n hypotension to systolic pressure in the 80s. This improved with fluids.\n He is now ready for rehabilitation.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension\n - F/u Is/Os\n - Continue metoprolol with holding parameters\n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n - Encourage POs\n # supratheraputic INR: Also on hep gtt. be from Amiodarone\n interaction. Pt also received 3 mg a day for 2 days which is above\n baseline regimen of 2 mg a day.\n - INR 3.4 today, unclear why so elevated. Possibly from poor\n nutrition.\n - Stop hep gtt\n - Decrease Coumadin to 2 mg q day\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - clarify length of cefpodoxime (for one week from vs life?)\n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarted Coumadin\n # Mental Status\n High cognitive ability at baseline and rapidly improving. Drs. \n and thought PEG would be warranted given likely recovery,\n but now does not need this given passing speech and swallow.\n # Dysphagia and dysarthria\n Passed swallow\n -Pureed (dysphagia); Nectar prethickened liquids\n - calorie counts\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - restarted diet\n - restart pancreatic enzyme supplementation\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "EP Note", "row_id": 531620, "text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: still quite delerious and wanting\n to pull NG tube out and trying to get out of bed.\n Medications\n Unchanged\n Physical Exam\n General appearance: alert to name and place\n BP: 107 / 64 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 37.3 C\n Tmax F last 24 hours: 99.2 F\n T current C: 37.3 C\n T current F: 99.2 F\n Previous day:\n Intake: 981 mL\n Output: 2,250 mL\n Fluid balance: -1,269 mL\n Today:\n Intake: 182 mL\n Output: 450 mL\n Fluid balance: -268 mL\n Cardiovascular: (Auscultation: rrr)\n Respiratory: (Auscultation: cta anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: name and place), (Mood / Affect: delerious)\n Labs\n 269\n 10.5\n 119\n 0.6\n 25\n 4.2\n 14\n 106\n 138\n 32.7\n 6.0\n [image002.jpg]\n 05:52 PM\n 03:38 AM\n 03:41 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.8\n 9.5\n 8.3\n 6.0\n Hgb\n 10.5\n 9.8\n 10.3\n 10.5\n Hct (Serum)\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 69\n INR\n 1.2\n 1.2\n 1.2\n 1.3\n 1.1\n PTT\n 59.9\n 74.1\n 29.1\n 83.2\n 32.8\n Na+\n 143\n 143\n 138\n 136\n 138\n K + (Serum)\n 3.8\n 3.6\n 4.4\n 3.7\n 4.2\n Cl\n 109\n 111\n 110\n 107\n 106\n HCO3\n 27\n 24\n 23\n 23\n 25\n BUN\n 20\n 15\n 16\n 12\n 14\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n Glucose\n 100\n 88\n 193\n 171\n 132\n 119\n O2 sat (arterial)\n 99\n ABG: / / / 25 / Values as of 05:33 AM\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED - s/p new ICD with new RA, RV and\n ICD. Doing well from device perspective. Current issue is his\n delerium and need for baby sitter. Continue lifelong antibiotic\n suppression.\n PT/OT\n Repeat swallow eval again in the week once better.\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "EP Note", "row_id": 531621, "text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: still quite delerious and wanting\n to pull NG tube out and trying to get out of bed.\n Medications\n Unchanged\n Physical Exam\n General appearance: alert to name and place\n BP: 107 / 64 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 37.3 C\n Tmax F last 24 hours: 99.2 F\n T current C: 37.3 C\n T current F: 99.2 F\n Previous day:\n Intake: 981 mL\n Output: 2,250 mL\n Fluid balance: -1,269 mL\n Today:\n Intake: 182 mL\n Output: 450 mL\n Fluid balance: -268 mL\n Cardiovascular: (Auscultation: rrr)\n Respiratory: (Auscultation: cta anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: name and place), (Mood / Affect: delerious)\n Labs\n 269\n 10.5\n 119\n 0.6\n 25\n 4.2\n 14\n 106\n 138\n 32.7\n 6.0\n [image002.jpg]\n 05:52 PM\n 03:38 AM\n 03:41 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.8\n 9.5\n 8.3\n 6.0\n Hgb\n 10.5\n 9.8\n 10.3\n 10.5\n Hct (Serum)\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 69\n INR\n 1.2\n 1.2\n 1.2\n 1.3\n 1.1\n PTT\n 59.9\n 74.1\n 29.1\n 83.2\n 32.8\n Na+\n 143\n 143\n 138\n 136\n 138\n K + (Serum)\n 3.8\n 3.6\n 4.4\n 3.7\n 4.2\n Cl\n 109\n 111\n 110\n 107\n 106\n HCO3\n 27\n 24\n 23\n 23\n 25\n BUN\n 20\n 15\n 16\n 12\n 14\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n Glucose\n 100\n 88\n 193\n 171\n 132\n 119\n O2 sat (arterial)\n 99\n ABG: / / / 25 / Values as of 05:33 AM\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED - s/p new ICD with new RA, RV and\n ICD. Doing well from device perspective. Current issue is his\n delerium and need for baby sitter. Continue lifelong antibiotic\n suppression.\n PT/OT\n Repeat swallow eval again in the week once better.\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 Dr \n nothing to add\n Physical Examination\n Per Dr \n nothing to add\n Medical Decision Making\n Per Dr \n nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 30 minutes.\n Additional comments:\n remains delirious but is improving\n needs a sitter but will eventually try and transition to a rehab\n facility\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:16 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531625, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n \n - continued to have delirium, agitation, restlessness, worse at night\n - gave haldol to control agitation\n - unable to find sitter so kept him in CCU another night given concern\n for significant agitation\n - was negative 1200cc with just his home PO lasix dose (40mg)\n - per review of speech/swallow recs, he is unlikely to regain\n significant swallow function in a timely manner; possibility of PEG\n should be discussed w/ family\n - dc'd art line\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (72 - 78) bpm\n BP: 118/68(80) {97/42(57) - 152/68(80)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 981 mL\n 144 mL\n PO:\n TF:\n IVF:\n 681 mL\n 144 mL\n Blood products:\n Total out:\n 2,250 mL\n 100 mL\n Urine:\n 2,250 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,269 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18th. Was reoriented.\n Labs / Radiology\n 269 K/uL\n 10.5 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 106 mEq/L\n 138 mEq/L\n 32.7 %\n 6.0 K/uL\n [image002.jpg]\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.5\n 5.8\n 9.5\n 8.3\n 6.0\n Hct\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 09\n 269\n Cr\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n TCO2\n 28\n 26\n Glucose\n 120\n 100\n 88\n 193\n 171\n 132\n 119\n Other labs: PT / PTT / INR:13.3/32.8/1.1, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR \n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Microbiology: Nothing since - coag. negative staph thought to be\n contaminant\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restarting Coumadin\n -heparin IV weight based protocol bridge to coumadin\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Hypoxia: Resolving. Patient was intubated from for\n hypoxemic respiratory failure. Etiology likely pneumonia + heart\n failure. Currently resolving, was on room air, but drifts down to high\n 80s while sleeping, possibly related to undiagnosed OSA. Got some 2L or\n so of fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Look into speech and swallow evaluations to see if delirium has been\n masking ability to swallow. If not, then consider surgery consult for\n PEG\n -wean O2 as tolerated\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. U/A negative. Abx course for PNA complete. Failed\n videoswallow so NPO for now.\n - Frequent reorientation\n - Maintain adequate bowel regimen\n - continue to follow clinically\n - minimize sedating medications\n - Avoid ativan, try haldol for last resort\n - Geriatrics consult today\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n - Will need to consider PEG in future\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: FULL\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530483, "text": "Delirium / confusion\n Assessment:\n Pt and at times Ox2 which is an improvement. States he is at the\n , remembered the year, the president. At other times Very\n angry and agitated. At 9 PM last night pt angry wanted a glass of\n wine, and\n Demanding yelling and Kicking side rails yelling\n I am a prisoner!\n Cut this thing\n you can not keep me here\n pulling off his gown\n and leads.\n Action:\n For Acute agitation given 0.5 mg IV Lorazepam with good effect. Placed\n mittens on and untied pt with close supervision. Pt much more calm,\n able to turn but by midnight he was throwing his legs over the side\n rail and required posey vest. After bed bath he fell asleep, however\n he woke up at 0400, wiggled out of one mitten and self dc\nd feeding\n tube again. Now has soft wrist restraint on left arm.\n Response:\n Pt currently calm, on/off again sleeping tonight ( more sleep than\n usual) Very agitated x 1\n calmer when not restrained, However he again\n dc\nd his NGT.\n Plan:\n Family comes in during the day and they have calming influence. Pt is\n a fall risk and need supervision, bed alarm, posey vest and mittens.\n Requires frequent re orientation. Provide comfort with lines and\n tubes.\n OOB with lift ( pt balance is very poor per Physical therapy) .\n Heart failure (CHF), Systolic, Acute\n Assessment:\n NO VT,BP higher all day as he was off his metoprolol and lasix , but\n did recieive all his meds at 9 PM after dopoff was placed. BP did drop\n when pt was sleeping SBP 80-90 ( as he has been last 48 hours).\n Continues on heparin drip via New Picc line placed in IR.\n Action:\n PT remains on room air, lungs are clear, Denies SOB\n Response:\n PT remains on room air, lungs are clear, Denies SOB, making urine.\n Plan:\n No evidence of CHF no Arrhythmias.\n Dysphagia\n Assessment:\n FAILED Swallow study, strict NPO, Had feeding tube ( dopoff) placed\n but self dc\nd . was on feeding overnight x 7 hours was at goal of 55 cc\n per hour and tolerating.\n Action:\n NEEDS NEW FEEDING TUBE PLACED\n Response:\n Remains strict NPO\n Plan:\n REPLACE FEEDING TUBE ,RESUME TF,MEDS. Pt will be NPO after midnight\n for Lead placement and\n Battery change on ICD Thursday Dr will be in today to speak\n with family. Pt will need type and cross match with AM blood draw \n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530684, "text": "Delirium / confusion\n Assessment:\n Pt. initially was oriented to person and place but as night went on he\n became only Oriented to self. He was more calm in the eve, but\n becoming more restless and mildly agitated at times during the night.\n Calling out for , yelling\nhelp\n, talking to himself all night,\n mostly about getting out of this place and getting help. He was very\n confused and had difficulty responding approp. When spoken to.\n Moving legs all over the bed and at times over the siderails.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Trazadone\n 50mg at HS. Zyprexa 2.5 x2.\n Response:\n Appeared to have some effect- pt. appearing more sleepy , eyes half\n closed. But continued to talk and move in the bed.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531365, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n - \n - extubated\n - too agitated to get PA/Lat (will need that )\n - very agitated overnight, received ativan IV 0.5 mg x 2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (75 - 83) bpm\n BP: 106/57(73) {91/49(63) - 126/69(87)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,363 mL\n 336 mL\n PO:\n TF:\n 90 mL\n IVF:\n 1,993 mL\n 336 mL\n Blood products:\n Total out:\n 1,895 mL\n 340 mL\n Urine:\n 1,895 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: ///23/\n Ve: 11.4 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 309 K/uL\n 10.3 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 107 mEq/L\n 136 mEq/L\n 31.1 %\n 8.3 K/uL\n [image002.jpg]\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n 8.3\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n Plt\n 448\n 424\n 407\n 315\n 309\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 28\n 26\n Glucose\n 122\n 120\n 100\n 88\n 193\n 171\n 132\n Other labs: PT / PTT / INR:14.6/83.2/1.3, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531367, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n - \n - extubated\n - too agitated to get PA/Lat (will need that )\n - very agitated overnight, received ativan IV 0.5 mg x 2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (75 - 83) bpm\n BP: 106/57(73) {91/49(63) - 126/69(87)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,363 mL\n 336 mL\n PO:\n TF:\n 90 mL\n IVF:\n 1,993 mL\n 336 mL\n Blood products:\n Total out:\n 1,895 mL\n 340 mL\n Urine:\n 1,895 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: ///23/\n Ve: 11.4 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 309 K/uL\n 10.3 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 107 mEq/L\n 136 mEq/L\n 31.1 %\n 8.3 K/uL\n [image002.jpg]\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n 8.3\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n Plt\n 448\n 424\n 407\n 315\n 309\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 28\n 26\n Glucose\n 122\n 120\n 100\n 88\n 193\n 171\n 132\n Other labs: PT / PTT / INR:14.6/83.2/1.3, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n CXR AP :\n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restart Coumadin\n -heparin IV weight based protocol with an at least 3 day overlap on\n therapeutic INR\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA. Got some 2L or so of\n fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV yesterday\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. U/A negative. Abx course for PNA complete. Failed\n videoswallow so NPO for now.\n - Frequent reorientation\n - Maintain adequate bowel regimen\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Probable call out to cardiology floor today\n" }, { "category": "Physician ", "chartdate": "2141-03-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531493, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n - \n - extubated\n - too agitated to get PA/Lat (will need that )\n - very agitated overnight, received ativan IV 0.5 mg x 2\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (75 - 83) bpm\n BP: 106/57(73) {91/49(63) - 126/69(87)} mmHg\n RR: 17 (15 - 25) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,363 mL\n 336 mL\n PO:\n TF:\n 90 mL\n IVF:\n 1,993 mL\n 336 mL\n Blood products:\n Total out:\n 1,895 mL\n 340 mL\n Urine:\n 1,895 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 468 mL\n -4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 550 (550 - 550) mL\n PS : 5 cmH2O\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: ///23/\n Ve: 11.4 L/min\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18th. Was reoriented.\n Labs / Radiology\n 309 K/uL\n 10.3 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 107 mEq/L\n 136 mEq/L\n 31.1 %\n 8.3 K/uL\n [image002.jpg]\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n 8.3\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n Plt\n 448\n 424\n 407\n 315\n 309\n Cr\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 28\n 26\n Glucose\n 122\n 120\n 100\n 88\n 193\n 171\n 132\n Other labs: PT / PTT / INR:14.6/83.2/1.3, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n CXR AP :\n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restarting Coumadin\n -heparin IV weight based protocol bridge to coumadin\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Hypoxia: Resolving. Patient was intubated from for\n hypoxemic respiratory failure. Etiology likely pneumonia + heart\n failure. Currently resolving, was on room air, but drifts down to high\n 80s while sleeping, possibly related to undiagnosed OSA. Got some 2L or\n so of fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Look into speech and swallow evaluations to see if delirium has been\n masking ability to swallow. If not, then consider surgery consult for\n PEG\n -wean O2 as tolerated\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. U/A negative. Abx course for PNA complete. Failed\n videoswallow so NPO for now.\n - Frequent reorientation\n - Maintain adequate bowel regimen\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Probable call out to cardiology floor today\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531588, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n \n - continued to have delirium, agitation, restlessness, worse at night\n - gave haldol to control agitation\n - unable to find sitter so kept him in CCU another night given concern\n for significant agitation\n - was negative 1200cc with just his home PO lasix dose (40mg)\n - per review of speech/swallow recs, he is unlikely to regain\n significant swallow function in a timely manner; possibility of PEG\n should be discussed w/ family\n - dc'd art line\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (72 - 78) bpm\n BP: 118/68(80) {97/42(57) - 152/68(80)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 981 mL\n 144 mL\n PO:\n TF:\n IVF:\n 681 mL\n 144 mL\n Blood products:\n Total out:\n 2,250 mL\n 100 mL\n Urine:\n 2,250 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,269 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\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 269 K/uL\n 10.5 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 106 mEq/L\n 138 mEq/L\n 32.7 %\n 6.0 K/uL\n [image002.jpg]\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.5\n 5.8\n 9.5\n 8.3\n 6.0\n Hct\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 09\n 269\n Cr\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n TCO2\n 28\n 26\n Glucose\n 120\n 100\n 88\n 193\n 171\n 132\n 119\n Other labs: PT / PTT / INR:13.3/32.8/1.1, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR \n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Microbiology: Nothing since - coag. negative staph thought to be\n contaminant\n ECG: .\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531589, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 03:30 PM\n \n - continued to have delirium, agitation, restlessness, worse at night\n - gave haldol to control agitation\n - unable to find sitter so kept him in CCU another night given concern\n for significant agitation\n - was negative 1200cc with just his home PO lasix dose (40mg)\n - per review of speech/swallow recs, he is unlikely to regain\n significant swallow function in a timely manner; possibility of PEG\n should be discussed w/ family\n - dc'd art line\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 75 (72 - 78) bpm\n BP: 118/68(80) {97/42(57) - 152/68(80)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 981 mL\n 144 mL\n PO:\n TF:\n IVF:\n 681 mL\n 144 mL\n Blood products:\n Total out:\n 2,250 mL\n 100 mL\n Urine:\n 2,250 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,269 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18th. Was reoriented.\n Labs / Radiology\n 269 K/uL\n 10.5 g/dL\n 119 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 106 mEq/L\n 138 mEq/L\n 32.7 %\n 6.0 K/uL\n [image002.jpg]\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n WBC\n 5.5\n 5.8\n 9.5\n 8.3\n 6.0\n Hct\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n Plt\n 09\n 269\n Cr\n 0.8\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n TCO2\n 28\n 26\n Glucose\n 120\n 100\n 88\n 193\n 171\n 132\n 119\n Other labs: PT / PTT / INR:13.3/32.8/1.1, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.2 mg/dL\n Fluid analysis / Other labs: .\n Imaging: CXR \n CHEST, AP: A left chest wall pacemaker is again seen with leads\n overlying the\n right atrium, right ventricle, and coronary sinus. Endotracheal tube\n ends 6\n cm from the carina. There is no pneumothorax or pleural effusion. Mild\n cardiomegaly is unchanged. The hilar and mediastinal contours are\n normal.\n IMPRESSION: ICD lead revision, without complications.\n Microbiology: Nothing since - coag. negative staph thought to be\n contaminant\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced.\n -restarting Coumadin\n -heparin IV weight based protocol bridge to coumadin\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Hypoxia: Resolving. Patient was intubated from for\n hypoxemic respiratory failure. Etiology likely pneumonia + heart\n failure. Currently resolving, was on room air, but drifts down to high\n 80s while sleeping, possibly related to undiagnosed OSA. Got some 2L or\n so of fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Look into speech and swallow evaluations to see if delirium has been\n masking ability to swallow. If not, then consider surgery consult for\n PEG\n -wean O2 as tolerated\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. U/A negative. Abx course for PNA complete. Failed\n videoswallow so NPO for now.\n - Frequent reorientation\n - Maintain adequate bowel regimen\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Restarting coumadin; started heparin gtt for bridging\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO, tube feeds\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 02:10 AM\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530737, "text": "Delirium / confusion\n Assessment:\n Pt. initially was oriented to person and place but as night went on he\n became only Oriented to self. He was more calm in the eve, but\n becoming more restless and mildly agitated at times during the night.\n Calling out for , yelling\nhelp\n, talking to himself all night,\n mostly about getting out of this place and getting help. He was very\n confused and had difficulty responding approp. When spoken to.\n Moving legs all over the bed and at times over the siderails.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Trazadone\n 50mg at HS. Zyprexa 2.5 x2.\n Response:\n Appeared to have some effect- pt. appearing more sleepy , eyes half\n closed. But continued to talk and move in the bed.\n 0400- had bed bath, hands left unrestrained and pt. was allowed more\n freedom in the bed with the RN at bedside monitoring and watching. He\n was very sleepy and settled onto his right side and fell asleep with\n occas. leg movements. Much more calm.\n Plan:\n Safety precautions. Restrain when sitter not present in the room.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n BP 87-117/50\ns. HR 70\ns vpaced. No VEA.\n Negative 1.4L for \n Heparin 1300units/hr. PTT 59.9\n AM K+ 3.8\n Action:\n Lopressor held at for SBP<100 per order (87-90\ns/).\n Heparin increased to 1500units/hr.\n Repleted with 20meq KCL IV\n Response:\n u/o dropped to 25-30cc/hr rest of night.\n NPO after MN for cath lab procedure today.\n AM PTT 74.\n Plan:\n AM labs. Clot sent to BB.\n" }, { "category": "General", "chartdate": "2141-03-23 00:00:00.000", "description": "Generic Note", "row_id": 530962, "text": "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 have also reviewed the note by Dr. today.\n I would add the following remarks:\n History\n Today underwent EPS laser removal of pacer leads\n new pacemaker\n defibrillator placed without complications.\n Medical Decision Making\n Recover in CCU tonight\n Total time spent on patient care: 30 minutes of critical care time\n" }, { "category": "Nursing", "chartdate": "2141-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531021, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated defibrillated.\n Ventricular tachycardia, sustained\n Assessment:\n Went to EP/OR for lead extraction\n new leads and\n generator placed. Arrived back to CCU ~ 1900, intubated for overnight\n on proofol.\n Received pt. on phenylephrine 0.9mcq/k/min. BP\n 90\ns-110/50\ns. HR 75 AV paced. BP higher with stimulation.\n Left upper chest dsg is D/I. no bleeding noted. Left arm\n in sling.\n EBL of 500cc in OR . transfused 1UPC\ns in OR in addition to\n 1.5L IVF.\n K+ 3.6\n HCT 31.9\n Heparin gtt off.\n TM 100.1 at 0330 , assoc. with BP 83/50 on neo .3mcq.\n Action:\n Tylenol x1, gave IVF bolus 500cc at 0345. neo titrated up\n to 0.6mcq/k/min\n KCL total 60meq repleted. HCT checked again at 0100\n SC heparin started.\n Vanco IV q12hr x2 doses post op. (also received one dose in OR)\n Loressor dose was held while on pressor.\n Response:\n HCT 32. u/o 50-100cc/hr.\n BP coming up to 90\ns/50\ns. MAP 60\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Arrived on vent\n sats 100%. Initial ABG with PO2 >400.\n Action:\n FO2 weaned to 40%. Sats 95-97%. LS diminished bases. Suctioned for\n no to scant secretions.\n Response:\n Adequate u/o . no lasix needed. Check with team in AM regarding AM\n lasix dose (po/NG)\n Stable on CMV 550x14 5peep. 40%.\n Plan:\n Extubate today. RSBI in AM.\n Delirium / confusion\n Assessment:\n Pt. has been confused and very restless past few days, requiring\n restraints to maintain safety. Self d/c\nd feeding tube 3 x\ns in past\n week.\n Arrived to CCU on propofol 50mcq/k/min. pt. with no spontaneous\n movement.\n Extreme. Warm.\n Action:\n Propofol weaned to 10mcq.\n Response:\n Pt. starting to move all extremeties on the bed to stimulation and\n spontaneously. Moving mouth , resisting VAP care. Opening eyes\n slightly to stimulation.\n Occas. strong cough.\n Plan:\n After extubation, maintain restraints for safety.\n GI: TF was restarted after OR at goal 45cc/hr. NPO after 0200 for\n extubation today. No stool. Last stool was guiac negative.\n" }, { "category": "Nursing", "chartdate": "2141-03-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531980, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n To EP for lead extraction, new leads and generator, AICD placed\n : extubated. Neo weaned off.\n : agitated and yelling .. haldol with no effect.\n : gerontology consult. Recommended seroquel. Pt. self d/c\n dobhoff again (5^th time).\n : was sleepy from seroquel 12.5mg, trazadone and zyprexa given\n night previous. BP down to 60-70\ns/ when sitting up. Gave total 1L NS\n during day. Lopressor was held.\n Delirium / confusion\n Assessment:\n Pt. able to state name only. Remains confused but not as restless.\n Staying in bed and no attemps to swing legs over bed rails. No\n agitation. Asking for something to drink/eat.\n Action:\n Seroquel 6.25mg at per gerontology recs.\n Pt. in low bed with pads on side rails.\n Response:\n No restraints needed. Pt. slept for most of the night. Woke\n intermittently but would go back to sleep.\n Turned and positioned and tolerated well. No restlessness or\n agitation.\n Plan:\n Monitor MS following this good night sleep. Follow w/gerontoloty for\n recs.\n Heart failure (CHF), Systolic, Acute\n s/p Pacer/ICD .\n Assessment:\n LS clear bilat. RA sats 99-100%.\n BP 90s-114/40-50\ns. HR 75 Vpaced.\n Had hypotension with sitting up in bed and/or chair rx with IVF\n boluses for total 1L.\n Action:\n Lopessor held at .\n Response:\n u/o 25-30cc/hr . neg. 5.8 L LOS.\n BP better 90\ns-114/40\n Plan:\n OOB to chair. Monitor u/o . check with team about giving po lasix as\n ordered.\n Plan for feeding is for dobhoff with bridal. There is a concern that\n pt. would be at risk for pulling out PEG if that was placed. NPO for\n now except for meds\n he can swallow meds whole in applesauce, siting\n up right.\n" }, { "category": "Physician ", "chartdate": "2141-03-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531982, "text": "Chief Complaint: Dyspnea, decompensated heart failure\n 24 Hour Events:\n - had hypotension in morning tat responded to IV bolus\n - STAT echo obtained to r/o ventricular perforation --> no evidence\n - required PM bolus for hypotension to 60s\n - talked with geriatrics who recommend continue seroquel standing dose\n at night to promote sleep, and then PRN throughout the day.\n - ALso decreased paxil\n - talked with surgery about a PEG, but they recommend a bridled DH tube\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (97\n HR: 76 (72 - 90) bpm\n BP: 82/49(58) {63/32(45) - 116/81(85)} mmHg\n RR: 13 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,540 mL\n 151 mL\n PO:\n TF:\n IVF:\n 1,540 mL\n 151 mL\n Blood products:\n Total out:\n 1,215 mL\n 220 mL\n Urine:\n 1,215 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 325 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 11.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 36.1 %\n 5.6 K/uL\n [image002.jpg]\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n Hct\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n Plt\n 19\n 306\n Cr\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: Echo \n IMPRESSION: Moderately dilated left ventricular cavity with severe\n global systolic dysfunction accompanied by thinning and akinesis of the\n basal and mid anteroseptal walls and an apical aneurysm. Biatrial\n enlargement. Mild mitral regurgtitation. Mild tricuspid regurgitation.\n Borderline pulmonary artery systolic hypertension. No echocardiographic\n evidence of pericardial tamponade.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Microbiology: No new growth (only growth is coag - staph on \n thought to be contaminant.\n ECG: .\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility\n" }, { "category": "Physician ", "chartdate": "2141-03-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531984, "text": "Chief Complaint: Dyspnea, decompensated heart failure\n 24 Hour Events:\n - had hypotension in morning tat responded to IV bolus\n - STAT echo obtained to r/o ventricular perforation --> no evidence\n - required PM bolus for hypotension to 60s\n - talked with geriatrics who recommend continue seroquel standing dose\n at night to promote sleep, and then PRN throughout the day.\n - ALso decreased paxil\n - talked with surgery about a PEG, but they recommend a bridled DH tube\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Coumadin (Warfarin) - 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 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (97\n HR: 76 (72 - 90) bpm\n BP: 82/49(58) {63/32(45) - 116/81(85)} mmHg\n RR: 13 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,540 mL\n 151 mL\n PO:\n TF:\n IVF:\n 1,540 mL\n 151 mL\n Blood products:\n Total out:\n 1,215 mL\n 220 mL\n Urine:\n 1,215 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 325 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Somnolent, minimally responsive, pedaling movements of legs when\n in light sleep. Not alert and only oriented to self this a.m.\n Labs / Radiology\n 306 K/uL\n 11.3 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 36.1 %\n 5.6 K/uL\n [image002.jpg]\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n Hct\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n Plt\n 19\n 306\n Cr\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: Echo \n IMPRESSION: Moderately dilated left ventricular cavity with severe\n global systolic dysfunction accompanied by thinning and akinesis of the\n basal and mid anteroseptal walls and an apical aneurysm. Biatrial\n enlargement. Mild mitral regurgtitation. Mild tricuspid regurgitation.\n Borderline pulmonary artery systolic hypertension. No echocardiographic\n evidence of pericardial tamponade.\n Compared with the prior study (images reviewed) of , the\n findings are similar.\n Microbiology: No new growth (only growth is coag - staph on \n thought to be contaminant.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured, now removed and replaced on .\n -cefpodoxime for one week from \n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG (avoid Haldol)\n #hypotension: This am pt noted to have hypotension with SBPs in the\n high 60\ns upon sitting in chair. Concern for tampenade given recent\n lead revision. However, pulsus was 10 mm hg which is baseline for the\n patient. STAT echo obtained showed no evidence of effusion. Pt given\n 250 cc NS and BP corrected to 90s. Likely etiology is intravascular\n depletion in setting of poor PO intake.\n - continue to monitor BP\n - small boluses PRN\n - hold lasix\n - BP holding parameters on metoprolol\n # Mental Status\n Delirium markedly exacerbated by many psychotropics and sedatives. D/w\n geriatrics and appreciate their recommendations. The patient likely\n had hypoxic injury, ICU delirium, with possible undderlying\n neurodegenerative disease. Given possibility of Body Disease, they\n recommended not using Haldol or ativan, but instead using Seroquel or,\n if this is not possible, then Zydis. Avoid Haldol because of likely\n underlying disease and arrhythmogenicity/prolonged QT. Also taper Paxil\n because of the anticholinergic properties. Last night the patient\n agitation was improved with seroquel, however he was heavily sedated\n this am. Of note, we should make sure not to score limb movements\n (restless legs) as agitation.\n - decrease Seroquel to 6.25 (if possible) for standing dose before\n bedtime with repeat x 1 if no result within 1 hour\n - if pt requires more sedation overnight may try PRN seroquel, or if\n unable to give may try zydis x 1 PRN\n - try to avoid sedation during the day to preserve better sleep/wake\n cycle\n - Taper paxil to 20 mg q day\n - Avoid Haldol and ativan\n # Dysphagia\n Failed video swallow on multiple occasions. Had NGT but removed\n several times by patient. Mental status improving and pt tolerated\n applesauce last night. However, failed repeat swallow study this am.\n - consider PEG tube for short term nutrition as pt has potential to\n improve with time once ICU delirium/mental status improves\n - NPO except meds\n # Hypoxia\n Resolving\n doing well on nasal canula. Patient was intubated from\n for hypoxemic respiratory failure from pneumonia + heart\n failure. Reintubated for pacemaker revision. Was on room air, but\n drifts down to high 80s while sleeping, possibly related to undiagnosed\n OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n - F/u Is/Os\n -no abx for now (except cefpodoxime for one week as above)\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - Continue coumadin\n - continue heparin gtt until bridged (INR 1.2)\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic.\n - holding PO lasix given hypotension this am\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now, but may consider restarting different \n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility\n" }, { "category": "Physician ", "chartdate": "2141-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530329, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n \n - EP recommended against calling pt out because he's already had two VT\n arrests and now is without an ICD back-up, code blue response much\n slower on floor than CCU, thus, we did not call him out to the floor\n - speech and swallow evaulated and thought at high aspiration risk.\n recommended NPO and consider PEG\n - HCP wants to talk with Dr. before any decisions are\n made regarding surgery for ICD revision\n - patient failed video swallow had dobhoff placed\n - nutrition recs to start isosource TF at 25 cc/hr and titrate up to 55\n cc/hr\n - ordered fluoro guided PICC replacement (since was pulled out with\n dressing change) which will happen tomorrow\n - Ca low so added on albumin to labs, is 3.0 - correct to 9.0.\n - Hypotensive to 80s/40s by NBP, but A-line in the past showed higher\n pressures, patient putting out about 50-80 cc urine per hour and\n mentating at baseline. Given past VT, decided to give metoprolol 12.5\n mg then 12.5 mg, instead of 25mg at one time\n - EP recs:\n ICD malfunction: Fidelis RV coil fracture\n -Tentative left sided single lead extraction (Fidelis) and new ICD lead\n placement Thursday with Dr. \n - NPO Wed evening. Please type and cross 4 units of PRBC for procedure\n Thurs.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 81 (76 - 84) bpm\n BP: 101/36(53) {71/36(49) - 104/78(82)} mmHg\n RR: 15 (9 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,713 mL\n 385 mL\n PO:\n 340 mL\n TF:\n 131 mL\n 251 mL\n IVF:\n 852 mL\n 104 mL\n Blood products:\n Total out:\n 1,970 mL\n 225 mL\n Urine:\n 1,970 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -257 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 448 K/uL\n 10.1 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 106 mEq/L\n 141 mEq/L\n 31.8 %\n 6.2 K/uL\n [image002.jpg]\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n Plt\n 521\n 523\n 478\n 448\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n Other labs: PT / PTT / INR:13.6/79.0/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: No new imaging. Wet read of CXR AP :\n CP angles excluded. NG tube passes into the stomach and off the\n inferior\n margin of the film. pacer leads unchanged. stable cardiomegally. no\n acute\n cardiopulm process.\n Microbiology: No new growth\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be NPO Wednesday after MN, and will have 4 units crossmatched\n for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Add Lasix 40mg IV ONCE today given no response to 40 PO + 20 IV\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:45 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt, pnuemoboots\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition : CCU\n" }, { "category": "Physician ", "chartdate": "2141-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530397, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n \n - EP recommended against calling pt out because he's already had two VT\n arrests and now is without an ICD back-up, code blue response much\n slower on floor than CCU, thus, we did not call him out to the floor\n - speech and swallow evaulated and thought at high aspiration risk.\n recommended NPO and consider PEG\n - HCP wants to talk with Dr. before any decisions are\n made regarding surgery for ICD revision\n - patient failed video swallow had dobhoff placed\n - nutrition recs to start isosource TF at 25 cc/hr and titrate up to 55\n cc/hr\n - ordered fluoro guided PICC replacement (since was pulled out with\n dressing change) which will happen tomorrow\n - Ca low so added on albumin to labs, is 3.0 - correct to 9.0.\n - Hypotensive to 80s/40s by NBP, but A-line in the past showed higher\n pressures, patient putting out about 50-80 cc urine per hour and\n mentating at baseline. Given past VT, decided to give metoprolol 12.5\n mg then 12.5 mg, instead of 25mg at one time\n - EP recs:\n ICD malfunction: Fidelis RV coil fracture\n -Tentative left sided single lead extraction (Fidelis) and new ICD lead\n placement Thursday with Dr. \n - NPO Wed evening. Please type and cross 4 units of PRBC for procedure\n Thurs.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 81 (76 - 84) bpm\n BP: 101/36(53) {71/36(49) - 104/78(82)} mmHg\n RR: 15 (9 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,713 mL\n 385 mL\n PO:\n 340 mL\n TF:\n 131 mL\n 251 mL\n IVF:\n 852 mL\n 104 mL\n Blood products:\n Total out:\n 1,970 mL\n 225 mL\n Urine:\n 1,970 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -257 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 448 K/uL\n 10.1 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 106 mEq/L\n 141 mEq/L\n 31.8 %\n 6.2 K/uL\n [image002.jpg]\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n Plt\n 521\n 523\n 478\n 448\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n Other labs: PT / PTT / INR:13.6/79.0/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: No new imaging. Wet read of CXR AP :\n CP angles excluded. NG tube passes into the stomach and off the\n inferior\n margin of the film. pacer leads unchanged. stable cardiomegally. no\n acute\n cardiopulm process.\n Microbiology: No new growth\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be NPO Wednesday after MN, and will have 4 units crossmatched\n for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Add Lasix 40mg IV ONCE today given no response to 40 PO + 20 IV\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:45 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt, pnuemoboots\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition : CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the note by Dr. today.\n I would add the following remarks:\n History\n Mental status essentially unchanged but remains oriented\n No additional V Tach after pacemaker reprogrammed but two prior\n episodes and ICD not functioning\n Failed video swallow test and Dobhoff tube placed for nutrition\n Medical Decision Making\n Lead extraction on Thursday\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 20:28 ------\n" }, { "category": "Physician ", "chartdate": "2141-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531790, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 12:41 AM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98\n HR: 75 (73 - 77) bpm\n BP: 94/54(63) {91/44(58) - 123/80(84)} mmHg\n RR: 21 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Wgt (current): 92.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,163 mL\n 98 mL\n PO:\n TF:\n 741 mL\n IVF:\n 422 mL\n 98 mL\n Blood products:\n Total out:\n 2,040 mL\n 145 mL\n Urine:\n 2,040 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n -877 mL\n -47 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 319 K/uL\n 11.2 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 106 mEq/L\n 141 mEq/L\n 35.6 %\n 5.4 K/uL\n [image002.jpg] mg 2.1 ca 9.1 mg 2.1 INR 1.2 PTT\n 82.3\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n WBC\n 5.8\n 9.5\n 8.3\n 6.0\n 5.4\n Hct\n 32.2\n 31.9\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n Plt\n 69\n 319\n Cr\n 0.9\n 0.8\n 0.8\n 0.7\n 0.6\n 0.8\n TCO2\n 28\n 26\n Glucose\n 100\n 88\n 193\n 171\n 132\n 119\n 116\n Other labs: PT / PTT / INR:14.4/82.3/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n MICROBIOLOGY:\n Urine cx pending\n RADIOLOGY\n Chest X ray\n The position of the lines of the ICD device is unchanged. No\n pneumothorax is\n present. The lung fields are clear. The endotracheal tube has been\n removed.\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531910, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531918, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT. To EP for lead extraction, new leads and generator, AICD\n placed. Pt successfully extubated post procedure.\n Delirium / confusion\n Assessment:\n Pt sleepy this am, but easily arousable and cooperative.\n Continually asking for po\ns. Recognizes (sig other).\n Action:\n No sedatives administered this shift. Attempted to maintain sleep/\n wake cycle; having pt get OOB x2, lights on during day, TV on during\n day. Geriatric service consulted.\n Placed in low bed for safety.\n Response:\n Still occasionally calling out, did request and received bedpan, no\n stool\n Plan:\n Meds per recommendation. Maintain safe environment as well as\n sleep/wake cycle.\n Dysphagia\n Assessment:\n Pt w/ hx having pulled out feeding tube x5\n Action:\n Speech and swallow eval. w/ HOB up > 45\n for all po\n Response:\n Pt able to tolerate thickened liquids and pills whole in applesauce.\n Asking for more po\n consulted for PEG placement.\n Plan:\n Surgery suggested to CCU team, insertion of dobbhoff w/ bridal. MD\n to address.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 70-80\ns a sensed/ v paced.\n LS clear on RA w/ sats 100%.\n Weight down to 89.9 kg today.\n Action:\n Pt OOB to chair. SBP down to 60\ns while pt w/ HOB up 90\n, occurring\n this am while pt OOB, as well as this afternoon. Stat echo to r/o\n card. Tamponade. Pt rx w/ 250cc IVF bolus w/ these 2 episodes, w/\n subsequent BP\ns up to 90\n This afternoon, u/o down to 15cc/hr and BP again down to 63/ while HOB\n up at 90\n. Pt treated w/ 500cc IVF bolus. BP up to 90/ post.\n Lopressor held. Lasix dc\nd today.\n Warfarin given this afternoon.\n Response:\n Poor po intake, decreased bp and u/o. Poss intervascularly dry.\n Plan:\n Continue to follow i/o, hemodynamics, gentle hydration as necessary.\n Daily weights as ordered.\n" }, { "category": "Physician ", "chartdate": "2141-03-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530605, "text": "Chief Complaint: Dyspnea\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum, with some\n low-grade temps at home (Tm 99.8).\n 24 Hour Events:\n PICC LINE - STOP 09:02 AM\n PICC LINE - START 10:23 AM\n \n - NGT replaced\n then pulled by patient\n - Increased free water flushes\n - No Dopoff, but managed to give amiodarone and metoprolol. Gave Lasix\n 20 mg IV.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Lorazepam (Ativan) - 09:07 PM\n Other medications:\n Changes to medical and family history:\n None.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 82) bpm\n BP: 119/62(75) {82/54(65) - 132/74(85)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 94%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,037 mL\n 432 mL\n PO:\n TF:\n 475 mL\n 228 mL\n IVF:\n 323 mL\n 104 mL\n Blood products:\n Total out:\n 925 mL\n 250 mL\n Urine:\n 925 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 112 mL\n 182 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 424 K/uL\n 10.7 g/dL\n 120 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 108 mEq/L\n 142 mEq/L\n 32.5 %\n 5.5 K/uL\n [image002.jpg]\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n Plt\n 521\n 523\n 478\n 448\n 424\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n Other labs: PT / PTT / INR:13.9/111.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - dobhoff now in proximal stomach. no other interval\n chnage, though note that lateral left hemithorax is excluded from the\n film.\n Microbiology: 8:48 pm BLOOD CULTURE 1 OF 2.\n **FINAL REPORT **\n Blood Culture, Routine (Final ):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET\n ONLY.\n SENSITIVITIES PERFORMED ON REQUEST..\n Aerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n REPORTED BY PHONE TO DR. , PAGER @ 08:30\n .\n Subsequent blood cultures on ,26 - no growth so far.\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be after MN, and will have 4 units crossmatched for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n Diuresis gently continues, and likely to be safe.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed 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 have also reviewed the note by Dr. today.\n I would add the following remarks:\n History\n Mental status shows orientation but difficulty sitting upright for\n today\n No additional V Tach\n Dobhoff tube in place for nutrition\n Medical Decision Making\n Lead extraction on Thursday\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 17:05 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530881, "text": "Delirium / confusion\n Assessment:\n Pt remains confused Ox1-2. Family in early today at bedside (both\n daughters and significant other). Pt remains with SR up x 4, waist\n posey, bilat wrist restraints, bed low and locked and bed alarm on. Pt\n attempting to pull out NGT and to get out of bed. Pt constantly in\n motion, moving legs arms and sliding self down in bed. NPO. Dobhoff\n tube for feeding due to failing video swallow.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Bed alarm\n on. Family at bedside assisting with reorientation with minimal\n success.\n Response:\n To EPS at 1415hrs. Planned intubation and sedation for procedure.\n Plan:\n Fall precautions. Aspiration precautions. Restraints to prevent\n pulling out of lines/tubes.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n sBP 90-117/50\ns. HR 70-90s\ns vpaced. No VEA. Heparin 1300units/hr.\n Action:\n Heparin gtt stopped at noon for EPS.\n Response:\n To EPS at 1415hrs for lead revisions.\n Plan:\n Awaiting pt to come back to CCU post procedure.\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530955, "text": "Delirium / confusion\n Assessment:\n Pt remains confused Ox1-2. Family in early today at bedside (both\n daughters and significant other). Pt remains with SR up x 4, waist\n posey, bilat wrist restraints, bed low and locked and bed alarm on. Pt\n attempting to pull out NGT and to get out of bed. Pt constantly in\n motion, moving legs arms and sliding self down in bed. NPO. Dobhoff\n tube for feeding due to failing video swallow.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Bed alarm\n on. Family at bedside assisting with reorientation with minimal\n success.\n Response:\n To EPS at 1415hrs. Planned intubation and sedation for procedure.\n Plan:\n Fall precautions. Aspiration precautions. Restraints to prevent\n pulling out of lines/tubes.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n sBP 90-117/50\ns. HR 70-90s\ns vpaced. No VEA. Heparin 1300units/hr.\n Action:\n Heparin gtt stopped at noon for EPS. To EPS after 1400hrs for lead\n revisions.\n Response:\n During EPS: Atrial and fractured RV leads extracted on Lt side. New RV\n and Atrial leads placed and new generator. On Neo during procedure for\n some hypotension. 1Gm Vanco given pre procedure. Rt radial Aline in\n place. Rt brachial PICC still intact. Receiving 1unit PRBCs for EBL\n 300-500cc during procedure. Lt chest dsg over pacer site. Neo @\n 1.5mcg/k/min.\n Awaiting pt to arrive from EP lab.\n Plan:\n Sling Lt arm, keep Lt arm immobilized x 24hrs post pacer lead\n placement. Monitor dsg over site.\n Wean NEO as tolerated. Vent support with sedation overnite to help keep\n pt immobilized.\n Recheck HCT this evening\n post transfusion HCT. Pt will\n need more blood products tonite.\n Needs Post pacer placement CXR this evening.\n" }, { "category": "Physician ", "chartdate": "2141-03-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532175, "text": "Chief Complaint:\n 24 Hour Events:\n - \n - Emailed Drs. and about Neurologic status\n - Consensus is to try PEG tube. GI to see pt on . Holding\n warfarin in anticipation. Pt already NPO as no tube in place.\n - Taking pudding and apple sauce without difficulty.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.6\nC (97.9\n HR: 80 (69 - 111) bpm\n BP: 99/55(66) {74/49(44) - 121/83(76)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 875 mL\n 580 mL\n PO:\n TF:\n IVF:\n 875 mL\n 580 mL\n Blood products:\n Total out:\n 600 mL\n 195 mL\n Urine:\n 600 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 275 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 320 K/uL\n 10.7 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.6 %\n 5.5 K/uL\n [image002.jpg]\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n Plt\n \n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n TCO2\n 28\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n Other labs: PT / PTT / INR:28.9/108.0/2.8, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: No new.\n Microbiology: No new.\n ECG: .\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility, likely\n tomorrow.\n" }, { "category": "Physician ", "chartdate": "2141-03-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 532176, "text": "Chief Complaint:\n 24 Hour Events:\n - \n - Emailed Drs. and about Neurologic status\n - Consensus is to try PEG tube. GI to see pt on . Holding\n warfarin in anticipation. Pt already NPO as no tube in place.\n - Taking pudding and apple sauce without difficulty.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.6\nC (97.9\n HR: 80 (69 - 111) bpm\n BP: 99/55(66) {74/49(44) - 121/83(76)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: V Paced\n Wgt (current): 89.9 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 875 mL\n 580 mL\n PO:\n TF:\n IVF:\n 875 mL\n 580 mL\n Blood products:\n Total out:\n 600 mL\n 195 mL\n Urine:\n 600 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 275 mL\n 385 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n GEN: NAD. Elderly man.\n HEENT: Arcus senilius, no icterus, MM dry.\n CV: R (occasional ectopy) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND\n Lines: Foley in place..\n Ext: WWP. No edema.\n Neuro: Alert and oriented to person and place this a.m. (improvement).\n Less sedated this a.m. Moving limbs purposively. Gait not evaluated.\n Labs / Radiology\n 320 K/uL\n 10.7 g/dL\n 96 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.6 %\n 5.5 K/uL\n [image002.jpg]\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n 05:31 AM\n 05:33 AM\n 04:00 AM\n 05:34 AM\n 05:07 AM\n WBC\n 9.5\n 8.3\n 6.0\n 5.4\n 5.6\n 5.5\n Hct\n 32.4\n 31.6\n 31.1\n 32.7\n 35.6\n 36.1\n 32.6\n Plt\n \n Cr\n 0.8\n 0.7\n 0.6\n 0.8\n 0.9\n 0.9\n TCO2\n 28\n 26\n Glucose\n 193\n 171\n 132\n 119\n 116\n 112\n 96\n Other labs: PT / PTT / INR:28.9/108.0/2.8, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:9.8 mg/dL,\n Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: No new.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring defibrillation and reintubation,\n and runs of VT, including one VT arrest.\n Plan\n # Chronic systolic heart failure\n Patient with EF 20-25%. Currently euvolemic, perhaps slightly low\n intravascular given recent hypotension.\n - Holding PO lasix given recent hypotension and NPO\n - F/u Is/Os\n - Continue metoprolol \n # Hypotension\n Low blood pressure yesterday a.m. and then later in the day\n responded\n to small boluses. No tampenade physiology\n normal echo and pulsus of\n 10 mmHg. Likely due to being NPO.\n - continue to monitor BP\n - small boluses PRN, rather than maintenance fluids\n - hold lasix\n - BP holding parameters on metoprolol\n # VT/VF/AF/\n ICD dysfunction with fractured lead, now successfully replaced for dual\n chamber. Paced continually now. Patient had VT/VF arrest on during\n which ICD failed to defibrillate him and he required external therapy.\n Some VT following. Etiology of recent increased ectopy thought to be\n fast/short sequences, pacer settings, and QT prolongation in\n setting of amiodarone. Now not a problem. Past-history of AF,\n non-active, but given apical akinesis, should definitely be\n anticoagulated. RV coil was found to be fractured, now removed and\n replaced on .\n - cefpodoxime for one week from \n - f/u EP recs, appreciate their input\n - continue current amiodarone dose 200mg daily, metoprolol 25mg \n - monitor QTC on EKG (avoid Haldol)\n - metoprolol \n - Restarting Coumadin, bridged with heparin gtt\n # Mental Status\n Patient has evidence of ischemic injury on CT (white matter hypodense\n in watershed between ACA and MCA left posterior frontal. Some frontal\n release on exam (grasp). Some mild dysarthria with dysphagia, per S&S\n (see below). Delirium markedly exacerbated by many psychotropics and\n sedatives. D/w geriatrics and appreciated their recommendations. The\n patient likely had hypoxic injury, ICU delirium, with possible\n underlying neurodegenerative disease. Given possibility of Body\n Disease, they recommended not using Haldol or ativan, but instead using\n Seroquel or, if this is not possible, then Zydis. Avoid Haldol because\n of likely underlying disease and arrhythmogenicity/prolonged QT. Also\n taper Paxil because of its anticholinergic properties and exacerbation\n of akathisia. Initial dose of seroquel was very sedating (12.5) so\n halved and standing dose shifted from am to pm. Of note, we should\n make sure not to score limb movements (restless legs) as agitation.\n - Seroquel to 6.25 mg PO QPM with repeat x 1 if no result within 1 hour\n - if pt requires more sedation overnight may try PRN seroquel, or if\n unable to give may try zydis x 1 PRN\n - try to avoid sedation during the day to preserve better sleep/wake\n cycle\n - Taper paxil to 20 mg q day\n - Avoid Haldol and Ativan\n - Talk to Dr. about pre-admission mental status\n # Dysphagia and dysarthria\n Dysarthria may suggest that dysphagia likely to show little recovery.\n Failed video swallow on multiple occasions. Had NGT but removed five\n times by patient. Mental status improving and pt tolerated applesauce\n last night. However, failed repeat swallow study yesterday. Reluctant\n to place PEG, as not good long-term solution (aspiration risk just as\n high as swallowing), but will talk to electrophysiologist (Dr.\n who knows the patient well and can likely comment on\n neurologic function at baseline.\n - D/w Dr. \n - Consider PEG versus bridled NGT (depending on above concerns) for\n short term nutrition as pt has potential to improve with time once ICU\n delirium/mental status improves\n - NPO except meds\n .\n # Coronary Artery Disease\n Pt has a history of an anterior wall MI in . Of note, the patient\n did report some chest pressure previously, but this has since\n resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol (with holding parameters given\n hypotension)\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to rehab / long term care facility, likely\n tomorrow.\n" }, { "category": "Nursing", "chartdate": "2141-03-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530466, "text": "Delirium / confusion\n Assessment:\n Pt and at times Ox2 which is an improvement. States he is at the\n , Knew the year, the president. At other times Very angry\n and agitated. At 9 PM last night pt angry wanted a glass of wine, and\n Demanding yelling and Kicking side rails yelling\n I am a prisoner!\n Cut this thing\n you can not keep me here\n pulling off his gown\n and leads.\n Action:\n For Acute agitation given 0.5 mg IV Lorazepam with good effect. Placed\n mittens on and untied pt with close supervision. Pt much more calm,\n able to turn but by midnight he was throwing his legsgs over the side\n rail and requied posey vest. After bed bath fell asleep, however he\n woke up at 0400, wiggled out of one mitten and self dc\nd feeding tube\n again.\n Response:\n Pt currently calm, on/off again sleeping tonight ( more sleep than\n usual) Very agitated x 1\n calmer when not restrained, However he again\n dc\nd his NGT.\n Plan:\n Family comes in in the day and they have calming influence. Pt is a\n fall risk and need supervision, bed alrm, posey vest and mittens.\n Requires frequent re orientation. Provide cmfort with lines and tubes.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n NO VT,BP higher all day as he was off his metoprolol and lasix , but\n did recieive all his meds at 9 PM after dopoff was placed. BP did drop\n when pt was sleeping SBP 80-90 ( as he has been last 48 hours).\n Continues on heparin drip via New Picc line placed in IR.\n Action:\n PT remains on room air, lungs are clear, Denies SOB\n Response:\n PT remains on room air, lungs are clear, Denies SOB\n Plan:\n No signs of CHF no Arrythmias.\n Dysphagia\n Assessment:\n FAILED Swallow study strict NPO, Had feeding tube ( dopoff) placed\n but self dc\n Action:\n NEEDS FEEDING TUBE PLACED\n Response:\n Remains NPO\n Plan:\n REPLACE FEEDING TUBE ,RESUME TF,MEDS. Pt NPO after midnight for Lead\n placement and\n Battery change on ICD Thursday Dr will be in today to speak\n with family.\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531548, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Upon first rounds patient found actively trying to get out of bed.\n Legs between top and bottom bed rail with toes touching floor, despite\n bed low and in locked position with bed alarm on. Patient oriented\n times one only. Yelling out throughout the night\n Help Me\n Give\n me a drink\n . Confused as to time and place. Screaming out for\n .\n Action:\n Re-direction and re-orientation throughout the night . Given Haldol 2\n mg times 2 for extreme agitation as noted by patient banging the foot\n board with his feet.\n Response:\n Effects of haldol and re-orientation unsuccessful, as again patient\n without sleep\n Plan:\n Gerontology and/or psyche consult needed to assist with above concerns\n as well as patient safety. Low bed on order. Patient to have sitter\n for safety\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531704, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Patient awake/ restless, actively trying to get out of bed. Wrists/\n ankles restrained.\n Action:\n 4 siderails up, ankle restraints removed. Gerontology services met w/\n pt & sig other, recommended seraquil.\n Response:\n Pt becoming more lucid throughout shift. Able to converse w/ staff,\n asking appropriate questions.\n Plan:\n Ordered for one time dose of seraquil & has prn order for sleep\n tonight.\n Dysphagia\n Assessment:\n Pt NPO. Dobhoff remains in place for TF Isosource at 55cc/hr & po\n medications.\n Action:\n While in wrist restraints pt able to reach his feeding tube & remove\n it. HO aware.\n Response:\n With mouth care pt able to take water from sponges w/o s/s of\n aspiration. HO aware, will attempt to try sips of clears.\n Plan:\n Pt tol sips, given meds w/ applesauce & tol well. HO able to witness\n pts swallowing mechanics. Attempt to give AM meds po tomorrow. ?\n Speech/ Swallow follow up for diet.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V-paced in 70s no vea . NBP 100-120\ns/50-60s\n Action:\n Conts on Heparin at 1500 u/hr. AM PTT (35) Re-sent.\n Response:\n Hemodynamics stable. Repeat PTT 62.4 therapeutic\n Plan:\n Call out to floor.\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530384, "text": "Delirium / confusion\n Assessment:\n PT ALERT,STATES HE IS IN HOSPITAL AT TIMES ,RECOGNIZES FAMILY\n .AGITATED AT TIMES . SELF DC FEEDING TUBE\n Action:\n ORIENTED PT FREQUENTLY\n FAMILY VISITING MOST OF DAY\n WRIST RESTRAINTS PER PROTOCOL\n SAFETY MEASURES\n PT OOB TO CHAIR\n Response:\n PT CALM OVERALL,SOME EPISODES OF AGITATION RESPONDING TO REORIENTATION\n Plan:\n CONTINUE REORIENTATION,FALL RISK PREVENTION\n Heart failure (CHF), Systolic, Acute\n Assessment:\n NO VT,BP STABLE,SAT 98 AT 2LNP\n UNABLE TO GIVE MEDS,NO FEEDING TUBE\n PTT 79 ON HEPARIN DRIP\n Action:\n NEW PICC IN IR\n K REPLETED\n DEFIB PADS REPLACED\n NPO FOR THURSDAYS LEAD EXTRACTION,NEEDS TYPE AND CROSS C AM BLOODS\n Response:\n STABLE OOB C \n Plan:\n CONTINUE TO MONITOR\n Dysphagia\n Assessment:\n FAILED SWALLOW STUDY ,KEEP NPO\n Action:\n NEEDS FEEDING TUBE PLACED\n Response:\n UNCHANGED\n Plan:\n REPLACE FEEDING TUBE ,RESUME TF,MEDS\n" }, { "category": "Nutrition", "chartdate": "2141-03-17 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 529241, "text": "Subjective\n patient confused\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 105 kg\n 99.6 kg ( 06:00 AM)\n 31.3\n Pertinent medications: lansoprazole, RISS, glargine (4 units HS),\n others noted\n Labs:\n Value\n Date\n Glucose\n 201 mg/dL\n 05:02 AM\n Glucose Finger Stick\n 156\n 12:00 PM\n BUN\n 36 mg/dL\n 05:02 AM\n Creatinine\n 1.2 mg/dL\n 05:02 AM\n Sodium\n 142 mEq/L\n 05:02 AM\n Potassium\n 4.1 mEq/L\n 05:15 AM\n Chloride\n 103 mEq/L\n 05:02 AM\n TCO2\n 29 mEq/L\n 05:02 AM\n PO2 (arterial)\n 163 mm Hg\n 05:15 AM\n PCO2 (arterial)\n 39 mm Hg\n 05:15 AM\n pH (arterial)\n 7.49 units\n 05:15 AM\n pH (urine)\n 5.0 units\n 12:42 PM\n CO2 (Calc) arterial\n 31 mEq/L\n 05:15 AM\n Albumin\n 3.3 g/dL\n 01:07 AM\n Calcium non-ionized\n 8.3 mg/dL\n 05:02 AM\n Phosphorus\n 4.0 mg/dL\n 05:02 AM\n Ionized Calcium\n 1.10 mmol/L\n 08:00 AM\n Magnesium\n 2.5 mg/dL\n 05:02 AM\n ALT\n 224 IU/L\n 03:36 AM\n Alkaline Phosphate\n 92 IU/L\n 03:36 AM\n AST\n 204 IU/L\n 03:36 AM\n Total Bilirubin\n 0.7 mg/dL\n 03:36 AM\n WBC\n 9.1 K/uL\n 05:02 AM\n Hgb\n 9.6 g/dL\n 05:02 AM\n Hematocrit\n 31.0 %\n 05:02 AM\n Current diet order / nutrition support: NPO\n GI: soft, positive bowel sounds\n Assessment of Nutritional Status\n Specifics: 72 year old male admitted with dyspnea likely CHF\n exacerbation. Overnight patient had VT, was defribillated and had 1\n minute of CPR. Patient seen by SLP on and and recommended\n patient be NPO. Per discussion with MD plan to place feeding tube,\n likely not today as he irritable but likely over weekend. Recommend\n placing NGT for nutrition support as patient with little nutrition for\n last 4 days.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Once NGT placed, recommend goal of Isosource 1.5 @ 55 ml/hr\n with 14 g beneprotein to provide kcals/ 102 g protein\n 2. Check residuals hold if greater than 200 ml\n 3. Multivitamin via tube feeding\n 4. Will follow page with questions\n" }, { "category": "Nursing", "chartdate": "2141-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529332, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531681, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Patient awake/ restless, actively trying to get out of bed. Wrists/\n ankles restrained.\n Action:\n 4 siderails up, ankle restraints removed. Gerontology services met w/\n pt & sig other, recommended seraquil.\n Response:\n Pt becoming more lucid throughout shift. Able to converse w/ staff,\n asking appropriate questions.\n Plan:\n Ordered for one time dose of seraquil & has prn order for sleep\n tonight.\n Dysphagia\n Assessment:\n Pt NPO. Dobhoff remains in place for TF Isosource at 55cc/hr &\n medications.\n Action:\n While in wrist restraints pt able to reach his feeding tube & remove\n it. HO aware.\n Response:\n With mouth care pt able to take water from sponges w/o s/s of\n aspiration. HO aware, will attempt to try sips of clears.\n Plan:\n If pt tolerates sips of clears could attempt to try giving seraquil po.\n If unable will need new Dobhoff placed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V-paced in 70s no vea . NBP 100-120\ns/50-60s\n Action:\n Conts on Heparin at 1500 u/hr. PTT subtherapeutic Repeat sent.\n Response:\n Hemodynamic stable following ICD replacement\n Plan:\n Call out to floor with sitter if available\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531687, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Patient awake/ restless, actively trying to get out of bed. Wrists/\n ankles restrained.\n Action:\n 4 siderails up, ankle restraints removed. Gerontology services met w/\n pt & sig other, recommended seraquil.\n Response:\n Pt becoming more lucid throughout shift. Able to converse w/ staff,\n asking appropriate questions.\n Plan:\n Ordered for one time dose of seraquil & has prn order for sleep\n tonight.\n Dysphagia\n Assessment:\n Pt NPO. Dobhoff remains in place for TF Isosource at 55cc/hr &\n medications.\n Action:\n While in wrist restraints pt able to reach his feeding tube & remove\n it. HO aware.\n Response:\n With mouth care pt able to take water from sponges w/o s/s of\n aspiration. HO aware, will attempt to try sips of clears.\n Plan:\n If pt tolerates sips of clears could attempt to try giving seraquil po.\n If unable will need new Dobhoff placed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Tele V-paced in 70s no vea . NBP 100-120\ns/50-60s\n Action:\n Conts on Heparin at 1500 u/hr. PTT sub-therapeutic (35) Re-sent.\n Response:\n Hemodynamics stable. Repeat PTT\n Plan:\n Call out to floor with sitter if available\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528860, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs,\n BP on IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n labs sent\n Response:\n Excellent response to IV Lasix, PTT 85\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem\n Response:\n Stable sats with less oxygen\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529811, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Better day yesterday and good night tonight. He is Ox2-3, appropriate\n most of the time. Follows direction and commands. Not trying to get\n OOB but at times restless.\n Asking for water and coke.\n Action:\n Taking meds crushed with applesause well. Liquids thickened to nectar\n consistency.\n Aspiration precautions.\n Trazadone 50mg at HS\n Response:\n Slept on and off. Incontinent x2 stool- unable to tell RN he had to\n go.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . external defib pads\n dated .\n Heparin drip at 1850/hr. PTT >150\n - total 600cc u/o response from lasix given 1800.\n - D5W x total 2L completed for elevated Na+\n Action:\n Heparin on hold x1 hour and decresed to 1500units/hr at 0130.\n Po lopressor and amio as ordered.\n Monitored sat, u/o\n KCL repletion on \n Response:\n HR 70-80 Vpaced with rare PVC. BP 94-99/60\ns MAP 70\n u/o 60-80cc/hr.\n positive 800cc for .\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531677, "text": "71 yr old male with significant for systolic HF ( EF 20 ) , and\n paroxysmal av block , afib, h/o v-tach v fib s/p ICD implantation who\n presented to the ED with a chief complaint of dyspnea . initially\n thought to be due to CHF exacerbation but subsequently attributed to\n PNA in the setting of ifliltrate , fever, and white count. Hospital\n course complicated by high fevers, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation and runs of VT, including one\n VT arrest.\n Now s/p successful lead removal and received new functional ICD lead\n placement on \n Delirium / confusion\n Assessment:\n Patient awake/ restless, actively trying to get out of bed. Wrists/\n ankles restrained.\n Action:\n 4 siderails up, ankle restraints removed. Gerontology services met w/\n pt & sig other, recommended seraquil.\n Response:\n Pt becoming more lucid throughout shift. Able to converse w/ staff,\n asking appropriate questions.\n Plan:\n Ordered for one time dose of seraquil & has prn order for sleep\n tonight.\n Dysphagia\n Assessment:\n Pt NPO. Dobhoff remains in place for TF Isosource at 55cc/hr &\n medications.\n Action:\n While in wrist restraints pt able to reach his feeding tube & remove\n it. HO aware.\n Response:\n With mouth care pt able to take water from sponges w/o s/s of\n aspiration. HO aware, will attempt to try sips of clears.\n Plan:\n If pt tolerates sips of clears could attempt to try giving seraquil po.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR 75 V paced . SBP 110\ns/50\ns via right radial aline\n Action:\n Tolerating lopressor. Heparin at 1500 u/hr\n Response:\n Hemodynamic stable following ICD replacement\n Plan:\n Call out to floor with sitter if available\n" }, { "category": "Physician ", "chartdate": "2141-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530222, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n \n - EP recommended against calling pt out because he's already had two VT\n arrests and now is without an ICD back-up, code blue response much\n slower on floor than CCU, thus, we did not call him out to the floor\n - speech and swallow evaulated and thought at high aspiration risk.\n recommended video swallow and NPO except meds for now\n - HCP wants to talk with Dr. before any decisions are\n made regarding surgery for ICD revision\n - patient failed video swallow had dobhoff placed\n - nutrition recs to start isosource TF at 25 cc/hr and titrate up to 55\n cc/hr\n - ordered fluoro guided PICC replacement (since was pulled out with\n dressing change) which will happen tomorrow\n - Ca low so added on albumin to labs, is 3.0 - correct to 9.0.\n - Hypotensive to 80s/40s by NBP, but A-line in the past showed higher\n pressures, patient putting out about 50-80 cc urine per hour and\n mentating at baseline. Given past VT, decided to give metoprolol 12.5\n mg then 12.5 mg, instead of 25mg at one time\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 81 (76 - 84) bpm\n BP: 101/36(53) {71/36(49) - 104/78(82)} mmHg\n RR: 15 (9 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,713 mL\n 385 mL\n PO:\n 340 mL\n TF:\n 131 mL\n 251 mL\n IVF:\n 852 mL\n 104 mL\n Blood products:\n Total out:\n 1,970 mL\n 225 mL\n Urine:\n 1,970 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -257 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\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 448 K/uL\n 10.1 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 106 mEq/L\n 141 mEq/L\n 31.8 %\n 6.2 K/uL\n [image002.jpg]\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n Plt\n 521\n 523\n 478\n 448\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n Other labs: PT / PTT / INR:13.6/79.0/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: No new imaging. Wet read of CXR AP :\n CP angles excluded. NG tube passes into the stomach and off the\n inferior\n margin of the film. pacer leads unchanged. stable cardiomegally. no\n acute\n cardiopulm process.\n Microbiology: No new growth\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:45 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530223, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n \n - EP recommended against calling pt out because he's already had two VT\n arrests and now is without an ICD back-up, code blue response much\n slower on floor than CCU, thus, we did not call him out to the floor\n - speech and swallow evaulated and thought at high aspiration risk.\n recommended video swallow and NPO except meds for now\n - HCP wants to talk with Dr. before any decisions are\n made regarding surgery for ICD revision\n - patient failed video swallow had dobhoff placed\n - nutrition recs to start isosource TF at 25 cc/hr and titrate up to 55\n cc/hr\n - ordered fluoro guided PICC replacement (since was pulled out with\n dressing change) which will happen tomorrow\n - Ca low so added on albumin to labs, is 3.0 - correct to 9.0.\n - Hypotensive to 80s/40s by NBP, but A-line in the past showed higher\n pressures, patient putting out about 50-80 cc urine per hour and\n mentating at baseline. Given past VT, decided to give metoprolol 12.5\n mg then 12.5 mg, instead of 25mg at one time\n - EP recs:\n ICD malfunction: Fidelis RV coil fracture\n -Tentative left sided single lead extraction (Fidelis) and new ICD lead\n placement Thursday with Dr. if family agrees to degree of\n risk, re-intubation and GA\n - NPO Wed evening. Please type and cross 4 units of PRBC for procedure\n Thurs.\n -External defibrillation needed if VT\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 81 (76 - 84) bpm\n BP: 101/36(53) {71/36(49) - 104/78(82)} mmHg\n RR: 15 (9 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,713 mL\n 385 mL\n PO:\n 340 mL\n TF:\n 131 mL\n 251 mL\n IVF:\n 852 mL\n 104 mL\n Blood products:\n Total out:\n 1,970 mL\n 225 mL\n Urine:\n 1,970 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -257 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\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 448 K/uL\n 10.1 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 106 mEq/L\n 141 mEq/L\n 31.8 %\n 6.2 K/uL\n [image002.jpg]\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n Plt\n 521\n 523\n 478\n 448\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n Other labs: PT / PTT / INR:13.6/79.0/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: No new imaging. Wet read of CXR AP :\n CP angles excluded. NG tube passes into the stomach and off the\n inferior\n margin of the film. pacer leads unchanged. stable cardiomegally. no\n acute\n cardiopulm process.\n Microbiology: No new growth\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:45 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530228, "text": "Chief Complaint: Dyspnea\n 24 Hour Events:\n \n - EP recommended against calling pt out because he's already had two VT\n arrests and now is without an ICD back-up, code blue response much\n slower on floor than CCU, thus, we did not call him out to the floor\n - speech and swallow evaulated and thought at high aspiration risk.\n recommended NPO and consider PEG\n - HCP wants to talk with Dr. before any decisions are\n made regarding surgery for ICD revision\n - patient failed video swallow had dobhoff placed\n - nutrition recs to start isosource TF at 25 cc/hr and titrate up to 55\n cc/hr\n - ordered fluoro guided PICC replacement (since was pulled out with\n dressing change) which will happen tomorrow\n - Ca low so added on albumin to labs, is 3.0 - correct to 9.0.\n - Hypotensive to 80s/40s by NBP, but A-line in the past showed higher\n pressures, patient putting out about 50-80 cc urine per hour and\n mentating at baseline. Given past VT, decided to give metoprolol 12.5\n mg then 12.5 mg, instead of 25mg at one time\n - EP recs:\n ICD malfunction: Fidelis RV coil fracture\n -Tentative left sided single lead extraction (Fidelis) and new ICD lead\n placement Thursday with Dr. \n - NPO Wed evening. Please type and cross 4 units of PRBC for procedure\n Thurs.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsPenicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.3\n HR: 81 (76 - 84) bpm\n BP: 101/36(53) {71/36(49) - 104/78(82)} mmHg\n RR: 15 (9 - 24) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,713 mL\n 385 mL\n PO:\n 340 mL\n TF:\n 131 mL\n 251 mL\n IVF:\n 852 mL\n 104 mL\n Blood products:\n Total out:\n 1,970 mL\n 225 mL\n Urine:\n 1,970 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -257 mL\n 160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\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 448 K/uL\n 10.1 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 106 mEq/L\n 141 mEq/L\n 31.8 %\n 6.2 K/uL\n [image002.jpg]\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n Plt\n 521\n 523\n 478\n 448\n Cr\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n Other labs: PT / PTT / INR:13.6/79.0/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: No new imaging. Wet read of CXR AP :\n CP angles excluded. NG tube passes into the stomach and off the\n inferior\n margin of the film. pacer leads unchanged. stable cardiomegally. no\n acute\n cardiopulm process.\n Microbiology: No new growth\n Assessment and Plan\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday pending patient and\n family are in agreement\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be NPO Wednesday after MN, and will have 4 units crossmatched\n then\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. This is still above\n baseline as he does not usually use supplemental oxygen. Heart failure\n less likely etiology of hypoxia and received home dose PO lasix this\n am. Speech and swallow evaluated this am and recommend PNO for now\n except meds with repeat video swallow study.\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Add Lasix 40mg IV ONCE today given no response to 40 PO + 20 IV\n -check PM Is/Os\n if not 1 to 1.5 L negative will give one dose IV 40\n mg lasix as yesterday pt required extra IV dose\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile status post completed course of\n antibiotics. Previously, patient was spiking high fevers in spite of\n Tylenol, antibiotics, and improvement of pneumonia. This led to concern\n about an occult infection or non-infectious cause of fever. CT\n abd/pelvis and CT sinuses were negative. TEE showed no vegetation.\n There was one positive blood cx (coag neg staph), thought to be a\n contaminant. Patient was afebrile from , but spiked one fever\n to 101.8 thought to be related to possible aspiration pneumonitis in\n setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies which currently show no growth.\n Urine cultuire negative\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - will check Is/Os and if not 1-1.5 L negative will give extra 40 mg IV\n lasix\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - patient was given free water with D5W last night and sodium slightly\n improved, however pt more volume up\n - will consider giving free water if pm labs show worsening\n hypernatremia (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:45 PM 45 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt, pnuemoboots\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition : CCU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2141-03-17 00:00:00.000", "description": "Cardiology Teaching Physician Note", "row_id": 529225, "text": "TITLE:\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 have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n History\n Episodes of pulseless VT yesterday requiring defibrillation and CPR.\n Amio reduced for concern re prolonged QT.\n Continues intermittently confused but conversant.\n Medical Decision Making\n Plan to add Lido if becomes more unstable.\n EP procedure Mon with ? ablation, ? lead extraction.\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529395, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints on but removed at 0400, as pt was more restless and\n appears to be doing well without the restraints. Bed alarm activated,\n close supervision, bed locked and low. Frequent repositioning. Given\n 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, may use bilateral\n wrist restraints and posey restraint on for patient safety if needed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour. BUN\n elevated\n46. Creatinine 1.1. Hct 31.4 Hgb 10.4. Na slightly elevated at\n 149. PT elevated at 23.5, PTT WNL, and INR elevated--2.2.\n Action:\n Continuous monitoring of hemodynamic status.\n Response:\n Plan:\n Continue to monitor hemodynamic status. Monitor labs and redraw @\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at 1900.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2100 for fever with good effect and at 0300 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Patient afebrile with temp down to 98.5.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating.\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529397, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints on but removed at 0400, as pt was more restless and\n appears to be doing well without the restraints. Bed alarm activated,\n close supervision, bed locked and low. Frequent repositioning. Given\n 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless. Posey back on as\n pt was found again with leg over the side rail.\n Plan:\n Continue to reorient patient. Keep side rails up x4, may use bilateral\n wrist restraints if pt pulls off mask, and pt requires posey\n restraint as he has slid between the side rails before.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour.\n Pt has removed his oxygen and does desaturate 88-89, his pleth is poor\n at time but it seems he does have an o2 requirement. Pt has bilateral\n cracles but is clear anteriorly. No coughing or proiducing sputum.\n Action:\n Continuous monitoring of resp and CV staus, O2 on, pt fluid balance is\n Response:\n Fair urine output fluid balance positive, has o2 reqiurement.\n Plan:\n Continue to monitor Cv and resp status ? lasix ( did not respond well\n to 20 mg dose yesterday)\n Follow labs.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at 1900.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2100 for fever with good effect and at 0300 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Patient afebrile with temp down to 98.5.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating.\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529401, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints on but removed at 0400, as pt was more restless and\n appears to be doing well without the restraints. Bed alarm activated,\n close supervision, bed locked and low. Frequent repositioning. Given\n 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless. Posey back on as\n pt was found again with leg over the side rail.\n Plan:\n Continue to reorient patient. Keep side rails up x4, may use bilateral\n wrist restraints if pt pulls off mask, and pt requires posey\n restraint as he has slid between the side rails before.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour.\n Pt has removed his oxygen and does desaturate 88-89, his pleth is poor\n at time but it seems he does have an o2 requirement. Pt has bilateral\n crackles but is clear anteriorly. No coughing or producing sputum.\n Action:\n Continuous monitoring of resp and CV staus, O2 on, pt fluid balance is\n Response:\n Fair urine output fluid balance negative 740 cc at midnight and 250\n this AM continues to have , has o2 requirement.\n Plan:\n Continue to monitor Cv and resp status ? lasix ( did have moderate\n response l to 20 mg dose yesterday)\n Follow labs.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at last\n night.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2100 for fever with good effect and at 0300 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Patient afebrile with temp down to 98.5. ? sourse of fever lungs vs\n lead\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating at times\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529402, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints on but removed at 0400, as pt was more restless and\n appears to be doing well without the restraints. Bed alarm activated,\n close supervision, bed locked and low. Frequent repositioning. Given\n 50mg Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless. Posey back on as\n pt was found again with leg over the side rail.\n Plan:\n Continue to reorient patient. Keep side rails up x4, may use bilateral\n wrist restraints if pt pulls off mask, and pt requires posey\n restraint as he has slid between the side rails before.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour.\n Pt has removed his oxygen and does desaturate 88-89, his pleth is poor\n at time but it seems he does have an o2 requirement. Pt has bilateral\n crackles but is clear anteriorly. No coughing or producing sputum.\n Action:\n Continuous monitoring of resp and CV staus, O2 on, pt fluid balance is\n Response:\n Fair urine output fluid balance negative 740 cc at midnight and 250\n this AM continues to have , has o2 requirement.\n Plan:\n Continue to monitor Cv and resp status ? lasix ( did have moderate\n response l to 20 mg dose yesterday)\n Follow labs.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at last\n night.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2100 for fever with good effect and at 0300 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Patient afebrile with temp down to 98.5. ? sourse of fever lungs vs\n lead\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating at times\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529591, "text": "Delirium / confusion\n Assessment:\n Pt. able to state name,\nhospital\n and\n\n initially but then not\n able to repeat place or year. Talking to himself and having\n conversation with self. Thirsty , asking for diet coke. Able to take\n meds crushed with custard sitting up in bed.\n - follows commands, turns side to side with assist and by himself.\n Very active/restless in bed, turning side to side by himself. Follow\n commands.\n Action:\n Trazadone 50mg at 2200. freq. mouth swabs/VAP.\n Oriented freq. as needed. Bed alarm on. Side rails up. Close\n observation by RNs.\n Response:\n Pt. fell asleep ~ 2300. slept for ~ 3 hours- 4 hours. Woke ~ 0400,\n laying quiet in bed. Asking for something to eat or drink.\nwhen do I\n get breakfast?\n Plan:\n OOB to chair again today. Orient as needed. Safety precautions.\n Aspiration precautions: no thin liquids. ? rescreen Speech/swallow\n Monday.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Negative 500cc at 2200. LS crackles right base. Sats 97-98% on 4lnc.\n Action:\n IVF stopped early\n Na+ normalized at 140.\n NPO with no po liquids d/t failed swallow study.\n - Lopressor . Amio QD.\n Response:\n Ended up negative 800cc for . sats dipping to low 90\ns when\n asleep. Increased to 5lnc when sleeping.\n HR Vpaced 70-80\ns. BP 90\ns-111/.\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afeb. No cough. Laying flat to 30degrees with no distress.\n Action:\n VAP care q2-4hours.\n Response:\n Cultures pnd from (last spike)\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529594, "text": "Delirium / confusion\n Assessment:\n Pt. able to state name,\nhospital\n and\n\n initially but then not\n able to repeat place or year. Talking to himself and having\n conversation with self. Thirsty , asking for diet coke. Able to take\n meds crushed with custard sitting up in bed.\n - follows commands, turns side to side with assist and by himself.\n Very active/restless in bed, turning side to side by himself. Follow\n commands.\n Action:\n Trazadone 50mg at 2200. freq. mouth swabs/VAP.\n Oriented freq. as needed. Bed alarm on. Side rails up. Close\n observation by RNs.\n Response:\n Pt. fell asleep ~ 2300. slept for ~ 3 hours- 4 hours. Woke ~ 0400,\n laying quiet in bed. Asking for something to eat or drink.\nwhen do I\n get breakfast?\n Plan:\n OOB to chair again today. Orient as needed. Safety precautions.\n Aspiration precautions: no thin liquids. ? rescreen Speech/swallow\n Monday.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n ICD malfunction:\n -Will need attempt at Fidelis lead extraction in OR with general\n anesthesia + new lead placement as able with access issues\n No VT overnight. K+ 3.5 at 1700\n Negative 500cc at 2200. LS crackles right base. Sats 97-98% on 4lnc.\n Action:\n IVF stopped early\n Na+ normalized at 140.\n NPO with no po liquids d/t failed swallow study.\n - Lopressor . Amio QD.\n - KCL repleted po.\n - Pacer pads replaced.\n Response:\n Ended up negative 800cc for . sats dipping to low 90\ns when\n asleep. Increased to 5lnc when sleeping.\n HR Vpaced 70-80\ns. BP 90\ns-111/.\n Plan:\n ? thurs. for lead extraction under GA\n now with recent fever and\n worsening aspiration PNA.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Afeb. No cough. Laying flat to 30degrees with no distress.\n Action:\n VAP care q2-4hours.\n Response:\n Cultures pnd from (last spike)\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529235, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -ID recs: stop vanc and meropenem; restart cefpodoxime; no objection to\n PICC removal or device replacement during this admission from ID\n perspective\n -EP recs: Device interrogated with representative. RV coil\n fractured, leading to high impedence and inability to defibrillate.\n Since SVC coil impedence is calculated using RV coil, this appears\n elevated. LV coil is unipolar, with impedence calculated to RV coil,\n making is also appear elevated. A lead impedence is elevated, but still\n functional and may be due to scar or tissue impedence problem. \n discuss with Dr. re: extraction vs. new lead. Keep\n defibrillator at bedside. Increase amiodarone to 400 mg for VT. If\n VT continues, consider ablation next week.\n -increased amiodarone to 400 mg \n -looked into history of lead infection. Per clinic notes, TEE on\n showed mobile echodensities on both pacer leads\n -had runs of VT lasting as long as 30 seconds. Gave amiodarone 150 mg\n IV, followed by 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours\n -changed meropenem to cefpodoxime\n -will need to be NPO after midnight on Sunday for possible EP procedure\n -4:30 a.m. Had 30 seconds of VT with HR 200. Unclear if patient had\n pulse. RN, patient was exhibiting agonal breathing, so he was\n defibrillated. Following defibrillation, patient received approximately\n 1 minute of CPR.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 08:30 AM\n Infusions:\n Heparin Sodium - 1,400 units/hour\n Amiodarone - 1 mg/min\n Other ICU medications:\n Amiodarone - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:27 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: 73 (51 - 220) bpm\n BP: 120/66(78) {88/37(44) - 142/76(87)} mmHg\n RR: 25 (15 - 29) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 927 mL\n 246 mL\n PO:\n TF:\n IVF:\n 927 mL\n 246 mL\n Blood products:\n Total out:\n 3,280 mL\n 135 mL\n Urine:\n 3,280 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,353 mL\n 111 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: 7.49/39/163/29/6\n Physical Examination\n GENERAL: Oriented x 0-1. Does not respond to\n commands\n CARDIAC: RRR. II/VI HSM at apex.\n LUNGS: Diffuse rales.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 426 K/uL\n 9.6 g/dL\n 201 mg/dL\n 1.2 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 36 mg/dL\n 103 mEq/L\n 142 mEq/L\n 31.0 %\n 9.1 K/uL\n [image002.jpg]\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n WBC\n 9.2\n 9.3\n 8.4\n 9.1\n Hct\n 30.4\n 31.8\n 33.0\n 31.0\n Plt\n 371\n 468\n 464\n 426\n Cr\n 0.9\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n TCO2\n 37\n 39\n 42\n 31\n Glucose\n 198\n 151\n 137\n 122\n 152\n 131\n 201\n Other labs: PT / PTT / INR:37.4/110.5/3.9, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:3.5 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # s/p VT/VF arrest/ICD dysfunction: Patient had VT/VF arrest on \n during which ICD failed to defibrillate him and he required external\n therapy. Patient had multiple runs of VT, including second VT arrest\n last night requiring defibrillation. Etiology of recently increased\n ectopy is unclear.\n -f/u EP recs\n - pads in place\n -if develops VT, will need external therapy as ICD is not functioning\n -decrease amiodarone to 200 mg daily due to concern about prolonged QT\n -increase metoprolol to 25 mg \n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to last night\ns VT arrest, patient was satting well on 2L NC. Has had\n increased O2 requirement since, possibly related to aspiration or\n worsening heart failure.\n -aspiration precautions\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue cefpodoxime\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 1 L today\n .\n # Coagulopathy: INR markedly elevated today. Likely related to\n amiodarone.\n -continue to hold Coumadin\n -vitamin K 2 mg PO once\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529389, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints removed at 0400, doing well. Family is aware. Bed\n alarm activated, locked and low. Frequent repositioning. Given 50mg\n Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, use bilateral\n wrist restraints and posey restraint on for patient safety if needed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour. BUN\n elevated\n46. Creatinine 1.1. Hct 31.4 Hgb 10.4. Na slightly elevated at\n 149. PT elevated at 23.5, PTT WNL, and INR elevated--2.2.\n Action:\n Continuous monitoring of hemodynamic status.\n Response:\n Plan:\n Continue to monitor hemodynamic status. Monitor labs and redraw @\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at 1900.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2200 for fever with good effect and at 0230 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Sats lower 90s. Patient afebrile with temp down to 98.5.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Need to\n continuously awaken/stimulate patient and remind to swallow.\n Response:\n When reminded, patient swallowed all PO meds.\n Plan:\n NPO except for meds. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529390, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints removed at 0400, doing well. Family is aware. Bed\n alarm activated, locked and low. Frequent repositioning. Given 50mg\n Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, use bilateral\n wrist restraints and posey restraint on for patient safety if needed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour. BUN\n elevated\n46. Creatinine 1.1. Hct 31.4 Hgb 10.4. Na slightly elevated at\n 149. PT elevated at 23.5, PTT WNL, and INR elevated--2.2.\n Action:\n Continuous monitoring of hemodynamic status.\n Response:\n Plan:\n Continue to monitor hemodynamic status. Monitor labs and redraw @\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at 1900.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2200 for fever with good effect and at 0230 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Sats now lower 90s to 100. Patient afebrile with temp down to 98.5.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Need to\n continuously awaken/stimulate patient and remind to swallow.\n Response:\n When reminded, patient swallowed all PO meds.\n Plan:\n NPO except for meds. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529808, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Better day yesterday and good night tonight. He is Ox2-3, appropriate\n most of the time. Follows direction and commands. Not trying to get\n OOB.\n Asking for water and coke.\n Action:\n Taking meds crushed with applesause well. Liquids thickened to nectar\n consistency.\n Aspiration precautions.\n Trazadone 50mg at HS\n Response:\n Slept on and off. Incontinent x2 stool- unable to tell RN he had to\n go.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529392, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n CT head, chest, & pelvis-without noted infectious process.\n VF arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds.\n - pacer interrogated and rate increased to 70 as pt VT was\n attributed to slow HR and prolonged\n QT .\n Delirium / confusion\n Assessment:\n Patient is confused and oriented x1. Stating\nI want to go home, get me\n out of here\nI need to go to the hospital\n. When asked where he was\n he stated\n City, NY\n, but will sometimes say the hospital.\n Continuously restless and moving legs and arms all over and off to the\n side of the bed. Oxygen mask and nc frequently removed due patient\n shifting all over bed.\n Action:\n Continuous orienting. Side rails up x 4. Bilateral wrist restraints and\n posey restraints removed at 0400, doing well. Family is aware. Bed\n alarm activated, locked and low. Frequent repositioning. Given 50mg\n Trazadone at 0230 with poor effect.\n Response:\n Patient remains confused, oriented x1, and restless.\n Plan:\n Continue to reorient patient. Keep side rails up x4, use bilateral\n wrist restraints and posey restraint on for patient safety if needed.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n HR has been in the upper 80s to mid 90s. Systolics ranging from mid\n 120s to 140/ Diastolic mid 50s to 90s. On Amiodarone 200mg daily and\n Metoprolol 25mg . Urine output has been between 20-45mL/hour. BUN\n elevated\n46. Creatinine 1.1. Hct 31.4 Hgb 10.4. Na slightly elevated at\n 149. PT elevated at 23.5, PTT WNL, and INR elevated--2.2.\n Action:\n Continuous monitoring of hemodynamic status.\n Response:\n Plan:\n Continue to monitor hemodynamic status. Monitor labs and redraw @\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Patient on 5L n/c and high flow 95% with sats dropping to the 80s.\n Lungs with lower bilateral crackles. Patient febrile 101.8 at 1900.\n Action:\n Abx Cefpodoxime D/C and given Abx Meropenum 1000mg IV times one dose.\n Gave tylenol 650mg at 2100 for fever with good effect and at 0300 650mg\n for malaise. Urine and blood cultures sent\nresults pending.\n Response:\n Patient afebrile with temp down to 98.5.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures\n Dysphagia\n Assessment:\n Pt has weak cough. NPO, but can give meds in puree (applesauce or\n diabetic custard)\n Action:\n Gave PO meds with diabetic custard in small bites. Although pt is\n awake , requires reminders and stimulate patient and remind to\n swallow.\n Response:\n When reminded, patient swallowed all PO meds.Appears to forget that he\n is eating.\n Plan:\n NPO except for meds in applesause or custard . Aspiration precautions.\n No liquids.\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529797, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 529969, "text": "TITLE: PHYSICIAN INTERN PROGRESS NOTE\n Chief Complaint:\n Dyspnea and leg swelling\n HPI:\n 24 Hour Events:\n - Mental status dramatically improved. Allowed patient to take some PO\n with close nursing supervision. Will get formal speech and swallow\n evaluation on Monday.\n - Dr. now favoring doing lead extraction/revision on Thursday\n - did not respond to Lasix 40 mg PO, but responded well to Lasix 20 mg\n IV\n - started heparin gtt for subtherapeutic INR\n - repleted free water deficit with D5W\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium - 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 83) bpm\n BP: 85/53(61) {84/42(50) - 157/141(144)} mmHg\n RR: 14 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,514 mL\n 943 mL\n PO:\n 960 mL\n 340 mL\n TF:\n IVF:\n 1,554 mL\n 603 mL\n Blood products:\n Total out:\n 1,695 mL\n 1,100 mL\n Urine:\n 1,695 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 819 mL\n -157 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2 L\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema. Feet erythematous, capilary changes on skin\n Neuro: Alert, orientation waxing and . Initially oriented to\n hospital () and year. However, repeat questioning later\n during rounds pt was unable to state location at . Able to state\n why he is the hospital. Asking to see various equipment/machines in the\n room and not making sense with what he wants it for.\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: Maculopapular erythematous rash on upper shoulders and chest\n consistent with resolving stages of rash.\n Neurologic: Responds to verbal commands, answers questions:\n Labs / Radiology\n 10.0 g/dL\n 478 K/uL\n 103 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.2 %\n 7.8 K/uL\n [image002.jpg]\n INR 1.2\n PTT 94.9\n PT 14.3\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n WBC\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 23\n Cr\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n 428\n 126\n 118\n Other labs: PT / PTT / INR:15.9/150.0/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.7 mg/dL\n Imagine: no new images\n Microbiology: Urine culture final \n no growth\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday pending patient and\n family are in agreement\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. This is still above\n baseline as he does not usually use supplemental oxygen. Heart failure\n less likely etiology of hypoxia and received home dose PO lasix this\n am. Speech and swallow evaluated this am and recommend PNO for now\n except meds with repeat video swallow study.\n -aspiration precautions\n -Video swallow study\n - F/u speech and swallow recs based on results of video, but for now\n NPO except meds\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n -check PM Is/Os\n if not 1 to 1.5 L negative will give one dose IV 40\n mg lasix as yesterday pt required extra IV dose\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile status post completed course of\n antibiotics. Previously, patient was spiking high fevers in spite of\n Tylenol, antibiotics, and improvement of pneumonia. This led to concern\n about an occult infection or non-infectious cause of fever. CT\n abd/pelvis and CT sinuses were negative. TEE showed no vegetation.\n There was one positive blood cx (coag neg staph), thought to be a\n contaminant. Patient was afebrile from , but spiked one fever\n to 101.8 thought to be related to possible aspiration pneumonitis in\n setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies which currently show no growth.\n Urine cultuire negative\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - will check Is/Os and if not 1-1.5 L negative will give extra 40 mg IV\n lasix\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - patient was given free water with D5W last night and sodium slightly\n improved, however pt more volume up\n - will consider giving free water if pm labs show worsening\n hypernatremia (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n - recheck Ck\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 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": "2141-03-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 529970, "text": "TITLE: PHYSICIAN INTERN PROGRESS NOTE\n Chief Complaint:\n Dyspnea and leg swelling\n HPI:\n 24 Hour Events:\n - Mental status dramatically improved. Allowed patient to take some PO\n with close nursing supervision. Will get formal speech and swallow\n evaluation on Monday.\n - Dr. now favoring doing lead extraction/revision on Thursday\n - did not respond to Lasix 40 mg PO, but responded well to Lasix 20 mg\n IV\n - started heparin gtt for subtherapeutic INR\n - repleted free water deficit with D5W\n - this morning pateint states he has been coughing up soe brown sputum\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium - 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 83) bpm\n BP: 85/53(61) {84/42(50) - 157/141(144)} mmHg\n RR: 14 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,514 mL\n 943 mL\n PO:\n 960 mL\n 340 mL\n TF:\n IVF:\n 1,554 mL\n 603 mL\n Blood products:\n Total out:\n 1,695 mL\n 1,100 mL\n Urine:\n 1,695 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 819 mL\n -157 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2 L\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema. Feet erythematous, capilary changes on skin\n Neuro: Alert, orientation waxing and . Initially oriented to\n hospital () and year. However, repeat questioning later\n during rounds pt was unable to state location at . Able to state\n why he is the hospital. Asking to see various equipment/machines in the\n room and not making sense with what he wants it for.\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: Maculopapular erythematous rash on upper shoulders and chest\n consistent with resolving stages of rash.\n Neurologic: Responds to verbal commands, answers questions:\n Labs / Radiology\n 10.0 g/dL\n 478 K/uL\n 103 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.2 %\n 7.8 K/uL\n [image002.jpg]\n INR 1.2\n PTT 94.9\n PT 14.3\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n WBC\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 23\n Cr\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n 428\n 126\n 118\n Other labs: PT / PTT / INR:15.9/150.0/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.7 mg/dL\n Imagine: no new images\n Microbiology: Urine culture final \n no growth\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday pending patient and\n family are in agreement\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. This is still above\n baseline as he does not usually use supplemental oxygen. Heart failure\n less likely etiology of hypoxia and received home dose PO lasix this\n am. Speech and swallow evaluated this am and recommend PNO for now\n except meds with repeat video swallow study.\n -aspiration precautions\n -Video swallow study\n - F/u speech and swallow recs based on results of video, but for now\n NPO except meds\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n -check PM Is/Os\n if not 1 to 1.5 L negative will give one dose IV 40\n mg lasix as yesterday pt required extra IV dose\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile status post completed course of\n antibiotics. Previously, patient was spiking high fevers in spite of\n Tylenol, antibiotics, and improvement of pneumonia. This led to concern\n about an occult infection or non-infectious cause of fever. CT\n abd/pelvis and CT sinuses were negative. TEE showed no vegetation.\n There was one positive blood cx (coag neg staph), thought to be a\n contaminant. Patient was afebrile from , but spiked one fever\n to 101.8 thought to be related to possible aspiration pneumonitis in\n setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies which currently show no growth.\n Urine cultuire negative\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - will check Is/Os and if not 1-1.5 L negative will give extra 40 mg IV\n lasix\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - patient was given free water with D5W last night and sodium slightly\n improved, however pt more volume up\n - will consider giving free water if pm labs show worsening\n hypernatremia (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n - recheck Ck\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, this monring there was concern for aspiration so\n speech and swallow consulted\n - video swallow this afternoon\n - NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt, pnuemoboots\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition : call out to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2141-03-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 529972, "text": "TITLE: PHYSICIAN INTERN PROGRESS NOTE\n Chief Complaint:\n Dyspnea and leg swelling\n HPI:\n 24 Hour Events:\n - Mental status dramatically improved. Allowed patient to take some PO\n with close nursing supervision. Will get formal speech and swallow\n evaluation on Monday.\n - Dr. now favoring doing lead extraction/revision on Thursday\n - did not respond to Lasix 40 mg PO, but responded well to Lasix 20 mg\n IV\n - started heparin gtt for subtherapeutic INR\n - repleted free water deficit with D5W\n - this morning pateint states he has been coughing up soe brown sputum\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium - 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 83) bpm\n BP: 85/53(61) {84/42(50) - 157/141(144)} mmHg\n RR: 14 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,514 mL\n 943 mL\n PO:\n 960 mL\n 340 mL\n TF:\n IVF:\n 1,554 mL\n 603 mL\n Blood products:\n Total out:\n 1,695 mL\n 1,100 mL\n Urine:\n 1,695 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 819 mL\n -157 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2 L\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema. Feet erythematous, capilary changes on skin\n Neuro: Alert, orientation waxing and . Initially oriented to\n hospital () and year. However, repeat questioning later\n during rounds pt was unable to state location at . Able to state\n why he is the hospital. Asking to see various equipment/machines in the\n room and not making sense with what he wants it for.\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: 2+), (Left DP pulse: 2+)\n Skin: Maculopapular erythematous rash on upper shoulders and chest\n consistent with resolving stages of rash.\n Neurologic: Responds to verbal commands, answers questions:\n Labs / Radiology\n 10.0 g/dL\n 478 K/uL\n 103 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 29 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.2 %\n 7.8 K/uL\n [image002.jpg]\n INR 1.2\n PTT 94.9\n PT 14.3\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n WBC\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 23\n Cr\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n 428\n 126\n 118\n Other labs: PT / PTT / INR:15.9/150.0/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.7 mg/dL\n Imagine: no new images\n Microbiology: Urine culture final \n no growth\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday pending patient and\n family are in agreement\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. This is still above\n baseline as he does not usually use supplemental oxygen. Heart failure\n less likely etiology of hypoxia and received home dose PO lasix this\n am. Speech and swallow evaluated this am and recommend PNO for now\n except meds with repeat video swallow study.\n -aspiration precautions\n -Video swallow study\n - F/u speech and swallow recs based on results of video, but for now\n NPO except meds\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n -check PM Is/Os\n if not 1 to 1.5 L negative will give one dose IV 40\n mg lasix as yesterday pt required extra IV dose\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile status post completed course of\n antibiotics. Previously, patient was spiking high fevers in spite of\n Tylenol, antibiotics, and improvement of pneumonia. This led to concern\n about an occult infection or non-infectious cause of fever. CT\n abd/pelvis and CT sinuses were negative. TEE showed no vegetation.\n There was one positive blood cx (coag neg staph), thought to be a\n contaminant. Patient was afebrile from , but spiked one fever\n to 101.8 thought to be related to possible aspiration pneumonitis in\n setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies which currently show no growth.\n Urine cultuire negative\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose\n - will check Is/Os and if not 1-1.5 L negative will give extra 40 mg IV\n lasix\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - patient was given free water with D5W last night and sodium slightly\n improved, however pt more volume up\n - will consider giving free water if pm labs show worsening\n hypernatremia (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n - recheck Ck\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, this monring there was concern for aspiration so\n speech and swallow consulted\n - video swallow this afternoon\n - NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt, pnuemoboots\n Stress ulcer: lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition : call out to floor today\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530708, "text": "Delirium / confusion\n Assessment:\n Pt. initially was oriented to person and place but as night went on he\n became only Oriented to self. He was more calm in the eve, but\n becoming more restless and mildly agitated at times during the night.\n Calling out for , yelling\nhelp\n, talking to himself all night,\n mostly about getting out of this place and getting help. He was very\n confused and had difficulty responding approp. When spoken to.\n Moving legs all over the bed and at times over the siderails.\n Action:\n Posey belt on , bilat. Wrist restraints on, 4 side rails up. Trazadone\n 50mg at HS. Zyprexa 2.5 x2.\n Response:\n Appeared to have some effect- pt. appearing more sleepy , eyes half\n closed. But continued to talk and move in the bed.\n 0400- had bed bath, hands left unrestrained and pt. was allowed more\n freedom in the bed with the RN at bedside monitoring and watching. He\n was very sleepy and settled onto his right side and fell asleep with\n occas. leg movements. Much more calm.\n Plan:\n Safety precautions. Restrain when sitter not present in the room.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n BP 87-117/50\ns. HR 70\ns vpaced. No VEA.\n Negative 1.4L for \n Heparin 1300units/hr. PTT 59.9\n Action:\n Lopressor held at for SBP<100 per order (87-90\ns/).\n Heparin increased to 1500units/hr.\n Response:\n u/o dropped to 25-30cc/hr rest of night.\n NPO after MN for cath lab procedure today.\n Plan:\n AM labs. Clot sent to BB.\n" }, { "category": "Physician ", "chartdate": "2141-03-17 00:00:00.000", "description": "Electrophysiology Physician Note", "row_id": 529193, "text": "TITLE: EP Follow-up\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -VT requriing shock externally x\n 1, ATP failed\n -Amiodarone drip started\n Medications\n Changed\n Amio IV added\n Metoprolol 12.5 \n IV heparin\n Physical Exam\n General appearance: Confused, arousable\n BP: 114 / 75 mmHg\n HR: 96 bpm\n RR: 29 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 37.3 C\n T current F: 99.1 F\n O2 sat: 97 % on Supplemental oxygen: NC\n Previous day:\n Weight: 99.6 kg\n Intake: 927 mL\n Output: 3,280 mL\n Fluid balance: -2,353 mL\n Today:\n Intake: 227 mL\n Output: 235 mL\n Fluid balance: -8 mL\n HEENT: (Conjunctiva and lids: clear)\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND)\n Neurological: (Orientation: confused, arousable)\n Extremities:\n Right: (Edema: 1+)\n Left: (Edema: 1+)\n Labs\n 426\n 9.6\n 201\n 1.2\n 29\n 4.1\n 36\n 103\n 142\n 31.0\n 9.1\n [image002.jpg]\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 10:30 PM\n 05:45 AM\n 01:44 PM\n 08:23 PM\n 05:02 AM\n 05:15 AM\n WBC\n 9.3\n 8.4\n 9.1\n Hgb\n 10.4\n 10.6\n 9.6\n Hct (Serum)\n 31.8\n 33.0\n 31.0\n Plt\n 468\n 464\n 426\n INR\n 1.8\n 3.1\n 3.9\n PTT\n 29.4\n 85.1\n 48.8\n 77.8\n 110.5\n Na+\n 145\n 143\n 145\n 145\n 142\n K + (Serum)\n 3.5\n 3.8\n 4.2\n 4.5\n 4.3\n 4.0\n K + (Whole blood)\n 4.1\n Cl\n 102\n 104\n 103\n 104\n 103\n HCO3\n 38\n 34\n 34\n 32\n 29\n BUN\n 33\n 30\n 25\n 25\n 36\n Creatinine\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n Glucose\n 151\n 137\n 122\n 152\n 131\n 201\n O2 sat (arterial)\n 97\n 92\n ABG: 7.49 / 39 / 163 / / 6 Values as of 05:15 AM\n Tests\n Telemetry: MMVT episodes x 2, one requiring external shock\n Assessment and Plan\n 72 yo M with CAD, infarct related cardiomyopathy, h/o VT s/p ICD with\n multiple leads due to revision p/w sepsis, now hemodynamically improved\n with RV coil fracture and non-functioning device and VT storm.\n 1. VT:\n -Agree with IV amio load, lidocaine can be added if incessant VT\n -Increase Metoprolol to 25 \n -If continues, will consider ablation next week\n 2. RV coil fracture on Fidelis lead:\n -External defibrillation necessary, ICD unable to deliver therapy\n -Will d/w Dr. re: lead extraction/revision possibilities for\n next week.\n Will d/w Dr. today.\n ------ Protected Section ------\n Pt seen discussed and examined with DR ; agree with assessment\n and plan. Multiple VT episodes last nite, many associated with giant\n QT. Howeever, most are monomorphic suggesting they are scar related.\n QRS also very wide. I would decrease amio to 200. If many more VT will\n attempt ablation, but this will require intubation. Lead fix ? next\n week. DNR status should be addressed.\n ------ Protected Section Addendum Entered By: , MD\n on: 08:10 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529704, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Pt w/ much improved MS today compared to yesterday. Alert, oriented to\n . At times very clear, stating he\ns at in , stating\n year as , month as or . Other times, asking if we are in\n , or if he has been nominated to receive a heroic medal. Still w/\n some periods of agitation/ restlessness in bed, however no attempts as\n getting OOB by himself. No need for restraints today.\n Action:\n *Continuous reorienting. Bed alarm or chair alarm activated; close\n supervision, bed locked and low.\n *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place\n Response:\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Trazadone at bedtime for sleep (home regimen).\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced, no\n ectopy noted; no runs VT since PCM settings changed->PCM set DDD @ 70.\n As noted above, pt w/ fractured LV lead on ICD. K= 3.7/ magnesium 2.6/\n Na elevated at 150. INR down today 1.4.\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads, . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia. K repleted w/ 40mEq PO.\n Response:\n PM lytes 1700->\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 95-100% 5LNC. RR 20s. Trace LE edema.\n HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *Resumed pt\ns home dose of lasix PO 40mg- goal even I/Os\n *Weaned O2 to 2LNC\n Response:\n Plan:\n Continue to monitor fluid/volume status. Wean O2 as able.\n Pneumonia, Aspiration\n Assessment:\n Likely r/t aspiration pneumonitis that occurred during time of VT\n arrest. T max today 99.8 PR. Pt w/ rare, non-productive cough. WBC 11.\n Action:\n *Weaned O2 to 2LNC. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x\n 5.5 hrs. Followed by ID team.\n *Aspiration Risk- given pt\ns improved mental status, trial of nectar\n thick liquid attempted while pt completely awake and sitting in chair\n with no overt signs of aspiration. Team notified. Diet changed to\n Nectar liqs/ pureed solids w/ strict 1:1 supervision until S&S can\n reevaluate tomorrow. Ate ~ 50% of lunch.\n Response:\n Afebrile this shift. No sputum production noted. Aspiration\n Precautions.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Tylenol PRN.\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529718, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Pt w/ much improved MS today compared to yesterday. Alert, oriented to\n . At times very clear, stating he\ns at in , stating\n year as , month as or . Other times, asking if we are in\n , or if he has been nominated to receive a heroic medal. Still w/\n some periods of agitation/ restlessness in bed, and rare attempt to get\n OOB w/out assist. No need for restraints today.\n Action:\n *Continuous reorienting. Bed alarm or chair alarm activated; close\n supervision, bed locked and low.\n *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place\n Response:\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Trazadone at bedtime for sleep (home regimen).\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced,\n occasional PVCs noted; no runs VT since PCM settings changed->PCM set\n DDD @ 70. As noted above, pt w/ fractured LV lead on ICD. K= 3.7/\n magnesium 2.6/ Na elevated at 150. INR down today 1.4.\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads, . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia. K repleted w/ 40mEq PO. Heparin\n gtt restarted for INR 1.4- 1500unit/shr up at 10:50.\n Response:\n PM lytes 1700->\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 95-100% 5LNC. RR 20s. Trace LE edema.\n HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *Resumed pt\ns home dose of lasix PO 40mg- goal even I/Os\n *Weaned O2 to 2LNC\n Response:\n Plan:\n Continue to monitor fluid/volume status. Wean O2 as able.\n Pneumonia, Aspiration\n Assessment:\n Likely r/t aspiration pneumonitis that occurred during time of VT\n arrest. T max 98.6po. Pt w/ rare, non-productive cough. WBC 10.\n Action:\n *Weaned O2 to 2LNC. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x\n 5.5 hrs. Followed by ID team.\n *Aspiration Risk- given pt\ns improved mental status, trial of nectar\n thick liquid attempted while pt completely awake and sitting in chair\n with no overt signs of aspiration. Team notified. Diet changed to\n Nectar liqs/ pureed solids w/ strict 1:1 supervision until S&S can\n reevaluate tomorrow. Ate ~ 50% of lunch.\n Response:\n Afebrile this shift. No sputum production noted. Aspiration\n Precautions.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Aspiration precautions.\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529796, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530142, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on. Posey off. Given 50mg\n Trazodone for sleep at midnight with poor effect on sleep. Closely\n supervising patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up\n x4, bed low and locked, and bilateral wrist restraints on. Fall risk\n precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . External defib pads.\n Heparin gtt @ 1500units/hr. Systolic BP trailing in the low 70s\n questionably from metroprolol. Rechecked and verified with doppler.\n Lung sounds diminished at bases. Chest xray showed no\n cardiopulmonary process. Pt. was saturating 100% on 2L nc. removed O2\n and patient currently saturating 100% on RA. Patient tolerating well\n and denies feeling short of breath. Urine output between\n 20-65mLs/hour. Weight loss of 8kg since admission date .\n Action:\n ? fluid bolus to increase BP\n Response:\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Defibrillator at bedside.\n Dysphagia\n Assessment:\n Patient is currently strict NPO & no ice chips after failing swallow\n study. On tube feeding Isosource 1.5 cal Full strength.\n Action:\n Tube feeding: Starting rate at 25ml/hour. Currently at 35 ml/hour.\n Advance rate by 10ml every 6 hours.\n Response:\n Tolerating tube feedings well.\n Plan:\n Hold feeding if residual greater than or equal to 200mL\n" }, { "category": "Physician ", "chartdate": "2141-03-23 00:00:00.000", "description": "EP Note", "row_id": 530785, "text": "History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: Tele: no VT\n Difficult to control and pulls NG tube out. Currently being\n restrained.\n Medications\n Unchanged\n Physical Exam\n General appearance: alter and oriented,\n BP: 114 / 61 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 36.1 C\n Tmax F last 24 hours: F\n T current C: 35.7 C\n T current F: 96.3 F\n Previous day:\n Intake: 1,142 mL\n Output: 2,385 mL\n Fluid balance: -1,243 mL\n Today:\n Intake: 155 mL\n Output: 210 mL\n Fluid balance: -55 mL\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA Ant)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: alert to name, place and time)\n Labs\n 407\n 10.5\n 100\n 0.9\n 27\n 3.8\n 20\n 109\n 143\n 32.2\n 5.8\n [image002.jpg]\n 04:37 PM\n 11:34 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 12:58 PM\n 05:52 PM\n 03:38 AM\n 03:41 AM\n WBC\n 7.8\n 6.2\n 5.5\n 5.8\n Hgb\n 10.0\n 10.1\n 10.7\n 10.5\n Hct (Serum)\n 32.2\n 31.8\n 32.5\n 32.2\n Plt\n 07\n INR\n 1.2\n 1.2\n 1.2\n 1.2\n 1.2\n 1.2\n 1.2\n PTT\n 37.7\n 150.0\n 94.9\n 62.8\n 79.0\n 111.1\n 74.5\n 59.9\n 74.1\n Na+\n 147\n 145\n 147\n 141\n 142\n 143\n K + (Serum)\n 4.2\n 3.7\n 4.0\n 3.8\n 3.9\n 4.1\n 3.8\n Cl\n 110\n 107\n 108\n 106\n 108\n 109\n HCO3\n 30\n 30\n 31\n 29\n 27\n 27\n BUN\n 38\n 29\n 24\n 26\n 19\n 20\n Creatinine\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n Glucose\n 118\n 103\n 108\n 122\n 120\n 100\n CK\n 187\n ABG: / / / 27 / Values as of 03:38 AM\n Assessment and Plan\n VT - scheduled for lead extraction and new lead placement today.\n - NPO for now\n - Type and cross 4 units already\n - Consent in chart.\n" }, { "category": "Physician ", "chartdate": "2141-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530792, "text": "Chief Complaint: Dyspnea\n From HPI admission note:\n \"71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum for the past week.\n He also had some low-grade temps at home (Tm 99.8) earlier this week.\n He called his cardiologist on , complaining of this cough and LE\n edema. He was told to increase his lasix to 60mg TIW and 40 mg daily\n the rest of the week. He then presented to gerontology clinic on\n with similar complaints. CXR and CBC done that day were\n unremarkable. He then developed dyspnea over the past 24-36 hours. He\n called cardiology clinic this morning and was instructed to present to\n the ED.\"\n 24 Hour Events:\n \n -Pt still confused\n -Pulled out NG tube a second time on , NG tube replaced again and\n confirmed in correct position\n - NPO for probable lead revision, family aware of high risks involved\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:05 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 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 81) bpm\n BP: 114/61(73) {85/44(58) - 118/73(103)} mmHg\n RR: 20 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,143 mL\n 162 mL\n PO:\n TF:\n 479 mL\n IVF:\n 323 mL\n 162 mL\n Blood products:\n Total out:\n 2,385 mL\n 210 mL\n Urine:\n 2,385 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,242 mL\n -48 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 407 K/uL\n 10.5 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 109 mEq/L\n 143 mEq/L\n 32.2 %\n 5.8 K/uL\n [image002.jpg]\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n 5.8\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n 32.2\n Plt\n 521\n 523\n 478\n 448\n 424\n 407\n Cr\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n Glucose\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n 100\n Other labs: PT / PTT / INR:13.9/74.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: dobhoff reaches the upper stomach, minimally retracted from\n one day prior.\n could be advanced for optimal positioning. no other significant\n interval\n chnage from prior cxr. d.w Dr .\n Microbiology: No new.\n ECG: .\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n GAIT, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n TRANSFERS, IMPAIRED\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 530793, "text": "Chief Complaint: Dyspnea\n From HPI admission note:\n \"71 y/o M with PMHx significant for systolic HF (EF 20-25%), old\n anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular\n tachycardia, history of ventricular fibrillation in the past, status\n post eventual BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, who presented to the ED this\n morning with a chief complaint of dyspnea. The patient reports that he\n began having a cough productive of dark beige sputum for the past week.\n He also had some low-grade temps at home (Tm 99.8) earlier this week.\n He called his cardiologist on , complaining of this cough and LE\n edema. He was told to increase his lasix to 60mg TIW and 40 mg daily\n the rest of the week. He then presented to gerontology clinic on\n with similar complaints. CXR and CBC done that day were\n unremarkable. He then developed dyspnea over the past 24-36 hours. He\n called cardiology clinic this morning and was instructed to present to\n the ED.\"\n 24 Hour Events:\n \n -Pt still confused\n -Pulled out NG tube a second time on , NG tube replaced again and\n confirmed in correct position\n - NPO for probable lead revision, family aware of high risks involved\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:05 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 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 81) bpm\n BP: 114/61(73) {85/44(58) - 118/73(103)} mmHg\n RR: 20 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 1,143 mL\n 162 mL\n PO:\n TF:\n 479 mL\n IVF:\n 323 mL\n 162 mL\n Blood products:\n Total out:\n 2,385 mL\n 210 mL\n Urine:\n 2,385 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,242 mL\n -48 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 407 K/uL\n 10.5 g/dL\n 100 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 109 mEq/L\n 143 mEq/L\n 32.2 %\n 5.8 K/uL\n [image002.jpg]\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 06:30 AM\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n WBC\n 11.0\n 10.9\n 7.8\n 6.2\n 5.5\n 5.8\n Hct\n 31.4\n 33.3\n 32.2\n 31.8\n 32.5\n 32.2\n Plt\n 521\n 523\n 478\n 448\n 424\n 407\n Cr\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n 0.9\n 0.9\n 0.8\n 0.9\n Glucose\n 126\n 130\n 428\n 126\n 118\n 103\n 108\n 122\n 120\n 100\n Other labs: PT / PTT / INR:13.9/74.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: .\n Imaging: dobhoff reaches the upper stomach, minimally retracted from\n one day prior.\n could be advanced for optimal positioning. no other significant\n interval\n chnage from prior cxr. d.w Dr .\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil was\n found to be fractured.\n -Tentative plans for ICD revision on Thursday - patient and family are\n in agreement\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n -Pt to be after MN, and will have 4 units crossmatched for procedure\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n -continue home dose of PO Lasix\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: be medication induced versus being hypovolemic. Is\n near his baseline for the past few days, in past ranges from 80s-130s.\n Diuresis gently continues, and likely to be safe.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status:\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2141-03-17 00:00:00.000", "description": "Repeat Bedside Swallowing Evaluation", "row_id": 529199, "text": "TITLE:\n REPEAT BEDSIDE SWALLOWING EVALUATION:\n HISTORY:\n Returned today to reassess this 71 year old man initially admitted on\n with a week of cough productive of dark beige sputum x 1 week\n with progressive dyspnea. His respiratory failure progressed, and was\n intubated on . Initially symptoms were thought to be due to CHF\n exacerbation with infiltrate, fever, white count consistent with PNA.\n Bronch on notable for normal airways. Recently underwent TEE to\n evaluate for endocarditis. He was extubated on .\n We were consulted to evaluate oral and pharyngeal swallow function to\n determine the safest diet. Pt was seen on prior to intubation, and\n had no overt signs of aspiration or other odynophagia except for\n difficulty chewing with edentulous status. We recommended diet of\n regular solids and thin liquids. Pt was re-evaluated on s/p\n extubation and had s/sx of aspiration of thin liquids and nectar thick\n liquids today, tolerated small volumes of puree and meds whole in\n puree. Recommended NPO with meds whole or crushed in puree only. \n attempted repeat eval, however pt restless in bed, inattentive, and\n coughed on single ice chip. Further POs were deferred.\n PAST MEDICAL/SURGICAL HISTORY:\n - CAD s/p Anterior wall myocardial infarction in with\n ventricular tachycardia and complete heart block requiring\n pacemaker\n - CHF Systolic heart failure (EF 20-25%)\n - Atrial fibrillation\n - Hypertension.\n - Hypothyroidism.\n - Anemia.\n - Irritable bowel syndrome.\n - Constipation.\n - Obesity.\n - Hearing loss, requiring bilateral hearing aids.\n - Squamous cell carcinoma of the left lower eyelid.\n - Cerebral infarct.\n - History of Whipple operation, with subsequent E. coli and\n Klebsiella bacteremia, on chronic suppression with cefpodoxime\n - History of possible C3-C4 osteomyelitis\n s/p:\n 1. Placement of pacemaker and ICD.\n 2. Knee surgery.\n 3. Removal of squamous cell carcinoma of his left lower eyelid.\n 4. Recent Whipple's procedure for which he was diagnosed with\n dysplasia.\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the bed on CCU.\n Cognition, language, speech, voice:\n Asleep, occasionally moving around in bed. Wakes to verbal stim, but\n needs near constant verbal/tactile stim to maintain wakefulness.\n Oriented to self, \"\" but does not state last name. Answers a few\n other y/n questions, though inaccurately. Does not follow commands.\n Speech clear in short utterances observed today.\n Teeth: edentulous\n Secretions: dry oral cavity- mouth moisturizer provided.\n SWALLOWING ASSESSMENT:\n Pt offered ice chip, thin liquid (2 tspns), nectar thick liquid (2\n tspns), and puree (1 tspn + 2 tspns with meds chopped into small pieces\n provided by RN). Oral phase prolonged but functional for the few\n consistencies assessed today. Did eventually clear oral cavity,\n however required cues to clear with meds whole/chopped in puree.\n Laryngeal elevation delayed but adequate in height to palpation. Pt\n had immediate and delayed coughing consistently with ice chips, thin\n liquid, and nectar thick liquid. O2 sats started between 91-88, raised\n to 94 before PO intake, fluctuated back down to 88 with s/sx of\n aspiration, and were stable at 94 when I left the room. wife\n entered the room after 2nd tspn of meds + puree, very upset that pt\n being orally fed, even for minimal amounts required for PO meds.\n Requesting feeding tube.\n SUMMARY / IMPRESSION:\n Pt's swallow function appears stable between today and the evaluation\n on with continued s/sx of aspiration of ice chips, thin liquid,\n and nectar thick liquids. Continues to tolerate purees with meds\n whole/chopped/crushed. Would keep primarily NPO at this time with meds\n whole or crushed in puree only. Given that pt has now been 3 days with\n relatively stable swallow function and waxing/ MS, would\n encourage team to consider NGT for primary nutrition, hydration, and\n more reliable medication administration. Please consult Nutrition. We\n will f/u early next week for initiation of diet if pt's overall status\n has improved.\n This swallowing pattern correlates to a Functional Oral Intake Scale\n (FOIS) rating of 1 out of 7, NPO.\n RECOMMENDATIONS:\n 1. NPO except meds whole or crushed in puree\n 2. Q4 oral care while NPO\n 3. If providing whole meds, please check oral cavity to ensure the pill\n was swallowed prior to laying back.\n 4. Repeat swallowing evaluation early next week.\n 5. Please consider NGT/Dobbhoff for adequate source of nutrition,\n hydration, and more reliable source of med administration; Nutrition\n consult.\n These recommendations were shared with the patient, nurse and medical\n team.\n ____________________________________\n M.S., CCC-SLP\n Pager # \n Face time: 8:30-9:45\n Total time: 60 minutes\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529699, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - restarted cefpodoxime\n - gave 1 L D5W for hypernatremia\n - ID: signed off\n - EP: can attempt lead extraction in OR but risky, should readdress\n goals of care\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:50 AM\n Furosemide (Lasix) - 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 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 77 (75 - 82) bpm\n BP: 117/67(80) {61/27(35) - 142/80(91)} mmHg\n RR: 21 (15 - 30) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 956 mL\n PO:\n TF:\n IVF:\n 956 mL\n Blood products:\n Total out:\n 1,820 mL\n 340 mL\n Urine:\n 1,820 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -864 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN: NAD.\n CV: RRR. Normal s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, oriented to hospital, , year. Able to state\n why he is the hospital. Stated president was\n\n. Able to recall\n historical details relevant to his area of expertise as a professor.\n Talking about being award a\nmedal\n for being a\nhero\n Labs / Radiology\n 523 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 113 mEq/L\n 150 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 468\n 464\n 426\n 521\n 523\n Cr\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n TCO2\n 31\n Glucose\n 122\n 152\n 131\n \n 130\n 428\n 126\n Other labs: PT / PTT / INR:15.9/28.1/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.6 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil\n fractured.\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. Heart failure less likely\n etiology of hypoxia.\n -aspiration precautions\n -f/u speech and swallow recs\n -wean O2 as tolerated\n -restart home dose of PO Lasix\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had marked improvement in past 2 days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile. Previously, patient was spiking high\n fevers in spite of Tylenol, antibiotics, and improvement of pneumonia.\n This led to concern about an occult infection or non-infectious cause\n of fever. CT abd/pelvis and CT sinuses were negative. TEE showed no\n vegetation. There was one positive blood cx (coag neg staph), thought\n to be a contaminant. Patient was afebrile from , but spiked\n one fever to 101.8 thought to be related to possible aspiration\n pneumonitis in setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - restart PO Lasix at home dose\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - replete free water deficit D5W (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n ICU Care\n Nutrition: Patient more alert today. Will allow patient to consume\n dysphagia diet with close supervision and plan to formal speech and\n swallow evaluation on Monday.\n Glycemic Control: glargine + Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: heparin gtt (holding warfarin for possible EP procedure)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Rehab Services", "chartdate": "2141-03-20 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 529962, "text": "TITLE:\n REPEAT BEDSIDE SWALLOWING EVALUATION:\n HISTORY:\n Returned today to reassess this 71 year old man initially admitted on\n with a week of cough productive of dark beige sputum x 1 week\n with progressive dyspnea. His respiratory failure progressed, and was\n intubated on . Initially symptoms were thought to be due to CHF\n exacerbation with infiltrate, fever, white count consistent with PNA.\n Bronch on notable for normal airways. He was extubated on .\n Hospital course complicated by ICD malfunction, VT/VF arrest requiring\n debrillation and reintubation, and runs of VT, including one VT\n arrest. He's scheduled to undergo ICD revision on .\n We were consulted to evaluate oral and pharyngeal swallow function to\n determine the safest diet. Pt was seen on prior to intubation, and\n had no overt signs of aspiration or other odynophagia except for\n difficulty chewing with edentulous status. We recommended diet of\n regular solids and thin liquids. Pt was re-evaluated on s/p\n extubation and had s/sx of aspiration of thin liquids and nectar thick\n liquids, tolerated small volumes of puree and meds whole in puree.\n Recommended NPO with meds whole or crushed in puree only. \n attempted repeat eval, however pt restless in bed, inattentive, and\n coughed on single ice chip. Further POs were deferred. On , pt\n seen with results consistent with 3/24 evaluation, again recommended\n NPO with NGT for supplementation. Over the weekend, pt's MS improved\n significantly and pt was initiated on a PO diet of pureed solids and\n nectar thick liquids. RN notes indicated tolerating well and taking\n approx 50% of food offered. This morning's RN noted delayed cough with\n nectar thick liquid and requested repeat evaluation.\n PAST MEDICAL/SURGICAL HISTORY:\n - CAD s/p Anterior wall myocardial infarction in with\n ventricular tachycardia and complete heart block requiring\n pacemaker\n - CHF Systolic heart failure (EF 20-25%)\n - Atrial fibrillation\n - Hypertension.\n - Hypothyroidism.\n - Anemia.\n - Irritable bowel syndrome.\n - Constipation.\n - Obesity.\n - Hearing loss, requiring bilateral hearing aids.\n - Squamous cell carcinoma of the left lower eyelid.\n - Cerebral infarct.\n - History of Whipple operation, with subsequent E. coli and\n Klebsiella bacteremia, on chronic suppression with cefpodoxime\n - History of possible C3-C4 osteomyelitis\n s/p:\n 1. Placement of pacemaker and ICD.\n 2. Knee surgery.\n 3. Removal of squamous cell carcinoma of his left lower eyelid.\n 4. Recent Whipple's procedure for which he was diagnosed with\n dysplasia.\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the chair on CCU.\n Cognition, language, speech, voice:\n Awake, alert, attentive. Oriented to self and . Follows\n one step commands, though occasionally inaccurate - ?receptive language\n vs. hard of hearing vs. inattentive. Answers questions, however\n tangential/slightly off topic. For example, when asked \"is the ice\n gone?\" when offered ice chips, his response was \"well, I think it's all\n melting on the sidewalk.\" Expressive language fluent with ?word\n finding in conversational speech. Speech is mildly dysarthric, ?impact\n of edentulous status. Voice hoarse.\n Teeth: edentulous, sig other has dentures at home\n Secretions: WNL\n SWALLOWING ASSESSMENT:\n Pt offered ice chip, thin liquid (tpsn, cup, straw, consecutive),\n nectar thick liquid (tspn, cup, straw, consecutive), and puree. Oral\n phase WFL without anterior spill or oral cavity residue. Pt with\n difficulty self-feeding, poor grip on spoon/cup, spills water on self,\n poor hand-to-mouth coordination with spoon and cup. Laryngeal\n elevation delayed but adequate in height to palpation. Pt had\n intermittent cough with thin liquids, wet vocal quality with nectar\n thick liquids.\n SUMMARY / IMPRESSION:\n Pt presents with overt s/sx of aspiration of thin liquids, ?possible\n aspiration of nectar thick liquids. Pt's sig other, present for\n today's evaluation, says \"this has been happening for 10-15 years, he\n has a hiatus hernia.\" Would recommend videoswallow study for further\n objective assessment prior to continuing with PO intake. In the\n interim, can have essential medications with puree.\n RECOMMENDATIONS:\n 1. NPO except meds whole or crushed in puree\n 2. Q4 oral care while NPO\n 3. Videoswallow study this afternoon for objective assessment\n 4. All other recs pending.\n These recommendations were shared with the patient, nurse and medical\n team.\n ____________________________________\n M.S., CCC-SLP\n Pager # \n Face time: 11:30-11:45\n Total time: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529687, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - restarted cefpodoxime\n - gave 1 L D5W for hypernatremia\n - ID: signed off\n - EP: can attempt lead extraction in OR but risky, should readdress\n goals of care\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:50 AM\n Furosemide (Lasix) - 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 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 77 (75 - 82) bpm\n BP: 117/67(80) {61/27(35) - 142/80(91)} mmHg\n RR: 21 (15 - 30) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 956 mL\n PO:\n TF:\n IVF:\n 956 mL\n Blood products:\n Total out:\n 1,820 mL\n 340 mL\n Urine:\n 1,820 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -864 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN: NAD.\n CV: RRR. Normal s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, oriented to hospital, , year. Able to state\n why he is the hospital. Stated president was\n\n. Able to recall\n historical details relevant to his area of expertise as a professor.\n Talking about being award a\nmedal\n for being a\nhero\n Labs / Radiology\n 523 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 113 mEq/L\n 150 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 468\n 464\n 426\n 521\n 523\n Cr\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n TCO2\n 31\n Glucose\n 122\n 152\n 131\n \n 130\n 428\n 126\n Other labs: PT / PTT / INR:15.9/28.1/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.6 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers in spite of\n Tylenol and meropenem, runs of VT, and ICD malfunction. , narrowed to\n suppressive cefpodoxime regimen now spiking temp with meropenem\n restarted. Pt also had VT thought fast/short sequences due to pacer\n setting.\n .\n # s/p VT/VF arrest/ICD dysfunction: LV lead not pacing, only RV\n (). PMR programmed to DDD\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Patient had\n multiple runs of VT, including second VT arrest 2 nites ago requiring\n defibrillation. Etiology of recently increased ectopy thought \n fast/short sequences, pacer settings. A sensed V paced.\n . Device may not be able to detect VT/VF. Pt will have to be\n Externally defibrillated\n -Unlikely to need ablation as previously thought when etiology VT\n unclear.\n -continue current amnio dose 200mg daily, metoprololl 25mg \n monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n Possible lead extraction next week for RV coil fracture.\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to VT arrest, patient was satting well on 2L NC . Has had increased O2\n requirement since, requiring face mask and desating when not on it,\n possibly related to aspiration, less likely worsening heart failure.\n Spiked temp last night, most likely asp pneumonitis, mild\n leukocytosis. Heart failure lesser contributor, diuresed well to 20 IV\n lasix but no frther given, given bump in Cr. Not grossly volume\n overloaded on exam.\n Given prior hx, broadened to meropenem but can consider narrowing if\n remains afebrile, pending Cx data\n -aspiration precautions\n -allow to autodiurese today, if later in day appears positive, consider\n lasix bolus,\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has intermittent periods of lucidity, over\n general course slightl improved. MS currently limiting ability to take\n p.o . Plan currently to keep NPO except meds, repeat swallow eval early\n next week.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Acute renal failure: hypernatremia, Cr increased y/d in setting lasix\n IV. need to give free H20 to correct free h20 deficit today. Cr\n increased to 1.3 yesterday. Now 1.1\n Continue to trend Cr\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amio\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529690, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - restarted cefpodoxime\n - gave 1 L D5W for hypernatremia\n - ID: signed off\n - EP: can attempt lead extraction in OR but risky, should readdress\n goals of care\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:50 AM\n Furosemide (Lasix) - 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 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 77 (75 - 82) bpm\n BP: 117/67(80) {61/27(35) - 142/80(91)} mmHg\n RR: 21 (15 - 30) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 956 mL\n PO:\n TF:\n IVF:\n 956 mL\n Blood products:\n Total out:\n 1,820 mL\n 340 mL\n Urine:\n 1,820 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -864 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN: NAD.\n CV: RRR. Normal s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, oriented to hospital, , year. Able to state\n why he is the hospital. Stated president was\n\n. Able to recall\n historical details relevant to his area of expertise as a professor.\n Talking about being award a\nmedal\n for being a\nhero\n Labs / Radiology\n 523 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 113 mEq/L\n 150 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 468\n 464\n 426\n 521\n 523\n Cr\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n TCO2\n 31\n Glucose\n 122\n 152\n 131\n \n 130\n 428\n 126\n Other labs: PT / PTT / INR:15.9/28.1/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.6 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers in spite of\n Tylenol and meropenem, runs of VT, ICD malfunction, VT/VF arrest\n requiring debrillation and reintubation, and rapid VT requiring\n defibrillation, narrowed to suppressive cefpodoxime regimen now spiking\n temp with meropenem restarted. Pt also had VT thought fast/short\n sequences due to pacer setting.\n .\n # s/p VT/VF arrest/ICD dysfunction: LV lead not pacing, only RV\n (). PMR programmed to DDD\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Patient had\n multiple runs of VT, including second VT arrest 2 nites ago requiring\n defibrillation. Etiology of recently increased ectopy thought \n fast/short sequences, pacer settings. A sensed V paced.\n . Device may not be able to detect VT/VF. Pt will have to be\n Externally defibrillated\n -Unlikely to need ablation as previously thought when etiology VT\n unclear.\n -continue current amnio dose 200mg daily, metoprololl 25mg \n monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n Possible lead extraction next week for RV coil fracture.\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to VT arrest, patient was satting well on 2L NC . Has had increased O2\n requirement since, requiring face mask and desating when not on it,\n possibly related to aspiration, less likely worsening heart failure.\n Spiked temp last night, most likely asp pneumonitis, mild\n leukocytosis. Heart failure lesser contributor, diuresed well to 20 IV\n lasix but no frther given, given bump in Cr. Not grossly volume\n overloaded on exam.\n Given prior hx, broadened to meropenem but can consider narrowing if\n remains afebrile, pending Cx data\n -aspiration precautions\n -allow to autodiurese today, if later in day appears positive, consider\n lasix bolus,\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has intermittent periods of lucidity, over\n general course slightl improved. MS currently limiting ability to take\n p.o . Plan currently to keep NPO except meds, repeat swallow eval early\n next week.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Acute renal failure: hypernatremia, Cr increased y/d in setting lasix\n IV. need to give free H20 to correct free h20 deficit today. Cr\n increased to 1.3 yesterday. Now 1.1\n Continue to trend Cr\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amio\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529693, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Pt w/ much improved MS today compared to yesterday. Alert, oriented to\n . At times very clear, stating he\ns at in , stating\n year as , month as or . Other times, asking if we are in\n , or if he has been nominated to receive a heroic medal. Still w/\n some periods of agitation/ restlessness in bed, however no attempts as\n getting OOB by himself. No need for restraints today.\n Action:\n *Continuous reorienting. Bed alarm or chair alarm activated; close\n supervision, bed locked and low.\n *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place\n Response:\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Trazadone at bedtime for sleep (home regimen).\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced, no\n ectopy noted; no runs VT since PCM settings changed->PCM set DDD @ 70.\n As noted above, pt w/ fractured LV lead on ICD. K= 3.7/ magnesium 2.6/\n Na elevated at 150. INR down today 1.4.\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads, . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia. K repleted w/ 40mEq PO.\n Response:\n PM lytes 1700->\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: diminished at bases. SPO2 95-100% 5LNC. RR 20s. Trace LE edema.\n HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *Resumed pt\ns home dose of lasix PO 40mg- goal even I/Os\n *Weaned O2 to 2LNC\n Response:\n Plan:\n Continue to monitor fluid/volume status. Wean O2 as able.\n Pneumonia, Aspiration\n Assessment:\n Likely r/t aspiration pneumonitis that occurred during time of VT\n arrest. T max today 99.8 PR. Pt w/ rare, non-productive cough. WBC 11.\n Action:\n *Weaned O2 to 2LNC. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x\n ___ hrs. Followed by ID team.\n *Aspiration Risk- given pt\ns improved mental status, trial of nectar\n thick liquid attempted while pt completely awake and sitting in chair\n with no overt signs of aspiration. Team notified. Diet changed to\n Nectar liqs/ pureed solids w/ strict 1:1 supervision until S&S can\n reevaluate tomorrow.\n Response:\n Afebrile this shift. No sputum production noted. Aspiration\n Precautions.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Tylenol PRN.\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529695, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - restarted cefpodoxime\n - gave 1 L D5W for hypernatremia\n - ID: signed off\n - EP: can attempt lead extraction in OR but risky, should readdress\n goals of care\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:50 AM\n Furosemide (Lasix) - 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 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 77 (75 - 82) bpm\n BP: 117/67(80) {61/27(35) - 142/80(91)} mmHg\n RR: 21 (15 - 30) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 956 mL\n PO:\n TF:\n IVF:\n 956 mL\n Blood products:\n Total out:\n 1,820 mL\n 340 mL\n Urine:\n 1,820 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -864 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN: NAD.\n CV: RRR. Normal s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, oriented to hospital, , year. Able to state\n why he is the hospital. Stated president was\n\n. Able to recall\n historical details relevant to his area of expertise as a professor.\n Talking about being award a\nmedal\n for being a\nhero\n Labs / Radiology\n 523 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 113 mEq/L\n 150 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 468\n 464\n 426\n 521\n 523\n Cr\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n TCO2\n 31\n Glucose\n 122\n 152\n 131\n \n 130\n 428\n 126\n Other labs: PT / PTT / INR:15.9/28.1/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.6 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil\n fractured.\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amnio dose 200mg daily, metoprololl 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. Heart failure less likely\n etiology of hypoxia.\n -aspiration precautions\n -f/u speech and swallow recs\n -wean O2 as tolerated\n -restart home dose of PO Lasix\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had marked improvement in past 2 day.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Acute renal failure: Cr transiently increased in setting of diruesis\n with IV lasix, now back to baseline. Likely pre-renal.\n - trend Cr\n .\n # Fever/Pneumonia: Now afebrile. Previously, patient was spiking high\n fevers in spite of Tylenol, antibiotics, and improvement of pneumonia.\n This led to concern about an occult infection or non-infectious cause\n of fever. CT abd/pelvis and CT sinuses were negative. TEE showed no\n vegetation. There was one positive blood cx (coag neg staph). This\n could represent true infection versus contaminant.\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amio\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2141-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529696, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - restarted cefpodoxime\n - gave 1 L D5W for hypernatremia\n - ID: signed off\n - EP: can attempt lead extraction in OR but risky, should readdress\n goals of care\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:50 AM\n Furosemide (Lasix) - 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 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 77 (75 - 82) bpm\n BP: 117/67(80) {61/27(35) - 142/80(91)} mmHg\n RR: 21 (15 - 30) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 956 mL\n PO:\n TF:\n IVF:\n 956 mL\n Blood products:\n Total out:\n 1,820 mL\n 340 mL\n Urine:\n 1,820 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -864 mL\n -340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN: NAD.\n CV: RRR. Normal s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, oriented to hospital, , year. Able to state\n why he is the hospital. Stated president was\n\n. Able to recall\n historical details relevant to his area of expertise as a professor.\n Talking about being award a\nmedal\n for being a\nhero\n Labs / Radiology\n 523 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 113 mEq/L\n 150 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 468\n 464\n 426\n 521\n 523\n Cr\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n TCO2\n 31\n Glucose\n 122\n 152\n 131\n \n 130\n 428\n 126\n Other labs: PT / PTT / INR:15.9/28.1/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.6 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil\n fractured.\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amnio dose 200mg daily, metoprololl 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. Heart failure less likely\n etiology of hypoxia.\n -aspiration precautions\n -f/u speech and swallow recs\n -wean O2 as tolerated\n -restart home dose of PO Lasix\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had marked improvement in past 2 day.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile. Previously, patient was spiking high\n fevers in spite of Tylenol, antibiotics, and improvement of pneumonia.\n This led to concern about an occult infection or non-infectious cause\n of fever. CT abd/pelvis and CT sinuses were negative. TEE showed no\n vegetation. There was one positive blood cx (coag neg staph), thought\n to be a contaminant. Patient was afebrile from\n - f/u culture data with plan to narrow vs provide HAP with aspiration\n coverage.\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n -\n # Coagulopathy: INR markedly elevated y/d. Likely related to\n amiodarone.\n -continue to hold Coumadin until below 2.0 then restart.\n -continue to trend.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Still not alert enough for speech and swallow. Will hold off\n on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n Prophylaxis:\n DVT: start hep SC, until INR below 2 then start amio\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529844, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Better day yesterday and o.k. night tonight. He is Ox2-3, appropriate\n most of the time. Follows direction and commands. Not trying to get\n OOB but at times restless.\n Awake much of the night. Eyes would be closed but open as soon as RN\n walks into room. Always asking for something to drink.\n Asking for water and coke.\n Action:\n Taking meds crushed with applesause well. Liquids thickened to nectar\n consistency.\n Aspiration precautions.\n Trazadone 50mg at HS\n Response:\n Slept on and off. Incontinent x2 stool- unable to tell RN he had to\n go.\n Plan:\n Safety precautions, OOB to chair 2 assist.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . external defib pads\n dated .\n Heparin drip at 1850/hr. PTT >150\n - total 600cc u/o response from lasix given 1800.\n - D5W x total 2L completed for elevated Na+\n Action:\n Heparin on hold x1 hour and decresed to 1500units/hr at\n 0130.\n Repeat lasix 20mg at 0230\n Po lopressor and amio as ordered.\n Monitored sat, u/o\n KCL repletion on \n IVF completed.\n Response:\n HR 70-80 Vpaced with rare PVC. BP 94-99/60\ns MAP 70\n u/o 60-80cc/hr.\n 800cc response to IV lasix over 3 hours. Negative 300cc\n since MN.\n positive 800cc for .\n Plan:\n Check PTT at 0700.\n Monitor lytes with diuresis.\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530139, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on. Posey off. Given 50mg\n Trazodone for sleep at midnight with poor effect on sleep. Closely\n supervising patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up\n x4, bed low and locked, and bilateral wrist restraints on. Fall risk\n precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . External defib pads.\n Heparin gtt @ 1500units/hr. Systolic BP trailing in the low 70s\n questionably from metroprolol. Rechecked and verified with doppler.\n Lung sounds diminished at bases. Chest xray showed no\n cardiopulmonary process. Saturating 100% on RA. Urine output between\n 20-65mLs/hour. Weight loss of 8kg since admission date .\n Action:\n Response:\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Defibrillator at bedside.\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-20 00:00:00.000", "description": "EP Note", "row_id": 529922, "text": "History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: Tele - no NSVT\n Medications\n Unchanged\n Physical Exam\n BP: 92 / 57 mmHg\n HR: 81 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.8 F\n T current C: 35.7 C\n T current F: 96.3 F\n Previous day:\n Intake: 2,512 mL\n Output: 1,695 mL\n Fluid balance: 817 mL\n Today:\n Intake: 968 mL\n Output: 1,100 mL\n Fluid balance: -132 mL\n Labs\n 478\n 10.0\n 103\n 0.9\n 30\n 3.7\n 29\n 107\n 145\n 32.2\n 7.8\n [image002.jpg]\n 05:15 AM\n 06:21 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 11:34 PM\n 06:30 AM\n WBC\n 11.0\n 10.9\n 7.8\n Hgb\n 10.4\n 10.6\n 10.0\n Hct (Serum)\n 31.4\n 33.3\n 32.2\n Plt\n 521\n 523\n 478\n INR\n 7.8\n 5.3\n 2.2\n 1.4\n 1.2\n PTT\n 75.1\n 37.6\n 33.1\n 28.1\n 37.7\n 150.0\n 94.9\n Na+\n 146\n 148\n 149\n 140\n 150\n 147\n 145\n K + (Serum)\n 5.2\n 4.5\n 4.3\n 3.5\n 3.7\n 4.2\n 3.7\n K + (Whole blood)\n 4.1\n Cl\n 105\n 107\n 110\n 102\n 113\n 110\n 107\n HCO3\n 31\n 30\n 30\n 31\n 31\n 30\n 30\n BUN\n 42\n 46\n 46\n 40\n 40\n 38\n 29\n Creatinine\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n ABG: / / / 30 / Values as of 06:30 AM\n Assessment and Plan\n VT\n" }, { "category": "Physician ", "chartdate": "2141-03-20 00:00:00.000", "description": "EP Note", "row_id": 529924, "text": "History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: Tele - no NSVT. Mentally\n recovering well with daily improvements.\n Medications\n Unchanged\n Physical Exam\n BP: 92 / 57 mmHg\n HR: 81 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.8 F\n T current C: 35.7 C\n T current F: 96.3 F\n Previous day:\n Intake: 2,512 mL\n Output: 1,695 mL\n Fluid balance: 817 mL\n Today:\n Intake: 968 mL\n Output: 1,100 mL\n Fluid balance: -132 mL\n Labs\n 478\n 10.0\n 103\n 0.9\n 30\n 3.7\n 29\n 107\n 145\n 32.2\n 7.8\n [image002.jpg]\n 05:15 AM\n 06:21 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n 11:34 PM\n 06:30 AM\n WBC\n 11.0\n 10.9\n 7.8\n Hgb\n 10.4\n 10.6\n 10.0\n Hct (Serum)\n 31.4\n 33.3\n 32.2\n Plt\n 521\n 523\n 478\n INR\n 7.8\n 5.3\n 2.2\n 1.4\n 1.2\n PTT\n 75.1\n 37.6\n 33.1\n 28.1\n 37.7\n 150.0\n 94.9\n Na+\n 146\n 148\n 149\n 140\n 150\n 147\n 145\n K + (Serum)\n 5.2\n 4.5\n 4.3\n 3.5\n 3.7\n 4.2\n 3.7\n K + (Whole blood)\n 4.1\n Cl\n 105\n 107\n 110\n 102\n 113\n 110\n 107\n HCO3\n 31\n 30\n 30\n 31\n 31\n 30\n 30\n BUN\n 42\n 46\n 46\n 40\n 40\n 38\n 29\n Creatinine\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n 0.9\n Glucose\n 124\n 126\n 130\n 428\n 126\n 118\n 103\n ABG: / / / 30 / Values as of 06:30 AM\n Assessment and Plan\n 72 yo M with complicated cardiac history, CAD with myopathy s/p VT and\n VF in past and ICD with multiple lead revisions, access issues p/w\n sepsis and RV coil fracture leading to ICD malfunction.\n Plan tentatively for ICD lead extraction, new lead placement on\n Thursday under GA. Procedure is high risk, and does require\n re-intubation.\n 1. ICD malfunction: Fidelis RV coil fracture\n -Tentative left sided single lead extraction (Fidelis) and new ICD lead\n placement Thursday with Dr. if family agrees to degree of\n risk, re-intubation and GA\n - NPO Wed evening. Please type and cross 4 units of PRBC for procedure\n Thurs.\n -External defibrillation needed if VT\n 2. VT:\n -No events on current amio dose\n -Continue higher pacing rate\n 3. PAF\n was on Coumadin, bridging with heparin.\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530059, "text": "Delirium / confusion\n Assessment:\n Pt remains very confused. Only occasionally pt will answer questions\n appropriately. Waxes and wanes.\n Action:\n Bed alarm on. OOB to chair this morning\n poor weight bearing\n requiring nurses for transfer. Pt incontinent large amt stool in\n chair. To Commode with no further results.\n Response:\n Pt more agitated this evening now that dobhoff tube placed\ngive me a\n knife\ncall the police\n Significant other in room with patient,\n assisting with distraction. Bilat wrist restraints on.\n Plan:\n Fall precautions, wrist restraints to prevent pt from pulling out\n dobhoff feeding tube. Bed alarms on. Bed low and locked. SR up x 4.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . external defib pads.\n Heparin gtt @ 1500units/hr.\n Action:\n Tolerating po lopressor and amio.\n Response:\n Pt remains Vpaced. Afternoon PTT WNL.\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Con\nt lopressor and amio po.\n Defibrillator at bedside.\n Dysphagia\n Assessment:\n Pt made NPO after noting delayed coughing after taking po meds in apple\n sauce.\n Action:\n Video swallow ordered after pt failed bedside speech swallow exam.\n Response:\n Pt failed video swallow. Pt made fully NPO. No ice chips. No meds in\n puree. Aspiriation precautions. Dobhoff placed at bedside, placement\n confirmed by xray\n started TF. Bilat wrist restraints placed to\n prevent pt from pulling out tube\n family aware and at bedside.\n Plan:\n Advance TF as tolerated. Bilat wrist restraints to prevent pt from\n pulling out dobhoff.\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530133, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on. Posey off. Given 50mg\n Trazodone at midnight with good effect. Closely supervise patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up x4\n and bilateral wrist restraints on. Fall risk precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530136, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on. Posey off. Given 50mg\n Trazodone at midnight with good effect. Closely supervising patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up\n x4, bed low and locked, and bilateral wrist restraints on. Fall risk\n precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . External defib pads.\n Heparin gtt @ 1500units/hr. Lung sounds diminished at bases. Chest xray\n today showed no cardiopulmonary process. Saturating 100% on RA. Urine\n output between 20-65mLs/hour. Weight loss of 8kg since admission date\n .\n Action:\n Response:\n Plan:\n Monitor PTTs. Con\nt heparin gtt. Con\nt lopressor and amio po.\n Defibrillator at bedside.\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528877, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs,\n BP on IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n given 40meq IV KCL with rapid diuresis labs sent ,\n Response:\n Excellent response to IV Lasix, PTT 85 on Heparin at 1400units/hour\n Plan:\n Cont to monitor hemodynamics, follow up with am labs, awaiting\n interrogation of ICD by EPS\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem, frequent turning,\n encouraged TCDB\n Response:\n Stable sats with less oxygen requirement\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n HOB>45 degrees, NPO, Pt. requesting tea or Coke, stating he is thirsty\n Action:\n Pills given in whole in applesauce with HOB at 90degrees,\n Response:\n Tolerated meds whole in applesauce, requires multiple mouthfuls to\n swallow pills\n Plan:\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, doesn\nt answer to month/year,\n asking for something to drink, follows simple commands, cooperative\n with care, MAE, able to lift and hold right arm, left arm lifts but\n falls back, left hand more edematous than right, moves lower\n extremities on bed constantly, family states he has restless leg\n syndrome, restless most of night, turning self frequently in bed, slept\n poorly, only in short intervals\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up\n Response:\n Confused and disoriented to place and time\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures,\n discuss with team need for sleep med\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528878, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs, BP\n 90\ns-130\ns/50-60\ns. IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n given 40meq IV KCL with rapid diuresis labs sent , cardiac meds given\n Response:\n Excellent response to IV Lasix, PTT 85 on Heparin at 1400units/hour\n Plan:\n Cont to monitor hemodynamics, follow up with am labs, awaiting\n interrogation of ICD by EPS\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem, frequent turning,\n encouraged TCDB\n Response:\n Stable sats with less oxygen requirement\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n HOB>45 degrees, NPO, Pt. requesting tea or Coke, stating he is thirsty\n Action:\n Pills given in whole in applesauce with HOB at 90degrees,\n Response:\n Tolerated meds whole in applesauce, requires multiple mouthfuls to\n swallow pills but no choking noted\n Plan:\n Aspiration precautions, Speech and swallow to reevaluate in am\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, then requesting to go to\n as he stated\nI am the Vice President of the United States\n doesn\nt answer to month/year, asking for something to drink, follows\n simple commands, cooperative with care, MAE, able to lift and hold\n right arm, left arm lifts but falls back, left hand more edematous than\n right, moves lower extremities on bed constantly, family states he has\n restless leg syndrome, restless most of night, turning self frequently\n in bed, slept poorly, only in very short intervals\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up\n Response:\n Confused and disoriented, safety maintained\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures,\n discuss with team need for sleep med\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530134, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Bilateral wrist restrains on. Posey off. Given 50mg\n Trazodone at midnight with good effect. Closely supervise patient.\n Response:\n Patient is calm, but will random sentences at times and remains\n confused.\n Plan:\n Continue to reorient and closely monitor patient. Keep side rails up x4\n and bilateral wrist restraints on. Fall risk precautions.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2141-03-19 00:00:00.000", "description": "Generic Note", "row_id": 529673, "text": "TITLE:\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 have also reviewed the housestaff notes today.\n I would add the following remarks:\n History\n Tmax < 100 past 24 hours\n Mental status continues to improve\n up in chair this AM\n Diuresis continues with improvement in his oxygenation. No additional\n V Tach after pacemaker reprogrammed.\n Medical Decision Making\n Will review with patient and family risks of possible lead extraction\n and ICD replacement currently scheduled for Thurs.\n In the interim, will maintain current euvolemia and restart daily does\n of maintenance diuretics.\n Above discussed extensively with family member, next of or health\n care proxy.\n Total time spent on patient care: 30 minutes of critical care time\n" }, { "category": "Physician ", "chartdate": "2141-03-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 529903, "text": "TITLE: PHYSICIAN INTERN PROGRESS NOTE\n Chief Complaint:\n HPI:\n 24 Hour Events:\n - Mental status dramatically improved. Allowed patient to take some PO\n with close nursing supervision. Will get formal speech and swallow\n evaluation on Monday.\n - Dr. now favoring doing lead extraction/revision on Thursday\n - did not respond to Lasix 40 mg PO, but responded well to Lasix 20 mg\n IV\n - started heparin gtt for subtherapeutic INR\n - repleted free water deficit with D5W\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Meropenem - 10:00 PM\n Infusions:\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:00 PM\n Heparin Sodium - 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.7\nC (96.3\n HR: 81 (75 - 83) bpm\n BP: 85/53(61) {84/42(50) - 157/141(144)} mmHg\n RR: 14 (10 - 22) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,514 mL\n 943 mL\n PO:\n 960 mL\n 340 mL\n TF:\n IVF:\n 1,554 mL\n 603 mL\n Blood products:\n Total out:\n 1,695 mL\n 1,100 mL\n Urine:\n 1,695 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 819 mL\n -157 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD.\n CV: RRR. Normal s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, oriented to hospital, , year. Able to state\n why he is the hospital. Stated president was\n\n. Able to recall\n historical details relevant to his area of expertise as a professor.\n Talking about being award a\nmedal\n for being a\nhero\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.6 g/dL\n 523 K/uL\n 118 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 110 mEq/L\n 147 mEq/L\n 33.3 %\n 10.9 K/uL\n [image002.jpg]\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n 05:01 PM\n 05:06 AM\n 04:37 PM\n WBC\n 8.4\n 9.1\n 11.0\n 10.9\n Hct\n 33.0\n 31.0\n 31.4\n 33.3\n Plt\n 23\n Cr\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n 1.0\n 0.9\n 0.9\n TCO2\n 31\n Glucose\n 152\n 131\n 201\n 124\n 126\n 130\n 428\n 126\n 118\n Other labs: PT / PTT / INR:15.9/150.0/1.4, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n .\n # VT/VF/ICD dysfunction: Patient had VT/VF arrest on during which\n ICD failed to defibrillate him and he required external therapy.\n Subsequently, patient has had multiple runs of VT, including one VT\n arrest which required external defibrillation. Etiology of recent\n increased ectopy thought to be fast/short sequences, pacer\n settings, and QT prolongation in setting of amiodarone. RV coil\n fractured.\n -f/u EP recs regarding need for EP procedure/ICD revision\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to second arrest, patient was satting well on 2L NC. Had increased O2\n requirement after arrest, thought to be related to aspiration\n pneumonitis, but now satting well on 2L NC. Heart failure less likely\n etiology of hypoxia.\n -aspiration precautions\n -f/u speech and swallow recs\n -wean O2 as tolerated\n -restart home dose of PO Lasix\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had marked improvement in past 2 days.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile. Previously, patient was spiking high\n fevers in spite of Tylenol, antibiotics, and improvement of pneumonia.\n This led to concern about an occult infection or non-infectious cause\n of fever. CT abd/pelvis and CT sinuses were negative. TEE showed no\n vegetation. There was one positive blood cx (coag neg staph), thought\n to be a contaminant. Patient was afebrile from , but spiked\n one fever to 101.8 thought to be related to possible aspiration\n pneumonitis in setting of recent arrest. Has been afebrile since.\n - f/u ID recs\n - f/u pending microbiological studies\n - no abx for now except chronic suppressive cefpodoxime therapy for\n history of device infection\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - restart PO Lasix at home dose\n - continue metoprolol \n .\n # Hypernatremia: Related to altered mental status/inability to take\n adequate PO.\n - replete free water deficit D5W (and orally if patient can take PO)\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient starts to eat.\n VENTRICULAR TACHYCARDIA, SUSTAINED\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 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": "2141-03-16 00:00:00.000", "description": "Attempted Repeat Bedside Swallow Evaluation", "row_id": 528980, "text": "TITLE:\nATTEMPTED REPEAT BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for reconsulting on this 71 year old man initially\nadmitted on with a week of cough productive of dark beige\nsputum x 1 week with progressive dyspnea. His respiratory failure\nprogressed, and was intubated on . Initially symptoms were\nthought to be due to CHF exacerbation with infiltrate, fever,\nwhite count consistent with PNA. Bronch on notable for\nnormal airways. Recently underwent TEE to evaluate for\nendocarditis. He was extubated on and has been asking for\nbreakfast this morning. We were consulted to evaluate oral and\npharyngeal swallow function to determine the safest diet.\nPt is known to our department from a bedside swallow eval on the\nday of admission . At that time he had no overt signs of\naspiration or other odynophagia except for difficulty chewing\nwith edentulous status. We recommended diet of regular solids\nand thin liquids with videoswallow study only if there remained\nconcern for aspiration on that diet. Pt was seen yesterday and\nhad s/sx of aspiration of thin liquids and nectar thick liquids\ntoday, however appears to tolerate small volumes of puree and\nmeds whole in puree. It was recommended he be kept primarily NPO\nwith meds whole or crushed in puree only. We returned today to\nrepeat the evaluation. RN reported pt was more awake this morning\nand tolerated meds crushed, but he continues to be confused.\nPAST MEDICAL/SURGICAL HISTORY:\n- CAD s/p Anterior wall myocardial infarction in with\nventricular tachycardia and complete heart block requiring\npacemaker\n- CHF Systolic heart failure (EF 20-25%)\n- Atrial fibrillation\n- Hypertension.\n- Hypothyroidism.\n- Anemia.\n- Irritable bowel syndrome.\n- Constipation.\n- Obesity.\n- Hearing loss, requiring bilateral hearing aids.\n- Squamous cell carcinoma of the left lower eyelid.\n- Cerebral infarct.\n- History of Whipple operation, with subsequent E. coli and\nKlebsiella bacteremia, on chronic suppression with cefpodoxime\n- History of possible C3-C4 osteomyelitis\ns/p:\n1. Placement of pacemaker and ICD.\n2. Knee surgery.\n3. Removal of squamous cell carcinoma of his left lower eyelid.\n4. Recent Whipple's procedure for which he was diagnosed with\ndysplasia.\nATTEMPTED EVALUATION:\nI met with the pt with RN and his daughter present. Pt was\nrestless in bed, pulling at sheets and lines. He was able to open\nhis eyes briefly, but was minimally participatory. I did give him\none ice chip, which he initially did not respond to but\neventually swallowed, followed by overt coughing. No further POs\nwere given.\nSUMMARY:\nMr. was too lethargic to safely trial POs and RN reports\nhe has been this lethargic all morning. I would agree with\ncurrent NPO status except for essential meds crushed with purees\nwhen fully awake. I do feel he will return to a PO diet as soon\nas he wakes up, but if he is not more awake to take POs tomorrow,\nwe will need to consider placing an NG tube for alternate\nnutrition. We will f/u tomorrow.\nRECOMMENDATIONS:\n1. Agree with NPO status, except for essential meds crushed with\npurees when fully awake.\n2. Q4 oral care.\n3. We will f/u tomorrow to repeat the evaluation.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 10:40-10:55\n Total time: 30 minutes\n 11:02\n" }, { "category": "Nursing", "chartdate": "2141-03-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530971, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated defibrillated.\n Ventricular tachycardia, sustained\n Assessment:\n Went to EP/OR for lead extraction\n new leads and generator\n placed.\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2141-03-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 531033, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 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: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering, Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2141-03-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531040, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated defibrillated.\n Ventricular tachycardia, sustained\n Assessment:\n Went to EP/OR for lead extraction\n new leads and\n generator placed. Arrived back to CCU ~ 1900, intubated for overnight\n on proofol.\n Received pt. on phenylephrine 0.9mcq/k/min. BP\n 90\ns-110/50\ns. HR 75 AV paced. BP higher with stimulation.\n Left upper chest dsg is D/I. no bleeding noted. Left arm\n in sling.\n EBL of 500cc in OR . transfused 1UPC\ns in OR in addition to\n 1.5L IVF.\n K+ 3.6\n HCT 31.9\n Heparin gtt off.\n TM 100.1 at 0330 , assoc. with BP 83/50 on neo .3mcq.\n Action:\n Tylenol x1, gave IVF bolus 500cc x2at 0345 and 0500. neo\n titrated up to 1.5mcq/k/min.\n KCL total 60meq repleted. HCT checked again at 0100\n SC heparin started.\n Vanco IV q12hr x2 doses post op. (also received one dose in OR)\n Loressor dose was held while on pressor.\n Response:\n HCT 32. u/o 30-100cc/hr.\n BP coming up to 90-100\ns/50\ns. MAP 60\ns. by 0530.\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Arrived on vent\n sats 100%. Initial ABG with PO2 >400.\n Action:\n FO2 weaned to 40%. Sats 95-97%. LS diminished bases. Suctioned for\n no to scant secretions.\n Response:\n Adequate u/o . no lasix needed. Check with team in AM regarding AM\n lasix dose (po/NG)\n Stable on CMV 550x14 5peep. 40%.\n Plan:\n Extubate today. RSBI in AM.\n Delirium / confusion\n Assessment:\n Pt. has been confused and very restless past few days, requiring\n restraints to maintain safety. Self d/c\nd feeding tube 3 x\ns in past\n week.\n Arrived to CCU on propofol 50mcq/k/min. pt. with no spontaneous\n movement.\n Extreme. Warm.\n Action:\n Propofol weaned to 10mcq.\n Response:\n Pt. starting to move all extremeties on the bed to stimulation and\n spontaneously. Periods of restlessness bordering on agitation, -\n propofol increased to 15mcq at 0430.\n Moving mouth , resisting VAP care. Opening eyes slightly to\n stimulation.\n Occas. strong cough.\n Plan:\n After extubation, maintain restraints for safety.\n GI: TF was restarted after OR at goal 45cc/hr. NPO after 0200 for\n extubation today. No stool. Last stool was guiac negative.\n" }, { "category": "Nursing", "chartdate": "2141-03-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529837, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Better day yesterday and good night tonight. He is Ox2-3, appropriate\n most of the time. Follows direction and commands. Not trying to get\n OOB but at times restless.\n Asking for water and coke.\n Action:\n Taking meds crushed with applesause well. Liquids thickened to nectar\n consistency.\n Aspiration precautions.\n Trazadone 50mg at HS\n Response:\n Slept on and off. Incontinent x2 stool- unable to tell RN he had to\n go.\n Plan:\n Safety precautions, OOB to chair 2 assist.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n S/P VT arrest x 2 this admission, last . external defib pads\n dated .\n Heparin drip at 1850/hr. PTT >150\n - total 600cc u/o response from lasix given 1800.\n - D5W x total 2L completed for elevated Na+\n Action:\n Heparin on hold x1 hour and decresed to 1500units/hr at\n 0130.\n Repeat lasix 20mg at 0230\n Po lopressor and amio as ordered.\n Monitored sat, u/o\n KCL repletion on \n IVF completed.\n Response:\n HR 70-80 Vpaced with rare PVC. BP 94-99/60\ns MAP 70\n u/o 60-80cc/hr.\n 600cc response to IV lasix x2 hours.\n positive 800cc for .\n Plan:\n Check PTT at 0700.\n Monitor lytes with diuresis.\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530130, "text": "Delirium / confusion\n Assessment:\n Patient alert and oriented x 2. He remains confused, but will\n occasionally answer questions appropriately. Will state he\nwants to\n go home and get out of here\n, but can be easily oriented back to time\n and place.\n Action:\n Frequently oriented to time and place. Bed in locked and low position,\n and alarm is on. Wrist restrains on. Given\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 528934, "text": "TITLE: Physician Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - EP recs: to come and interrogate whether there is a problem\n with the generator; timing of change of ICD and/or leads depends on\n when PICC is removed and on course of abx; if can't be done during this\n hospitalization, pt will need lifevest at d/c\n - d/c'ed coumadin; restarted heparin IV\n - d/c'ed Aline\n - Blood cx growing coag negative staph; d/c'ed vanc\n - ID says we can stop meropenem; when we stop meropenem, need to\n restart outpt cefpodoxime therapy\n - put in PT consult\n - gave 60 mg IV lasix; put out a lot of urine to that\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin Sodium - 1,400 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.7\nC (98.1\n HR: 51 (51 - 62) bpm\n BP: 122/58(73) {98/51(62) - 132/69(82)} mmHg\n RR: 18 (10 - 26) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 978 mL\n 365 mL\n PO:\n TF:\n IVF:\n 978 mL\n 365 mL\n Blood products:\n Total out:\n 1,545 mL\n 3,025 mL\n Urine:\n 1,545 mL\n 3,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -567 mL\n -2,660 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///34/\n Physical Examination\n GENERAL: Sedated, oriented x 1, does not respond to commands..\n CARDIAC: RRR. No M/G/R.\n LUNGS: Ventilated breath sounds bilaterally. No rales appreciated.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 464 K/uL\n 10.6 g/dL\n 152 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 103 mEq/L\n 145 mEq/L\n 33.0 %\n 8.4 K/uL\n [image002.jpg]\n 04:32 AM\n 05:30 PM\n 05:42 PM\n 02:51 AM\n 11:40 AM\n 03:25 PM\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n WBC\n 9.2\n 9.3\n 8.4\n Hct\n 30.4\n 31.8\n 33.0\n Plt\n 371\n 468\n 464\n Cr\n 1.2\n 0.9\n 0.7\n 0.7\n 0.8\n TCO2\n 37\n 37\n 37\n 39\n 42\n Glucose\n 164\n 130\n 198\n 151\n 137\n 122\n 152\n Other labs: PT / PTT / INR:30.7/48.8/3.1, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # Fever/Pneumonia: Now afebrile x 48 hours. Previously, patient was\n spiking high fevers in spite of Tylenol, antibiotics, and improvement\n of pneumonia. This led to concern about an occult infection or\n non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue meropenem/vanc\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Hypoxemic respiratory failure: Now s/p extubation. Was intubated on\n for hypoxemic respiratory failure. Etiology likely pneumonia\n + heart failure.\n - f/u pending cultures\n - treat pneumonia as above\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - lasix boluses for goal I/O negative 1 L\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin. His INR is currently near therapeutic. Telemetry currently\n showing v-paced rhythm.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # s/p ICD: high impedance. LV lead dysfunction. Of note, ICD did not\n shock patient during VT/VF arrest.\n -f/u EP recs\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: Pulled NG tube yesterday. Will under repeat speech and\n swallow evaluation tomorrow, as mental status is rapidly improving.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2141-03-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 531192, "text": "Chief Complaint: Dyspnea\n Worsened CHF\n VT/VF, found to have fractured ICD lead\n 24 Hour Events:\n CARDIAC CATH - At 02:20 PM\n To EPS.\n INVASIVE VENTILATION - START 03:00 PM\n ARTERIAL LINE - START 04:00 PM\n \n - two lead extractions (R ventricular and R atrial) and ICD implant\n without complications\n - returned to floor intubated on propofol\n - hematocrit was stable despite reported blood loss of 450 ccs\n - plan for extubation on \n - Blood pressure post-procedure 80/51 at 03:30, so gave 500 cc back,\n then another 500 cc\n - No pulsus physiology on arterial line wave-form\n EP recs\n - Start Coumadin today\n - Start IV heparin to bridge 24 hrs after procedure\n - Heparin 5000 U SC until IV starts\n - Make today d1 of cefpodoxime for 7 days post-procedure\n - Received 1.5 L fluid plus one unit blood in OR (lost about 1\n unit blood)\n Somewhat hypotensive overnight\n improved when propofol stopped.\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 01:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 75 (75 - 84) bpm\n BP: 105/61(76) {71/46(55) - 107/67(82)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Wgt (current): 96.8 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 2,439 mL\n 1,667 mL\n PO:\n TF:\n 205 mL\n 90 mL\n IVF:\n 2,054 mL\n 1,477 mL\n Blood products:\n Total out:\n 1,945 mL\n 320 mL\n Urine:\n 1,295 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 494 mL\n 1,347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 564 (553 - 564) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 13 cmH2O\n Plateau: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/41/182/23/0\n Ve: 11.1 L/min\n PaO2 / FiO2: 455\n Physical Examination\n GEN: NAD.\n CV: RRR (occasional premature beats) Soft s1 and s2. No M/G/R.\n Chest: CTAB.\n Abd: +BS. Soft. NT/ND.\n Ext: WWP. No edema.\n Neuro: Alert, orientation waxing and . AOx1, says he\ns in \n and has no idea of the date says it\ns the 18^th. Was reoriented.\n Labs / Radiology\n 315 K/uL\n 9.8 g/dL\n 171\n 0.8 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 110 mEq/L\n 138 mEq/L\n 31.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:31 PM\n 03:35 AM\n 05:05 AM\n 03:38 AM\n 07:23 PM\n 07:40 PM\n 12:52 AM\n 05:15 AM\n 05:25 AM\n 06:00 AM\n WBC\n 6.2\n 5.5\n 5.8\n 9.5\n Hct\n 31.8\n 32.5\n 32.2\n 31.9\n 32.4\n 31.6\n Plt\n 448\n 424\n 407\n 315\n Cr\n 0.9\n 0.9\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 28\n 26\n Glucose\n 108\n 122\n 120\n 100\n 88\n 193\n 171\n Other labs: PT / PTT / INR:13.9/29.1/1.2, CK / CKMB /\n Troponin-T:187/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.0 g/dL, LDH:360 IU/L, Ca++:7.7 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR - wet read\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly\n clear.\n heart remains enlarged. ? fullness of left hilum.\n Microbiology: No new.\n ECG: .\n Assessment\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation but\n subsequently attributed to pneumonia in setting of infiltrate, fever,\n white count. Hospital course complicated by high fevers, ICD\n malfunction, VT/VF arrest requiring debrillation and reintubation, and\n runs of VT, including one VT arrest.\n Plan\n # VT/VF/ICD dysfunction: S/p successful fractured lead removal and now\n new functional ICD lead placement.\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Subsequently,\n patient has had multiple runs of VT, including one VT arrest which\n required external defibrillation. Etiology of recent increased ectopy\n thought to be fast/short sequences, pacer settings, and QT\n prolongation in setting of amiodarone. RV coil was found to be\n fractured.\n -restart Coumadin\n -heparin SC BID then IV 24hrs after procedure\n -cefpodoxime for one week from today\n -f/u EP recs, appreciate their input\n -continue current amiodarone dose 200mg daily, metoprolol 25mg \n -monitor QTC on EKG\n .\n # Intubation: Pt intubed from procedure.\n - Extubate today, stop sedation prior, then afterward try to wean\n pressor\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure.\n Currently resolving, was on room air, but drifts down to high 80s while\n sleeping, possibly related to undiagnosed OSA. Got some 2L or so of\n fluid yesterday.\n -Wean O2 as tolerated\n -aspiration precautions\n -NPO per speech and swallow\n -Consider surgery consult for PEG once pacer issue is resolved\n -wean O2 as tolerated\n - Judge whether further Lasix required\n good output beginning to 20 mg\n IV earlier this a.m.\n - F/u Is/Os\n -no abx for now (except cefpodoxime, which patient takes chronically as\n outpt) as patient was felt to have aspiration pneumonitis rather than\n true pneumonia and ABX course completed for PNA.\n .\n # Hypotension: Most likely propofol as has improved after weaning\n down propofol.\n -Monitor\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits. Pt has had overall marked improvement in past 2\n days. U/A negative. Abx course for PNA complete. Failed videoswallow so\n NPO for now.\n - continue to follow clinically\n - minimize sedating medications\n - Consider neuropsychological outpatient follow-up\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Currently\n euvolemic.\n - continue PO Lasix at home dose when possible\n - f/u Is/Os\n - continue metoprolol \n .\n # Hypernatremia: Normalized.\n .\n # Elevated CK: Likely caused by statin (possibly exacerbated by\n concurrent azithromycin therapy). CK normalized.\n - holding statin for now\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: Was on tube feeds and did trial of PO as mental status\n improving. However, there was concern for aspiration so speech and\n swallow consulted\n - Strict NPO except meds for now\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation once patient has NGT again.\n # Dysphagia\n Failed video swallow.\n - NPO and consider GI to help with bridled NGT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 10:23 AM\n Arterial Line - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Full\n code, but was DNR in context of surgery.\n Code status: Full code\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 have also reviewed the note by Dr. today.\n I would add the following remarks:\n History\n Stable following EPS laser removal of pacer leads yesterday\n new\n pacemaker defibrillator placed without complications.\n Medical Decision Making\n Will maintain in ICU one additional day\n IV Heparin bridge to coumadin\n Total time spent on patient care: 30 minutes of critical care time\n ------ Protected Section Addendum Entered By: , MD\n on: 15:48 ------\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528869, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs,\n BP on IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n given 40meq IV KCL with rapid diuresis labs sent ,\n Response:\n Excellent response to IV Lasix, PTT 85 on Heparin at 1400units/hour\n Plan:\n Cont to monitor hemodynamics, follow up with am labs, awaiting\n interrogation of ICD by EPS\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem, frequent turning,\n encouraged TCDB\n Response:\n Stable sats with less oxygen requirement\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, doesn\nt answer to month/year,\n asking for something to drink, follows simple commands, cooperative\n with care, MAE, able to lift and hold right arm, left arm lifts but\n falls back, left hand more edematous than right, moves lower\n extremities on bed constantly, family states he has restless leg\n syndrome, restless most of night, turning self frequently in bed, slept\n poorly, only in short intervals\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up\n Response:\n Confused and disoriented to place and time\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures,\n discuss with team need for sleep med\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528870, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs,\n BP on IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n given 40meq IV KCL with rapid diuresis labs sent ,\n Response:\n Excellent response to IV Lasix, PTT 85 on Heparin at 1400units/hour\n Plan:\n Cont to monitor hemodynamics, follow up with am labs, awaiting\n interrogation of ICD by EPS\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem, frequent turning,\n encouraged TCDB\n Response:\n Stable sats with less oxygen requirement\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, doesn\nt answer to month/year,\n asking for something to drink, follows simple commands, cooperative\n with care, MAE, able to lift and hold right arm, left arm lifts but\n falls back, left hand more edematous than right, moves lower\n extremities on bed constantly, family states he has restless leg\n syndrome, restless most of night, turning self frequently in bed, slept\n poorly, only in short intervals\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up\n Response:\n Confused and disoriented to place and time\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures,\n discuss with team need for sleep med\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528927, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, freq. PVCs, BP\n 90\ns-130\ns/50-60\ns. IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n given 40meq IV KCL with rapid diuresis labs sent , cardiac meds given\n Response:\n Excellent response to IV Lasix, PTT 85 on Heparin at 1400units/hour,\n freq vea but no runs\n Plan:\n Cont to monitor hemodynamics, follow up with am labs, awaiting\n interrogation of ICD by EPS\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem, frequent turning,\n encouraged TCDB\n Response:\n Stable sats with less oxygen requirement , remains afebrile\n Plan:\n Cont to monitor, monitor temp off IV Vanco, follow up with cultures pnd\n Dysphagia\n Assessment:\n HOB>45 degrees, NPO, Pt. requesting tea or Coke, stating he is thirsty\n Action:\n Pills given in whole in applesauce with HOB at 90degrees, given 80% of\n usual dose Glargine at 2200, no regular insulin required\n Response:\n Tolerated meds whole in applesauce, requires multiple mouthfuls to\n swallow pills but no choking noted\n Plan:\n Aspiration precautions, Speech and swallow to reevaluate in am\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, then requesting to go to\n as he stated\nI am the Vice President of the United\n States\n, doesn\nt answer to month/year, asking for something to drink,\n follows simple commands, cooperative with care, MAE, able to lift and\n hold right arm, left arm lifts but falls back, left hand more edematous\n than right, moves lower extremities on bed constantly, family states he\n has restless leg syndrome, restless most of night, turning self\n frequently in bed, slept poorly, only in very brief intervals\n Action:\n Frequent observation and orientation, safety measures in place, bed\n alarms on, side rails up\n Response:\n Confused and disoriented, safety maintained\n Plan:\n Cont to monitor neuro status, frequent reorientation, safety measures,\n discuss with team need for sleep\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530124, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-15 00:00:00.000", "description": "EP Consult", "row_id": 528804, "text": "TITLE:\n DIVISION OF CARDIOLOGY\n COMPREHENSIVE CONSULTATION NOTE\n CHIEF COMPLAINT: Patient is seen in consultation today at the request\n of Dr. . We are asked to give consultative advice regarding\n evaluation and management of cardiac device malfunction.\n HISTORY OF PRESENT ILLNESS:\n 72 y/o man with past medical history significant for systolic HF (EF\n 20-25%), old anterior wall MI, paroxysmal AV block, atrial\n fibrillation, ventricular tachycardia, history of ventricular\n fibrillation, status-post BiV ICD implantation with subsequent\n revisions due to the presence of malfunctioning Fidelis lead, who\n presented to the ED on with a chief complaint of dyspnea,\n productive cough, and fever. He was pan-cultured and placed on broad\n spectrum antibiotics prior to CCU admission.\n While in the CCU he was persistently febrile from , a TEE was\n performed on and did not show vegetations. He is being treated\n with broad spectrum antibiotics and defeveresced on . Blood\n culture from are now growing GPCs in clusters and pairs, though\n all other cultures are no growth to date, and a source of his fever has\n not been identified. On he had an episode of VF, he was ATP'd but\n did not break, ICD did not fire, he returned to sinus following 1\n external shock. He had a central line in place from -> , and\n currently has a PICC line.\n PAST MEDICAL HISTORY:\n -Hypertension.\n -Hypothyroidism.\n -Anemia.\n -Irritable bowel syndrome.\n -Constipation.\n -Obesity.\n -Hearing loss, requiring bilateral hearing aids.\n -Squamous cell carcinoma of the left lower eyelid.\n -Vitamin D deficiency.\n -Cerebral infarct.\n -Falls.\n -Compression fractures.\n -History of Whipple operation, with subsequent E. coli and Klebsiella\n bacteremia\n -History of possible C3-C4 osteomyelitis\n HOME MEDICATIONS:\n -ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - 81 mg\n Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day\n -AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a\n day\n -FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1\n Tablet(s) by mouth Tues//Sat/Sun and 1.2 tabs (60mg) on M/W/F\n -SIMVASTATIN [ZOCOR] - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a\n day\n -CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily\n -LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by mouth\n once a day\n -LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-,000\n unit-,000 unit Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by\n mouth 3x/day\n -METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth\n once a day\n -NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth \n times/day swish in mouth and swallow\n -PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg\n Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth DAILY\n -PAROXETINE HCL [PAXIL] - 30 mg Tablet - 1 (One) Tablet(s) by mouth\n once a day\n -TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime Start with\n pill. increase to 1 pill if needed; may increase to total of 2\n pills as needed\n -WARFARIN - 1 mg Tablet - 1 (One)-3 Tablet(s) by mouth as directed by\n MD\n -ACETAMINOPHEN - (OTC) - Dosage uncertain\n -ASCORBIC ACID - (Prescribed by Other Provider) - 250 mg Tablet - 1\n Tablet(s) by mouth daily\n -FERROUS SULFATE [SLOW FE] - 142 mg (45 mg Iron) Tablet Sustained\n Release - 1 (One) Tablet(s) by mouth every other day\n -LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (OTC) - Dosage uncertain\n -MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1\n (One) Tablet(s) by mouth once a day\n CURRENT MEDICATIONS:\n Aspirin 81 mg PO/NG DAILY @ 1417\n Amiodarone 100 mg PO/NG DAILY @ 1417\n Senna 1 TAB PO/NG :PRN constipation @ 1247\n Levothyroxine Sodium 50 mcg PO/NG DAILY @ 1417\n Nystatin Oral Suspension 5 mL PO QID:PRN thrush @ 1417\n Paroxetine 30 mg PO/NG DAILY @ 1417\n traZODONE 50 mg PO/NG HS:PRN insomnia @ 1417\n MED Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL @\n 2100\n Albuterol Inhaler PUFF IH Q4H:PRN wheezing @ 2100\n Ipratropium Bromide MDI PUFF IH Q4H:PRN wheezing @ 2100\n Lansoprazole Oral Disintegrating Tab 30 mg PO/NG @ 0759\n Docusate Sodium 100 mg PO/NG Start: @ 0816\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol @ 0957\n Acetaminophen 325-650 mg NG/PR Q6H:PRN fever, pain please do not exceed\n 3000mg/day @ 0034\n MED Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose\n @ 1352\n Metoprolol Tartrate 12.5 mg PO/NG Hold for SBP<100.\n Meropenem 1000 mg IV Q8H @ 1641\n Ibuprofen Suspension 800 mg PO/NG Q8H:PRN fever @ 1817\n Vancomycin 1250 mg IV Q 12H @ 1038\n Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses\n Hold for K > @ 1505\n MED Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses\n Hold for K >5 @ 1830\n Potassium Chloride 20 mEq / 50 ml SW IV ONCE Duration: 1 Doses @\n 1830\n Neutra-Phos 2 PKT PO/NG ONCE Duration: 1 Doses @ 2103\n Potassium Chloride 20 mEq PO ONCE Duration: 1 Doses\n Hold for K > @ 0908\n Heparin IV Sliding Scale\n ALLERGIES: Penicillins, Ambien\n SOCIAL HISTORY: Divorced, 2 children. Former pipe and cigarette smoker\n (quit in ). Used to smoke 1ppd X 30 yrs. Drinks glasses of\n wine/day. No illicit drugs.\n FAMILY HISTORY: Strong family history of vascular disease with father\n deceased of CVA at 59, Mother with MI at 70, Brother with MI and CABG\n in 50's. Also reports a family history of diabetes.\n REVIEW OF SYSTEMS:\n Constitutional: No fevers, chills, nightsweats, unintentional weight\n change, or fatigue.\n Eyes: No blurry vision, double vision, or loss of vision.\n ENT: No bleeding from the nose or gums, nasal drainage or discharge,\n dry mouth, or oral ulcers.\n Heme/Lymph: No recurrent infections, easy bleeding or bruising, history\n of DVT, or history of anemia.\n Respiratory: No hemoptysis, wheezing, cough, or shortness of breath.\n Gastrointestinal: No abdominal pain, diarrhea, constipation,\n hematochezia, melena, nausea, vomiting.\n Integumentary: No rashes, petechiae, ecchymoses, or ulcers.\n Allergic/Immunology: No allergies or immunosuppression.\n Psychiatric: No suicidal ideation, delusions, hallucinations,\n depression, or sleep disorder.\n Genitourinary: No dysuria, hematuria, dark urine, cloudy urine, or\n history of UTIs.\n Neurological: No numbness, tingling, loss of sensation, weakness,\n headache, or abnormal movements.\n Musculoskeletal: No joint swelling, myalgias, or arthralgias.\n Endocrine: No history of thyroid disease, excessive sweating, dry skin\n or hair, hot, or cold intolerance.\n Pain: 0/10(( Scale = 0 (none) to 10 (severe))\n ALL OTHER SYSTEMS NEGATIVE EXCEPT AS NOTED ABOVE\n PHYSICAL EXAMINATION\n Vitals: T: 99.3 degrees Fahrenheit, BP: 116/45 mmHg supine, HR 53 bpm,\n RR 10 bpm, O2: 95% on NC.\n Gen: Pleasant, ill appearing man, confused, does not respond\n appropriately to questions.\n Eyes: +conjunctival pallor. No icterus.\n ENT: MM dry. OP clear.\n CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th\n intercostal space, mid clavicular line. RRR. nl S1, S2. II/VI\n holosystolic murmur at apex-> axilla, No rubs, clicks, or gallops. Full\n distal pulses bilaterally. No femoral bruits.\n LUNGS: Coarse breath sounds, poor effort.\n ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by\n palpation. No abdominal bruits.\n Heme/Lymph/Immune: Trace pedal edema. No CC, no cervicall\n ymphadenopathy.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&O to self. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Mood and affect were appropriate.\n TELEMETRY: v paced\n ECG: v paced\n TEE :\n No atrial septal defect is seen by 2D or color Doppler. There is\n moderate to severe regional left ventricular systolic dysfunction with\n septal, inferoseptal and inferior hypokinesis. There are complex (>4mm)\n atheroma in the descending thoracic aorta. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion. No masses\n or vegetations are seen on the aortic valve. No aortic regurgitation is\n seen. No mass or vegetation is seen on the mitral valve. Moderate to\n severe (3+) mitral regurgitation is seen. Moderate to severe [2+]\n tricuspid regurgitation is seen. There is at least mild pulmonary\n artery systolic hypertension. No vegetation/mass is seen on the\n pulmonic valve. There is no pericardial effusion.\n IMPRESSION: No vegetations seen on the pacemaker/ICD leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta.\n CARDIAC CATHETERIZATION :Coronary angiography of this right\n dominant system revealed single branch vessel coronary artery disease.\n The left main coronary artery revealed minimal distal luminal\n irregularities. The LAD had 30% stenoses before and after the D1. The\n LCX had no angiographically apparent flow limiting coronary artery\n disease. The RCA had a 70% ostial PDA stenosis with no other\n significant disease.\n OTHER TESTING:\n LABORATORY DATA:\n 143 104 30 10.4\n ---|-------|------<122 9.3 >------< 468\n 3.8 34 0.7 31.8\n PT 19.5 PTT 29.4 INR 1.8\n ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY\n ROUNDS:\n 72 y/o man with past medical history significant for systolic HF (EF\n 20-25%), old anterior wall MI, paroxysmal AV block, atrial\n fibrillation, ventricular tachycardia, ventricular fibrillation,\n status-post BiV ICD implantation with subsequent revisions due to the\n presence of malfunctioning Fidelis lead, admitted with dyspnea, cough,\n and persistent fevers which have now broken. TEE negative for\n vegetations, and only one set of blood cultures positive- waiting on\n speciation. Patient with recent history of VF, and malfunctioning ICD\n which will need to be replaced, though also with unclear source of\n fever, recently defeveresced.\n RECS:\n -Case d/w Dr. (ot's primary cardiologist). \n device rep to come and interrogate device to see if generator is\n playing a role in the multiple lead malfunctions, rather than three\n separate lead malfunctions.\n -Current leads may need to be removed to insert a new device, timing of\n this intervention will depend on when PICC line is removed and ID\n service recommendations regarding duration of therapy with IV\n antibiotics.\n -If patient unable to have definitive new device placed during this\n hospitalization b/c of infectious concerns, he will need to leave with\n a lifevest for secondary prevention of VF.\n This patient was seen, discussed and evaluated with Dr. .\n Please see his note in the inpatient medical record/OMR/Metavision for\n additional comments.\n" }, { "category": "Nursing", "chartdate": "2141-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528805, "text": "71 year old male with pmx significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of recent whipple\n procedure. Pt also is also being treated w/ antibiotics (chronic) for\n aicd lead infections. He was admitted to ccu with sob/dyspnea/\n orthopnea, increased weight gain (4lb in 2 days), chf exacerbation (BNP\n 3000) & pna.\n Pt initially treated w/ abx and bipap, however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and ivf bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. diuresis was\n started . NOTE: LV lead not pacing, only RV (). PMR\n programmed to DDD. CT head, chest, & pelvis-without noted\n infectious process.\n vf arrest requiring cpr & external defib X1.\n TEE: No vegetations seen on the pacemaker/icd leads (at least 4\n wires identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n HCP: significant other , 2 daughter\n and live out of\n state. and updated by Dr. today. \n following closely to help support .\n Pneumonia, Bacterial, Community Acquired (CAP)\n Assessment:\n Received on 50% shovel mask, with sats >95% when mask on, desatting to\n 88% when he removed mask. Lungs with crackles L base, bronchial at L\n base, few rhonchi.\n Action:\n * Rare, strong cough\n thick brown sputum (like a small ball). Dr.\n notified\n * O2 weaned to 2 L NP maintaining sats\n * Turned s\nS, enc to c & db, he is not cognitively ready for inc\n .\n * OOB to stretcher chair.\n Response:\n Maintained saturations throughout the day on L np.\n Plan:\n Continue to wean O2 as able. Enc c& db. When able, begin inc .\n OOB to C.\n Heart Failure (CHF)/VT\n Assessment:\n Remains V paced, rate 50\ns, underlying rhythm AF. Rare to occ PVC.\n SBP 106-132. A-line d/c\n Action/Response:\n * Monitored u/o. No diuretic so far today and is 650 cc\ns negative.\n Goal for today is 1L negative.\n * Coumadin on hold pending EP\ns recs re: ICD replacement.\n * IV heparin gtt begun, 1400 unit/hour\n * K 3.8\n20 meq po.\n * Hands off defib pads in place, pads changed today.\n Plan:\n Monitor I/O, daily weights. Follow BP. Monitor HR/Rhythm. Awaiting\n \ns Interrogation of pacemaker for plan of care. PTT due at\n 2200\n Delirium\n Assessment:\n Oriented x1 only\nself and family. At times thought he was in a Hotel\n Action:\n * Bed low/locked position\n * Frequent re-orientation, family at bedside.\n * Hearing aides in, glasses on\n * A-line removed.\n Response:\n Remains oriented x1 only. He is cooperative with care.\n Plan:\n Continue present management. Frequent reorientation. Appropriate safety\n measures. Glasses and bilateral hearing aides on during day. Attempt\n to establish day/night sleep cycle. Blinds open during day. Minimize\n lines.\n Dysphagia\n Assessment:\n Pulled out his NGT at the end of night shift. Speech and swallow in to\n evaluate patient. Coughing with thin liqs and nectar thick. Able to\n swallow pills whole with applesauce without difficulty\n Action:\n * Plan of care discussed with S&S re: ? to replace NGT or whether\n this would slow down his swallow recovery process. They recommend\n keeping NGT out today. Give pills whole in applesauce, but no\n other po\ns. They will re-evaluate patient in 24 hours as they\n anticipate his swallow to come back as he was able to have regular\n diet pre-intubation.\n * HOB ^ 90 degrees with po\n Response:\n Able to swallow pills in applesauce without coughing or throat clearin\n Plan:\n Continue with aspiration precautions. S&S re-eval in am.\n" }, { "category": "Nursing", "chartdate": "2141-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 528864, "text": "Heart failure (CHF), Systolic, Acute\n Assessment:\n Hemodynamically stable with HR 50\ns vpaced, occ. PVCs,\n BP on IV Heparin at 1400units/hour\n Action:\n Given 60mg IV Lasix at 2330 secondary to I/O only 500cc neg. for day,\n labs sent\n Response:\n Excellent response to IV Lasix, PTT 85\n Plan:\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Oxygenating well on 2L n/c with sats 95-98%, lungs with fine bibasilar\n rales, scattered rhonchi, afebrile\n Action:\n Monitored sats, IV Vanco dc\nd, conts on IV Meropenem\n Response:\n Stable sats with less oxygen\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Orientedx1 only, states he is in a hotel, doesn\nt answer to month/year,\n asking for something to drink, follows simple commands, cooperative\n with care, MAE, able to lift and hold right arm, left arm lifts but\n falls back, left hand more edematous than right, moves lower\n extremities on bed constantly, family states he has restless leg\n syndrome\n Action:\n Frequent observation and orientation\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529409, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by ATP ?\n pacer set at higher rate of 75 -100 A to avoid fast-slow-fast sequences\n that may have precipitated episode of ventricular tachycardia (note in\n chart). ATP were added in a FVT zone of 260-300 and ? DVT zone\n 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 529549, "text": "71 year old male with pmh significant for systolic hf (ef 20-25%), MI\n \n, dysrhythmias (paroxysmal av block, af, & vt/vf)-s/p icd\n implantation and ? TIA. Surgical hx significant of whipple procedure.\n Pt also is also being treated w/ antibiotics (chronic) for AICD lead\n infections. He was admitted to CCU with sob/dyspnea/ orthopnea,\n increased weight gain (4lb in 2 days), CHF exacerbation (BNP 3000) &\n PNA. Initially treated w/ abx and bipap however, pt required intubation\n d/t hypoxemic resp failure. Post intubation, pt required pressors\n and IVF bolus. CT shows bilat lL infiltrates w/ pleural\n effusions. Pt has been receiving antibiotics since admit. Diuresis was\n started . CT head, chest, & pelvis-without noted infectious\n process. VF arrest requiring cpr & external defib X1. TEE:\n No vegetations seen on the pacemaker/icd leads (at least 4 wires\n identified in the right atrium) or on the valves. Depressed left\n ventricular systolic function. Moderate to severe mitral regurgitation.\n At least mild pulmonary hypertension. Complex atheroma in descending\n aorta. Extubated after tee.\n another episode VT- rate 200, pt unresponsive, diaphoretic, defib\n x 1 back to paced rhythm Brief CPR x 30 seconds. Pacer interrogated and\n rate increased to 70 as pt VT was attributed to slow HR and prolonged\n QT .\n NOTE: LV lead not pacing, only RV (). PMR programmed to DDD.\n Device may not be able to detect VT/VF. Pt will have to be Externally\n defibrillated.\n Delirium / confusion\n Assessment:\n Patient is alert, oriented x 1 only. Rec\nd w/ bilat soft wrist\n restraints and posey belt in place. Stating\nI need to see the\n president of Denmarkl\n. When asked where he was he stated\n\n or\n\n, but will sometimes say the hospital. Continuously\n restless and moving legs and arms all over and off to the side of the\n bed. Oxygen mask and NC frequently removed due patient shifting all\n over bed.\n PICC dsg non-occlusive-> dsg changed when pt calm and pt suddenly\n agitated, pulling out PICC line inches. CCU team and IV team\n alerted. OK to use as a midline- signage changed at bedside.\n Pt w/ sudden increase in agitation after AM care- kicking legs over\n side rail, swearing at staff and his family.\n Action:\n *Continuous reorienting. Side rails up x 4. Bilateral wrist restraints\n maintained when alone, but removed when family /RN at bedside. Posey\n restraint removed. Bed alarm activated, close supervision, bed locked\n and low. *Frequent repositioning. Tubing/lines concealed.\n *OOB->chair w/ chair alarm in place and family at bedside.\n Response:\n Patient remains confused, oriented x1, and restless. Pt does seem to\n calm down after repositioning when more comfortable in bed. Pt calm\n while OOB to chair.\n Plan:\n Continue to monitor mental status/ safety. Frequent re-orientation.\n Reassess need for restraints for safety, currently off since 1400.\n Trazadone at bedtime for sleep (home regimen).\n Ventricular tachycardia, sustained\n Assessment:\n S/P VT arrest x 2 this admission, last . HR 70s-80s V-paced, no\n ectopy noted; no runs VT since PCM settings changed->PCM set DDD @ 70.\n As noted above, pt w/ fractured LV lead on ICD. K= 4.3/ magnesium 2.6/\n Na elevated at 149. INR 2.2 (had been on Coumadin).\n Action:\n Monitored HR and rhythm. Pt being followed by EP team. External defib\n pads on . Med mgt w/ PO lopressor and PO Amiodarone. IVF D5W at\n 100ml/hr x one liter for hypernatremia.\n Response:\n PM lytes-> Na improved to 140, K down 3.5.\n Plan:\n Continue to monitor HR and rhythm. Will need external defibrillation in\n the event of further VT. Possible lead removal and/or VT ablation next\n week, awaiting further imput from EP.\n Heart failure (CHF), Systolic, Acute\n Assessment:\n LS: rales at bases. SPO2 100% on highflow neb mask as 95% and 5LNC. RR\n 20s. Trace LE edema. HR 70s V-paced. BP 110s-120s/70s. UOP~ 60ml/hr.\n Action:\n *20mg IV lasix x one for goal diuresis neg 1 liter\n *Weaned O2 as noted below.\n Response:\n Negative 700ml at 1900.\n Plan:\n Continue to monitor fluid/volume status. Wean O2 as able.\n Pneumonia, Aspiration/ Bacterial/ FEVERS\n Assessment:\n Patient rec\nd on 5L n/c and high flow neb FiO2 95%. Lungs with lower\n bilateral crackles. Last Temp spike 20:00- pan cultured. Likely\n r/t aspiration pneumonitis that occurred during time of VT arrest. T\n max today 99.8 PR. Pt w/ rare, non-productive cough. WBC 11.\n Action:\n Weaned O2 to 5LNC. Resumed pt\ns home dose of PO cefpodoxime Q 12 hrs.\n Tylenol PRN. Trended Temp/ WBC. Encouraged C&DB. OOB->chair x 4 hrs.\n Followed by ID team.\n Response:\n Afebrile this shift. No sputum production noted.\n Plan:\n Cont to monitor respiratory status and temp. Follow up with urine and\n blood cultures. Tylenol PRN.\n" }, { "category": "Nursing", "chartdate": "2141-03-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530121, "text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Systolic, Acute\n Assessment:\n Action:\n Response:\n Plan:\n Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529412, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by ATP ?\n pacer set at higher rate of 75 -100 A to avoid fast-slow-fast sequences\n that may have precipitated episode of ventricular tachycardia (note in\n chart). ATP were added in a FVT zone of 260-300 and ? DVT zone\n 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE\n Episodes of pulseless VT yesterday requiring defibrillation and CPR.\n Amio reduced for concern re prolonged QT.\n Continues intermittently confused but conversant.\n Medical Decision Making\n Plan to add Lido if becomes more unstable.\n EP procedure Mon with ? ablation, ? lead extraction.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529414, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by ATP ?\n pacer set at higher rate of 75 -100 A to avoid fast-slow-fast sequences\n that may have precipitated episode of ventricular tachycardia (note in\n chart). ATP were added in a FVT zone of 260-300 and ? DVT zone\n 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE.\n 72 yo M with CAD, infarct related cardiomyopathy, h/o VT s/p ICD with\n multiple leads due to revision p/w sepsis, now hemodynamically improved\n with RV coil fracture and non-functioning device and VT storm.\n 1. VT:\n -Agree with IV amio load, lidocaine can be added if incessant VT\n -Increase Metoprolol to 25 \n -If continues, will consider ablation next week\n 2. RV coil fracture on Fidelis lead:\n -External defibrillation necessary, ICD unable to deliver therapy\n -Will d/w Dr. re: lead extraction/revision possibilities for\n next week.\n .\n Episodes of pulseless VT yesterday requiring defibrillation and CPR.\n Amio reduced for concern re prolonged QT.\n Continues intermittently confused but conversant.\n .\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # s/p VT/VF arrest/ICD dysfunction: Patient had VT/VF arrest on \n during which ICD failed to defibrillate him and he required external\n therapy. Patient had multiple runs of VT, including second VT arrest\n last night requiring defibrillation. Etiology of recently increased\n ectopy is unclear.\n -f/u EP recs\n - pads in place\n -if develops VT, will need external therapy as ICD is not functioning\n -decrease amiodarone to 200 mg daily due to concern about prolonged QT\n -increase metoprolol to 25 mg \n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to last night\ns VT arrest, patient was satting well on 2L NC. Has had\n increased O2 requirement since, possibly related to aspiration or\n worsening heart failure.\n -aspiration precautions\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue cefpodoxime\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 1 L today\n .\n # Coagulopathy: INR markedly elevated today. Likely related to\n amiodarone.\n -continue to hold Coumadin\n -vitamin K 2 mg PO once\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529415, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by ATP ?\n pacer set at higher rate of 75 -100 A to avoid fast-slow-fast sequences\n that may have precipitated episode of ventricular tachycardia (note in\n chart). ATP were added in a FVT zone of 260-300 and ? DVT zone\n 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n GENERAL: Oriented x 0-1. Does not respond to\n commands\n CARDIAC: RRR. II/VI HSM at apex.\n LUNGS: Diffuse rales.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE.\n 72 yo M with CAD, infarct related cardiomyopathy, h/o VT s/p ICD with\n multiple leads due to revision p/w sepsis, now hemodynamically improved\n with RV coil fracture and non-functioning device and VT storm.\n 1. VT:\n -Agree with IV amio load, lidocaine can be added if incessant VT\n -Increase Metoprolol to 25 \n -If continues, will consider ablation next week\n 2. RV coil fracture on Fidelis lead:\n -External defibrillation necessary, ICD unable to deliver therapy\n -Will d/w Dr. re: lead extraction/revision possibilities for\n next week.\n .\n Episodes of pulseless VT yesterday requiring defibrillation and CPR.\n Amio reduced for concern re prolonged QT.\n Continues intermittently confused but conversant.\n .\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA.\n .\n # s/p VT/VF arrest/ICD dysfunction: Patient had VT/VF arrest on \n during which ICD failed to defibrillate him and he required external\n therapy. Patient had multiple runs of VT, including second VT arrest\n last night requiring defibrillation. Etiology of recently increased\n ectopy is unclear.\n -f/u EP recs\n - pads in place\n -if develops VT, will need external therapy as ICD is not functioning\n -decrease amiodarone to 200 mg daily due to concern about prolonged QT\n -increase metoprolol to 25 mg \n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to last night\ns VT arrest, patient was satting well on 2L NC. Has had\n increased O2 requirement since, possibly related to aspiration or\n worsening heart failure.\n -aspiration precautions\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue cefpodoxime\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 1 L today\n .\n # Coagulopathy: INR markedly elevated today. Likely related to\n amiodarone.\n -continue to hold Coumadin\n -vitamin K 2 mg PO once\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2141-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 529426, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.8\nF - 07:00 PM\n -Spiked temp to 101.8 at around 10 PM; had been afebrile all day. Vital\n signs otherwise stable, although patient somewhat agitated.\n Pancultured. Patient given one-time dose of meropenem -- ?aspiration\n pneumonitis versus pneumonia. CXR ordered for AM rounds.\n -Cr and BUN bumped, have maxed his diuresis.= -ve 600 by 7:30pm.\n -amiodorone decreased, metoprolol increased per EP recs\n -per Dr. ,vt initiated by long short sequences, lower rate\n limit of pacing was too low,VT could have been terminated by ATP ?\n pacer set at higher rate of 75 -100 A to avoid fast-slow-fast sequences\n that may have precipitated episode of ventricular tachycardia (note in\n chart). ATP were added in a FVT zone of 260-300 and ? DVT zone\n 300-400./\n -per speech and swallow, keep NPO except meds. Aspiration precautions,\n follow for signs infection, sent blood/sputum cx\n Allergies:\n Penicillins\n Hives; Rash;\n Ambien (Oral) (Zolpidem Tartrate)\n Lightheadedness\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 09:00 AM\n Furosemide (Lasix) - 09:40 AM\n Other medications:\n Changes to medical 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 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 36.9\nC (98.5\n HR: 85 (77 - 93) bpm\n BP: 130/61(78) {111/56(71) - 140/92(96)} mmHg\n RR: 20 (18 - 31) insp/min\n SpO2: 91%\n Heart rhythm:A sensing, V Paced\n Wgt (current): 99.6 kg (admission): 105 kg\n Height: 72 Inch\n Total In:\n 400 mL\n PO:\n TF:\n IVF:\n 400 mL\n Blood products:\n Total out:\n 1,140 mL\n 280 mL\n Urine:\n 1,140 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -740 mL\n -280 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb, Other\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n GENERAL: Oriented to person, able to follow commands, improved from\n y/d\n CARDIAC: RRR. II/VI HSM at apex.\n LUNGS: Diffuse rales.\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No significant pitting edema noted.\n NEURO: Mental status as above. PERRL\n Labs / Radiology\n 521 K/uL\n 10.4 g/dL\n 130 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 46 mg/dL\n 110 mEq/L\n 149 mEq/L\n 31.4 %\n 11.0 K/uL\n [image002.jpg]\n 04:56 PM\n 05:03 PM\n 03:59 AM\n 05:45 AM\n 01:44 PM\n 05:02 AM\n 05:15 AM\n 01:55 PM\n 08:25 PM\n 03:46 AM\n WBC\n 9.3\n 8.4\n 9.1\n 11.0\n Hct\n 31.8\n 33.0\n 31.0\n 31.4\n Plt\n 468\n 464\n 426\n 521\n Cr\n 0.7\n 0.7\n 0.8\n 0.8\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 42\n 31\n Glucose\n 137\n 122\n 152\n 131\n 30\n Other labs: PT / PTT / INR:23.5/33.1/2.2, CK / CKMB /\n Troponin-T:337/1/0.10, ALT / AST:224/204, Alk Phos / T Bili:92/0.7,\n Differential-Neuts:85.5 %, Lymph:7.8 %, Mono:4.4 %, Eos:2.0 %, Lactic\n Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:360 IU/L, Ca++:8.7 mg/dL,\n Mg++:2.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DYSPHAGIA\n HEART FAILURE (CHF), SYSTOLIC, ACUTE.\n 72 yo M with CAD, infarct related cardiomyopathy, h/o VT s/p ICD with\n multiple leads due to revision p/w sepsis, now hemodynamically improved\n with RV coil fracture and non-functioning device and VT storm.\n 1. VT:\n -Agree with IV amio load, lidocaine can be added if incessant VT\n -Increase Metoprolol to 25 \n -If continues, will consider ablation next week\n 2. RV coil fracture on Fidelis lead:\n -External defibrillation necessary, ICD unable to deliver therapy\n -Will d/w Dr. re: lead extraction/revision possibilities for\n next week.\n .\n Episodes of pulseless VT yesterday requiring defibrillation and CPR.\n Amio reduced for concern re prolonged QT.\n Continues intermittently confused but conversant.\n .\n 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in ',\n paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD\n implantation, who presented to the ED with a chief complaint of\n dyspnea, initially thought to be due to CHF exacerbation with\n infiltrate, fever, white count consistent with PNA initially on\n meropenem for concern resistant klebsiella who has been cx negative,\n narrowed to suppressive cefpodoxime regimen now spiking temp with\n meropenem restarted. Pt also had VT thought fast/short sequences\n due to pacer setting.\n .\n # s/p VT/VF arrest/ICD dysfunction: LV lead not pacing, only RV\n (). PMR programmed to DDD\n Patient had VT/VF arrest on during which ICD failed to\n defibrillate him and he required external therapy. Patient had\n multiple runs of VT, including second VT arrest 2 nites ago requiring\n defibrillation. Etiology of recently increased ectopy thought \n fast/short sequences, pacer settings. A sensed V paced.\n . Device may not be able to detect VT/VF. Pt will have to be\n Externally defibrillated\n -Unlikely to need ablation as previously thought when etiology VT\n unclear.\n -continue current amnio dose 200mg daily, metoprololl 25mg \n monitor QTC on EKG\n -continue Telemetry\n -if develops VT, will need external therapy as ICD is not functioning\n .\n # Hypoxia: Patient was intubated from for hypoxemic\n respiratory failure. Etiology likely pneumonia + heart failure. Prior\n to last night\ns VT arrest, patient was satting well on 2L NC . Has had\n increased O2 requirement since, possibly related to aspiration, less\n likely worsening heart failure. Spiked temp last night, most likely asp\n pneumonitis, mild leukocytosis.\n Given prior hx, broadened to meropenem but can consider narrowing if\n remains afebrile, pending Cx data\n -aspiration precautions\n -\n -f/u speech and swallow recs\n -diurese for goal negative 1 L today\n .\n # Altered mental status: Disorientation, waxing and , reversal of\n sleep/wake cycle characteristic of delirium. Etiology is likely recent\n intubation (with sedating meds) and ICU environment. No focal\n neurologic deficits.\n - continue to follow clinically\n - minimize sedating medications\n .\n # Fever/Pneumonia: Now afebrile for several days. Previously, patient\n was spiking high fevers in spite of Tylenol, antibiotics, and\n improvement of pneumonia. This led to concern about an occult infection\n or non-infectious cause of fever. CT abd/pelvis and CT sinuses were\n negative. TEE showed no vegetation. There was one positive blood cx\n (coag neg staph). This could represent true infection versus\n contaminant.\n - continue cefpodoxime\n - f/u ID recs\n - f/u pending microbiological studies\n .\n # Chronic systolic heart failure: Patient with EF 20-25%. Has been\n diuresing well to lasix boluses.\n - continue to monitor fluid status\n - continue metoprolol \n - goal negative 1 L today\n .\n # Coagulopathy: INR markedly elevated today. Likely related to\n amiodarone.\n -continue to hold Coumadin\n -vitamin K 2 mg PO once\n .\n # Elevated CK: Likely caused by stain (possibly exacerbated by\n concurrent azithromycin therapy). CK trending down.\n - holding statin\n .\n # CORONARIES: Pt has a history of an anterior wall MI in . Of note,\n the patient did report some chest pressure previously, but this has\n since resolved. MI ruled out with 3 sets of cardiac enzymes.\n - continue aspirin, metoprolol\n .\n # Atrial fibrillation: Pt with a history of a.fib, for which he is on\n coumadin.\n - metoprolol \n - holding Coumadin; started heparin gtt in anticipation of possible EP\n procedure\n .\n # Hypothyroidism:\n - continue levothyroxine 50 mcg daily\n .\n # Anemia: Pt with a history of anemia, baseline Hct of approx. 33-35.\n Hct gradually trending down. No evidence of bleeding.\n - continue iron supplementation\n - continue to trend hct\n .\n # S/p Whipple: On tube feeds.\n - Holding pancreatic enzyme supplementation for now. Will need to\n restart enzyme supplementation if patient is cleared by speech and\n swallow.\n ICU Care\n Nutrition: : Still not alert enough for speech and swallow. Will hold\n off on feeding tube for now.\n Glycemic Control: Insulin Sliding Scale\n Lines:\n PICC Line - 08:47 AM\n 22 Gauge - 08:59 AM\n Prophylaxis:\n DVT: therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "ECG", "chartdate": "2141-03-12 00:00:00.000", "description": "Report", "row_id": 120489, "text": "Sinus rhythm with ventricular pacing. Left atrial abnormality. Since the\nprevious tracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2141-03-03 00:00:00.000", "description": "Report", "row_id": 120490, "text": "Sinus rhythm. Ventricular pacing. Since the previous tracing atrial premature\nbeat is not seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-03-03 00:00:00.000", "description": "Report", "row_id": 120491, "text": "Sinus rhythm. Left atrial abnormality. Ventricular pacing. There is probably a\nsingle atrial premature beat. Since the previous tracing of the pacing\nmorphology has changed suggesting loss of left ventricular capture. The rate is\nalso faster. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2141-03-27 00:00:00.000", "description": "Report", "row_id": 120485, "text": "Baseline artifact is present. Regular ventricular pacing with an unclear atrial\nmechanism. The QRS duration is markedly prolonged at 240 milliseconds which is\nconcerning for significant electrolyte or metabolic abnormalities. Clinical\ncorrelation is advised.\n\n" }, { "category": "ECG", "chartdate": "2141-03-26 00:00:00.000", "description": "Report", "row_id": 120486, "text": "A-V sequential pacing. Compared to the previous tracing of the paced\nQRS duration is shorter. There appears to be biventricular pacing.\n\n" }, { "category": "ECG", "chartdate": "2141-03-24 00:00:00.000", "description": "Report", "row_id": 120487, "text": "Atrial and ventricular sequential pacing. Compared to the previous tracing\natrial pacing is new.\n\n" }, { "category": "ECG", "chartdate": "2141-03-17 00:00:00.000", "description": "Report", "row_id": 120488, "text": "Sinus rhythm with ventricular pacing. Probable left atrial abnormality.\nCompared to the previous tracing of no change.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126383, "text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CHF, admitted with dyspnea, now with resp failure s/p\n intubation ?CHF exacerbation vs. PNA vs. other etiology\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 72-year-old man with congestive heart failure, admitted with\n dyspnea.\n\n COMPARISON: Chest radiograph from .\n\n IMPRESSION: Single frontal chest radiograph:\n\n Again noted is asymmetric left upper opacification likely representing\n asymmetric edema. Left lower lobe atelectasis is unchanged. There are small\n bilateral pleural effusions. Pacer wires, ET tube, and NG tube are all\n unchanged.\n\n IMPRESSION:\n\n Slightly worsened asymmetric pulmonary edema with left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-07 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1125855, "text": " 11:47 AM\n CT CHEST W/CONTRAST Clip # \n Reason: ? abcess/fluid collection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 y/o male admitted with dyspnea thought PNA, now intubated\n REASON FOR THIS EXAMINATION:\n ? abcess/fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 2:36 PM\n 1. No intrathoracic abscess/collection.\n 2. Subtotal atelectasis of the lower lobes, with air-bronchogram. Focal\n consolidation in the left uppper lobe, could also represent atelectasis, less\n likely PNA.\n 3. Bilateral pleural effusions, small-to-moderate, non-hemorrhagic.\n 4. ETT termiantes 4.1 cm above the carina.\n WET READ VERSION #1 ENYa TUE 12:28 PM\n 1. No intrathoracic abscess/collection.\n 2. Subtotal consolidation of the lower lobes, with air-bronchogram, compatible\n with bilateral lower lobar PNA.\n 3. Bilateral pleural effusions, small-to-moderate, non-hemorrhagic.\n 4. ETT termiantes 4.1 cm above the carina.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male, admitted with dyspnea, thought to be secondary to\n pneumonia. Now intubated. Assess for abscess versus fluid collection.\n\n COMPARISON: Multiple chest radiographs with the latest on .\n\n TECHNIQUE: MDCT images were acquired from the thoracic inlet to the lung\n bases after administration of IV contrast. Multiplanar reformatted images\n were reconstructed in 5-mm and 1.25-mm slice thickness for evaluation.\n\n CT CHEST WITH CONTRAST: Bilateral, small-to-moderate, non-hemorrhagic pleural\n effusions are largely gravitational; any loculation, if any, is small, on the\n right. There is no pleural enhancement to suggest empyema or an abscess\n anywhere in the chest. The left lower lobe is completely collapsed and the\n right only slightly less so. Consolidation in the posterior segments of both\n upper lobes, is also likely atelectasis, though small foci of pneumonia can't\n be occlude. There is no pneumothorax.\n\n The right ventricle is normal size, the other are moderately to\n severely enlarged. There is no pericardial effusion. Coronary artery\n calcifications are scattered. The left-sided pacemaker lead terminate in the\n right atrium, right ventricle and venous circulation to the left ventricle.\n Epicardial pacer leads are seen in the right anterior chest wall. Enlarged\n mediastinal lymph nodes are likely reactive, measuring 13 mm in the right\n upper paratracheal station (2:19) and 16 mm anterior to the carina (2:27).\n There is no axillary lymphadenopathy. The thyroid is normal.\n\n (Over)\n\n 11:47 AM\n CT CHEST W/CONTRAST Clip # \n Reason: ? abcess/fluid collection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The endotracheal tube terminates 4cm above the carina. Small amount of\n secretion pools in above the inflated cuff. The enteric tube terminates in\n the stomach.\n\n The study is not designed for subdiaphragmatic diagnosis. There is trace\n perisplenic and perihepatic ascites. The visualized adrenal glands are\n grossly normal.\n\n There is no bone lesions suspicious for malignancy. Multilevel degenerative\n changes are noted at the thoracolumbar junction.\n\n IMPRESSION:\n 1. No intrathoracic abscess. Bilateral non-hemorrhagic small-to-moderate\n pleural effusions, minimally loculated, if at all, on the right.\n\n 2. Severe lower lobe and moderate upper lobe atelectasis. Minimal pneumonia\n cannot be excluded.\n\n 3. Mediastinal lymphadenopathy, likely reactive.\n\n Dr. communicated the updated findings to the primary team, Dr.\n , at 2 p.m. on the day of the study.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126721, "text": " 3:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumo, lung pathology\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hx of LBB, s/p vf arrest, code, cpr\n REASON FOR THIS EXAMINATION:\n evaluate for pneumo, lung pathology\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pneumonia, lung pathology.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are unchanged. The pre-existing left pleural effusion has slightly\n decreased. The very basal parts of the left costophrenic sinus, however, are\n not visualized on the image. Persisting moderate cardiomegaly and left lower\n lobe atelectasis. No newly appeared focal parenchymal opacities suggesting\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126157, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change. Tech to have nurses prop patient up for g\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hx pna, chf on mechanical ventilator\n REASON FOR THIS EXAMINATION:\n ? interval change. Tech to have nurses prop patient up for good image. Thanks\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of pneumonia, mechanical ventilator, evaluation for\n interval change.\n\n FINDINGS: As compared to the previous examination of , the\n extent of the left basal effusion and the extent of the subsequent atelectasis\n has slightly decreased. Improved ventilation of the right lung base.\n\n Unchanged size of the cardiac silhouette. Unchanged position and course of\n the multiple monitoring and support devices. No evidence of pneumothorax.\n The right lateral hemithorax is not included in the image.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126561, "text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with atelectasis, pleural effusions, and ?pneumonia, intubated\n in CCU.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Atelectasis, no pleural effusion, questionable pneumonia.\n Evaluation for interval change.\n\n COMPARISON: . 08:36 a.m.\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Increased transparency of the lung\n parenchyma, reflecting either improved ventilation or increased ventilatory\n pressures. Unchanged size of the cardiac silhouette with minimal retrocardiac\n atelectasis. Minimal blunting of the left costophrenic sinus, potentially\n suggestive of a small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126749, "text": " 5:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for acute change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hx of LBB, s/p vf arrest, code, cpr; now with low O2 sats\n on ventilator\n REASON FOR THIS EXAMINATION:\n please evaluate for acute change\n ______________________________________________________________________________\n WET READ: DLrc SUN 8:32 PM\n Worsening multifocal alveolar consolidation now diffusely involving the upper\n lobes, could relate to edema, infection, or ARDS.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, \n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Low oxygen saturations.\n\n FINDINGS: Indwelling support devices are unchanged in position. Widespread\n areas of airspace opacification have developed in the lungs with an upper and\n mid lung predominance, and likely represent pulmonary edema. They are\n superimposed upon preexisting underlying interstitial edema pattern.\n Otherwise, no relevant changes since recent study.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126278, "text": " 4:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: PLEASE EVALUATE NG TUBE PLACEMENT\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with respiratory distress, intubated and with NG tube; s/p\n readvancement of NG tube\n REASON FOR THIS EXAMINATION:\n please evaluate NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: A 72-year-old male patient with respiratory distress, intubated,\n and now with NG tube. Status post readvancement of NG tube. Evaluate\n position.\n\n FINDINGS: AP single view of the chest was obtained with patient in sitting\n semiupright position. Comparison is made with the next preceding AP single\n projection chest examination obtained eight hours earlier during the same day.\n\n Left-sided permanent pacer ICD device and previously described multiple\n abandoned the cavitary electrodes unchanged. The patient is intubated, as\n before. An NG tube is again identified and is seen to reach far below the\n diaphragm. Its termination point escapes the lower border of the image field.\n The same finding was observed on the preceding examination in as much as the\n NG tube also reach below the diaphragm with uncertain termination point. No\n pneumothorax has developed, cardiac enlargement, as before, hazy densities\n over the bases, more on the left than the right as before, indicative of\n pleural effusions, partially layering in the posterior portions of the pleural\n spaces as the patient is in sitting semi-erect position.\n\n IMPRESSION: No significant interval change. NG tube reaches far below the\n diaphragm.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-14 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1127091, "text": " 5:03 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs PICC for IV antibiotics.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with pneumonia, CHF exacerbation.\n REASON FOR THIS EXAMINATION:\n Needs PICC for IV antibiotics.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. ,\n the attending radiologist, reviewed the study.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access with images on file. A peel-away sheath was\n then placed over a guidewire and a double lumen PICC line measuring 35 cm in\n length was then placed through the peel-away sheath with its tip positioned in\n the SVC under fluoroscopic guidance. Position of the catheter was confirmed by\n a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5-French\n double lumen PICC line placement via the right brachial venous approach. Final\n internal length is 35 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1128826, "text": " 12:17 PM\n CHEST (PA & LAT) Clip # \n Reason: EVAL DEVICE POSITION, PNEUMOTHORAX\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: ICD placement, check position. Evaluate for pneumothorax.\n\n The position of the lines of the ICD device is unchanged. No pneumothorax is\n present. The lung fields are clear. The endotracheal tube has been removed.\n\n IMPRESSION:\n No pneumothorax, no change in ICD device.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126810, "text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval tube/device positioning, interval change in infiltrates\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CHF, had VT arrest yesterday, remains intubated\n REASON FOR THIS EXAMINATION:\n Eval tube/device positioning, interval change in infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Evaluate endotracheal tube.\n\n FINDINGS: Tip of endotracheal tube terminates about 6.3 cm above the carina.\n Other indwelling devices remain in standard position. Improving alveolar\n opacities likely due to pulmonary edema. Otherwise no substantial interval\n change allowing for positional differences between the radiographs.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1125530, "text": " 10:31 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess cvl\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p cvl\n REASON FOR THIS EXAMINATION:\n assess cvl\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 10:54\n\n INDICATION: CVL placement.\n\n FINDINGS:\n\n A right IJ catheter is seen with the tip in the SVC and no PTX. Tip of ETT is\n 5.7 cm above the carina. An NGT is visualized but its tip cannot be localized\n as a good portion of the inferior lung field (and all anatomy below) is cut\n off from view. Some increased opacity at the right lung base is probably\n pleural fluid layering out associated with a component of atelectasis. The\n left lung appears better aerated compared to the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127979, "text": " 4:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm nasogastric tube placement.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p nasogastric tube placement.\n REASON FOR THIS EXAMINATION:\n confirm nasogastric tube placement.\n ______________________________________________________________________________\n WET READ: AJy MON 9:55 PM\n CP angles excluded. NG tube passes into the stomach and off the inferior\n margin of the film. pacer leads unchanged. stable cardiomegally. no acute\n cardiopulm process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n Dobbhoff tube that extends into the upper stomach. Pacer devices remain in\n place. Stable cardiomegaly with opacification in the retrocardiac region\n consistent with volume loss in the left lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125440, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 y/o M with PMHx of systolic HF, admitted to CCU with dyspnea likely CHF\n exacerbation, s/p diuresis\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 7:56\n\n INDICATION: Dyspnea - check for change.\n\n COMPARISON: at 20:45.\n\n FINDINGS: Again seen is increased patchy density in the left mid lung zone\n which is most consistent with pneumonia. There is increasing left pleural\n fluid. The pulmonary vascular markings are not distended. Pacemaker hardware\n and lines are similar in appearance. There is no PTX.\n\n IMPRESSION: Little change versus prior with slightly increased left pleural\n fluid and findings suggesting left pneumonia in the appropriate clinical\n setting.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125490, "text": " 7:03 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CHF, pneumonia, now with hypoxemia\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 19:23\n\n INDICATION: Hypoxemia - check for change.\n\n COMPARISON: at 7:56.\n\n FINDINGS:\n\n Since the prior study, the patient has been intubated with the tip of the ETT\n 6 cm above the carina. An NGT has been placed. There is persistent patchy\n density in the left mid lung zone consistent with pneumonia in the appropriate\n clinical setting, but no new consolidations or evidence for exacerbation of\n fluid status. Pacemaker hardware and wires remain in place.\n\n IMPRESSION:\n\n Other than new ETT and NGT, there is little change versus prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-11 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 1126611, "text": " 4:01 PM\n CT HEAD W/ CONTRAST Clip # \n Reason: 72 year old man with persistent fevers with no clear source,\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with intubated with NG tube, has persistent fevers with no\n clear source\n REASON FOR THIS EXAMINATION:\n 72 year old man with persistent fevers with no clear source, also with elevated\n LFTsQuestions to be answered: Eval for evidence of infectious process or\n collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc SAT 5:44 PM\n No evidence of infectious or other acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male, intubated with NG tube, persistent fevers,\n evaluate for fluid collection.\n\n COMPARISON: Non-contrast head CT, .\n\n TECHNIQUE: Imaging was performed from the foramen magnum to the skull base\n following the uneventful administration of IV contrast. Multiplanar\n reformations including sinus reformations were provided.\n\n HEAD CT WITHOUT IV CONTRAST AND REFORMATIONS THROUGH THE SINUSES: There is no\n hemorrhage, edema, mass effect, shift of midline structures, or evidence of\n major vascular territorial infarction. The ventricles and sulci are normal in\n size and configuration for the patient's age. There is unchanged appearance\n of encephalomalacia in the left frontal periventricular location consistent\n with prior infarction. Osseous structures and soft tissues appear\n unremarkable. There is no fluid collection or evidence of sinusitis. The\n maxillary sinuses bilaterally demonstrate mucus retention cysts.\n\n IMPRESSION: No evidence of infectious or other acute process.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-11 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1126612, "text": " 4:02 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Eval for evidence of infectious process or collection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with persistent fevers with no clear source, also with elevated\n LFTs\n REASON FOR THIS EXAMINATION:\n Eval for evidence of infectious process or collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 6:01 PM\n No definite infectious process. Slightly increased small pleural\n effusions/atelectasis at lung bases. Ground glass opacity at lung bases may\n represent fluid overload, but this makes definitive exclusion of infectious\n process in lung bases difficult. Post-whipple changes again seen, with soft\n tissue in post-operative bed not significantly changed since .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male with persistent fevers, no clear source and\n elevated LFTs. Also history of Whipple for cholangiocarcinoma performed at\n .\n\n COMPARISON: CT abdomen and pelvis, .\n\n TECHNIQUE: MDCT helical acquisition was performed from the lung bases to the\n pubic symphysis following the uneventful administration of IV contrast.\n Multiplanar reformations were provided.\n\n CT CHEST WITH IV CONTRAST: The lung bases demonstrate bilateral small pleural\n effusions which are increased since the prior study with associated\n compressive atelectasis. Most of this enhances. However, diffuse\n ground-glass opacity in the lung bases is seen which may relate to the\n previously identified fluid overload, although this makes exclusion of the\n infectious process at the lung bases difficult. Unchanged findings of left\n ventricular apical thinning are seen which may relate to prior myocardial\n infarction. Pacer wires are again seen terminating in the right ventricle and\n coronary sinus. A nasogastric tube terminates with its tip in the stomach.\n\n There has been prior Whipple procedure, with unchanged anatomy from the prior\n study, numerous clips in the hepatic hilum, with a portacaval soft tissue\n density which may represent a lymph node, post-surgical soft tissue or\n recurrence, measuring 5.2 x 2.5 cm, which is similar in size to the prior\n study (2A:35). Numerous surgical clips surround this region.\n\n The spleen, adrenal glands, large bowel, and small bowel appear otherwise\n unremarkable. The kidneys demonstrate bilateral cystic lesions which are\n likely simple cysts, with one of the larger cysts on the left again\n demonstrating layering calcification. The abdominal wall demonstrates\n apparently new bowel-containing rectus muscle hernia without evidence of\n obstruction.\n (Over)\n\n 4:02 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Eval for evidence of infectious process or collection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n On this single-phase study, the portal vein is not well assessed. Previous\n variant anatomy, with the replaced left hepatic artery, is unchanged but\n better assessed on previous imaging.\n\n There are unchanged subcentimeter prominent nodes in the left paraaortic\n region and near the celiac axis.\n\n There is no abnormal fluid collection suggestive of an infectious process in\n abdomen.\n\n CT PELVIS WITH IV CONTRAST: A rectal probe has been placed with tip\n terminating in the rectum. There is Foley catheterization. The bladder is\n therefore collapsed. The prostate and seminal vesicles appear unremarkable.\n The aorta and its branches demonstrate moderate calcification, but no\n aneurysmal dilation.\n\n There is no pelvic sidewall lymphadenopathy or abnormal fluid collection.\n Bilateral fat-containing inguinal hernias are again seen.\n\n Osseous structures again demonstrate degenerative changes of the lumbosacral\n spine, with osteophyte formation. There is also vacuum disc phenomenon at\n L1-L2, and unchanged compression fracture of L1 with slight posterior\n protrusion of the deformed vertebral body.\n\n IMPRESSION:\n\n 1. No evidence of infectious process in the abdomen or pelvis.\n\n 2. Ground-glass opacity in lung bases may partially be explained by fluid\n overload, although an infectious component should be considered.\n\n 3. Slightly increased bilateral small pleural effusions with associated\n atelectasis.\n\n 4. Unchanged postoperative findings related to prior Whipple and\n hepatojejunostomy, with soft tissue in the postoperative bed, which appears\n stable, of unclear significance.\n\n 5. Apparently new rectus muscle herniation containing non-obstructed bowel.\n\n 6. Unchanged compression fracture of L1.\n (Over)\n\n 4:02 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Eval for evidence of infectious process or collection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2141-03-11 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1126613, "text": ", J. 4:02 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Eval for evidence of infectious process or collection\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 45 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with persistent fevers with no clear source, also with elevated\n LFTs\n REASON FOR THIS EXAMINATION:\n Eval for evidence of infectious process or collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No definite infectious process. Slightly increased small pleural\n effusions/atelectasis at lung bases. Ground glass opacity at lung bases may\n represent fluid overload, but this makes definitive exclusion of infectious\n process in lung bases difficult. Post-whipple changes again seen, with soft\n tissue in post-operative bed not significantly changed since .\n\n" }, { "category": "Radiology", "chartdate": "2141-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125802, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with fever and hypoxic respiratory failure, intubated in CCU,\n ?pneumonia.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever and respiratory failure.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. There is continued or worsening elevation of\n pulmonary venous pressure with persistent bilateral layering pleural effusions\n and adjacent compressive atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127658, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with h/o recent pneumonia, VT and possible aspiration event on\n .\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of recent pneumonia and possible aspiration.\n\n FINDINGS: A single semi-upright radiograph of the chest was obtained and\n compared to prior exam performed . Pacer and leads are in\n stable position. The cardiac silhouette is enlarged and stable. There has\n been some improvement in vascular congestion. There is bibasilar probable\n atelectasis, left greater than right and probable layering effusions\n bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1126973, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hypoxemic respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 72-year-old male with hypoxia post-intubation.\n\n COMPARISON: Serial chest radiographs since , most recent on .\n\n CHEST, AP: Indwelling support devices are unchanged and include an\n endotracheal tube 6 cm from the carina, a temperature probe in the proximal\n esophagus, a nasogastric tube with tip beyond the inferior edge of the film,\n right internal jugular line terminating in the upper SVC, and a left chest\n wall pacemaker/AICD device with multiple leads, including one that crosses the\n chest to enter the right subclavian vein. There is persistent mild\n cardiomegaly. There is no pulmonary edema. There is bibasilar atelectasis\n with probable small layering pleural effusions.\n\n IMPRESSION: Stable mild cardiomegaly, bibasilar atelectasis, and small\n pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125984, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with b/l lower lobe infiltrate and low EF currently intubated\n in CCU.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:22 A.M. ON \n\n HISTORY: Bilateral lower lobe infiltrate and low ejection fraction.\n\n IMPRESSION: Lateral aspect of the right lower chest is excluded from the\n examination. Previous mediastinal and pulmonary vascular congestion have both\n improved, but there is still severe bibasilar consolidation which could be\n pneumonia or atelectasis in either lower lobe. Moderate left pleural effusion\n is smaller reflecting improved hemodynamic status. In addition to what\n appeared to be the operating right ventricular pacer defibrillator lead, right\n atrial and left ventricular pacer leads, there is a myriad of additional\n remnant pacer wires, some of which cross from the left axilla to the right and\n then into the chest that I would need careful clinical history in order to\n assess.\n\n ET tube is in standard placement and a nasogastric tube passes into\n non-distended stomach and out of view. No pneumothorax.\n\n Dr. was paged.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128483, "text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p lead extraction; new icd leads\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n WET READ: AJy FRI 1:47 AM\n multiple pacer wires. ETT 5-6 cm from carina. no ptx. lungs grossly clear.\n heart remains enlarged. ? fullness of left hilum.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after new pacemaker\n placement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5.5 cm above the carina. The Dobbhoff tube tip passes\n below the diaphragm with its tip not included in the field of view. The\n pacemaker leads appear to be terminating in right atrium and right ventricle,\n unchanged since the prior study. There is no evidence of pneumothorax. There\n is bibasal left more than right opacities most likely consistent with\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1127500, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate s/p CPR\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with VT arrest s/p CPR and defibrillation\n REASON FOR THIS EXAMINATION:\n evaluate s/p CPR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with ventricular tachycardia, post-CPR.\n\n COMPARISON: .\n\n CHEST, AP: Endotracheal tube has been removed. Other monitoring and support\n devices are unchanged in position and course. Lung volumes are decreased, but\n right lower lobe atelectasis has improved. Mildly increased interstitial\n edema and cardiomegaly likely reflect cessation of positive pressure\n ventilation. No pneumothorax is present. There are no fractures.\n\n IMPRESSION: Unchanged mild vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2141-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125405, "text": " 8:22 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with CHF, admitted with dyspnea, now s/p restarting BiPAP 2/2\n worsening of his dyspnea\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dyspnea.\n\n COMPARISON: at 10:16 a.m.\n\n FINDINGS:\n\n Again seen is mild bilateral pulmonary interstitial edema. There is increased\n focal patchy opacity in the left upper and left mid lung, slightly progressed\n since the previous radiographs and concerning for a superimposed process such\n as pneumonia. Small left pleural effusion and atelectasis in the left lower\n lung, slightly increased. Left-sided ICD again noted. Residual pacemaker\n wires again noted. Persistent cardiomegaly.\n\n IMPRESSION:\n\n Persistent pulmonary interstitial edema.\n\n Increased airspace opacity in the left upper and mid lung concerning for a\n superimposed process such as pneumonia.\n\n Findings were discussed with Dr. on .\n\n" }, { "category": "Radiology", "chartdate": "2141-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125497, "text": " 12:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate NG tube\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p intubation and NG tube placement. Need to verify NGT\n positioning. Previous film does follow NG tube below diaphagm.\n REASON FOR THIS EXAMINATION:\n evaluate NG tube\n ______________________________________________________________________________\n WET READ: JXRl SUN 1:07 AM\n NGT in stomach, directed cephalad. ETT at level of thoracic inlet, approx 8cm\n above carina. D/ 1am . Persistent left lung, retrocardiac\n consolidation. Bilateral layering effusions.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 00:50\n\n INDICATION: NGT placement.\n\n FINDINGS: Tip of the NGT is coiled back upon itself but is in the left upper\n quadrant below the diaphragm. Again seen is a patchiness in the left mid lung\n zone extending lower and evidence of pleural fluid layering out. Tip of the\n ETT is somewhat high at 8.2 cm above the carina. Pleural fluid seems to layer\n out on the right now, unchanged from prior but positioning differences could\n contribute to that. There is no pneumothorax and stable cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1125317, "text": " 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with sob, hypoxia\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with shortness of breath and hypoxia.\n\n COMPARISON: .\n\n CHEST, AP: There is diffusely increased interstitial pulmonary edema, with\n prominent vascular markings and fullness of the bilateral hila. Vaguely\n increased opacity in the region of the left lower lobe likely represents\n asymmetric pulmonary edema, although a superimposed process cannot be\n excluded. Again noted is moderate cardiomegaly. There are no pleural\n effusions or pneumothorax.\n\n A left chest wall pacemaker/AICD device is present, with one lead overlying\n the right atrium and two leads overlying the right ventricle. Discarded right\n chest wall leads are seen with tips overlying the right ventricle and coronary\n sinus.\n\n IMPRESSION: Increased pulmonary edema. Superimposed infectious process in\n the left lower lobe cannot be excluded. Recommend follow-up post diuresis.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2189-03-31 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1178129, "text": " 3:33 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please evaluate for pancreatitis, liver pathology\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with abd pain, history of varices\n REASON FOR THIS EXAMINATION:\n please evaluate for pancreatitis, liver pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 4:59 PM\n 1. No CT evidence of acute pancreatitis. Radiologic findings typcially lag\n behind biochemical markers.\n 2. Moderately edematous gallbladder, with trace pericholecystic fluid. While\n this could be seen with liver disease, concern is raised for acute\n cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old woman, with abdominal pain and history of NASH. Also\n history of varices. Evaluate for acute pancreatitis or liver pathology.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT images were acquired from the lung bases to the pubic\n symphysis after administration of IV contrast. No prior oral contrast was\n administered. Multiplanar reformatted images were obtained for evaluation.\n\n CT ABDOMEN WITH IV CONTRAST ONLY: The visualized lung bases are clear without\n pleural effusion. Nodular hepatic contour is most evident along the anterior\n margin, compatible with the known history of NASH. There is no intrahepatic\n or extrahepatic biliary ductal dilatation. The non-fully distended\n gallbladder is markedly edematous, with suggestion of trace pericholecystic\n fluid. No CT evidence of gallstone is noted.\n\n The spleen is markedly enlarged, measuring up to 26 cm craniocaudally. There\n are scattered perisplenic and perigastric varices. The pancreas is normal,\n without CT evidence of acute pancreatitis. The adrenal glands and kidneys are\n normal. There is prompt excretion of IV contrast into the collecting system\n bilaterally, without hydronephrosis, hydroureter or evidence of renal stone.\n The stomach, duodenum and loops of small bowel are unremarkable. There is no\n free air or gross lymphadenopathy. Small mesenteric lymph nodes are not\n pathologically enlarged.\n\n CT PELVIS WITH CONTRAST: The urinary bladder is normally distended without\n focal abnormalities. The colon is grossly unremarkable. There is no free\n fluid, air or lymphadenopathy in the pelvis. Midline abdominal soft tissue\n scarring is most compatible with prior surgical incision.\n\n BONE WINDOW: There are no suspicious lytic or sclerotic lesions. Minimal\n posterior disc bulge is noted at L5-S1 level.\n\n IMPRESSION:\n (Over)\n\n 3:33 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please evaluate for pancreatitis, liver pathology\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Markedly edematous gallbladder, but not fully distended, could be\n secondary to underlying liver disease. However, acute cholecystitis cannot be\n excluded. Recommend right upper ultrasound to further assess acute\n gallbladder abnormality.\n\n 2. No evidence of acute pancreatitis.\n\n 3. Marked splenomegaly, with scattered varices.\n\n" }, { "category": "Radiology", "chartdate": "2189-03-31 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1178130, "text": " 5:17 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval portal venous flow\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with abd pain and history of varices\n REASON FOR THIS EXAMINATION:\n eval portal venous flow\n ______________________________________________________________________________\n WET READ: ENYa TUE 5:45 PM\n 1. No gallstone. No biliary dilatation. CBD 5 mm.\n 2. Diffusely thickened and edematous gallbladder wall.\n 3. Negative son sign.\n The constellation of the findings makes it more likely to liver disease,\n and less likely acute cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old woman, with history of NASH, now presenting with\n abdominal pain and history of varices. Assess for abnormal finding of\n gallbladder from the CT.\n\n COMPARISON: Concurrent CT abdomen and pelvis.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is mild heterogeneously echogenic,\n compatible with fatty infiltration. There is a 6-mm focal echogenic lesion in\n the right hepatic lobe without internal vascularity. There is no intrahepatic\n or extrahepatic biliary ductal dilatation. The CBD measures 5 mm in diameter.\n There is normal hepatopetal portal venous flow.\n\n The gallbladder is not markedly distended, but the gallbladder wall is\n diffusely thickened and edematous, measuring 6-mm in maximum thickness. There\n is no gallstone or sludge. Trace pericholecystic fluid is noted. The\n son sign is negative.\n\n IMPRESSION:\n 1. Diffusely heterogeneous and echogenic liver, compatible with fatty\n infiltration.\n 2. Diffusely thickened and edematous gallbladder wall is a non-specific\n finding, and may be secondary to hypoproteinemia and underlying liver disease.\n If there is continued clinical concern for acute cholecystitis, a HIDA scan\n can be obtained.\n 3. 6-mm echogenic right hepatic lesion, likely a hemangioma, but in the\n setting of underlying chronic liver disease is not fully characterized on this\n exam. Recommend MRI of the liver for further evaluation.\n\n" }, { "category": "Echo", "chartdate": "2189-04-02 00:00:00.000", "description": "Report", "row_id": 92317, "text": "PATIENT/TEST INFORMATION:\nIndication: Assess for wall motion abnormalities, right-sided filling pressures prior to potential TIPS.\nHeight: (in) 68\nWeight (lb): 350\nBSA (m2): 2.60 m2\nBP (mm Hg): 117/65\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 11:33\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Doppler parameters are indeterminate for\nLV diastolic function. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV not well\nseen.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nDoppler parameters are indeterminate for left ventricular diastolic function.\nThere is no ventricular septal defect. The diameters of aorta at the sinus,\nascending and arch levels are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The estimated pulmonary artery systolic pressure is normal. There is\nno pericardial effusion.\n\nIMPRESSION: Suboptimal image quality due to body habitus. Left ventricular\nsystolic function is probably normal, a focal wall motion abnormality cannot\nbe excluded. The right ventricle is not well seen but again is probably\nnormal. No significant valvular abnormality.\n\n\n" }, { "category": "ECG", "chartdate": "2189-04-01 00:00:00.000", "description": "Report", "row_id": 256993, "text": "Sinus rhythm. Early R wave transition. Non-specific ST-T wave changes.\nCompared to the previous tracing of the rate has slowed.\n\n" }, { "category": "ECG", "chartdate": "2189-03-31 00:00:00.000", "description": "Report", "row_id": 256994, "text": "Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available\nfor comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2113-06-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1241159, "text": " 5:37 PM\n CHEST (PA & LAT) Clip # \n Reason: pna chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 76M with weakness\n REASON FOR THIS EXAMINATION:\n pna chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: Weakness, assess for pneumonia or CHF.\n\n FINDINGS: PA and lateral views of the chest were obtained. Lung volumes are\n low with bronchovascular crowding in the lower lungs. No definite sign of\n pneumonia or CHF. No large effusion or pneumothorax. Heart size cannot be\n assessed on the frontal view though appears within normal limits on the\n lateral view. Mediastinal contour is normal. Bony structures appear intact.\n Mild degenerative changes in the upper thoracic spine noted.\n\n IMPRESSION: Limited, negative.\n\n\n" }, { "category": "ECG", "chartdate": "2113-06-30 00:00:00.000", "description": "Report", "row_id": 272329, "text": "Sinus tachycardia. Right bundle-branch block. Left anterior fascicular block.\nLeft ventricular hypertrophy. Compared to the previous tracing of right\nbundle-branch block has appeared.\n\n" }, { "category": "ECG", "chartdate": "2113-06-30 00:00:00.000", "description": "Report", "row_id": 272330, "text": "ECG interpreted by ordering physician.\n see corresponding office note for interpretation.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 774298, "text": " 2:26 AM\n CHEST (PA & LAT) Clip # \n Reason: 75 y/o male with fall and some right sided rib pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with as above\n REASON FOR THIS EXAMINATION:\n 75 y/o male with fall and some right sided rib pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76 y/o male with right sided rib pain, status post fall.\n\n PA AND LATERAL CHEST: The heart size, mediastinal contour and pulmonary\n vasculature are within normal limits. There is a tapered opacity arising along\n the right lateral chest wall consistent with a loculated pleural effusion. ?\n prior history of hematoma or empyema. Lungs are otherwise clear. Osseous\n structures demonstrate degenerative changes and demineralization but are\n otherwise grossly unremarkable.\n\n No rib fractures are identified.\n\n IMPRESSION: Opacity along the right lateral chest wall likely represents a\n loculated pleural effusion, or pleural thickening. Comparison with prior\n studies and clinical history is recommended. Further evaluation if\n clinically indicated could be performed with ultrasound or CT of the chest. No\n rib fractures are identified. If there is persistent clinical concern for rib\n fracture, dedicated rib films could be obtained.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 774299, "text": " 3:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 76 y/o male h/o cll with thrombocytopenia and fall r/o sudur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with as above\n REASON FOR THIS EXAMINATION:\n 76 y/o male h/o cll with thrombocytopenia and fall r/o sudural\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76 y/o male status post fall with thrombocytopenia and history\n of CLL.\n\n COMPARISONS: None.\n\n TECHNIQUE: CT of the head without contrast.\n\n FINDINGS: There are ill defined areas of increased attenuation within the\n anterior aspects of the frontal lobes bilaterally, right greater than left.\n Appearance is consistent with subarachnoid hemorrhage. A small, more rounded\n focus of increased attenuation is present within the right frontal lobe\n suggesting intra-parenchymal hemorrhage. There is a small amount of right\n frontal subdural hemorrhage. There is prominence of the ventricles and\n sulci. There is no mass effect or shift of the normally midline structures.\n /white matter differentiation is preserved. There is soft tissue\n prominence in the supra sellar cistern. There are dense vascular\n calcifications.\n\n The visualized paranasal sinuses or mastoid air cells are well aerated. There\n is a soft tissue hematoma along the superior lateral aspect of the right\n orbital rim.\n\n IMPRESSION:\n\n 1) Bilateral frontal subarachnoid hemorrhage with probable punctate foci of\n right frontal intraparenchymal hemorrhage and a small right subdural hematoma.\n Findings were discussed with the ER resident and neurosurgical resident.\n\n 2) Soft tissue prominence within the supresellar cistern. Finding is\n concerning for neoplasm (e.g, pituitary macroadenoma) or aneurysm (less\n likely). MR could be performed if clinically indicated for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 774300, "text": " 4:28 AM\n C-SPINE, TRAUMA Clip # \n Reason: 76 y/o male with fall, altered ms\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with as above\n REASON FOR THIS EXAMINATION:\n 76 y/o male with fall, altered ms\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 y/o man s/p fall with altered mental status.\n\n AP, LATERAL, SWIMMER'S OPEN MOUTH VIEW OF THE CERVICAL SPINE (7 IMAGES): No\n prior images for comparison. C1 through C7 are visualized on the lateral and\n Swimmers views. There is extensive multilevel degenerative changes with\n prominent osteophyte formation and end plate degenerative changes. There is\n narrowing of the 6th and 7th intervertebral disc space. Alignment appears\n normal. There is no prevertebral soft tissue swelling. AP view demonstrates\n slight angulation of the cervical spine to the right, likely relating to\n patient positioning. Open mouth view reveals normal relationship between the\n lateral masses of C1 and C2. The tip of the dens is not visualized.\n\n IMPRESSION: Extensive multilevel degenerative changes without definite\n evidence of fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "T-SPINE", "row_id": 774297, "text": " 2:11 AM\n T-SPINE Clip # \n Reason: 76 y/o male with T2-T3 spinal tenderness post fall\\\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with as above\n REASON FOR THIS EXAMINATION:\n 76 y/o male with T2-T3 spinal tenderness post fall\\\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76 y/o male with T2-3 spinal tenderness, post fall.\n\n AP AND LATERAL THORACIC SPINE: No prior images for comparison. There are\n multilevel degenerative changes with osteophyte formation. The superior\n thoracic spine is poorly visualized on the lateral view. Alignment is grossly\n normal.\n\n IMPRESSION: No evidence of of fracture or dislocation. The superior thoracic\n spine is poorly visualized on a lateral projection.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-21 00:00:00.000", "description": "CAROTID DUPLEX US", "row_id": 774423, "text": " 2:23 PM\n CAROTID DUPLEX US Clip # \n Reason: S/P SYNCOPE. R/O PLAQUE.\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n S/P SYNCOPE. R/O PLAQUE.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 year old man with recent history of syncope.\n\n TECHNIQUE AND FINDINGS: -scale, color Doppler and spectral Doppler\n examinations were performed bilaterally at the level of the cervical portions\n of the carotid and vertebral arteries.\n\n On the right, there is minimal plaque at the origin of the internal and\n external carotid arteries. The peak systolic velocities in the internal,\n common and external carotid arteries are 62, 70 and 82 cm/sec, respectively.\n The ICA-to-CCA peak systolic velocity ratio is 0.9. These findings are\n consistent with a luminal narrowing less than 40% in diameter. There is\n antegrade flow in the right vertebral artery with a peak systolic velocity of\n 64 cm/sec.\n\n On the left, there is minimal plaque at the terminal, upper portion of the\n common carotid artery. The peak systolic velocities in the internal, common\n and external carotid arteries are 79, 82 and 86 cm/sec, respectively. The left\n ICA-to-CCA peak systolic velocity ratio is 1.0. These findings are consistent\n with the absence of stenosis by more than 40% in diameter. There is antegrade\n flow in the left vertebral artery with a peak systolic velocity of 62 cm/sec.\n\n CONCLUSION: Minimal bilateral carotid plaque without significant stenosis.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-24 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 774709, "text": " 4:47 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: please eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p syncopal episode with r shoulder pain\n REASON FOR THIS EXAMINATION:\n please eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 y/o male status post syncopal episode with right shoulder\n pain, evaluate for fracture.\n\n THREE VIEWS OF THE RIGHT SHOULDER:\n\n AP, neutral and axillary views were obtained. No prior examinations available\n for comparison. No evidence for fracture, dislocation or subluxation. There\n is mild narrowing of the AC joint compatible with degenerative changes. There\n is a rounded density noted along the medial right apex which likely represents\n a tortuous innominate artery when correlated with the recent chest CT from\n . There is a right effusion present which is also associated with an\n empyema seen on the recent chest CT.\n\n IMPRESSION:\n 1) No evidence for right shoulder dislocation or fracture.\n 2) Mild degenerative changes of the right AC joint.\n 3) Right pleural effusion\n\n" }, { "category": "Radiology", "chartdate": "2138-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774831, "text": " 6:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for worsening R pleural effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with R loculated pleural effusion, ?worsening lung exam\n REASON FOR THIS EXAMINATION:\n please eval for worsening R pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Right pleural effusion.\n\n IMPRESSION: Continued moderate sized right pleural effusion.\n\n COMMENT: Frontal radiograph of the chest is reviewed, and compared to a\n previous study of .\n\n There is continued loculated right pleural effusion, which is consistent with\n CT finding of empyema. The left lung appears clear. The heart is normal in\n size. There is tortuosity of the thoracic aorta. A pace maker is terminating\n in the right atrium and right ventricle. Multiple surgical staples are seen\n in the right upper quadrant indicating cholecystectomy.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-10-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 774571, "text": " 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placement, PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man S/P PPM\n REASON FOR THIS EXAMINATION:\n lead placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pacemaker placement.\n\n COMPARISONS: PA & lateral chest radiograph from .\n\n PA & LATERAL CHEST RADIOGRAPH: A dual lead pacemaker is visualized overlying\n the left anterior chest wall. The atrial lead is in good position. The\n ventricular lead takes a tortuous course before it terminates in a\n satisfactory position. There is no evidence of pneumothorax. The patient is\n slightly rotated to the right. Given the patient's positioning, the heart size\n and mediastinal contours are stable in appearance. A partially loculated right\n pleural effusion is again demonstrated, and is stable in appearance. The\n osseous structures are unchanged.\n\n IMPRESSION: Slightly tortuous ventricular lead, but overall both leads are in\n satisfactory position. No evidence of pneumothorax. Stable partially loculated\n right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 774301, "text": " 4:29 AM\n PELVIS (AP ONLY) Clip # \n Reason: 76 y/o male s/p fall\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with as above\n REASON FOR THIS EXAMINATION:\n 76 y/o male s/p fall\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76 y/o male status post fall.\n\n AP PELVIS: No prior images for comparison. Bones are well mineralized without\n evidence of fracture, dislocation or focal area of bone destruction. Soft\n tissues are grossly unremarkable.\n\n IMPRESSION: No evidence of fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-21 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 774391, "text": " 10:10 AM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: s/p fall, r.o vascular malfunction\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n s/p fall, r.o vascular malfunction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 year old male status post falls, rule out vascular\n malfunction.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images pre and post gadolinium\n enhancement were obtained. In addition, 3D time of flight imaging of the\n circle of and its main tributaries was performed.\n\n This study is compared to the prior CT of the head on .\n\n FINDINGS: This study is partially degraded by patient motion. The previously\n described subarachnoid hemorrhage within the sulci of the anterior frontal\n lobes is seen as increased T2 signal on the FLAIR images, and is similar in\n appearance. Susceptibility images demonstrate the previously described\n parafalcine subdural hematoma, as well as minimal intraventricular hemorrhage\n within the occipital horns bilaterally. Susceptibility images also\n demonstrate punctate foci of dark signal within the right basal ganglia and\n white matter bilaterally that could represent small foci of intraparenchymal\n blood, but also could represent small cavernomas or amyloid angiopathy, as a\n few of these foci do not correspond to the foci of hemorrhage seen on the CT.\n There is no shift of normally midline structures or mass effect, and the\n ventricles and sulci are stable in size compared with prior exam but\n demonstrate moderate enlargement consistent with involutional change\n appropriate for the patient's age. The major vascular flow voids are\n preserved. 3D time of flight imaging of the circle of and it major\n tributaries demonstrates no aneurysms or flow abnormalities.\n\n The previously described soft tissue prominence within the sella seen on prior\n CT is demonstrated, which on today's examination appears as an intrasellar\n mass expanding the sella and with suprasellar extension through the\n diaphragmatic sellae. The suprasellar extension appears to touch and/or\n minimally displace the optic chiasm. The mass demonstrates uniform\n enhancement. There is no other evidence of abnormally enhancing lesions\n within the brain parenchyma.\n\n IMPRESSION:\n\n 1. Bilateral subarachnoid hemorrhage and parafalcine subdural hematoma,\n stable in appearance.\n\n 2. Intrasellar mass with suprasellar extension, demonstrating uniform\n enhancement.\n\n (Over)\n\n 10:10 AM\n MR HEAD W & W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: s/p fall, r.o vascular malfunction\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Nonspecific foci within the right basal ganglia and white matter with\n differential described above.\n\n 4. No evidence of aneurysm or flow abnormality within the circle of or\n its major tributaries.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 774401, "text": " 11:35 AM\n CHEST (PA & LAT) Clip # \n Reason: EVAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man S/P FALL\n REASON FOR THIS EXAMINATION:\n EVAL EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76 y/o man status post fall.\n\n CHEST, PA AND LATERAL: Comparison is made to film . The\n cardiomediastinal silhouette is unremarkable. A right sided pleural effusion\n is seen along with right lower lobe collapse. There is increased collapse of\n the right lobe in comparison to one day prior. The left lung appears clear.\n\n IMPRESSION: Right pleural effusion with worsened right lower lobe collapse\n compared to one day prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-10-21 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 774449, "text": " 5:10 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: s/p fall with effusion on the right and failed attempt at ch\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n s/p fall with effusion on the right and failed attempt at chest tube secondary\n to thickened pleura; assess for mesothelioma and assess hemothorax vs. effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Failed attempt at chest tube placement for pleural effusion\n secondary to thick pleura. Evaluate for mesothelioma, hemothorax.\n\n TECHNIQUE: Helically acquired axial images wer obtained from the thoracic\n inlet to the lung bases with contrast, using 5 mm collimation.\n\n CONTRAST: 90 of Optiray was given due to debility .\n\n CHEST CT WITH IV CONTRAST: There is a moderate-sized right pleural effusion,\n the majority of which is loculated. The pleura around this loculated pleural\n effusion shows evidence of enhancement. There is slight thickening of the\n pleura adjacent to this. Within the chest wall on the right side laterally,\n there is evidence of subcutaneous emphysema, which is likely related to\n attempt at chest tube placement. There is also some thickening of the chest\n wall muscles, likely related to a edema and hematoma secondary to attempted\n chest tube placement. No pleural fluid or significant pleural thickening is\n seen on the left hand side.\n\n Multiple small mediastinal lymph nodes are seen in the right paratracheal,\n prevascular, precarinal and subcarinal distribution. There is a 13 mm right\n paratrachel lymph node present. There is a 15 mm subcarinal lymph node\n present. A few small left lower paratracheal lymph nodes aere also seen.\n Several small axillary lymph nodes are seen bilaterally. The heart size is\n wihtin normal limits. There are coronary artery calcifications. Review of\n the lung windows demonstrates evidence of passive atelectasis at the right\n lung base, adjacent to the area of loculated effusion. In addition, there is\n a tiny 3 mm nodule in the left upper lobe.\n\n In the imaged portions of the abdomen, there is a 3.2 x 3.0 cm fluid filled\n cystic structure in the right upper quadrant posterior to the liver, in the\n region of pouch. This contains a coarse calcification. Just\n superior to this, there is a dropped cholecystectomy clip. The liver,\n pancreas, adrenal glands, and upper poles of the kidneys are unremarkable. The\n spleen is mildly enlarged measuring approximately 15 cm. Numerous small\n retroperitoneal lymph nodes are seen in and around the celiac axis.\n\n No suspicious osseous lesions are identified. No fractures are seen.\n\n IMPRESSION:\n\n (Over)\n\n 5:10 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: s/p fall with effusion on the right and failed attempt at ch\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Predominantly loculated, moderate-sized right pleural effusion with\n evidence of surrounding pleural enhancement (split pleura sign). This\n appearance is concerning for an empyema, which is probably chronic in nature\n and is unlikely related to the patient's recent trauma.\n\n 2. Small, approximately 3 cm, fluid collection in the right upper quadrant\n just posterior to the liver in the region of Morrisons pouch, adjacent to a\n dropped cholecystectomy clip. This is felt to represent a small abscess.\n\n 3. Numerous small mediastinal, axillary and retroperitoneal lymph nodes. Note\n is also made of a slightly enlarged spleen measuring 15 cm.\n\n 4. There is a small amount of adjacent pleural thickening of the right lung\n base adjacent to the loculated pleural fluid collection. Although the\n thickened pleura may simply be related to a chronic empyema, associated\n neoplasm cannot be excluded, including the possibility of lymphoma,\n mesothelioma, and metastases.\n\n 5. Tiny 3 mm nodule in the left upper lobe.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-10-23 00:00:00.000", "description": "PLEURAL ASP BY RADIOLOGIST", "row_id": 774602, "text": " 2:41 PM\n PLEURAL ASP BY RADIOLOGIST; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n CHEST U.S.\n Reason: please eval for infection or other process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with loculated right pleural effusion, attempted drainage with\n chest tube, unable to drain\n REASON FOR THIS EXAMINATION:\n please eval for infection or other process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right loculated pleural effusion, ? infection vs. malignancy. For\n diagnostic thoracentesis.\n\n TECHNIQUE:\n\n After obtaining informed consent, the right posterior thorax was prepped and\n draped in the usual sterile fashion. Under real time ultrasound guidance, a\n needle was advanced into the fluid collection. Lidocaine 1% was\n instilled for pain control. 60 cc of serosanguineous fluid were removed.\n There were no complications.\n\n Dr. , staff radiologist, was present throughout the entire procedure.\n\n FINDINGS:\n\n 60 cc of serosanguineous fluid were removed from a complex multiloculated\n fluid collection with the right thorax.\n\n CONCLUSION:\n\n Successful diagnostic thoracentesis.\n\n The specimen was sent with the patient to the floor.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 774371, "text": " 9:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: .R/O BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with above\n r/o bleed\n REASON FOR THIS EXAMINATION:\n s/p head trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n\n Multiple axial images were obtained from base to vertex without IV contrast.\n Comparison is made to recent CT dated at 2 A.M. This exam represents\n an 18 hour follow up.\n\n There is a subarachnoid hemorrhage again noted along the anterior portion of\n the frontal sulci and interhemispheric fissure. A small area of contusion is\n seen within the right frontal lobe. The ventricular system remains symmetric\n without evidence for hydrocephalus.\n\n There is a round soft tissue lesion in the suprasellar region which could\n represent either volume averaging through an enlarged pituitary macroadenoma\n or less likely an aneurysm. Correlation with MRA would be recommended for\n further evaluation.\n\n IMPRESSION:\n\n 1) No significant interval change seen involving the subarachnoid hemorrhage\n from the frontal sulci and small intraparenchymal frontal hemorrhage\n suggestive of a contusion. Round soft tissue lesion in the suprasellar\n cistern representing either volume averaging through a pituitary macroadenoma\n or less likely an aneurysm. Correlation with MRA would be helpful for further\n evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2138-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774366, "text": " 7:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with above\n r/o fracture, ptx, ...\n REASON FOR THIS EXAMINATION:\n s/p trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: at 2:30 A.M.\n\n PORTABLE UPRIGHT CHEST AT 19:21: The heart and mediastinal contours\n are normal. There is diffuse increased hazy opacity over the right\n hemithorax, likely reflecting a moderate-sized right pleural effusion, with a\n possible loculated component laterally. There is a slightly more confluent\n area of opacity at the right base, reflecting an area of contusion versus\n atelectasis. The left lung is clear. No pneumothorax. No definite rib\n fracture is identified.\n\n IMPRESSION: Moderate right-sided pleural effusion which is partially\n loculated. The thickening along the right lateral lung could also be related\n to hematoma, given the patient's history of trauma. Right lower lobe\n contusion versus atelectasis.\n\n" }, { "category": "Echo", "chartdate": "2138-10-20 00:00:00.000", "description": "Report", "row_id": 74163, "text": "PATIENT/TEST INFORMATION:\nIndication: Syncope.\nHeight: (in) 74\nWeight (lb): 150\nBSA (m2): 1.92 m2\nBP (mm Hg): 118/50\nStatus: Inpatient\nDate/Time: at 15:16\nTest: 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: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). There is no resting left ventricular outflow\ntract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The 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 aortic valve leaflets appear structurally normal with good\nleaflet excursion. The aortic valve leaflets are moderately thickened. There\nis no aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. Trivial mitral regurgitation is seen. The transmitral E-wave\ndecelleration time is prolonged (>250 ms).\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 70%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. The aortic valve leaflets are\nmoderately thickened. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2138-10-23 00:00:00.000", "description": "Report", "row_id": 171837, "text": "Sinus arrhythmia\n - demand ventricular pacing, pseudo fusing with conducted complexes\nPacemaker rhythm - no further analysis\nSince previous tracing, pacer spike new\n\n" }, { "category": "ECG", "chartdate": "2138-10-20 00:00:00.000", "description": "Report", "row_id": 171838, "text": "Sinus rhythm. Since the previous tracing of the same dawte no significant\nchange in previously described abnormalities. However, limb lead voltage is low\nin both tracings.\n\n" }, { "category": "ECG", "chartdate": "2138-10-20 00:00:00.000", "description": "Report", "row_id": 171839, "text": "Sinus rhythm. Left anterior fascicular block. Right bundle-branch block. Miold\nQ-T interval prolongation. Clinical correlation is suggested. No previous\ntracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2138-10-21 00:00:00.000", "description": "Report", "row_id": 1435580, "text": "FOCUS; NURSING PROGRESS NOTE.\nREVEIW OF SYSTEMS-\nNEURO- PATIENT ALERT AND OREINTED X3. PEARL. GOOD STRENGTH IN ALL EXTREMITIES. HAD MRI AND MRA OF HEAD PERFORMED TODAY W/O INCIDENCE. DID C/O OF HA S/P MRI DUE TO POUNDING AND WAS MEDICATED WITH 2 TYLENOL WITH GOOD EFFECT. HCT STABLE AT 28.8. INR 1.0 AND PLT 80 TODAY. CAROTID NONINVASIVE STUDIES DONE TODAY. PER TECH HE HAD < 40% OCCLUSION OF BOTH CAROTID ARTERIES.\nRESP- SATS DOWN TO 90% THIS AM ON RA. PLACED ON 2L NC WITH SATS 95-100%. PA AND LAT CXR DONE SHOWING RIGHT PLEURAL EFFUSION. DR ATTEMPTED TO PLACE CHEST TUBE TO DRAIN EFFUSION BUT WAS UNSUCESSFUL DUE TO PLEURAL THICKENING. TO GO FOR CHEST CT THIS EVENING TO HELP DIFFERENTIATE IF THIS IS BLOOD OR FLUID. BS CLEAR UPPER DECREASED AT BASES ESPECIALLY RIGHT. DOING IS Q 1 HOUR AS INSTUCTED. COUGHING AND DEEP BREATHING WHEN ASKED. COUGH SOUNDS WET. IT IS NONPRODUCTIVE.\nCARDIAC- EPISODE OF BRADYCARDIA AS IN NOTE ABOVE WHILE PATIENT WAS DEFICATING TODAY. CARDIOLOGY CONSULTED. EP TO SEE PATIENT FOR ? PACEMAKER. ? IF BRADYCARDIC EPISODES CAUSE OF PATIENT'S FALLING. HR IN THE 50-60'S SB TO NSR EXCEPT FOR THE ONE EPISODE OF HR DOWN TO 33. SBP 115 TO 122 EXCEPT FOR THE HYPOTENSION ASSOCIATED WITH THE BRADYCARDIC EPISODE.\nGI- ABD SOFT WITH HYPOACTIVE BS. HAD LARGE BROWN STOOL TODAY THAT WAS GUIAC NEG. DIET ADVANCED TO DAT TODAY. HE HAD 500CC IN PO AND ATE A TUNA .\nGU- INCONTINENT OF LARGE AMOUNTS OF URINE TODAY. DIAPERS CHANGED PRN THROUGHOUT THE DAY.\nACTIVITY- DID NOT GET OUT OF BED TODAY DUE TO BRADYCARDIC EPISODE. DR MADE AWARE OF THIS.\nID- PATIENT AFEBRILE. WBC 49.8 RELATED TO CLL.\nSOCIAL- DAUGHTER IN AND VISITED TODAY. HER QUESTIONS WERE ANSWERED BY NURSING. DR ALSO CALLED HER AT HOME AND UPDATED HER.\nDISPO- REMAINS IN THE MICU A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2138-10-21 00:00:00.000", "description": "Report", "row_id": 1435581, "text": "FOCUS; ADDENDUM\nRESP- CHEST CT PERFORMED. RESULTS PENDING.\nCARDIAC- EP UP TO SEE PATIENT. HE IS SCHEDUALED FOR PACER PLACEMENT AT 0730 IN THE AM. HE IS ORDERED TO BE NPO AFTER MN.\n" }, { "category": "Nursing/other", "chartdate": "2138-10-21 00:00:00.000", "description": "Report", "row_id": 1435582, "text": "focus; addendum\nCARDIAC- ORDER WRITTEN FOR IV OF LR TO START AT MN AT 40CC/HR.\n" }, { "category": "Nursing/other", "chartdate": "2138-10-22 00:00:00.000", "description": "Report", "row_id": 1435583, "text": "Nursing Progress Note\nNeuro: Awake, alert, oriented x3. C/O Rt sided chest, arm pain with movement.\nResp: Sats > 96% on 2l NP. BS clear, diminished at bases bilat.\nCV: No further bradycardic/hypotensive episodes over night. Pacing pads applied to anterior chest, attempted to test for capture after giving pt total 1mg Midazolam IV, had to abort testing at 50mA d/t pt discomfort.\nGI: NPO since 2400 in prep for permanent pacer placement in EP lab at 0730 this morning. Hypoactive bowel sounds, no stool overnight.\nGU: Incont large amts urine in diapers. Unsuccessful attempts to insert Foley, 18, 20Fr, 20Coude. IVF LR @ 40ml/hr begun at 2400.\nSocial: Full code. Pt's daughter in to visit in evening, updated re: POC.\n" }, { "category": "Nursing/other", "chartdate": "2138-10-20 00:00:00.000", "description": "Report", "row_id": 1435576, "text": "MICUB 0700-\n\nNeuro: No deficits noted, MAE w/=strength. PERLA. Pt. anxious to find out why he is having dizzy spells and weakness in LE. Remains alert and oriented x3.\n\nCV: Sinus brady. B/P stable. Transthoracic echo and ECG done.\n\nResp: Lungs clear to rhonchorus @ times, decreased in bases. Congested cough, swallows secretions.\n\nGU: Voids in urinal w/occassional incontinence, states he has to go fast when he needs to go. Random UA pending. Intake=IV fluids, LR @50/hr. c/o being hungry. Remains NPO for now until tests are completed.\n\nGI: No stools today. Distant bowel sounds.\n\nID: Afebrile. No issues.\n\nSocial: Daughter in, neuro medical team updated her on tests planned to search for etiology of syncope.\n\nPlan: ECG done today, needs reviewing.Plan for Holter @ some point.\n Transthoracic echo done, needs reviewing.\n Corotid ultrasound planned for .\n MRI and MRA planned for somewhere around 0800 on .\n Seen today by DR. (neurosurgery), he reports from CT\n Scan, ? pitutary tumor. Pt. believes he just has troubles w/\n his balance that we will fix w/meds. Support and orientation\n to procudures given. ,RN\n\n\n" }, { "category": "Nursing/other", "chartdate": "2138-10-21 00:00:00.000", "description": "Report", "row_id": 1435577, "text": "Nursing Progress Note\nNeuro: MAE equally, oriented x3. Needs much assistance/prompting turning side-side in bed. Transported to CT for head scan overnight without incident, prelim report-> no change from previous scan.\nResp: Sats > 95% on RA. Has dry cough, BS clear bilat, diminished at bases.\nCV: Stable SB-SR 50's-60's, no ectopy SBP 110-120\nGI: NPO, + bowel sounds, no stool\nGU: Incont large amts yellow urine in diaper. IVF LR @ 50ml/hr\nSkin: Ecchymosis surrounding Rt eye/forehead, otherwise intact.\nSocial: Pt's daughter and son-in-law in to visit earlier, updated. Plan for MRI/MRA of head, carotid U/S today. Anticipate call out to floor later this AM.\n" }, { "category": "Nursing/other", "chartdate": "2138-10-21 00:00:00.000", "description": "Report", "row_id": 1435578, "text": "FOCUS; PRE MRI/MRA\nMRI CHECK LIST FILLED OUT BY QUETIONING PATIENT. HE STATED HE WAS A MEDAL WORKER. WHEN QUESTIONED AS TO IF HE HAD EVER GOTTEN ANY METAL IN HIS EYE HE STATED NO. HE ALSO STATED HE HAD AN MRI LAST YEAR AND HAS NOT WORKED WITH METAL SINCE. MRI CALLED AND INFORMED OF THIS. THEY STATE HE DOES NOT NEED FILMS DONE OF HIS ORBITS.\n" }, { "category": "Nursing/other", "chartdate": "2138-10-21 00:00:00.000", "description": "Report", "row_id": 1435579, "text": "FOCUS; ALTERATION IN CARDIAC STATUS.\nO. PATIENT MOVING HIS BOWELS ON THE BEDPAN WHEN HIS HR DROPPED TO 33 WITH SBP OF 66. PATIENT WITH C/O OF NAUSEA AT THE TIME. DR NOTIFIED. BP AND HR UP TO SBP 130'S HR 60'S IN MINUTES. PATIENT FELT OK AFTER THIS EPISODE AS NAUSEA HAD SUBSIDED. DR WAS UP TO SEE THE PATIENT AND WILL LET DR KNOW OF THE EVENT.\n" } ]

[ { "category": "Radiology", "chartdate": "2126-09-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 773708, "text": " 11:05 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate/chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with dyspnea on exertion recent admission for chf\n REASON FOR THIS EXAMINATION:\n r/o infiltrate/chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81 year old man with dyspnea on exertion with recent admission for\n CHF.\n\n COMPARISON: \n\n PA AND LATERAL CHEST: There are medial sternotomy wires and surgical clips\n seen over the cardiac silhouette consistent with CABG. The cardiac silhouette\n is enlarged. There is bilateral pulmonary edema with bilateral pleural\n effusions. There is calcification seen in the aortic arch. The visualized\n bones are within normal limits.\n\n IMPRESSION: Cardiomegaly with pulmonary edema and bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2126-09-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773721, "text": " 7:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with incr sob\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: .\n\n FINDINGS: The cardial-pericardial silhouette is enlarged but unchanged.\n Calcification of the transverse aorta is again identified, and the patient is\n status post median sternotomy and CABG.\n\n Diffuse haziness of the pulmonary vasculature with peribronchial cuffing is\n present and slighlty worse when compared with the prior exam. Also noted is\n bibasilar air space disease, left greater than right, with obscuration of each\n hemidiaphragm and blunting of each costophrenic angle, all of which is worse.\n No acute bony abnormalities are identified.\n\n IMPRESSION: Cardiomegaly with worsening interstitial edema and bilateral\n pleural fluid collections, consistent with worsening congestive heart failure.\n\n" }, { "category": "ECG", "chartdate": "2126-09-28 00:00:00.000", "description": "Report", "row_id": 165958, "text": "Sinus tachycardia. Left bundle-branch block. Since the previous tracing\nof no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-09-27 00:00:00.000", "description": "Report", "row_id": 165959, "text": "Probable sinus tachycardia. Borderline first degree A-V delay. Left\nbundle-branch block. Since the previous tracing of further\nintraventricular conduction delay/left bundle-branch block is present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2126-09-22 00:00:00.000", "description": "Report", "row_id": 165960, "text": "Sinus rhythm\nLong QTc interval\nQRS changes V3/V4 - probably due to LVH but consider anterior infarct\nLVH with secondary ST-T changes\nIntraventricular conduction delay\nLeft atrial abnormality\nSince previous tracing, complete left bundle branch block is gone\n\n" }, { "category": "Nursing/other", "chartdate": "2126-09-28 00:00:00.000", "description": "Report", "row_id": 1434384, "text": "CCU NURSING NOTE\nPT IS AN 81 TO MAN WITH SEVERE CARDIOMYOPATHY/AORTIC TRANSFERRED FROM 3 AT 0700 IN SEVERE CHF SATTING IN 80'S ON 100% NRB, ON DOPAMINE AT 6 MCGS/KG W/BP 80'S/; HR INITIALLY 100 ST W/BBB W/PVC'S QUICKLY NOTED TO LOSE P-WAVES W/WIDENED COMPLEX AND HR SLOWING TO 60'S W/PVC'S, DOPAMINE TITRATED TO INCREASE HR, PT INITIALLY AWAKE THEN LOST CONSCIOUSNESS W/RESP ARREST - BAGGED, ARREST CALLED, CPR INITIATED - HR 40-70'S PEA (SEE ARREST FORM), PT INITIALLY BUT NOT DNR PER SELF AND FAMILY, FAMILY THEN MADE PT DNR, ARREST CALLED AT 0757, FAMILY IN W/PATIENT, FAMILY DECLINED POST MORTEM EXAM ACCORDING TO CCU TEAM.\n" } ]

[ { "category": "Echo", "chartdate": "2191-03-24 00:00:00.000", "description": "Report", "row_id": 73389, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. ?tamponade.\nHeight: (in) 66\nWeight (lb): 131\nBSA (m2): 1.67 m2\nBP (mm Hg): 110/80\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nLimited transthoracic imaging in the electrophysiology laboratory demonstrates\nthe presence of a trivial pericardial effusion without evidence of tamponade.\nContractile function of the left ventricle (in atrial fibrillation) appears to\nbe reduced. Further imaging performed immediately after direct current\ncardioversion to sinus rhythm demonstrated slight improvement of overall left\nventricular ejection fraction.\n\n\n" }, { "category": "Echo", "chartdate": "2191-03-24 00:00:00.000", "description": "Report", "row_id": 73354, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nStatus: Inpatient\nDate/Time: at 14:29\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient under general anesthesia, intubated.\nLEFT ATRIUM: The left atrium is normal in size. All four pulmonary veins could\nnot be identified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\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 rhythm appears to be\natrial fibrillation. The rhythm appears to be atrial flutter. The results were\npersonally reviewed with the physician caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Visualization of pulmonary veins was\ntechnically challenging. Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is a trivial/physiologic pericardial effusion.\nThere are no echocardiographic signs of tamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2191-03-24 00:00:00.000", "description": "Report", "row_id": 73355, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Pericardial effusion.\nHeight: (in) 66\nWeight (lb): 131\nBSA (m2): 1.67 m2\nStatus: Inpatient\nDate/Time: at 13:10\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is 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: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. No 2D echo or Doppler evidence\nof coarctation of the distal aortic arch.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\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 60%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. There is a trivial/physiologic pericardial effusion.\nThere are no echocardiographic signs of tamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2191-03-25 00:00:00.000", "description": "Report", "row_id": 73376, "text": "PATIENT/TEST INFORMATION:\nIndication: followup, pericardial effusion.\nStatus: Inpatient\nDate/Time: at 12:03\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nOverall left ventricular systolic function is low normal (LVEF 50-55%). There\nis no resting left ventricular outflow tract obstruction.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is low normal (LVEF 50-55%). The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. There is\nno pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2191-03-25 00:00:00.000", "description": "Report", "row_id": 166620, "text": "Atrial fibrillation\nNonspecific ST-T wave changes\nConsider early repolarization\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2191-03-24 00:00:00.000", "description": "Report", "row_id": 166621, "text": "Atrial fibrillation\nNonspecific ST-T wave changes - consider early repolarization\nSince previous tracing, ST changes have improved\n\n" }, { "category": "Nursing/other", "chartdate": "2191-03-24 00:00:00.000", "description": "Report", "row_id": 1378815, "text": "ccu nursing progress note\n26yr old adm to ccu for monitoring s/p attempted ablation for monitoring of ?pericardial effusion\n pmh: afib x sev months. resistant to meds and attempts at cdv.\n\nros: ms: a+o x3. moving all extremities. concerned about return to afib. awaiting removal of foley cath.\nid: afeb.\ncv: hr 70s sr on arrival from pacu. converted spon to afib with rates 90-110, occ bursts to 120-130. team aware of rhythm change. ekg completed. pt aware w feeling of palpitiations. bp stable at 110-130/60-80. min pulsus noted.\necho completed in pacu noted minimal effusion, nml lv fxn.\nwill repeat echo tomorrow.\nr and l fem sheaths removed in pacu. cn sit up at 3:30pm. sites d/i. pulses palp.\n\nresp: dim at bases, cta. sat 100% on 2lnc.\ngi: offered drink but pt declined. no n/v.\ngu: foley to w good uop.\nrec'ing ns at 75cc/hr. to complete w 500cc infused.\n\na: s/p eps, attempted ablation. back in afib\np: follow rhythm/hemodynamics. monitor for s/s of pericardial effusion. assess for bleeding complications. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2191-03-24 00:00:00.000", "description": "Report", "row_id": 1378816, "text": "CCU NPN 3-11pm\nCV: hemodynamically stable, HR 70-90 a.fib, no ectopy. BP 100-120/60. On po dilt. No pulses paradox. Groin sites without bleeding or hematoma, DP, PT pulses palpable. LS clear, sat 100% on RA. Completed 500cc NS IV. 1 peripheral IV. Flat in bed until 3:30PM, able to stand at side of bed or use bedside commode with assistance.\n\nGI/GU: eating reg dinner. Foley dc'd, voided in urinal, stood at side of bed with assist.\n\nCoping: asking appropriate questions of RN/MD's. A little apprehensive, but reassured after discussion with EP fellow.\n\nA/P: pt with a.fib, s/p attempted ablation c/b sm pericardial effusion, back in a.fib since earlier today. Stable. Watch overnight.\n" }, { "category": "Nursing/other", "chartdate": "2191-03-25 00:00:00.000", "description": "Report", "row_id": 1378817, "text": "CCU Nursing Note 2300-0700: Pericardial Effusion\nS-\"I'm okay.\n\nO-PLEASE SEE CAREVUE FOR ALL OBJECTIVE DATA AND VSS\n\nUNEVENTFUL NIGHT. DILTIAZEM HELD ACCORDING TO PARAMETERS.\nVSS REMAING STABLE TRHOUGHOUT NIGHT. GROIN CDI WITH NO HEMATOMA\n\nPLS SEE TRANSFER NOTE FOR COMPLETE ASSESMENT\n\nA/P: 26 YO S/P EBLATION WITH SMALL PERICARDIAL EFFUSION. TX TO CCU FOR 24HR MONITORING\n\nTRANSFER TO FLOOR TODAY\n" }, { "category": "Nursing/other", "chartdate": "2191-03-25 00:00:00.000", "description": "Report", "row_id": 1378818, "text": "CCU Nursing Discharge Note-\n\nCV- 70-100 Afib w/ BP 98-110/60-70. On Diltiazem 180 mg qd, Amiodorone 400 mg qd, and ASA 325 qd. HD stable on above Rx.\nDecision to d/c to home by Cardiology and CCU Team.\nPt given explicit d/c instructions wh/ included:\n*Visit by of Hearts to review resumption of recorder @ home. Instructed to send strip qd and if sx occur.\n*REview of prescriptions of above/d/c medications.\n*Plant of TB on R arm- will return to CCU in 48 hours for read by CCU Team MDs\n*CXRAY done prior to d/c for baseline re: initiation of Amiodarone.\n*Pt instructed to contact Dr. office or CCU for any questions, concerns.\nPt ambulated to CC- lobby/discharge lounge via elevator w/ CCU RN- , RNC. He will obtain a cab, or call home for a ride to get home.\n*\n\n" } ]

[ { "category": "Echo", "chartdate": "2110-05-16 00:00:00.000", "description": "Report", "row_id": 65965, "text": "PATIENT/TEST INFORMATION:\nIndication: Meningitis. Endocarditis.\nHeight: (in) 65\nWeight (lb): 117\nBSA (m2): 1.58 m2\nBP (mm Hg): 97/57\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 15:00\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\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. 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.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. No masses or vegetations are seen on\nthe aortic valve. The mitral valve leaflets are structurally normal. There is\nno mitral valve prolapse. No mass or vegetation is seen on the mitral valve.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: No vegetations seen. Mild mitral regurgitation in a\nstructurally-normal valve.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-05-15 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1243611, "text": " 9:25 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for evidence of encephalitis, communication between sin\n Admitting Diagnosis: SEIZURE\n Contrast: GADAVIST Amt: 6\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with hx of TBI with prior skull fracture presenting with\n seizures, fever, and HA - likely bacterial meningitis in setting of sinusitis\n REASON FOR THIS EXAMINATION:\n eval for evidence of encephalitis, communication between sinuses and\n intracranial cavity given hx of fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of traumatic brain injury with prior skull fractures\n presenting with seizures, fever and headache.\n\n COMPARISON: Outside hospital CT head from and CT head from\n .\n\n TECHNIQUE: MRI of the head was obtained before and after administration of\n contrast per department protocol.\n\n FINDINGS: There is diffuse leptomeningeal enhancement and enhancement along\n the margins of the ventricles. An area of slow diffusion seen within the\n occipital horns bilaterally, left more than right. There is no acute\n intracranial hemorrhage or infarction. Encephalomalacic changes are seen in\n bilateral frontal lobes. On the gradient echo images, there are multiple\n areas of abnormal susceptibility scattered in bilateral cerebral hemispheres,\n may represent old blood products. There is no hydrocephalus or midline shift.\n Major intracranial flow voids are preserved. There is polypoid mucosal\n thickening in the sphenoid sinus. Mild mucosal thickening is seen in\n bilateral maxillary sinuses with fluid levels on the left. There is mild\n fluid signal in bilateral mastoid air cells.\n\n IMPRESSION:\n 1. Diffuse enhancement of the leptomeninges and along the margins of the\n lateral ventricles with fluid-fluid levels in the occipital horns showing slow\n diffusion. Findings are concerning for leptomeningitis with ventriculitis and\n intraventricular pus.\n\n 2. Encephalomalacic changes in the frontal lobes bilaterally, likely from\n prior trauma.\n\n Findings discussed by Dr with Dr over phone on\n at 11:50 am.\n\n" }, { "category": "Radiology", "chartdate": "2110-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243495, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: monitor resp status\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with seizures, intubated\n REASON FOR THIS EXAMINATION:\n monitor resp status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old with seizures, assess for respiratory status after\n intubation.\n\n COMPARISONS: .\n\n Endotracheal tube terminates in the mid trachea, 3.1 cm above the carina.\n Nasogastric tube courses into the stomach and out of view. Otherwise, the\n lungs appear clear aside from minimal left basal atelectasis. without pleural\n effusion or pneumothorax. The heart is normal in size with normal\n cardiomediastinal contours.\n\n IMPRESSION: No acute intrathoracic process.\n\n" }, { "category": "Radiology", "chartdate": "2110-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243480, "text": " 8:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 33F with tx from osh intubated\n REASON FOR THIS EXAMINATION:\n confirm tube placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison with an outside hospital study from three hours earlier.\n\n CLINICAL HISTORY: Outside hospital intubated, confirm ET tube position.\n\n FINDINGS: AP supine portable chest radiograph is obtained. Endotracheal tube\n tip resides 2.5 cm above the carina. NG tube courses into the left upper\n abdomen, tip not included in field of imaging. The lungs appear mostly clear\n bilaterally. There may be a tiny retrocardiac atelectasis. No large effusion\n is seen. Cardiomediastinal silhouette appears normal. No bony abnormalities\n are detected.\n\n IMPRESSION: ET and NG tubes positioned appropriately. Possible left lower\n lobe mild atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-05-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1243554, "text": " 1:39 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with meningitis\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate line placement in patient with meningitis.\n\n COMPARISON: Most recent radiograph from earlier today, at\n 04:20.\n\n FINDINGS: Bedside semi-upright AP radiograph of the chest demonstrates a new,\n appropriately-positioned, left subclavian central venous catheter, terminating\n in the lower portion of the superior vena cava. There is no pneumothorax or\n other evidence of immediate complication. The endotracheal tube terminates\n 3.9 cm above the carina, also appropriate. An OGT courses into the stomach\n and inferior beyond the field of view. Aside from a new, small focus of\n linear atelectasis at the right costophrenic angle, the remainder of the\n examination is unchanged from approximately 9 hours earlier.\n\n IMPRESSION:\n\n 1. Appropriate positioning of new left subclavian central line terminating in\n the low SVC, without evidence of complication. All other tubes and lines are\n well-positioned.\n\n 2. New minimal right basilar atelectasis, stable minimal left basilar\n atelectasis. Otherwise unchanged from this morning.\n\n" }, { "category": "Radiology", "chartdate": "2110-05-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1243890, "text": " 2:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 45 cm right Picc Peg \n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 45 cm right Picc Peg \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study, .\n\n Right PICC tip is in the lower SVC. There is no pneumothorax.\n Cardiomediastinal contours are normal. Bibasilar opacities larger on the\n right side have increased, consistent with increasing atelectasis and pleural\n effusion.\n\n PICC location was discussed with IV nurse, , at the time of the\n interpretation of the study at 3:00 p.m.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2168-05-31 00:00:00.000", "description": "Report", "row_id": 76663, "text": "PATIENT/TEST INFORMATION:\nIndication: 39yo with AML admitted febrile, extra heart sound.\nHeight: (in) 60\nWeight (lb): 101\nBSA (m2): 1.40 m2\nBP (mm Hg): 130/70\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 13:01\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Low normal\nLVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve. No AS.\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. 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 normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nNo masses or vegetations are seen on the aortic valve. There is no aortic\nvalve stenosis. The mitral valve appears structurally normal with trivial\nmitral regurgitation. No mass or vegetation is seen on the mitral valve. The\nestimated pulmonary artery systolic pressure is normal. There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the\nLV systolic function appears slightly less vigorous.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-06-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 872784, "text": " 12:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please check for PICC line placement right basilic for home\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA: NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with AML, neutropenic fever, and cough with pleuritic chest\n pain\n REASON FOR THIS EXAMINATION:\n Please check for PICC line placement right basilic for home antibx.\n Thanks! #\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML, neutropenic fevers, status post right PICC placement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: There has been interval placement of a right-sided PICC. The PICC\n wire is visualized to the SVC/RA junction. The tip of the catheter is poorly\n visualized beyond the wire. The heart size and mediastinal contours are\n within normal limits. The lungs are clear. No pleural effusion and no\n pneumothorax. The osseous structures appear unchanged.\n\n IMPRESSION:\n 1. Status post placement of right-sided PICC. The PICC wire terminates at\n the SVC/RA junction. The catheter tip is poorly visualized beyond the wire.\n Findings were discussed with of IV therapy at the time of\n interpretation.\n 2. No acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 872526, "text": " 11:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: History of pleural effusions, are there changes?\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA: NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with AML, neutropenic fever, and cough with pleuritic chest\n pain\n REASON FOR THIS EXAMINATION:\n History of pleural effusions, are there changes?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old female with neutropenic fever.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS: The heart is of normal size. Mediastinal and hilar contours are\n within normal limits. The lung fields are clear. There is interval\n improvement of bibasilar opacities. There are no obvious pleural effusions.\n The keletal structures are unremarkable.\n\n IMPRESSION: Interval improvement of bibasilar opacities. The lung fields are\n clear. There is no evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 872332, "text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare to prior - status of bibasilar and retrocardiac opac\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA: NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with AML, neutropenic fever, and cough with pleuritic\n chest pain\n REASON FOR THIS EXAMINATION:\n compare to prior - status of bibasilar and retrocardiac opacities\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST DATED .\n\n COMPARISON: One day earlier.\n\n INDICATION: Neutropenic fever, cough and pleuritic chest pain.\n\n The examination is technically limited due to lack of collimation and\n suboptimal exposure technique. Cardiac and mediastinal contours are within\n normal limits. The lung volumes are quite low. There are hazy and patchy\n opacities at both lung bases, apparently slightly worse on the left in the\n interval with greater silhouetting of the left hemidiaphragm contour than\n before. There has been interval removal of a left subclavian vascular\n catheter with no pneumothorax.\n\n IMPRESSION: Limited chest radiograph demonstrating patchy bibasilar\n opacities, left greater than right, with slight worsening at the left base.\n Given history of fever and cough, evolving aspiration pneumonia should be\n considered. Attention to this area on follow- up chest radiograph with\n improved technique would be helpful.\n\n" }, { "category": "Radiology", "chartdate": "2168-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 872257, "text": " 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O effusion\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA: NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with AML, neutropenic fever, and cough needs to r/o\n infection.\n REASON FOR THIS EXAMINATION:\n R/O effusion\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: One day earlier.\n\n INDICATION: Cough and fever.\n\n The left subclavian vascular catheter remains in satisfactory position in the\n superior vena cava. Cardiac and mediastinal contours are stable allowing for\n differences in lung volumes. There has been interval development of a\n layering right pleural effusion. There is also new patchy increased opacity\n within both lung bases, particularly in the left retrocardiac region.\n\n IMPRESSION:\n 1. New patchy bibasilar opacities, particularly in the left retrocardiac\n region. Given rapid development, this may represent aspiration or\n atelectasis. The rapidity of development would be unusual for infectious\n pneumonia.\n 2. New right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 872192, "text": " 4:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: neutropenic fever r/o pneumonia\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA: NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with AML, neutropenic fever, and cough needs to r/o\n infection.\n REASON FOR THIS EXAMINATION:\n neutropenic fever r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML with neutropenic fever and cough, evaluate for pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: A left subclavian venous access catheter is again seen with tip\n terminating in the mid SVC. The heart size and mediastinal contours are\n within normal limits. The pulmonary vascularity appears unremarkable. No\n focal pulmonary parenchymal consolidation is identified. No pleural effusion\n and no pneumothorax. The surrounding osseous structures appear unchanged.\n\n IMPRESSION: Stable radiographic appearance of the chest. No evidence of\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2168-05-28 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 872221, "text": " 1:24 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: CP, DESATS\n Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA: NEUTROPENIA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with AML/neutropenia now with plueritic chest pain, new\n desat, tachycardia.\n REASON FOR THIS EXAMINATION:\n Evaluate for PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old woman with neutropenia and pleuritic chest pain and\n hypoxia.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet to the upper abdomen in the pulmonary arterial phase. Oblique\n sagittal reformatted images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITH CONTRAST: There is no evidence for pulmonary\n embolus. There is no pathologically enlarged axillary, mediastinal, or hilar\n lymphadenopathy. The pericardium is unremarkable. The airways are patent to\n the subsegmental level bilaterally. The lung fields show minimal bibasilar\n atelectasis, right greater than left. The visualized intraabdominal viscera\n are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or blastic osseous lesions.\n\n CT REFORMATS: Oblique sagittal reformatted images confirm the axial findings.\n\n IMPRESSION: No evidence of pulmonary embolus. Bilateral lung base\n atelectasis. No evidence for consolidation.\n\n\n" }, { "category": "ECG", "chartdate": "2168-06-03 00:00:00.000", "description": "Report", "row_id": 197142, "text": "Sinus rhythm. Within normal limits. Compared to the previous tracing of \nno significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2168-05-31 00:00:00.000", "description": "Report", "row_id": 197143, "text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2168-05-27 00:00:00.000", "description": "Report", "row_id": 197144, "text": "Sinus tachycardia\nModest nonspecific inferior T wave changes\nSince previous tracing of , sinus tachycardia and modest T wave changes\npresent\n\n" }, { "category": "ECG", "chartdate": "2168-05-28 00:00:00.000", "description": "Report", "row_id": 197145, "text": "Sinus tachycardia\nOtherwise normal ECG\nSince previous tracing of , sinus tachycardia rate and inferior T wave\nchanges decreased\n\n" }, { "category": "Nursing/other", "chartdate": "2168-05-29 00:00:00.000", "description": "Report", "row_id": 1450365, "text": "Nursing Assessment Note 1900-0700\nNEURO: Pt speaks mostly cantonese, but is able to answer \"YES or NO\" questions and makes needs known, pt moves all extremities slowly and can reposition self in bed, PERL\n\nCV: Pt's vss, afebrile, pt c/o chest pain with deep inspiration, EKG done without changes, md IV, pt received 4 mg IV with good effect, pt had hickman tunnel cath D/C'd, and was medicated with additional total of 8 mg and 2 mg versed for pain during removal, removal was slightly traumatic, and pt has dry sterile dsg applied to insert site and incision made to loosen up scar tissue holding cath in place, pt received 2 units PRBC's during day and 2nd unit finished at begining of my shift, pt has #20 in left hand with NS @ kvo infusing well without problems\n\nRESP: Pt's lung sounds revealed crackles in bases at begining of my shift, but by midnight bases were clear, but diminished, when pt c/o chest pain, pt placed on O2 @ 3 L V/NC, with sats 98-100%, pt sats on R/A were 93-95%, pt denies cough or sob at this time\n\nGI: Pt able to tolerate po liquids well without N/V, but pt does not seem to have a big appitite taking only a few bites from dinner tray, bowel sounds are positive, with soft abd, pt did not want stool softners this evening\n\nGU: Pt's foley draining clear yellow urine qs\n\nENDO: Pt's midnight blood sugar was 98, no coverage needed\n\nINTUG: Pt has left breast DSD which is clean, dry, and intact, and right posterior hip/buttock dsg which is clean, dry, and intact\n" }, { "category": "Nursing/other", "chartdate": "2168-05-29 00:00:00.000", "description": "Report", "row_id": 1450366, "text": "Addendum Note\nPt slept rest of night without complaints or problems, pt had no drainage from left breast dsg, which remains clean, dry, and intact, am blood sugar was 118, no coverage needed\n" }, { "category": "Nursing/other", "chartdate": "2168-05-29 00:00:00.000", "description": "Report", "row_id": 1450367, "text": "nursing progress note: neutropenic prec and contact for MRSA. allergic to vancomycin and full code\n\nNEURO: MAE PERL, A&O x3, c/o numbness in rt leg and has been told this is due to chemo . c/o dizziness but is not orthostatic. pt able to ambulate to toilet without c/o dizziness. ho aware.\n\ncard: tachy 110-125 NSR with bp 100-120 sys. no ectopy. pulse did not decrease with fluid replacement of 500 cc overr 2 hr as ordered.\n\nresp: xray showed rt pleural effusion and basilar opacities. sat 98-100 on 2l nc and 95-96 on ra. no cough or sputum\n\ngi: pt had lg bm in toilet not guiaced. no obvious blood.\ntaking resource and boost. few bites of solid food. encouraged to take po fluids.\ngu: lg amts output, lt to clear urine, urine sent for lytes and osmo.\nneg balance of 960 cc currently. replaced output with 500 cc ns x1.\n\nheme: crit at 1600 33.3 and plat cnt down to 52, no products given today. per hem onc the bone marrow show prob return aml but pt and family have not been told.\n\nendo : d/c insulin and fs as glu WNL:\n\naccess: placed 2nd periphera line and both perrpheral lines working\n well. dsg over old hickman site D&I>\n\nID: remains on triple antibx , afebrile today and has not had tylenol today.\n\nsocial: pt family in. social services need to talk with them for assistance in getting twin sister to us for bmt. interpreter needed to explain plan and procedures ( cantonese)\n\nplan: encourage pt get oob and improve resp status with incent spirometry. transfer but not planned currently.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-05-28 00:00:00.000", "description": "Report", "row_id": 1450364, "text": "39 yr old pt with AML and fever with 4/4 pos bc with gm pos growth. placed on contact for poss MRSA. admitted to icu for feveer and hypotension.\n\nneuro: A&O sleepy MAE , pt understands some english and requires simple explaination\n\ncard: bp 92-110 sys NSR 95-122,\n\nresp: clear upper lobs with diminished LL, on 2l nc with sat 97-98. earlier sat dropped with HR increasing and pt c/o being cold and pt given tylenol to avoid temp spike.\n\nhem: wbc .4 crit dropped to 20 prob due to 5+ liter infused and transfused with 1 unit and then 2nd unit up at 1535 for hct 24.\nBONE MARROW BX DONE BY HEM ONC FELLOW TO EVAL FOR CURRENT PRESENCE OF AML, IF NOT PRESENT IN BM START ON NEUPOGEN TO RAISE WBC. pt premedicated with benedryl for blood.\n\naccess: hickman in x 2 months and pt with pos bc and may d/c line perpheral line placed and using. only able to draw red port of hickman. tpa ordered for venous port and is fridge and good to use until 0500 am . did not place as poss that this line will be d/ced soon.\n\nID: triple antibx coverage and allergic to vanco. t max 99.4 1700 and given tylenol at 1700. pt stated she takes tylenol 3x/day at home.\n\ngi: vomited this am?? due to demerol but able to hold down 300= cc fluids and allowing to resume diet. no bm and pt concerned and wants to use camode. pt seems confused about purpose of foley and need to use bed pan for bm.\n\ngu: foley in place and ?? for how long should be in place with low wbc.\nlg vol out with aggressive hydration.\n\npain: c/o insppain and pain in upper chest muscle with moving. tolerable\n\nlytes: phos still low and no replacement ordered this shift.\n\nsocial: pt family aware of statusbut will not be in today. pt has cell phone in bed with her.\n\nplan: poss line d/c and monitor for fev er. hydrated with po fluids now and offer tylenol and antianxiety med PRN.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-05-28 00:00:00.000", "description": "Report", "row_id": 1450363, "text": "micu/sicu nsg note: 3:30-7:00\nthis is a 39 y.o. woman with aml dx in when she presented with neutropenia and low grade fevers. she received chemo treatments and was in remission for 18 months and then finished another chemo treatment in . she presented to the er with neutropenia, fever up to 101.5po and 2 day intermittent myalgias, headache and chest pain. she was seen 3 days ago for f/u after being placed on neurontin 300mg qd for le peripheral neuropathy and pain. pt developed hypotension with sbp down to 90, hr up to 150s, and was treated with 1 liter total of ns boluses. pt was sent to chest ct and ruled out for pna and was transferred to for close monitoring.\n\nneuro: a&ox3, primarily cantonese speaking but understands and speaks some english. mae, requires 1 assist with repositioning.\n\ncv: hr ranging 136 now down to 106 st with no ectopy. bp 92-105/55-63.\n\nresp: lungs cta, sp02 92% on rm air. placed on 2lnc with sp02 100%. rr 21-28. denies sob.\n\ngi/gu: abd soft, nt,nd, + hypoactive bs, c/o nausea and headache and given 0.5mg iv ativan with good effect. foley placed and draining 170-350cc/hr light yellow urine.\n\nskin: cwd&i.\n\nlines: l sc dl hickman intact with sl redness and dry crusted area around exit site. md aware. no drainage noted.\n\nid: t max 99.2po, t current 97 po. bld cx x2 and fungal isolater bld cx and ucx pending. no sputum to send. continues on iv cefepime and daptomycin.\n\nheme: receiving 1 unit prbc for hct of 20.9 infusing over 3 hours. due for next hct check with am labs at 8am.\n\nf/e/n: phosphate level=-1.5, k=3.9. receiving kphos over 6 hours and ns at 125cc/hr.\n\nsocial: lives with husband, no contact with family this shift. pt wishes to wait until the morning to contact her husband.\n\nplan: continue to monitor vs closely with aggressive hydration as ordered. continue 1 unit prbc and obtain hct with am labs at 8am. contine k phos. continue ivabx and monitor micro data. ativan prn nausea. place tpa in blue port of hickman when port not in use as no blood return from blue port. + blood return from red port.\n" } ]

[ { "category": "Radiology", "chartdate": "2141-12-01 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1171444, "text": " 4:17 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Picc power flushed, need recheck for placement\n Admitting Diagnosis: ATRIAL FLUTTER\\ATRIAL FLUTTER ABLATION;TRANSESOPHAGEAL ECHOCARDIOGRAM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with need for second cxr for Picc placement\n REASON FOR THIS EXAMINATION:\n Picc power flushed, need recheck for placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after PICC line placement\n after power flush.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 2:51 p.m.\n\n The current study demonstrates the PICC line tip being still in the left\n brachiocephalic vein before crossing the midline. Since the most distal\n portion of the PICC line was not involved in the field-of-view, the presence\n of the loop in the brachial vein cannot be established.\n\n\n" }, { "category": "Echo", "chartdate": "2141-12-01 00:00:00.000", "description": "Report", "row_id": 96817, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial flutter.\nHeight: (in) 71\nWeight (lb): 238\nBSA (m2): 2.27 m2\nBP (mm Hg): 160/107\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:29\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate to severe spontaneous echo contrast in the body of the\nLA. No mass/thrombus in the LAA. Moderate to severe spontaneous echo\ncontrast in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderate to severe spontaneous echo contrast\nin the body of the RA. No mass or thrombus in the RA or RAA. Moderate to\nsevere spontaneous echo contrast in the RAA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall hypokinesis.\n\nAORTA: Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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 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\nglycopyrrolate was administered. No TEE related complications. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nModerate to severe spontaneous echo contrast is seen in the body of the left\natrium and left atrial appendage. No mass/thrombus is seen in the left atrium\nor left atrial appendage. Moderate to severe spontaneous echo contrast is seen\nin the body of the right atrium and right atrial appendage. No mass or\nthrombus is seen in the right atrium or right atrial appendage. No atrial\nseptal defect is seen by 2D or color Doppler. Overall left ventricular\nsystolic function is normal (LVEF>55%). The right ventricular cavity is\ndilated with moderate global free wall hypokinesis. There are complex (>4mm)\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: No atrial thrombus seen. Moderate to severe spontaneous echo\ncontrast in the left and right atria and left and right atrial appendages.\nNormal left ventricular systolic function. Dilated right ventricle with\ndepressed right ventricular systolic function.\n\nDr. was notified in person of the results on at 9 am.\n\n\n" }, { "category": "ECG", "chartdate": "2141-12-03 00:00:00.000", "description": "Report", "row_id": 271429, "text": "Atrial flutter with rapid ventricular response. Compared to tracing #1 no\ndiagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2141-12-01 00:00:00.000", "description": "Report", "row_id": 271430, "text": "Atrial flutter with controlled ventricular response and variable block.\nDelayed R wave transition. Left anterior fascicular block. Compared to the\nprevious tracing of the ventricular rate is slower.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2163-07-27 00:00:00.000", "description": "Report", "row_id": 271878, "text": "Normal sinus rhythm, rate 72\nEarly transition\nLateral Q waves noted\nAnterolateral ST-T abnormalities, Consider Ischemia\nABNORMAL ECG\n\n" }, { "category": "ECG", "chartdate": "2163-07-28 00:00:00.000", "description": "Report", "row_id": 271879, "text": "Normal sinus rhythm, rate 57\nProminent nterior forces ( ? RVH or posterior MI)\nNonspecific Anterolateral T wave abnormalities\nCannot exclude ischemia\nSince last ECG, no significant change\nABNORMAL ECG\n\n" }, { "category": "Radiology", "chartdate": "2163-08-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 739762, "text": " 3:02 PM\n CHEST (PA & LAT) Clip # \n Reason: ?? pulmonary source for fever\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with\n s/p endovasc aaa with post op fever\n REASON FOR THIS EXAMINATION:\n ?? pulmonary source for fever\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man S/P endovascular repair of AAA presents with\n post-op fever to rule out pneumonia.\n\n COMPARISONS: .\n\n PA AND LATERAL CHEST RADIOGRAPHS: The heart size is normal. The aorta is\n tortuous. The hilar contours and pulmonary vascularity are within normal\n limits. There is interval decrease in the extent of right lower lobe opacities\n consistent with almost complete resolution of atelectasis. There is no\n evidence of pneumonia. There are no pleural effusions. The soft tissues are\n unremarkable. The osseous structures again reveal degenerative changes of the\n spine.\n\n IMPRESSION: 1) Interval decrease of linear atelectasis in the right lower\n lobe.\n 2) No evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-26 00:00:00.000", "description": "ENDOVAS ABD REP W/MOD BIF PROS", "row_id": 739684, "text": " 10:37 AM\n ABDOMINAL AORTA Clip # \n Reason: STENT GRAFT IN OR\n Contrast: OPTIRAY Amt: 120\n ********************************* CPT Codes ********************************\n * ENDOVAS ABD REP W/MOD BIF PROS -62 MAJOR ASST COMB PROCEDURE *\n * -50 BILAT INTRO CATH-AORTA -51 MULTI-PROCEDURE SAME DAY *\n * INTRA VAS FB RETRIEVAL -51 MULTI-PROCEDURE SAME DAY *\n * ENDVASC REP ABD ANEUR RAD S&I PLMT EXT PROS REP ABD ANR S&I *\n * PLMT EXT PROS REP ABD ANR S&I -59 DISTINCT PROCEDURAL SERVICE *\n * TRANSCATHETER RETRIEVAL INTRAV *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Abdominal aortic aneurysm repair with a modular bifurcation\n AneuRx prosthesis and two extension cuffs.\n\n PHYSICIANS INVOLVED IN PROCEDURE: Dr. and Dr. are\n co-surgeons of the procedure performed with the aid of Dr. .\n\n PROCEDURE/TECHNIQUE: Cut downs had been performed bilaterally to expose to the\n common femoral arteries. Subsequently the left side was cannulated and an 8\n french sheath was placed. Over this a 5 french SOS catheter was advanced. An\n Amplatz wire was then placed through the catheter. Subsequently the right\n side was cannulated. Due to the large aneurysm of the right common iliac\n artery we were unable to advance a wire cephalad. We tried a combination of a\n Berenstein catheter with wire and a glidewire. Finally we decided\n to come from the contralateral side and after the right external iliac artery\n was traversed with a glidewire, we snared the wire acrss the right iliac\n system. A straight catheter was then advanced over the glidewire. subsequently\n we removed the guidewire and we advanced two Amplatz wires through each of the\n groins. The main module of stent graft was then advanced through the right\n side. The cephalic portion was advanced passed the expected level of the\n renal arteries. Through the SOS catheter an angiogram was performed to\n delineate the position of the renal arteries. After this was performed, we\n deployed the main portion of the stent graft under fluoroscopic guidance.\n Subsequently, the gate on the left was catheterized using the omniflush\n catheter and glide wire. The 8 french sheath was exchanged for a 16 french\n sheath. A 14 mm balloon was inflated within the gate to confirm that the gate\n was traversed. The iliac limb was then deployed under fluoroscopic guidance.\n\n Subsequently two extension modules were deployed to anchor the limbs of the\n stent graft better. The stent graft does not cover the ostium of the left\n internal iliac artery. Of note the right internal iliac artery had been\n previously embolized and is covered by the graft.\n\n The patient tolerated the procedure well.\n\n COMPLICATIONS: None immediately.\n\n CONTRAST: 210 optiray. Optiray was used due to critical nature of the\n procedure.\n\n (Over)\n\n 10:37 AM\n ABDOMINAL AORTA Clip # \n Reason: STENT GRAFT IN OR\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n MEDICATIONS: None by angio. The procedure was performed under general\n anesthesia.\n\n FINDINGS: Technically successful deployment of an aortic stentgraft with\n appropriate extension into the right external iliac artery and left common\n iliac artery. The patient had a preoperative right internal iliac artery\n embolization. In the final angiogram that was performed, no endoleak was\n observed. The renal arteries are widely patent bilaterally.\n\n IMPRESSION: Technically successful placement of stent graft in the operating\n room.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-07-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739694, "text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n Chest single film.\n\n For CV line placement.\n\n CV line is in proximal SVC. No pneumothorax. Linear atelectases are present\n in both lower zones.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2152-08-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150409, "text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval film\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with hypotension, difficulty weaning vent\n REASON FOR THIS EXAMINATION:\n Eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Difficulty weaning from ventilator.\n\n FINDINGS: In comparison with the study of , there is continued diffuse\n bilateral pulmonary opacification that again could reflect widespread\n pneumonia, vascular congestion, or ARDS. Monitoring and support devices\n remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150055, "text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm process\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with hypoxia, respiratory insufficiency, ?PNA vs edema\n REASON FOR THIS EXAMINATION:\n pulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of hypoxia and respiratory insufficiency.\n\n COMPARISONS: Chest x-ray from .\n\n\n FINDINGS:\n\n Bilateral diffuse opacities demonstrate no significant change when compared to\n radiograph. These findings are likely due to pulmonary edema,\n ARDS and superimposed infection cannot be excluded. Small bilateral pleural\n effusions are unchanged. Hilar, mediastinal, and cardiac silhouettes are\n stable. No pneumothorax is present.\n\n The bony structures appear unremarkable.\n\n Right internal jugular central venous catheter and enteric tube are in\n unchanged and satisfactory position.\n\n IMPRESSION:\n\n Bilateral diffuse opacities demonstrate no significant change from prior exam.\n These findings are consistent with pulmonary edema, ARDS, and superimposed\n infection cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149959, "text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change from prior re: overload, poss PNA\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with new respiratory distress\n REASON FOR THIS EXAMINATION:\n please eval for change from prior re: overload, poss PNA\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate lung abnormalities. Patient with new respiratory\n distress.\n\n Comparison is made with prior study performed eight hours earlier.\n\n There is no interval change in moderate-to-severe pulmonary edema. Cardiac\n size is likely enlarged. The right IJ and enteric tube are in place. Small\n right pleural effusion is unchanged. There is probably also a small left\n pleural effusion. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150503, "text": " 5:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for aspiration, thank you\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with suctioning of bile and worsening respiratory status\n REASON FOR THIS EXAMINATION:\n please eval for aspiration, thank you\n ______________________________________________________________________________\n WET READ: KKgc WED 10:21 PM\n Diffuse bilateral pulmonary opacification, allowing for differences in\n technique, has not changed significantly. This could represent ARDS, pulmonary\n edema. Underlying infection cannot be excluded. Right IJ line and ETT\n unchanged in position. NG tube and intestinal tube course out of view.\n Cardiomegaly, unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Worsening respiratory status.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Extensive bilateral alveolar opacity are unchanged most likely severe\n pulmonary edema, less likely ARDS or infection. Cardiac size is top normal.\n Small bilateral pleural effusions are stable, left greater than right. Lines\n and tubes remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149091, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post-op film, tube/line position\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with s/p R colectomy\n REASON FOR THIS EXAMINATION:\n post-op film, tube/line position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-operative.\n\n FINDINGS: In comparison with the study of , the endotracheal tube has\n been substantially withdrawn with the tip now above the clavicles,\n approximately 7.5 cm from the carina. The central catheter tip is in the mid\n to lower SVC.\n\n There is increasing opacification at the left base with poor definition of the\n hemidiaphragm. This could represent substantial volume loss, though the\n presence of air bronchograms raises the possibility of aspiration or\n infectious process. Mild atelectatic changes are seen at the right base.\n\n Blunting of the left costophrenic angle is consistent with effusion. The\n right lung is essentially clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-07 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1150230, "text": " 9:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Please eval for fluid collection/abscess- with IV and po con\n Admitting Diagnosis: HYPOTENSION\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with cirrhosis, with R colon perf, s/p R hemicolectomy, with\n persistent leukocytosis/fevers. Please eval for fluid collection/abscess\n REASON FOR THIS EXAMINATION:\n Please eval for fluid collection/abscess- with IV and po contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc MON 11:54 PM\n 1. Bilateral apical predominant ground glass opacities with consolidation in\n the mid and lower lungs seen bilaterally. The differential diagnosis includes\n ARDS, asymmetric pulumonary edema. However especially in the lung bases where\n the consolidation is patchy, superimposed infection cannot be excluded.\n 2. Moderate right and small left pleural effusion.\n 3. R IJ catheter ends in the low SVC, ET tube 2.6 cm above carina, \n intestinal tube ends in the jejunum.\n 4. Cirrhosis of the liver, with portal hypertension (recanalized umbilical\n vein and porto-systemic collaterals)\n 5. Small amount of free fluid in the abdomen and pelvis, unchanged since prior\n study. No drainable abscess is seen in the abdomen and pelvis. No free air in\n the abdomen.\n 6. The patient is s/p right colectomy with ileostomy. Oral contrast is seen in\n the ileostomy bag, limiting the evaluation of the pelvis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right colectomy with pathology revealing\n pseudomembranous colitis preenting with leukocytosis and fevers. Evaluate for\n intra-abdominal source.\n\n COMPARISON: CT and radiograph.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest,\n abdomen, and pelvis with intravenous and oral contrast. Coronal and sagittal\n reformations were evaluated.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Patient is intubated with\n nasojejunal endotracheal tube in place. Scattered mediastinal lymph nodes are\n noted with none meeting criteria for pathological enlargement by CT imaging\n and no pathologically enlarged axillary nodes are present. There is diffuse\n opacities involving the majority of the lungs, some of which are solid and\n some of which are ground-glass with slight thickening of the interstitial\n septa outlining the pulmonary lobules. Multiple air bronchograms are also\n noted, however, the mainstem and proximal bronchi appear patent. No\n pneumothorax. Bilateral small to moderate-sized simple pleural effusions with\n adjacent compressive atelectasis is noted, the effusion on the right is\n larger.\n\n (Over)\n\n 9:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Please eval for fluid collection/abscess- with IV and po con\n Admitting Diagnosis: HYPOTENSION\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE ABDOMEN WITH INTRAVENOUS AND ORAL CONTRAST: The liver is shrunken\n with a nodular contour consistent with history of cirrhosis with portal\n hypertension with recanalized paraumbilical vein. A vague sub-cm\n hypoattenuating lesion is noted within the hepatic dome, too small to\n definitely characterize but can be assessed on future imaging given the\n patient's history of underlying cirrhosis. Portal vein remains patent.\n Remaining intra-abdominal organs including the pancreas, spleen, adrenal\n glands which appear bilaterally slightly hypertrophied, and kidneys are within\n normal limits. Scattered retroperitoneal and mesenteric adenopathy is without\n significant change, A moderate amount of intra-abdominal ascites persists\n slightly decreased from the exam. No residual pneumoperitoneum is\n present.\n\n CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: Patient is status post\n right colectomy with chain sutures noted at the resection site and diverting\n ileostomy present with contrast within the ostomy bag. While the remaining\n large bowel is completely decompressed. It does appear slightly thick-walled\n and edematous. Remaining intrapelvic contents are unremarkable. Foley is in\n place. No pathologically enlarged pelvic sidewall or inguinal lymph nodes\n present. A moderate amount of free fluid is noted within the pelvic cavity\n without any rim enhancement or organization.\n\n BONES AND SOFT TISSUES: The included upper thighs are unremarkable with\n diffuse progression of soft tissue anasarca noted. No malignant-appearing\n osseous lesions are present.\n\n IMPRESSION:\n 1. While the remaining colon is completely decompressed, it does appear\n mildly edematous and thickened which may suggest involvement by patient's\n known pseudomembranous colitis. No other intra-abdominal source of fever\n identified with no organized free fluid collection is present.\n\n 2. Diffuse pulmonary opacities including solid and ground-glass opacities.\n In conjunction with respiratory failure findings are most suggestive of\n diffuse alveolar damage/ARDS although the differential includes severe\n multifocal pneumonia or combination of pulmonary edema and/or hemorrhage.\n\n 3. Moderate amount of intra-abdominal ascites. Moderate right and small left\n pleural effusion.\n\n 4. Known cirrhotic-appearing liver with portal hypertension. Vague\n hypoattenuating sub-cm lesion within the hepatic dome can be better\n characterized with dedicated MRI or multiphasic liver exam on non-emergent\n basis.\n (Over)\n\n 9:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Please eval for fluid collection/abscess- with IV and po con\n Admitting Diagnosis: HYPOTENSION\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Updated findings discussed with Dr. on at 9:40 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150247, "text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate/effusion\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD, with resp failure, please eval for\n infiltrate/effusion\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure.\n\n COMPARISON: Chest x-ray from .\n\n FINDINGS:\n\n Diffuse severe bilateral pulmonary opacities are worse when compared to\n study. These findings may represent severe pulmonary edema, ARDS,\n or multifocal infection. Hilar, mediastinal, and cardiac silhouettes are\n difficult to delineate given surrounding opacities. No pneumothorax is\n present.\n\n ET tube is approximately 4.5 cm from the carina. Left IJ tip projects over\n mid SVC. Enteric tube is in nondistended stomach, terminal tip out of view.\n\n Bony structures appear unremarkable.\n\n IMPRESSION:\n\n Interval worsening of the diffuse severe bilateral pulmonary opacities,\n consistent with severe pulmonary edema, ARDS, or multifocal infection.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149225, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for volume overload\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD, intubated post-procedure, please eval for volume\n overload.\n REASON FOR THIS EXAMINATION:\n Please eval for volume overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage liver disease with post-procedure intubation, to assess\n for volume overload.\n\n FINDINGS: In comparison with the study of , there is further increase in\n opacification at the left base that has spread to involve the lower half of\n the left hemithorax. The findings are consistent with developing aspiration\n or infectious pneumonia with elevation of pulmonary venous pressure. Probable\n bilateral pleural effusions with areas of compressive atelectasis.\n\n Monitoring and support devices remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1149034, "text": " 3:02 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: IJ placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Findings were discussed with Dr. on \n approximately at 4:40 p.m.\n\n\n\n 3:02 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: IJ placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman s/p R IJ CVL placement\n REASON FOR THIS EXAMINATION:\n IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after right internal jugular\n central venous line placement.\n\n Portable AP chest radiograph was compared to .\n\n The patient was intubated in the meantime interval with the ET tube being 1.5\n cm above the carina and should be pulled back for at least 2 cm. Right\n internal jugular line tip is at the level of low SVC. There is interval\n development of left lower lobe consolidation that is worrisome for aspiration\n versus infectious process. There is also interval development of left pleural\n effusion. There is no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149862, "text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD, with increasing wbc count. Please eval for\n infiltrate\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Increase in white blood count, patient with ESLD.\n\n Comparison is made with prior study of .\n\n The patient is rotated. Allowing this technical limitation, left perihilar\n and right upper lobe consolidations are unchanged. Left lower lobe aeration\n has minimally improved.\n\n Cardiomediastinal contours are unchanged. Right lower lobe opacity is\n probably unchanged, likely atelectasis. Right pleural effusion is unchanged.\n\n Right IJ and NG tube remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150074, "text": " 7:56 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval for tube placement/PTX\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD and resp failure, intubated for airway protection.\n Please eval for ETT placement/PTX\n REASON FOR THIS EXAMINATION:\n Please eval for tube placement/PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Liver disease and respiratory failure.\n\n FINDINGS: In comparison with the study of earlier in this date, there has\n been placement of an endotracheal tube with the tip approximately 2.3 cm above\n the carina. Diffuse bilateral pulmonary opacifications persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-29 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1148967, "text": " 8:24 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: please evaluate for perforation\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with acute abdominal pain, rebound\n REASON FOR THIS EXAMINATION:\n please evaluate for perforation\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Acute abdominal pain.\n\n AP supine and upright radiographs of the abdomen were reviewed.\n\n There is no free air below the diaphragm. There is central location of the\n bowel loops in the abdomen, which is correlated with the presence of ascites,\n as demonstrated on the CT abdomen obtained the same day later There are no\n pathological air-fluid level that would be worrisome for obstruction.\n Overall, the bowel gas is nonspecific. Please review the CT abdomen from\n and corresponding report.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-02 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1149451, "text": " 2:54 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric dobhoff, thank you\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with need for enteral feeds\n REASON FOR THIS EXAMINATION:\n please place post-pyloric dobhoff, thank you\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 4:42 PM\n Successful placement of post-pyloric nasointestinal tube.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Need for enteral feeds. Please place post-pyloric Dobbhoff tube.\n\n TECHNIQUE: Fluoroscopic-guided nasointestinal tube placement.\n\n FINDINGS: Under fluoroscopic guidance, an 8 French -\n nasointestinal tube was placed with distal tip in the distal duodenum or\n proximal jejunum. Post-pyloric location was confirmed with instillation of\n contrast medium demonstrating tip in the proximal jejunum.\n\n IMPRESSION: Successful placement of post-pyloric nasointestinal tube.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-02 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1149452, "text": ", R. SICU-A 2:54 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric dobhoff, thank you\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with need for enteral feeds\n REASON FOR THIS EXAMINATION:\n please place post-pyloric dobhoff, thank you\n ______________________________________________________________________________\n PFI REPORT\n Successful placement of post-pyloric nasointestinal tube.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149936, "text": " 10:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for fluid overload, other path\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with desats and rapid breathing\n REASON FOR THIS EXAMINATION:\n please eval for fluid overload, other path\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Desaturation and tachypnea.\n\n Comparison is made with a prior study performed the same day earlier in the\n morning.\n\n Cardiomediastinal contours are unchanged. Diffuse multifocal alveolar\n opacities mainly located in the perihilar regions, worsened in the right lower\n lobe are consistent with moderate-to-severe pulmonary edema. A small right\n pleural effusion is unchanged. There is no evidence of pneumothorax. Right\n IJ and NG tube remain in place.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150564, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for worsening ARDS\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD, with possible ARDS, please eval for worsening\n REASON FOR THIS EXAMINATION:\n eval for worsening ARDS\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Possible ARDS with worsening respiratory status.\n\n Comparison is made with prior study performed a day earlier.\n\n Extensive alveolar diffuse opacities have markedly improved on the right.\n Minimally worsened on the left. This is most likely due to asymmetric\n pulmonary edema. As mentioned before, less likely infection. The asymmetry\n and improvement is not typical of ARDS. Right IJ catheter tip is in the lower\n SVC. ET tube tip is 6.4 cm above the carina. Two NG tube tips are below the\n diaphragm out of view. Bilateral pleural effusions are small left greater\n than right.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149381, "text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval film\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with s/p R colectomy\n REASON FOR THIS EXAMINATION:\n Eval interval film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative opacifications, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. There is continued opacification at the left base\n consistent with aspiration or infectious pneumonia. Indistinctness of\n pulmonary vessels is consistent with a substrate of elevated pulmonary venous\n pressure. Probable bilateral pleural effusions with areas of compressive\n atelectasis persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149664, "text": " 10:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: underlying pulmonary process\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with s/p exlap, resolving sepsis now with inc WOB, hypoxia,\n extubated earlier today\n REASON FOR THIS EXAMINATION:\n underlying pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:50 P.M. ON \n\n HISTORY: Hypoxia after surgery. Resolving sepsis.\n\n IMPRESSION: AP chest compared to and 19:\n\n Substantial increase in bilateral pulmonary consolidation particularly in the\n upper lobe and superior segment of the left lower lobe most readily explained\n by severe and rapidly progressing pneumonia. Asymmetric pulmonary edema would\n be a diagnosis of exclusion though certainly possible given the persistent\n moderate cardiomegaly and increasing small-to-moderate right pleural effusion.\n Right internal jugular line ends at the superior cavoatrial junction and a\n feeding tube goes into the duodenum and out of view. No pneumothorax. No\n endotracheal tube. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-07 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1150088, "text": " 9:04 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: please eval for DVT\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with newly edematous UE\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n WET READ: RSRc MON 10:20 AM\n No DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old female with newly edematous left upper extremity.\n\n COMPARISON: None available.\n\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND: The left subclavian vein, jugular\n vein, axillary vein, brachial veins, and cephalic veins demonstrate normal\n color flow and respiratory phasicity. Responses to augmentation, Valsalva,\n and compression maneuvers are appropriate.\n\n IMPRESSION: No DVT.\n\n" }, { "category": "Radiology", "chartdate": "2152-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1150322, "text": " 1:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess underlying cardiopulmonary process and r/o PTX\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with sepsis, R IJ line changed over wire\n REASON FOR THIS EXAMINATION:\n please assess underlying cardiopulmonary process and r/o PTX s/p R IJ line\n change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 50-year-old female patient with sepsis, right internal jugular\n line changed over wire, assess underlying cardiopulmonary process and evaluate\n for pneumothorax.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with the next preceding\n supine chest examination obtained 10 hours earlier during the same day.\n Unchanged appearance of right internal jugular approach central venous line\n apparently exchanged over wire during the interval. No pneumothorax can be\n identified. Previously described NG tube and ETT remain unchanged. The\n previously described bilateral diffuse parenchymal densities consistent with\n pulmonary edema, have cleared up to some degree, but have not disappeared\n completely. Diaphragmatic contours again visible and no major blunting of\n lateral pleural sinuses is observed.\n\n IMPRESSION:\n Partial clearing up of widespread bilateral pulmonary parenchymal densities.\n Coarse not clear. Information about form of treatment, dehydration,\n antibiotics and ventilation pressure may give more hints about genesis of\n infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1148383, "text": " 12:46 AM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with abdominal pain, altered mental status, hypotension\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Abdominal pain.\n\n PA and lateral upright chest radiographs were reviewed with no prior studies\n available for comparison.\n\n Heart size is normal. Mediastinum is normal. Lungs are clear. There is no\n pleural effusion or pneumothorax.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "ECG", "chartdate": "2152-07-31 00:00:00.000", "description": "Report", "row_id": 237541, "text": "Sinus tachycardia. Non-specific T wave abnormalities. Consider drug or\nelectrolyte effect. Compared to the previous tracing of sinus rate is\nfaster. The other findings are quite similar.\n\n" }, { "category": "ECG", "chartdate": "2152-07-26 00:00:00.000", "description": "Report", "row_id": 237542, "text": "Sinus rhythm. Normal tracing. Since the previous tracing of there is no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2152-07-25 00:00:00.000", "description": "Report", "row_id": 237543, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2152-07-29 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1148977, "text": " 10:34 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please evaluate for acute pathology\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD, fever, abdominal pain and rebound\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SUN 6:06 AM\n 1. Cirrhotic liver with ascite. Evidence of portal hypertension. Portal\n vein patent.\n 2. Cholelithiasis. Edematous GB wall, like from liver disease. Recomemnd\n clinical correlations to assess acute cholecystitis.\n 3. No bowel obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old woman, with end-stage liver disease, fever, and\n abdominal pain and rebound. Assess for acute abdominal pathology.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT images were acquired from the lung bases to the pubic\n symphysis after administration of IV contrast and oral contrast. Multiplanar\n reformatted images were obtained for evaluation.\n\n CT ABDOMEN WITH CONTRAST: There is no pleural effusion in the visualized lung\n bases. There is moderate amount of ascites in the abdomen, simple in\n attenuation. The liver appears shrunken and nodular in contour, compatible\n with the known end-stage liver disease. There is recanalization of the\n umbilical vein, compatible with expected portal hypertension. In the\n gallbladder, there is hyperdense material, compatible with partially calcified\n stone. The gallbladder wall is thickened, likely secondary to the underlying\n end-stage liver disease. The portal vein remains patent. The spleen is\n enlarged, measuring 14 cm. The pancreas, adrenal glands and kidneys are\n grossly unremarkable. There are perisplenic and perigastric varices.\n\n There is no excretion of IV contrast likely secondary to bolus timing.\n\n The stomach, duodenum and loops of small bowel are patent with oral contrast.\n\n CT PELVIS WITH IV AND ORAL CONTRAST: There is ascites tracking into the deep\n pelvis. The uterus is normal in size for perimenopausal female. The urinary\n bladder has a pocket of air, likely secondary to recent instrumentation. The\n colonic wall is slightly edematous, possibly secondary to third spacing from\n the underlying medical disease. There is normal bowel gas and fecal matter in\n the colon.\n\n Assessment of lymphadenopathy is difficult in the setting of ascites.\n\n (Over)\n\n 10:34 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please evaluate for acute pathology\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOW: There are no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Cirrhotic liver with evidence of portal hypertension.\n 2. Moderate amount of ascites in the abdomen.\n 3. Edematous colonic wall likely secondary to portal colonopathy. However\n penumatosis raises concern for ischemia and clinical correlation is\n recommened. There is no portal venous air or evidence of perforation.\n 4. Cholelithiasis in a gallbladder with edematous wall, also likely secondary\n to the patient's cirrhotic status.\n 5. No bowel obstruction. No free air.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1148978, "text": " 11:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumonia\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with ESLD, new fever\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia\n ______________________________________________________________________________\n WET READ: ENYa SUN 12:54 AM\n No PNA.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever in a patient with end-stage liver disease.\n\n Portable AP chest radiograph was compared to .\n\n Heart size is mildly enlarged, essentially stable. Mediastinal contours are\n unchanged. Note is made of the interval development of azygous vein\n distension as well as slight upper zone redistribution, findings that might be\n consistent with interval development of volume overload. Lungs are\n essentially clear and there is no pleural effusion or pneumothorax. Overall,\n no evidence of infectious process is demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1149507, "text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrates or other acute abnormalities.\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with End stage liver disease in ICU.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrates or other acute abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with end-stage liver disease\n located in intensive care unit.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5 cm above the carina. The feeding tube passes below the\n diaphragm with its tip not included in the field of view. The right internal\n jugular line tip is at the cavoatrial junction. Cardiomediastinal silhouette\n is unchanged. There is overall no change in widespread parenchymal opacities\n that at least in part represent volume overload/pulmonary edema but underlying\n infectious process cannot be excluded. Significant distention of azygos vein\n is in favor of substantial contribution of pulmonary edema to the appearance\n of the lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-25 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1148376, "text": " 10:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: liver venous system thrombosis?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with liver failure and diffuse abd pain w/ little-no ascites\n on bedside u/s\n REASON FOR THIS EXAMINATION:\n liver venous system thrombosis?\n ______________________________________________________________________________\n WET READ: ENYa TUE 11:11 PM\n 1. Nodular and coarsened liver. Mild ascites.\n 2. Contracted GB with stones. Normal CBD.\n 3. Major intrahepatic vasculature patent and normal directional flow.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old woman with liver failure and diffuse abdominal pain.\n Assess for liver venous system thrombosis.\n\n COMPARISON: None.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The nodular liver is diffusely echogenic and\n coarsened in echotexture, suggestive of cirrhosis. There is no intrahepatic\n or extrahepatic biliary ductal dilatation. The CBD is normal in caliber,\n measuring 4 mm in diameter. The contracted gallbladder is noted with multiple\n gallstones. The enlarged spleen measures 13 cm. There is trace amount of\n perihepatic ascites.\n\n The main and left portal veins are patent and normal in Doppler waveforms.\n The right portal vein is patent and normal in color flow. The main, left and\n right hepatic arteries and veins, and IVC are all patent and normal in Doppler\n waveforms.\n\n IMPRESSION:\n 1. Major intrahepatic vasculature patent and normal in direction of flow.\n 2. Coarsened and nodular liver, compatible with cirrhosis. Trace ascites and\n splenomegaly.\n 3. No biliary dilatation.\n 4. Contracted gallbladder with stones.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2155-02-26 00:00:00.000", "description": "Report", "row_id": 1520004, "text": "addenum:\n\nwound: r old quinnton site- dsd saturated with sero-sang drg large amt-dsd changed x2 today.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-27 00:00:00.000", "description": "Report", "row_id": 1520005, "text": "Respiratory Care\nPt remains intubated on ventilatory support. Sx for sm. to moderate amounts thick yellow green secretions, no cough or gag stimulated when sx. ABG with slight respiratory alkalosis, pt regulating own minute ventilation. No vent settign changes made this shift. AM RSBI 31\nNo plans for further weaning at this time.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-27 00:00:00.000", "description": "Report", "row_id": 1520006, "text": " 7p-7a\nneuro: pt unresponsive to verbal/painful stimuli, occasional increase in bp/resp rate with movement/suctionning (but inconsistently), pupils 3mm nonreactive to light, slight movement of head/eyes/jaw noted when pt requires ett suctionning (resolves once suctionned), bilateral foot drop-multipodus boots placed (slightly impeded by stiffness of ankles)\n\ncv: junctional low 60s, short run (<30 seconds) afib self-resolved bp stable, map 65-85 neo gtt x ~2hrs to maintain map >70, midnight lopressor dose held for low bp, afeb\n\nresp: bilateral rhonchi this am, increasing need for ett suctionning of thick yellow secretions, stable on cpap with ps fi02 40%, mild improvement of respiratory alkalosis, 02 sats >95%\n\ngi: tube feed nutren renal at 35ml/hr (goal), hypoactive bowel sounds, soft nondistended belly, fingersticks ssri, large smelly liquid dark brown stool-sample sent for c diff\n\ngu: foley to gravity draining minimal clear yellow/light amber urine, crrt continues (pfr dropped to 0 when map<70 and on neo gtt), filter changed this am once clotted, crrt machine changed out for spontaneous resets (turned itself off and on x2), able to pull off 100ml/hr at beginning of shift, now pulling off 50ml/hr, calcium and K gtts continue\n\nlabs: stable\n\nassess: stable\n\nplan: eeg, possible head ct, continue crrt goal 100ml/hr off, restart lopressor as tolerated by maps, goal map >70 for renal perfusion\n" }, { "category": "Nursing/other", "chartdate": "2155-02-27 00:00:00.000", "description": "Report", "row_id": 1520007, "text": "Respiratory Care\nPt remains intubated (#7.5 ETT 21@lip) and on vent support. No vent changes were made during shift. Lung sounds were course to clear t/o. Suctioned for sm-mod thk yellow secretions. MDI's given with no adverse effects. Last ABG showed resp alk with normal oxygenation. Family meeting took place today, care plan is to continue current therapy and will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-13 00:00:00.000", "description": "Report", "row_id": 1520065, "text": "ROS:\n\nNeuro: Pupils fixed and non reactive. No corneal, gag, or cough reflex. When providing cares noted to move left arm bringing it slightly off the bed and towards face. Also during bath and trach cares becomes HTN and moves head towards what could be considered painful stim.\n\nCV: RSR, SB at times w/occ non conducted beats. Levophed slowly weaned off., maintaining MAPs > 60. Has left radial ABP line oozing blood in small amt. Has right femoral triple lumen central line. Left femoral dialysis cath dc'd, tip sent for culture. Right subclavian (tunneled) dialysis cath. Peripheral pulses via doppler. Left DP absent. Left foot dusky, right foot cyanotic. Sternal incision at both ends open. Scant serosang drng from prox end. Small thick bloody drng from distal end. Both open x's 2-3 mm. Other skin issues as noted on Care Vue flow record. Heparin SQ for DVT prophylaxis.\n\nResp: Trached and on vent, MMV mode. Lungs clear, diminished in bases. ABGs WNL. As per RT note above. No resp distress noted, = rise and fall of chest.\n\nGI: ABD soft w/o bowelsounds. G tube to gravity drainage, drainging scant clear. NPO via tube this shift, all po meds held. Will resume this AM along w/TF. Protonix for GI prophylaxis.\n\nGU: Foley patent draining scant clear to clowdy urine.\n\nEndo: No coverage required for FSG.\n\nLytes: K 3.6, repleted w/20 KCL\n\nSocial: Family in several times up untill 2200. Supportive.\n\nPlan: Resume po meds via G tube. Resume TF. Pulmonary toileting. ? Attempt HD today if levophed remains off. Mobilize. Family support. Rehab screening. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-22 00:00:00.000", "description": "Report", "row_id": 1519983, "text": "Resp Care\nPt was extubated last evening at 2300 but immediately required reintubation/cpr. Surgical team in and open chest cpr performed. Right atrium repair done in unit. Multiple vent adjustments were made during this time.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-22 00:00:00.000", "description": "Report", "row_id": 1519984, "text": "Addendum: pts chest closed no further bleeding. Chest tubes 40-50cc/hr pt on Milrinione 0.25mcg and Epi 0.02mcg Neo on briefly but off for past several hours. pt received a total of 19units of PRBc's 12units of FFP, 6units Plts, cryoprecipatate 1unit and 3L crystaloids throughout event.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-22 00:00:00.000", "description": "Report", "row_id": 1519985, "text": "Family notified and came to hospital. Dr spoke with Family about severity of condition. Family at bedside briefly with pasture to pray.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-22 00:00:00.000", "description": "Report", "row_id": 1519986, "text": "Resp Care\nPt remains intubated, vent settings weaned today to a/c 500x14 +5 60%. BLBS course, suctioned for sm amt of tan secretions, MDis given per order. Plan to continue vent support.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-22 00:00:00.000", "description": "Report", "row_id": 1519987, "text": "CSRU UPDATE\nEVENTS: ATTEMPT TO DIURESE. NO WAKE-UP TODAY.\n\nNEURO: REMAINS ON PROPOFOL 20 MCQ/K/MIN. PUPILS SLIGHTLY UNEVEN AND NON-REACTIVE. NO SPONT MOVEMENTS NOTED.\n\nCV: VS/HEMOS AS PER FLOWSHEET. MIKRINONE TO OFF, THOUGH SVO2 DRIFTING NOW. RECALC LAB VALUE PENDING. ATTEMPTING TO DIURESE TODAY. LASIX DRIP ADDED AS WELL AS 100MG IV BOLUS DOSE X2. NO REPSONE FROM INITIAL DOSING, NATRECOR ADDED. FREQUENT PVC THIS AM W/ SOME BIGEM. AMIODARONE REGIME GIVEN AND PRESENTLY JUNCTIONAL 70'S. A V WIRES PRESENT. MEIDASTINAL/PLEURAL TUBES W/ 30-50CC DNG OF THICK, CLOTTY DNG. 2 UNIT PRBC TODAY. HCT STABLE 31->33. HAS HAD INCREASING NEO REQUIREMENTS. K+ REPLETION DONE. LACTATE DOWN TO 5.\n\nRESP: NO VENT CHANGES TODAY. SEE FLOWSHEET. MARGINAL PAO2 ON .60 AND + 5 PEEP. SIGNIFICANT MET ALKALOSIS, TEAM AWARE. O2 SATS HIGH 90'S MUCH OF DAY.\n\nGI/GU: UOP CLEAR LIGHT YELLOW AMT AS NOTED W/ NO RESPONCE TO LASIX,NATRECOR. CREAT TO 1.8, LFT CONT SOMEWHAT ELEVATED. ABD SOFTLY DISTENDED. OGT IRRIGATED, MIN THICK BILOUS DNG.\n\nSOCIAL: SEVERAL CALLS FROM DFM. SONM TO VISIT THIS AFTERNOON. APPROPRIATE AT BEDSIDE.\n\nASSESS: NOT RESPONDING TO DIURSING. INCREASED NEO REQUIREMNTS. NO AWAKENING ON LOW DOSE PROPOFOL.\n\nPLAN: ? RENAL CONSULT. PROPOFOL OFF WHEN OK PER TEAM. CONT AGGRESSIVE SUPOORT, MONITOR VS,HEMOS,LABS, ETC\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-03 00:00:00.000", "description": "Report", "row_id": 1520021, "text": "respiratory care\npt remains intubated, no changes made overnight. ABG results revels compensated respiratory alklosis with hyperoxygenation.Suctioned for moderate amounts of yellow thick secretions. Breath sounds coarse with crackels b/l. MDI given as ordered. will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-23 00:00:00.000", "description": "Report", "row_id": 1519988, "text": "Respiratory Care:\nPatient on full vent support with increase to PEEP of 10 and 70% during this shift to maintain oxygenation. BS=bilat with scattered rales. Possible CVVHD this am. Suctioned for small amounts of thick yellow sputum. Cough present. Receiving combivent MDI Q4 with good effect for occassional exp wheezing. See Carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-08 00:00:00.000", "description": "Report", "row_id": 1520044, "text": "Resp Care\nPt remains intubated on MMV 500x10 no vent changes made this shift. Pt continues to make minimal spontaneous effort 1-3 breaths per minute <150cc. BLBS course suctioned for sm-mod amt of white-pale yellow secretions, MDIs given per order. ABGs WNL. PLan to continue current vent support.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-08 00:00:00.000", "description": "Report", "row_id": 1520045, "text": "PROB: \n\nCV: SR NO ECTOPY NOTED, AMIO DRIP CONT TIL BAG EMPTY, TO BE CHANGED TO PO/NGT. LEVO WEANED TO .01MCG/KG/, BP DROPS TO 80/SYS WHEN OFF. MIDODRINE INCREASED TO 5MG TID. CHEST DRESSINGS CLAN AND DRY. EXTREMITIES COOL. L FOOT CYANOTIC IN APPEARANCE. DOPPLER PULSES PRESENT, ALTHOUGH NOT STRONG AND DIFFICULT TO LOCATE. L THIGH LARGER THAN R, DR. AWARE.\n\nRESP: ABGS ADEQUATE, SUCTION FOR THICK WHITE TO YELLOW. LUNGS COARSE, DIM IN BASES. UNABLE TO GET SVO2 TRACE DESPITE CHANGING PROBE, CABLE AND BOX.\n\nGU: CONT, PT BEING RUN EVEN DURING SHIFT. TOLERATING WELL. CA PRESENTLY OFF FOR ELEVATED VALUE. K REPLACE AND DRIP INFUSUNG. SCANT AMOUNT YELLOW URINE WITH SEDIMENT.\n\nGI: FLEXISEAL INTACT. TFEEDS RESTARTED FOR LOW RESIDUAL. SHUT OFF AFTER SEVERAL HOURS FOR RESIDUAL OF 180CC. BOWEL SOUNDS PRESENT. PTT ELEVATED, RETESTED BUT STILL ELVATED ALTHOUGH NOT AS MUCH, DR. AWARE, LFTS ELEVATED BUT IMPROVED.\n\nENDO: BS WNL.\n\nSOCIAL: FAMILY IN TO VISIT.\n\nNEURO: NONPURPOSEFUL MOVEMENT. MOVING L HAND ON BED, TURNING HEAD OCCASIONALLY. PUPILS EQUAL, NONREACTIVE. FLEXES ARM WITH STERNAL RUB.\n\nSKIN: DECUB SITE CLEANED AND TREATED WITH ALOE VESTA CREAM. L ARM DRESSING CHANGED, MINIMAL DRAINAGE.\n\nASSESSMENT: CONDITION POOR.\n\nPLAN: CONT.\nMONITOR LYTES/BS.\nRECHECK PT/PTT WITH AM LABS.\nCONT -DISCONTINUE X12HRS IF FILTER CLOTS OFF, AND EVALUATE RENAL RESPONSE.\nALOE VESTA CREAM TO COCCYX.\nCHANGE L ARM DRESSING.\nEYE CARE.\nPULM HYGIENE.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-28 00:00:00.000", "description": "Report", "row_id": 1520012, "text": "Neuro: not responding to any stimuli including pain, not moving extremities, pupils are equal but not reacting to light, no pain meds or sedation medication given this shift.\n\nCardiac: junctional in the 50's to afib in the one teens, was on and off neo gtt throughout shift currently off, did get x2 doses of lopressor this shift, cvp running 0-5 range, dopplerable pedial pulses, skin warm dry and intact, afebrile, +3 edema in extremities.\n\nResp: no changes on vent, lungs coarse to dim in bases, abg with met acidosis and is resp compensating, did get x 1 sodium bicarb this shift.\n\nSkin: chest with dsd that is cdi, left leg with steri strips and one small blister with small serosang drainage on dsd that is cdi, left arm dsd that is cdi.\n\nSocial: multiple family members in and out with multiple questions, daughter \"cookie\" wrote down list of patients medications, amd staff caring for patient, daughter also did request second neuro opinion, np relayed message to neuro team and plan for monday for second opinion, nurse manager and np from team are planing to have meating with crystal daughter about family recieving information\n\nGi/Gu: did get iv phosphate for low phos this shift, continues cvvh with goal to keep 100 neg each hour hard to do as bp does not tolerate, currently is even for past 24 hrs, have been able to slighty slowly go up on pfr the past few hours, foley pulled and np will do daily straight caths, cdiff sent, changed fib for leakage.\n\nPlan: continue on and off neo gtt, continue cvvh, monitor for any neuro changes, do straight cath qd, c-diff on and urine culture with catherization.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 1520069, "text": "Neuro: pupils with no reaction to light, no changes in neuro status this shift.\n\nCardiac: nsr with rare pvc's that corrolated with low k post k pvc's weaned, sbp's wnl's no pressor iv medication, dopplerable pedial pulses, skin warm in upper extremities, in lower extremities skin is cool and cyanotic, afebrile, +1 edema in extremities.\n\nResp: no vent changes made, lungs coarse and dim throughout, sxned for small amounts of thick tan.\n\nSkin: chest with dsd that is cdi, old ct sites cdi, g-tube dsd cdi, all central line dsds changed, coccyx with stage one breakdown and small amount of serosang drainage-double bond cream applied, left leg with x 2 abraisions that moderate serosang, left arm abraision with small amounts ofserous drainage.\n\nGi/Gu: conts tf's advancing towards goal with residuals, abd is soft and round, blood sugars wnl's, low u/o.\n\nsocial: Family in to visit and updated.\n\nPlan: hd today, ? with rn about air mattress, monitor for neuro changes.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 1520070, "text": "Respiratory care:pt remains trached and vented. No vent changes made this shift. Lung sounds slightly coarse. Suctioned for small to moderate thick white secretions.MDIs given per order. will follow.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-03 00:00:00.000", "description": "Report", "row_id": 1520022, "text": "NEURO: UNRESPONSIVE TO ANY STIMULI EXCEPT SLIGHT WITHDRAWAL WITH L HAND AT TIMES. PUPILS EQUAL, NONREACTIVE TO LIGHT. NO GAG, NO COUGH. IRREGULAR RESPIRATORY PATTERN, LABILE BP.\n\nPULM: MMV MODE ALL SHIFT, NO VENT CHANGES. CONTINUES WITH IRREGULAR RESP PATTERN, LOW VT'S, APNEIC PERIODS. SX'D FREQUENTLY FOR MOD AMTS THICK YELLOW SECRETIONS FOR ETT. CONTINUAL SX OF CLEAR SALIVA FROM MOUTH. LUNGS COARSE THROUGH OUT. WBC 36K. RECEIVED VANCO DOSE AT 2200 D/T TROUGH LEVEL DRAWN AT 18.7. TEMP 94.0, BAIR HUGGER ON. ABG SHOWING RESP COMPENSATION FOR METABILIC ACIDOSIS.\n\nCV: RAF 105-120'S TO NSR WITH FREQ PAC'S AND PVC'S. CA AND K REPLETED CONTINUOUSLY PER CRRT ORDERS. PROGRESIVELY MORE HYPOTENSIVE THROUGHOUT SHIFT REQUIRING HIGH DOSES OF NEO. WBC 36K, TEMP 94 PO, LACTIOC ACID 4.4. LECO GTT STARTED, NEO GTT WEANED OFF. 1 LITER NS OVER 2H. 1 AMP OF BICARB AT 0130 FOR HCO3 DOWN TO 15. CVP 8-15. UNABLE TO DOPPLE ANY PEDAL PULSES, + DOPPLERING POPLITEALS BILATERALLY.\n\nRENAL: CVVHDF CONTINUES, INITIAL GOAL 100CC REMOVAL, NOW EVEN BALANCE D/T HYPOTENSION. CREATININE 1.6. NO FOLEY, NO UO.\n\nENDO: Q4H BLD SUGARS. 10 UNITS REGULAR INSULIN AT 0030 FOR BS 210.\n\nGI: DOBHOFF TUBE L NARES, CLAMPED AT 1900. ABDOMEN SOFT, + BS. 300 CC TEA COLORED FLUID AND TUBE FEED ASPIRATED FROM TUBE AT 2200, LEFT CLAMPED. 15 CC ASPIRATED AT 2400, TF RESUMED AT 15CC/HR THEN DC'D D/T HYPOTENSION AND REQUIRING FLAT POSITION.\n\nSOCIAL: FAMILY VISITED UNTIL ~ 2100.\n\nPLAN: CONTINUE AGGRESSIVE MULTI-ORGAN SUPPORT. NEURO CONSULT TODAY TO GUIDE FAMILY WITH PROGNOSIS AND PLAN OF CARE. LEVO TO KEEP MAP > 70 D/T SEPTIC STATE. CONTINUE CVVHDF. LABS Q4H AND PRN. CONTINUE TRIPLE ANTIBIOTIC COVERAGE. EM0TIONAL SUPPORT TO FAMILY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-02-26 00:00:00.000", "description": "Report", "row_id": 1520000, "text": "Respiratory Care\nPt remains intubated on ventilatory support. AM RSBI 44 ABG PH normal but leaning toward Respiratory alkalosis. BS coarse, sx for minimal amount of yellow secretions. Pt does not cough or gag with sx. No plans to extubate at this time.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-26 00:00:00.000", "description": "Report", "row_id": 1520001, "text": "7p-7a\nneuro: pt twitches left eyes; blinks eyes when saline to corneas. pupils equal, round, 3mm/3mm, VERY MINIMAL responce to light. no movement of any extremities, no withdrawls from pain, no grimacing. bp goes up with turns occasionally, not consistantly. no gag, no cough reflexes.\n\ncv: a-fib at the beginning of the shift, then junctional 50's. sbp 100-130, map>70. amio gtt decreased to 0.5. absent pulses remain in bilat lower extremities.\n\nresp: see flowsheet for vent settings and abg's. cpap all night, tolerating well. ls coarse bilat, suctioning mod amts yellow thick secretions.\n\ngi/gu: abd soft, +bowel sounds, +large green liquid stool. indwelling cath draining minimal amts clear yellow urine. cvvh continues, goal up to -100, pt tolerating well.\n\nendo: RISS\n\nplan: continue to monitor neuro; continue to take fluid off as tolerating, continue cvvh. continue skin care, pulm toilet. ?skin nurse consult regarding left elbow.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-26 00:00:00.000", "description": "Report", "row_id": 1520002, "text": "neuro: neuro/mental status unchanged from previous shifts. pupil round/equal bilat. minimum sluggish/non reactive. No corneal reflex/gag/cough. no movement to stimulus. eye brown and jaw twichtes with inhalation. ^bp/rr inconsistently with stimulations. attending at bs->neuro team consulted and seen pt. con't neuro check.\n\nid: low grade temp. wbc dipped 21. sputum cx result -see ccc-update to np . vanco level >15-no doses. con't levoquin iv. other cx's still pnd\nLab: platelet dipped->heparin sc d'c.\ncv: junctional 60s all day-run 6 beats v-tach x1->d'c amio gtt->started on amio po & BB. no pressure supporting gtts. MAP>70 with CVVHDF running. peripheral cool, dopplerable pulses. 2+edema.\n\nresp: no vent changed. cpap .40/5/5. rr 20s-occaision 30s. gas resp alkolosis. pao2 in 90s. breathing even. ls coarses. sxn sm amt.\n\ngi: tolerating tf at goal-nutren renal fs. no residual. nutritionish evaluate->add benoprotein\nendo: bs in controll 120s-140s. treat with riss\ngu: anuric-oliguric 0-25cc/hr. Goal crrt negative 100 or more if bp tolerated per c- team.\nwound: sternal and legs dsd cdi. removed dsd on left arm->2 large area of skin lacerations with few small ones and few small blister->notified np m. courtner. per order, applied petrolium gauze and dry dsd wrap. closely monitor\n\ncomfort/social: no s/s pain. care proxy daughter at bs->talked to attending. status updated to family. much support given.\n\na/p:pod 5: no wake up/non responsive. neuro consult. con't neuro check.?head CT. amio po/BB. keep MAP>70. CRRT goal keep negative 100. f/u cx's. wound care. support\n" }, { "category": "Nursing/other", "chartdate": "2155-02-26 00:00:00.000", "description": "Report", "row_id": 1520003, "text": "Respiratory Care\nPt remains intubated (#7.5 ETT 21 @lip) and on vent support. No vent changes were made during shift. Lung sounds were clear/course t/o. Sxn for scant thk yellow secretions. MDI's given with no adverse effects. Last ABG showed acute resp alk with good oxygenation. Care plan is to continue current therapy and follow neuro status. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 1520071, "text": "PLEASE SEE CAREVUE FOR EXACT DATA\n\nREVIEW OF SYSTEMS:\n\nNEURO-Neuro exam remains unchanged. Pupils 4 bilaterally and non-reactive. Negative corneals, gag and cough. Nonpurposeful movement noted to head and bilateral arms when care provided/turning. No signs/symptoms of pain noted.\n\nCV-Pt remains in SR rate 70-80's, with rare PVC's noted during HD. BP stable SBP 100-120's, continues on amiodorone and midodrine. No episodes of hypotension. Left radial arterial line with bloody oozing from site, dressing changed. Right groin TLC and right Quinton cath. Planned for PICC placement today however, IV RN unable to place at bedside. IR placement ordered, unable to go to IR due to HD. Possible placement on Monday if not at rehab sooner. Heparin SQ.\n\nRESP-Lung sounds coarse, suctioned for thick off white secretions, moderate amounts. Continues on MMV TV 500 R8 P5 40%FIo2. Sats 100%. #8 trach, trach care given at 1630.\n\nGI-G tube with Vivonex full strength at goal, 60cc/hr. No residuals this shift. Positive bowel sounds. Copious liquid stool drainage from Flexiseal, draining around insertion site.\n\nGU-INdwelling foley catheter with amber urine output. HD at bedside today, tolerated without issues. 600cc taken off.\n\nENDO-Glucose elevated, covered per protocol. ICU .\n\nINTEG-Wound care RN at bedside. Left arm dressing changed, some necrotic areas noted, . Continue with xeroform and aquacel to site. Coccyx with Stage 1-2 breakdown, double guard and aquacel applied. Left groin puncture site with serous drainage, aquacel applied. Left LE puncture sites with aquacel and DSD.\n\nID-Continues on Flagyl and Vanco, Zosyn d/c'd.\n\nPLAN-Possible discharge to rehab/ Kindercare tonight. PA awaiting family arrival to discuss.\n -If pt remains in hospital, locate KInAir bed, plan for PICC placement on Monday at IR\n -Wound care as described above.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-24 00:00:00.000", "description": "Report", "row_id": 1519995, "text": "update\nD: pt off sedative this am- remains unresponsive. pt into afib this am-amiodarone bolus given-drip inc to 1 mg--where it remains- pt cont in afib rate 80-90-a wire traces done x 2 to eval. pt weaned off neo cont on levo only for bp control- pt sbp up to >100/-with inc bp and no need to inc levo- plan now is to pull \"some fluid off via CVVH\".\nFT placed today f/u xray shows FT post pyloric- plan to start feedings in am. ct d/c this am.\nplan: if Bp stable, with no need to inc levo- remove up to-50cc/hr fluid via cvvh.\n? ct tomorrow if pt remains unresponsive.\nneuro: pt unresponsive to all stimulation, no gag, cough, corneal reflect neg, pupils 3mm-no response-no movement noted other than some tongue movement and rare lid movement of eyes. pt of versed at 7:30am-low dose fentanyl only.\ncardiac: pt into afib- amiodarone given with no conversion- cont on drip at 1 mg/hr- extremities cool to touch, unable to obtain dp/pt dopplerable pulses. dopplerable popliteal pulses bilat.\nresp: pt bs clear, sx for scant clear secretions- pt weaned to cpap with 5 peep and 5 ips- tol tv >400cc, abg adeq. resp rate 14-18.\ngi: abd soft, no bs present, ft placed, ogt d/c-plan to start feedings in am per team. ppi cont.\ngu: foley with small amt clear yellow urine, tol cvvh- initial goal running even-presently pulling off 50cc/hr. lytes and abg's improved.\nskin: inc intact, left arm with skin tears, no skin breakdown on back or coccyx area.\nfamily: socail worker () in to see family today- introduced herself. family very suportive of pt- explain pt present situation- off all sedations- waiting and watching for pt to wake--pt family with positive attitiude- pt will get thru this--she will wake up-\n" }, { "category": "Nursing/other", "chartdate": "2155-02-25 00:00:00.000", "description": "Report", "row_id": 1519996, "text": "Resp Care:\nPatient remains non-responsive, no cough noted with suctioning tonight. BS=bilat, coarse with rhonchi. Secretions are thick yellow-green tinged. Receiving combivent MDI Q4 and flovent . She is tolerating PSV of % well. RSBI-58 this am.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-25 00:00:00.000", "description": "Report", "row_id": 1519997, "text": "7p-7a\nneuro: pt does not withdraw from pain, no spontaneous movement noticed other than left upper eye twitching. pt closing eyes toward the end of the shift when saline is applied to the corneas. pupils round, equal 3mm/3mm, not reacting to light. no cough or gag reflex. fent gtt off.\n\ncv: remains afib 80-120, no ectopy. sbp 90-120. neo remains off, weaning levo. absent pulses by doppler bilat lower DPP and posterior tibial. unable to check a-wires due to afib; v wires not tested due to tachycardia. svo2>60; ci>2.\n\nresp: remains on cpap overnight. ls coarse, suctioning for large amts of thick yellow sputum. see flowsheet for vent settings and abg's.\n\ngi/gu: abd soft, absent bowel sounds. npo overnight. continuing cvvh, maintaining goal -50cc/hr. creat and bun coming down. indwelling cath draining minimal amts of clear yellow urine.\n\nendo: RISS\n\nplan: continue to monitor hemodynamics. continue cvvh. continue to monitor neuro.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-25 00:00:00.000", "description": "Report", "row_id": 1519998, "text": "Respiratory Care: pt remains orally intubated and vented. No vent changes made today. BLBS coarse. Increased in secretions noted today, suctioned for thick yellow secretions, spec collected and sent to lab.Last ABG this shift showed non compensated respiratory alkalosis. MDIs given per order.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-02-25 00:00:00.000", "description": "Report", "row_id": 1519999, "text": "Neuro: No sedation. pt remain unresponsive to any stimulation. bilat pupil equally round 3mm, r reactive sluggish and l react brisk to light. twitching eye brown more l>r with facial stimulus. ^bp and RR w any stimulus. Absent gag & cough. breathing on own. no head scan today per attending/team. neuro check q2h. see careview.\n\nid: afebrile. but wbc remain elevated 30. Pan cx. new line placement- MTLC and dialysis lines -cxr. confirmed to use np . cx tips of old trauma line and quinton. pt recieving levoquin iv. held vanco d/t level >15 with ATN\nLab: plt dipped to 62->HIT sent. heparin sc ordered but hold now NP HIT resulted.\n\ncv: afib-converted for ~3hr to junctional rhymth 58-60s confirmed w AEG without bp consequences-now back in Afib. no ectopies. Amio gtt from 1-0.5->now 1mg/ np . lytes per crrt ss. able to wean levo gtt to now .02mcg/kg/ -goal keeping MAP >70. peripheral extremeties x4 -cool, 2+edema. absent PD/PT/Popliteal in both les. dopplerable pulses left femoral (quinnton r fem)-Team assessed pt in am-to monitor. unable to check cap refill and coloration d/t skin tones and nail bed discoloration.\n\nresp: remain on cpap .40/5/5. RR low 20s->30s with stimulation. Vt 400s. gas good. see careview. Ls coarsesx4 fields. diminish lll. sxn sm-mod purulent sputum-cx sent. sat >96%. CXR done\n\ngi: started tf nutren renal fs via dobhoff. advancing to goal 35cc/hr.\nendo: treat bs with riss protocol\n\ngu: smear bm. oliguric-anuric 0-25cc/hr. con't CVVHDF-able to keep goal -50-to more with pt bp/hemodynamic tolerated per attending/c- team. no dialysate. f/u creatininie decrease from 2.9 to now 2.3\n\nwound: coccyx and heels intact. see careview. applied vesta cream to peripheral d/t dryness\ncomfort/social: no s/s pain. spoke person daughter at bs-talked to attending. frequent family member visits with pastor too. status updated. Much support .\n\na: POD# 4. con't remained unresponsive. CVVHDF goal -50 or more if hemod/bp tolerated-keep pt negative. Amio gtt for afib. wires d'c. levo gtt to keep MAP>70. pan cx and changed lines\n\np: con't neuro check. ?head scan. Advance tf to goal. cpap. support family.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-12 00:00:00.000", "description": "Report", "row_id": 1520060, "text": "Neuro) unchanged condition. Occ. has spont. movements of upper extr/ LUE>RUE. Draws left arm in medially and shirks right shoulder subtly. No response to commands. No movement of LE.\nCV) weaning levophed slowly, presently @ .002mcq/kg/hr. Heart rhythm unchanged, nSR with occ. PVC. K+ adjusted per sliding scale. Distal pulses as per AFS.\nPulm) Orally intubated. sx for white creamy secretions. Sputum culture pending. ABG wnl. No vent changes.\nGI) tube feedings held at 2400 for operative procedures today. No stool output via flexiseal system this shift.\nGU) minimal huo. cvvh continues. Keeping pt. even on I/O.renal status stable.\nSKin) see AFS for skin care and wound care. Heels kept off bed by elevating on pillows. Bair hugger prn for warming. Staples removed from sternal surgical site. Covered with DSD.\nID) Vanco IV d'cd. continues with vanco per ogt. Zosyn/Flagyl continued pending sputum culture.\nPlan) Trach/PEG/tunneled dialysis cath today. Keep family informed.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-12 00:00:00.000", "description": "Report", "row_id": 1520061, "text": "Day shift\nNeuro: Pt arousable. NR pupils 4mm, inconsistent flexion of bilat arms L>R w/ hands on care, no leg movement. Does not follow commands, no gag, no cough w/ mouthcare and ett suctioning. No signs of pain.\n\nCV: HR 70-100s. SR w/ PACs. Episodes of afib, see carevue, SBP 80s, see carevue for levo titration and vs. Amio bolus given as ordered. Dopplerable bilat DP and right PT, not new.\n\nResp: LS coarse. Continues on MMV mode orally, w/ acceptable abgs, see carevue. At present time pt in OR for planned trach, peg and tunnel cath. Sats 100%.\n\nGI/GU: Abd soft, +BS.+NPO for surgery. + liquid dark greenish brown stool, draining around flexiseal, irrigated x3, no further drainage seen since last irrigation. CVVH dc'd per protocol at 0730, NP and MD aware.\n\nEndo: No coverage needed.\n\nSocial: Family visited updated w/ POC.\n\nSkin: See carevue.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Wean levo as pt tolerates. Plan to wean levo and keep off, and start HD in am, if unable, restart CVVH.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-12 00:00:00.000", "description": "Report", "row_id": 1520062, "text": "Respiratory Therapy\n\nPt received this AM orally intubated on MMV. Went to OR this afternoon for trach/PEG/dialysis cath placement. Remained on MMV all morning not spontaneously breathing, ventilator back-up Vt/RR=500/10. Ve = 5LPM. MDIs given as ordered. SpO2 90s. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2155-03-12 00:00:00.000", "description": "Report", "row_id": 1520063, "text": "Addendum\nReceived pt at 1820 back from OR on 0.03mcg/kg/ of levo. Uneventful OR case for trach,peg and tunnel cath. Trach #8.0 cuffed trach, back on MMV mode w/ acceptable abg. G tube clamped for now MD . HR 60s SR. Levo weaned to 0.005mcg at present time. See carevue for further details.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-13 00:00:00.000", "description": "Report", "row_id": 1520064, "text": "Resp Care\nPt was trached and pegged yesterday. Remains ventilated on mmv with only sporadic spontaneous efforts. ABGs within normal limits. MDIs given as ordered. Plan to maintain ventilation/pt. exempted from RSBI protocol due to neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-02 00:00:00.000", "description": "Report", "row_id": 1520018, "text": "NEURO: ORALLY INTUBATED, UNRESPONSIVE TO ANY STIMULATION EXCEPT SLIGHT WITHDRAWAL L HAND AT TIMES. NO GAG, NO COUGH, IRREGULAR RESPIRATORY PATTERN, LABILE BP. PUPILS 3MM, NONREACTIVE. NO SEDATIVES OR NARCOTICS ADMINISTERED.\n\nPULM: CONTINUES ON CPAP MODE WITH IRREGULAR RESPIRATORY PATTERN AND TIDAL VOLUME. RSBI 10. SX'D FOR COPIOUS AMTS THICK TAN-YELLOW SECRETIONS FROM ETT ~ Q2H, CONTINUAL SUCTIONING THIN CLEAR-BLD TINGED SECRETION FROM MOUTH. ABG'S SHOW CONTINUED MET ACIDOSIS WITH RESP COMPENSATION. ON VANCO AND ZOSYN IV. WBC UP TO 29K. BLD CX X 1 FROM R RADIAL ALINE AT 0630.\n\nCV: NSR WITH OCC-FREQ PAC'S, OCC PVC'S TO ATRIAL FIB-FLUTTER. NEO GTT USED INTERMITTENTLY FOR LABILE BP, MAP 55-115. CONTINUOUS CA AND K GTTS TITRATED PER CVVHD ORDERS. LYTES CHECKED Q4H. PEDAL PULSES ABSENT EXCEPT ABLE TO DOPPLE L DP, FEET COOL, POPLITEALS PALPATED BILATERALLY. R RADIAL A-LINE DAMPENED, POSITIONAL, HARD TO DRAW BLD FROM. MONITORING NIBP Q10\".\nPLATELETS UP TO 178.\n\nENDO: BS 114-140, 4 UNITS REGULAR INSULIN SC AT 0030 PER PROTOCOL.\n\nGI: ABDOMEN SOFT, + BS. TF AT GOAL 35CC/HR VIA DOBHOFF. 15-20CC RESIDUALS. REGLAN 5MG IV Q6H.\n\nRENAL: CVVHDF INCONSISTENT D/T FREQUENT (5 TIMES) CLOTTING OF FILTER. GOAL IS 100CC/HR REMOVAL BUT BP TOO LABILE TO TOLERATE MORE THAN PFR AT 160CC/HR. ACCESS AND RETURN LINES REVERSED WITH IMPROVEMENT IN FILTRATION. BUN 28/CREATININE 1.5. NO FOLEY, NO URINE OUT.\n\nSOCIAL: FAMILY VISITED UNTIL ~ 2130.\n\nPLAN: CONTINUE AGGRESSIVE MULTI-ORGAN SUPPORT. ASSESS NEURO Q2H. ? CHANGE LINES D/T SPIKE IN WBC, NEED SPUTUM CX AND SECOND BLD CX. SUPPORT FAMILY. NEURO TO RECONSULT TO DETERMINE PROGNOSIS AND MEET WITH FAMILY TO DISCUSS PLAN.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-02 00:00:00.000", "description": "Report", "row_id": 1520019, "text": "Respiratory Care\n\n Pt changed to MMV due to increasingly longer periods of apnea. Ve set at 4.8 once pt hits it she continues to breath on her own. B/S sl coarse and diminished. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-21 00:00:00.000", "description": "Report", "row_id": 1519981, "text": "Nursing Admission Note: S/P CABG X2, MV repair, and PFO closure\n\nPt arrived from OR @ 1245pm. Intubated and sedated with propofol 40. On epi at .012 and neo .5 on arrival. CCO swan. CO by CCO swan very low on admission 1.7. SVO2 71. Per anesthesia CO ran in OR. CCO swan recal done. SVO2's in 60's. Following FICK CO.\n\nNeuro: Sedated with propofol. PERRL.\nCV: 90-70's SR with occ PVC's and rare couplet seen. On epi .012-.03 and neo to 1. SVO2 61-50's despite 5L volume. Very labile pressure and volume status. Given 1u PRBC's for hct 28.3. SVO2's improved to 68-73%. K and Ca Repleted. Pedal pulses by doppler-L very difficult to get.\nID: cold on arrival-now 100.8 core. On Vanco postop doses.\nResp: Ventilated-weaned to 40%-Now placed on CPAP/10 PS. ABG's slightly acidotic. No secretions. CT's to LWS-small -mod serosang drainage. No airleak.\nGU: Foley to gd. UO-30-120cc/hr. Light clear yellow urine.\nGI: Abd soft, NT, ND . OGT placed-clear secretions. Carafate given.\nEndo: Placed on insulin gtt per CTS protocol.\nComfort: Morfhine 2mg IV given q 2 hrs with good effect.\nActivity: Bedrest.\nA: Very labile with low CO\nP: Volume as needed-responded well to PRBC's. Replete lytes. Awaken and possibly wean and extubate. Neo/epi as needed.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-11 00:00:00.000", "description": "Report", "row_id": 1520056, "text": "Resp Care\nPt remains inubated in MMV mode of ventilation. No vent changes made this shift. BS coarse bilaterally and throughout. When suctioned, pt has no active cough. Suctioning for moderate amounts of thick white secretions. Breathing pattern continues to be irratic with TV as high as 1200cc's and at times as low at 50cc's. MDI's given as ordered. Pt exempt from weaning protocol at this time due to pt's neuro status and inablity to protect her airway, therefore RSBI not completed at this time. ABG shows compensated respiratory acidiosis with good oxygenation. See CareVue for details and specifics.\nPlan: Maintain vent support.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-11 00:00:00.000", "description": "Report", "row_id": 1520057, "text": "7a-7p\nNeuro: Pt unarousable, no corneal reflexes, NR pupils 4mm, w/ hands on care bilat arms noted to flex inward inconsistently, also head movement noted randomly, does not follow commands. No signs/symptoms of pain.\n\nCV: HR 70s SR w/ occasional pacs. K per sliding scale, given additional dose of k phos as ordered, last K 4.1. SBP labile. On levo gtt, weaning to keep MAP>60, presently at 0.007mcg/kg/, see carevue for details. Midodrine increased to 10mg tid. Stress dose steroid done as ordered, see careweb for details. Dopplerable bilat DP and dopplerable PT right.\n\nResp: LS coarse. Orally intubated 7.5mm 21cm at lip, on MMV mode w/ acceptable abgs, see carevue. Sats >94%.\n\nGI/GU: Abd soft, hypoactive BS. TF restarted at 11am at 20cc/hr NP , 4 hours later, residual 210cc. NP aware, continue TF at 10cc/hr NP . Flexiseal draining green liq. stool. Foley draining 0-100cc/hr, see carevue. as ordered to keep even, see carevue for details.\n\nEndo: RISS.\n\nSocial: Many family members in at bedside.\n\nPlan: Monitor hemodynamics. Monitor resp. status. CVVH as ordered to keep pt even. Wean levo as pt tolerates. NPO after midnoc. Hold heparin sc NP . ? to OR in am for trach/peg/tunnel cath.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-11 00:00:00.000", "description": "Report", "row_id": 1520058, "text": "Resp Care\n\nPt remains intubated in the MMV mode. Pt maintaining a MV in the 6l range with an abg of 7.35/42/189/24. BS are coarse and suctioning small amts of yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2155-03-12 00:00:00.000", "description": "Report", "row_id": 1520059, "text": "Resp Care\nPt remains intubated on MMV mode of ventilation. No vent changes made this shift. BS coarse/diminished bilaterally. Pt suctioned for moderate amounts of thick white/pale yellow secretions. MDI's given as ordered. Pt exempt from weaning protocol due to poor neuro status, therefore no RSBI completed this morning. ABG WNL with good oxygenation and ventilation. See CareVue for details and specifics.\nPlan: ? OR for Trach/PEG today.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-02 00:00:00.000", "description": "Report", "row_id": 1520020, "text": "Neuro: unresposive to any stimuli including painful stimuli, pupils are equal but non reactive to light, no mvement in extremities, no pain or sedative medication given this shift.\n\nCardiac: afib, did get po dose and 2.5 iv lopressor for fast rate at 1800, continues neo at higher dose then yesterday but not as labile, changed a line over to left arm from right, no pulses in feet only able to dopller popliteal pulses, legs are cool to touch, skin in general cool to touch, +2 edema in extremities, afebrile.\n\nResp: lungs are coarse throughout, sxned for small to moderate tan thick and sputum culture was sent, unable to get o2 sats and going by abg's, did put patient on low mmv rate for long periods of apnea.\n\nSkin: Chest with dsd that is cdi, left leg with small to moderate serosang drainage and dsd changed, yeast in groin area-nystatin aplied, coccyx is intact, fib bag intact.\n\nId: wbc up today continues triple abx.\n\nSocial: family in to visit and updated, md r. rodrigaz placed phone call to spokesperson and updated\n\nGi/Gu: lots of clotting with cvvh and multiple times had difficulty, renal ? starting citrate in replacement fluid later today, cathed for 250cc, not tolerating tf's lots of residuals, tf's are off team aware.\n\nPlan: ? starting citrate, continue cvvh, continue neo, monitor for any improvement in neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-17 00:00:00.000", "description": "Report", "row_id": 1520081, "text": "Resp Care: Pt continues on mechanical ventilation: MMV 500x10 40%+5 PS+5. Spontaneous volumes <100 ml. NO changes overnight. ABG: 7.42/41/158/28/2. LS coarse bilaterally. sxn'd for small-moderate amounts of thick yellow secretions. MDI's given per . RSBI not done: MD order, pt is exempt from weaning protocol secondary to inability to protect airway/neuro status. PLAN: possible discharge to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-22 00:00:00.000", "description": "Report", "row_id": 1519982, "text": "Neuro: pt weaned off propofol. Waking slowly following all commands. by 2300 pt awake alert anxious to have breathing tube out.\nResp: Weaned to Cpap IPS 10 then down to 5 pt had underlying metabolic acidosis. Fellow in to see pt oked to extubate. pt extubated at 2300 coughing and gaging up thick sputum breath sounds present pt shaking head she was not doing well anesthesia called and fellow,\nC/V: pt passed out, losing pressure and heart rate, chest tubses noted to have large amount of blood coming from them Code called. Compressions started and fluid pushed in to pt along with blood products reintubated by anesthesia CHest opened, Whole found in right atrium OR team to bedside pt given numerous doses of Epinephrine, Calcium , Atropine, Sodium Bicarbonate. Neosynephrine and Epinephrine drip continued. Dr called Dr at bedside doing open cardiac massage. After numerous medications and blood, rhythm returned then went into v fib pt required internal defibillation x3 Sinus rhythm with blood pressure. Dr in Cardiac team arrived pt placed on bypass.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-07 00:00:00.000", "description": "Report", "row_id": 1520039, "text": " nursing update\nNSR->AFIB->NSR, sbp drops to 60-80mmhg when in Afib, requiring to increase back levo/ and temporarily taking off nothing via crrt, otherwise map mostly>70mmhg. k+ and ca++ continuous, may need to replace phosphate. absent distal pulses, team aware, able to doppler left dp x1 but very faint. cold ext, centrally hypothermic also, bair hugger resumed after warm blanket was ineffective. vent settings unchanged, abg per carevue, ET secretions thick, yellow. lungs very dim allthroughout, left upper more coarse than the rest. neuro unchanged, spontaneous movements seen but nithing to commands. tf held as residuals still ~100cc or more off tf, bs wnl, not requiring insulin doses. crrt continuous, not clotted overnight, foley drains ~5-25cc/2hrs. liquid mucoid stools, FIB changed to flexiseal, bowel sounds very hypoactive. pressure areas per carevue, both legs elevated to 1-pillow high instead of multipodus, team re-informed of left elbow wound. family in early in the shift, talked to \n\nplan: plan to discontinue crrt when clotted and will review post 12hrs\n cont neuro status\n pls acquire allevyn dressing for cooccyx pressure wound\n cont plan of care\n" }, { "category": "Nursing/other", "chartdate": "2155-03-07 00:00:00.000", "description": "Report", "row_id": 1520040, "text": "Resp Care\n\nPt remains intubated and currently vented on MMV with no changes made to parameter settings this shift. BS clear to slightly course sxing for small to mod amts of thick white secretions. MDIs given x3 with little effect noted. Last ABg WNL with excellent oxygenation. ETT rotated and retaped this shift. Pt continues to take shallow breaths with spontaneous volumes around 80-100cc on PS 5. Will cont with vent support.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-07 00:00:00.000", "description": "Report", "row_id": 1520041, "text": "7am-7pm update\nneuro: pt remains unresponsive. pt noted to move left arm x 1 - team aware. no cough and no gag. pupils non reactive. right pupil 4 mm, left pupil 3 mm. neuro reconsulted per family's request.\n\nCV: pt remains in NSR, rare PVC and rare PAC noted. pt had 2 breif episodes of afib. with afib the pt became hypotensive -> SBP went into the low 70's -> levo gtt increased -> once BP was more stable the pt was given 2.5 mg IV lopressor -> pt went back into NSR. When in NSR, SBP 80-130's. MAP 60-80's. levo gtt titrated to keep MAP > 60 and SBP > 90 - per Dr . levo gtt weaned to 0.06 mcg/kg/. pt started on midodrine today TID. pt started iv lopressor q6h d/t burst of afib. hct this am was 25 -> pt given 2 units PRBC's. repeat hct was 32. ext cool. right foot with back sole and black top of foot - team aware. pt with + doppler right anterior tibial and + doppler right femoral. right pt and dp absent, right popilteal absent. left foot with no PT or DP pulse, left foot with no popliteal and no fermoral pulse - team aware. lacate 1.8-2.4. lytes treated with CRRT protocol\n\nresp: Ls coarse throughout. pt remains on MMV at 40% with 5 PEEP and 5 PS - abg's good - see flosheet. unable to get o2 pleth - team aware - trending PaO2 off of abg's. pt suctioned from small amount of thick white sputum. Ett rotated\n\ngi/gu: pt with + hypoactive bs. abd soft. pt started on vivonex TF at 10 cc/hr -> advanced to 20 cc/hr. (goal 65 cc/hr). minimal residuals. foley draining small amount of clear yellow urine. creatinine 1.4 this am. CRRT ran ~ even thoughtout the day. pt given 2 units PRBC's (volume from 2 units PRBC's not taken off with CRRT) pt ~ + 500 cc's today.\n\nendo: BS 118-135 today. elvated bs treated with ss reg insulin per protocol\n\nsocial: family -> sister -> updated with Dr over the phone today. family into visit the pt this evening\n\nID: pt afebrile today. pt continues on zoysn,flagyl,vanco IV and vanco PO. wbc's 58.3 this am. wbc's 42.5 this evening. hem/onc consulted today d/t high wbc's. ID also following\n\nskin: skin care nurse into see the pt today. skin care RN recommendations are as follows -> left arm - covered with xeroform, covered with guaze, cover with abd and cover with kerlix or netting, left arm with multiple areas of skin tears. coccyx also noted to have skin tears -> keep coccyx open to air, cover coccyx with double guard and aloe vesta. left leg also with skin tears. left leg to be covered with aquacel, follewed by gauze, follow by abd pad, followed by kerlix or netting.\n\n\nplan: continue supportive care, pulm toleit, monitor neuro status, neuro reconsulted, continue antiobiotics, titrated levo gtt to keep MAP > 60 and SBP > 90, continue CRRT -> if CRRT clots off then leave it off for 12 hrs and re evalaute the need for CRRT or HD, skin care\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-08 00:00:00.000", "description": "Report", "row_id": 1520042, "text": "Respiratory Care:\n\nPatient intubated on MMV. Vent settings Vt 500, Rate 10, Fio2 40%, Peep 5, and PSV 5. Minimal spont effort this shift. Spont vols 90-160cc. BS slightly coarse R lung, L lung clear. Sx'd for sm amount of thick white secretions. ABG's WNL. Fluid positive. CVVHD. No further changes made. ? Change to Simv/PSV with ^ PSV level.\nPlan: Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-08 00:00:00.000", "description": "Report", "row_id": 1520043, "text": " nursing update\nNSR, no episode of Afib all shift, isolated ectopies present. lopressor iv given slowly over 2hrs as sbp is borderline 80-120mmhg, but map mostly>60. weaning down levo gtt very slowly as well. some improvement in distal pulses, rt radial and ulnar now weakly palpable and very faint left dp dopplerable. temp 97F off bair hugger all shift. unchanged vent settings, ET secretions thick white, lungs coarse/dim. head and left arm with non porpuseful movements occassionally, otherwise neuro remained unchanged. tf with >430cc residual on vivonex 20cc/hr, tf off and not restarted md . stools remained liquid/mucoid and with large overflows off flexiseal, still awaiting further c.diff result, pt already on oral vanco. uop ~10-30cc/2hr, continued on cvvh aiming even or negative balance, total fluid balance remained positive d/t bp not tolerating and the aim to wean off levo per team. skin care per carevue, family still anxious and continuous to verbalize hope for pt's complete recovery\n\nplan: cont plan of care\n not to restart cvvh x12hrs once filter clots off\n wound dressing qd\n ?restart tf once residual lessened\n" }, { "category": "Nursing/other", "chartdate": "2155-02-27 00:00:00.000", "description": "Report", "row_id": 1520008, "text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and non reactive. Does not respond to noxious stimuli. Does not blink to threat. No movement all 4 ext. Does not track. Does not follow commands. Does not nod or shake head to questions asked. No corneals, No gag, No cough. EEG done at bedside.\n\nRESP: LS coarse and rhoncerous. Mouth sxn for large amts of thick white secretions. Deep sxn for small to moderate amts of thick yellow secretions.\n\nCARDIAC: Tmax 100.4. 1600-temp 95.1 po. Placed bair hugger. NEO gtt titrated on and off throughout shift to maintain MAP > 70. 1800 HR decreased to 44 junctional rhythm. NP notified came to assess. Pedal pulses by doppler.\n\nGI: Abd soft +BS. Tol TF at goal. Large amts of loose stool with some formed pieces x 3.\n\nGU: Foley intact draining 0-17cc/hr of clear yellow urine.\n\nCVVHDF: Attempting to remove 1000cc by midnight. Issues with access pressure today. NP sutured dialysis cath down to ensure better flow. Flushes well. Machine changed.\n\nINTEG: See Carevue for numerous skin issues. Skin very dry lotion and baby oil applied throughout shift.\n\nFAMILY MEETING: , MD met with family re: poor prognosis. Family not ready to give up trying. MD will meet with family again in a few days to reassess. Family very emotionally upset with news social work paged and she came immediately to support family. Family members visiting constantly since 11am. Very emotional. All family members given frequent updates by RN throughout shift. Families pastor said prayers with family at bedside.\n\nPLAN: Continue with CVVHDF goal is 1L negative by midnight, Maintain MAP > 70, Monitor hemodynamics, Provide frequent suctioning, Provide extra support to family, Provide comfort.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-02-28 00:00:00.000", "description": "Report", "row_id": 1520009, "text": "Respiratory Therapy\nPt remains orally intubated on PSV no vent changes overnight. BS slight coarse sx sml amt thick yellow secretions. Pt neurologically impaired no RSBI done. Prognosis; poor. Plan: another family meeting to discuss CMO. Please see nsg note and carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-28 00:00:00.000", "description": "Report", "row_id": 1520010, "text": " 7p-7a\nneuro: unresponsive to painful/verbal stimuli, pupils 3mm no reaction to light, no spontaneous movements, does not follow commands\n\ncv: junctional 46-74 -> afib 110-120 this am at 0600 1mg ivp lopressor-> afib 100-110 then afib 130-140 2.5mg ivp lopressor-> junctional 50s, maps 67-84 neo gtt to maintain map>70, 1 unit prbc given when neo requirements up to 1.75, cvp 4-15, peak temp 38.1 pan cultured, bair hugger removed (temp at beginning of shift 34.8)\n\nresp: lungs cta diminished to bases, suctionned from ett for yellow secretions q 2-3hrs, 02 sats 92-100% (often poor pleth waveform, regardless of placement of oxisensor), respiratory alkalosis partially compensated by metabolic acidosis\n\ngi: soft distended belly, tf residual at 0000 190 tf stopped, residual 360 at 0600 team aware, reglan 5mg ivp q6h, fingersticks ssri, bowel sounds present, fib in place for liquid stool\n\ngu: foley to gravity draining 0-25ml/hr clear yellow urine, cvvh on hold while map <70 and neo requirements high (pfr to 0), pfr to 100 this am post bld, replacement fluid rate increased to 2000ml/hr to decrease incidence of filter clotting, filter changed at beginning of pm shift for clotting\n\nassess: stable\n\nplan: wean neo to off as tolerated to keep map>70, crrt goal 100ml/hr off, ssri\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-02-21 00:00:00.000", "description": "Report", "row_id": 1519980, "text": "respoiratory care\npt on the vent changes made tol well. see the respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-13 00:00:00.000", "description": "Report", "row_id": 1520066, "text": "neuro: pt remain unresponsive. pupil r 3mm/l 4mm, NR. NO corneal reflex, gag, cough. minimum movement of left arm spontanous and inconsistently when stimulate left shoulder/rub on left sternal. no movement RUE/bilateral LEs. team is awared - no indications. con't monitor\n\nid: wbc trending down. on multi abx's. see ccc for cx r/s. afebrile\n\ncv; nsr. rare pvc. replete lytes. off levo gtt all shift. con't on midorine po and amiodarone. map >70. both UEs skin w/d. Both . r foot's sole and top blacken/dusky, left dusky. dopplerable pulses in both feet-PD & PT. 1+edema. multipodus boots. heparin sc for dvt prophylactic.\n\nresp: trial cpap--but failed. pt has only 4-5 breaths per -each breath with 1L vT - placed back to MMV, gas good- weaned to 500x8 from 10. sat>97%. ls coarses x all fields. sxn scan amt sputum. but copious amt from oral and subglottic. MDIs.\n\nGu: no dialysis today. gave lasix 40mg x1 - no respond. oliguric. flexiseal intact- liquid green stool\ngi: restart tf vivonext-goal 60cc/hr via G-tube.\nendo: no blood sugar coverage required.\nwound: sternal wound cdi-dsd applied. reinforce dsd on lue. coccyx with stage 2 pressure sore- raw, red wound bed -multiple sites->con'treatment wound rn-applied double and vesta cream. left leg dsd remain intact. see above note for both feet issues.\n\naccess: r scv dialysis tunneled. rfem mtlc. left radial art line-drainage - dsd reinforced\ncomfort: no s/s pain. family vist pt throughout shifts. status update and support given. con't provision of tlc\n\na/p: POD 20. s/p trach & peg, tunnel dialysis cath . con't remain unresponsive.\nkeep map>60. trach &resp care. HD tomorrow . advance diet as ordered. wound care. support. ??? rehab screening\n" }, { "category": "Nursing/other", "chartdate": "2155-03-13 00:00:00.000", "description": "Report", "row_id": 1520067, "text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex on MMV. Attempted CPAP/trach collar trials but pt had only agonal breaths of >1 liter Vt per minute. TM inappropriate at this time. Continues on MMV, rate weaned to 8BPM; rarely overbreathes vent back up support. Trach in place/patent, MDIs given as ordered. SpO2 90s. See resp flowsheet for specifics.\n\nPlan: continue current support\n" }, { "category": "Nursing/other", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 1520068, "text": "Respiratory Care:\nPatient remains on MMV ventilatory support due to periods of apnea and neurologic breathing patterns. Latest abg results determined a compensated metabolic acidemia with excellent oxygenation.\n\nRSBI = 31 on 0-PEEP and 5 cm PSV. It should be noted that these numbers are not a completely accurate picture of the patient's capacity to breathe spontaneously. The total number of breaths were 11, of which several were only 200 ml or less, with occassional VT grreater than 1.2 liters.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-06 00:00:00.000", "description": "Report", "row_id": 1520035, "text": " 7p-7a\nneuro: unchanged, unresponsive to verbal/painful stimuli, right pupil 3mm, left pupil 4mm both unresponsive to light and accomodation, no spontaneous movements, does not follow commands\n\ncv: received in afib rate 90-130 2gm magnesium sulfate iv-> sr 82-90 with occasional pacs/pvcs->afib rate 90-140 150mg amio bolus and amio gtt 1mg/ x 6hours, sbp 80-113, map 61-82 titrated levo gtt to maintain map>70, cvp 8-11, upper extremities cool and normal in colour, cap refill <3 seconds; lower extremities cool, left foot normal in colour, right foot dusky, cap refill < 3 seconds; unable to doppler pulses bilaterally dp or pt, bilateral femoral pulses dopplerable\n\nresp: lungs sounds coarse bilaterally, 02 sats 94-98% on vent settings, irregular respiratory rate, pt suctionned for moderate amounts thick yellow secretions, abg wnl\n\ngi: hypoactive bowel sounds, tolerating tf at 30ml/hr with minimal residuals, fib in place draining green liquid stool, fingersticks ssri\n\ngu: straight cath on days, crrt continues, filter changed for clotting (able to return blood before d/cing filter)\n\nlabs: 20 meq kcl given x1 in addition to crrt k+ sliding scale\n\nassess: stable\n\nplan: wean levo as tolerated, crrt goal even, family to decide this weekend re plan of care, advance tf to goal 35ml/hr, continue care as ordered\n" }, { "category": "Nursing/other", "chartdate": "2155-03-06 00:00:00.000", "description": "Report", "row_id": 1520036, "text": "Resp Care\nPt remains intubated on MMV no vent changes made this shift, pt continues to take only small shallow respirations. BLBS course and diminished, suctioned for mod amt of thick yellow secretions, MDIs given. ABGs WNL. Will continue vent support.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-06 00:00:00.000", "description": "Report", "row_id": 1520037, "text": "PROB: NEURO CHANGES\n\nCV: SR NO ECTOPY, CONT ON AMIO DRIP. LEVO WEANED TO .1MCG/KG/, SBP>90. LARGE CYANOTIC AREA ON RIGHT SOLE OF FOOT, MULTIPODIS BOOTS OFF. HEELS ELAVATED WITH BLANKETS.\n\nRESP: SUCTION FOR LARGE AMOUNT OF THICK YELLOW SPUTUM. ABGS ADEQUATE. BREATH SOUNDS DIMINISHED THROUGHOUT. O2 SATS NOT ACCURATE, CHANGED FOREHEAD PROBE WITHOUT IMPROVEMENT.\n\nRENAL: FOLEY CATH REINSERTED PER D. MCDOUGHAL, SCANT AMOUNT OF YELLOW URINE WITH SEDIMENT. CRRT CONTINUES, RUNNING PT SLIGHTLY POSITIVE FOR DAY. GROIN SITE CATH DRAINING SEROUS DRAINAGE. KCL AND CA DRIPS INFUSING. K REMAINS LOW, BOLUSES GIVEN X3 DURING SHIFT.\n\nGI: FIB LEAKING, CHANGED TO MUSHROOM CATHETER, WHICH DIDN'T CONTAIN STOOL. FIB REAPPLIED, DUODERM BECAME SOILED AND REMOVED. PT WITH HIGH NGT RESIDUALS THIS AM, RESTARTED WHEN 100CC PER TEAM. 18:00 RESIDUALS 330, FEEDS TURNED OFF AGAIN. BOWEL SOUNDS HYPOACTIVE. REGLAN CONT.\n\nENDO: BS TREATED PER S/S. SEE FLOW SHEET.\n\nNEURO: PT MOVING HEAD SIDE TO SIDE, HANDS WITH SLIGHT MOVEMENT OCCASIONALLY. BLINKING EYES OCCASIONALLY. PUPILS UNEQUAL AND NONREACTIVE. NONRESPONSIVE TO STIMULI. NONPURPOSEFUL MOVEMENT.\n\nSOCIAL: FAMILY UPDATED BY TEAM. SOCIAL WORKER UP TO SEE FAMILY. FAMILY REQUESTING PEPERWOK TO BE FILLED OUT.\n\nASSESSMENT: COND UNCHANGED.\n\nPLAN: MONITOR LYTES/BS\nFLEXISEAL IN ROOM\nPULM HYGIENE.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-07 00:00:00.000", "description": "Report", "row_id": 1520038, "text": "RESP CARE: Pt remains intubated/on vent on MMV with set MV of 5.0 liters. Pts own Vts <100cc, periods of apnea noted triggering MMV.SEE CAREVUE FOR SPECIFICS. ABGs acceptable. Lungs coarse, sxd thick pale yellow sputum. No cough noted. No RSBI. Pt exempt from weaning protocol per POE order.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-24 00:00:00.000", "description": "Report", "row_id": 1519993, "text": "Neuro: pt on Versed and Fentanyl drip, Pupils still do not react, no gag or cough reflex noted. pt has a noted twitch/spasm of lower eye area. PA in to evaluate no treatment\nResp: With sedation respiratory rate has come down to 18-25 with improving blood gases. 7.46 37 144 27 base excess 3. Peep was also decreased to 8.\nC/V: Blood pressure dipped into the 80's last evening pt started on Levo and tirated up to 1.0mcg/kg with SBP improving to >100 but then pt went into afib rate up to 140's SBP dropped back to 80's with MAP>60 pt given Amiodarone bolus and drip restarted rate slowed to 110-120 but bp did not improve. Pt cardioverted x2 1st with 100joules then with 150joules. Ea time she would convert to junctional rhythm but then go right back into a fib. Pt then given additional dose of amiodarone 150mg and Magnesium Sulfate 2gms and cardioverted again with 150 joules which the pt did convert to junctional rhythm and remained there for the rest of night. Attempted to a pace but wires did not work. SBP did not improve in the junctional rhythm but Map was greater than 60. SVO2 running 68-70 down to 64 this am. Neo on at .75mcg and not changed. Levo increased to .14 and SBP has been around 90. Pedal pulses very difficult to find intermittent at best feet cool to touch and has not changed.\nGI: OGT draining brown fluid Protonix increased to \nENdo: insulin gtt back on at 2 units.\nReNal: pt started on CVVH last evening ran even for several hours and then pulling 50cc/hr\nSkin: left arm large area around anticub where skin has peeled from blister covered with adaptic and DSD draining small amount of serous sang drainage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-02-24 00:00:00.000", "description": "Report", "row_id": 1519994, "text": "Respiratory care: Pt remains orally intubated an vented. Several vent changes made this shift, PEEP dropped to 5, FiO2 to 40%, ABGs showed normal acid base and oxygenation. Then Pt tried on PS 5, PEEP5, follow up ABG showed normal acid base and oxygenation. BLBS clear/diminished at bases. Suctioned for none. MDIs given per ordered. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-04 00:00:00.000", "description": "Report", "row_id": 1520026, "text": "NEURO: PUPILS EQUAL AT 3MM, NON REACTIVE. NO GAG, COUGH, CORNEAL REFLEXES. IRREGULAR RESPIRATORY PATTERN. NONPURPOSEFUL MOVEMENT L ARM AND HEAD INTERMITTENTLY.\n\nPULM: ORALLY INTUBATED, RESPIRATTORY PATTERN IRREGULAR, PERIODS OF APNEA, LOW TIDAL VOLUMES, ON MMV MODE ALL SHIFT, NO VENT CHANGES. ABG'S SHOW RESP COMPENSATION FOR MET ACIDOSIS. WBC 44K. T MAX 95.9 WITH BAIR HUGGER ON. SUCTIONING SCANT-SMALL AMTS THICK YELLOW SECRETIONS. TROUGH VANCO LEVEL 20, VANCO HELD MD , RANDOM LEVEL SENT AT 0400. CONTINUES ON IV ZOSYN Q6H. LUNGS COARSE THROUGHOUT, BRONCHIAL LLL.\n\nCV: RHYTHM CHAOTIC, ATRIAL FIB 90-110 TO ATRIAL FLUTTER 125-145 TO NSR 90'S WITH FREQ PVC'S/PAC'S. AMIODARONE 150MG BOLUS GIVEN AT 0300, CONVERTED BRIEFLY TO NSR, AMIODARINE GTT STARTED AT 1MG/ AT 0400. BP VERY LABILE, LEVO GTT TITRATED FROM 0.24-0.48MCG/KG TO KEEP MAP > 70. CONTINUOUS CA AND K INFUSIONS PER CRRT ORDERS WITH ADDITIONAL BOLUS'S OF BOTH. SEE CAREVUE AND . UNABLE TO DOPPLE PEDAL PULSES BILATERALLY. FAINT DOPPLE OF POPLITEALS. LACTIC ACID 3.4-2.4. PLATELETS 149K.\n\nRENAL: CCVHDF, SET PFR OF 100CC/HR D/T SEPSIS, HYPOTENSION AND UNABLE TO RUN EVEN OR TAKE FLUID OFF. NO FOLEY, NO URINE OUT.\n\nGI: LARGE AMT LOOSE BROWN STOOL AROUND MUSHROOM CATHETER, CATHETER LEFT OUT. 300CC RESIDUAL FROM DOBHOFF, TF DC'D. ABDOMEN SOT, HYPACTIVE BS.\n\nSOCIAL: FAMILY VISITED.\n\nPLAN: CONTINUE CURRENT AGGRESSIVE RX OF MULTI-SYSTEM FAILURE. MONITOR LABS Q4H AND PRN. WEAN LEVO KEEPING MAP > 70. EMOTIONAL SUPPORT OF FAMILY. ? SOCIAL SERVICE INVOLVEMENT TO HELP FAMILY WITH COPING MECHANISMS.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-04 00:00:00.000", "description": "Report", "row_id": 1520027, "text": "resp care - Pt remains intubated with no changes made this shift. MMV in use due to pt's increasing periods of apnea. Last ABG shows slight hypercarbia. Vts range between .065L and 1.12L. BLBS were coarse t/o. Pt suctioned for moderate amounts of thick, yellow secretions. Meds given as ordered. Continued care planned.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-04 00:00:00.000", "description": "Report", "row_id": 1520028, "text": "ammendment to resp care note - Pt's MMV increased to 5L.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-04 00:00:00.000", "description": "Report", "row_id": 1520029, "text": "NEURO: pt remain in comatose. pupil 3mm round/non-reactive. NO corneal reflex/gag/cough. no spontaneous or stimulus movement. No pain respond. Breathing irregular with cycles of apnea-prolongs inhalation-and few short breaths. apnea 5-15 seconds. Gas ^respiratory acidosis - ^minute volume -remain in MMV. Multipodus boots.\n\ncv: AFIB 90s-140s. rare to occasional pvcs/couplets pvcs. held lopressor po d/t hypotensive/levo gtt. d'c amio gtt and po amio was increased to . sbp dipped to ~15pts when HR >120s. titrate Levo gtt to keep MAP >70. CRRT lytes repletion-and gave add'l k. hct 30s. peripheral 2+edema, absent PD/PT/Popliteal pulses on both legs, Femoral pulses dopplerable, feet and both . NP was updated to status. con't care as ordered.\n\nLABS: Febrile, wbc ^44 in am->tynolol given np and now 52->cxr, blood cx order, new lines-MTLC & dialysis. team order to d'c old MTLC and dialysis and cx tips. cdiff spec sent. cont' piperacillin-tazobactam, flagyl iv.\n\nRESP: remain in MMV. see above note. ls very coases. sxn sm-mod amt. gas now resp acidosis->^minute volume 5. sat>98%. VAP protocol. receiving continous oral sxn -larg amt\n\nGU: CRRT goal keep positive or even if BP tolerate. straight cath 200cc removal.\nGI: NPO. large amt residual 300s-580cc bile matter mixed with tf ->held tf all np. con't reglan iv q6h. incont large loose BM x1\nENDO:treat bs per protocol\n\nWOUND: sternal and left leg wound dsd cdi. L arm dsd cdi. Coccyx with multiple small areas redden, skin lacerated->cleansed with NS and applied duoderm. Bilateral groins/perinum areas redden/rashy and multiple laceration on both upper thights->applied miconazole powder, vesta cream.\n\nFAMILY MEETING: WITH ATTENDING DR , NP , SOCIAL WORK RN, AND PT'S SPOKEPERSONS->dr. discuss with family regarding to Pt's status & prognosis. pt's spokepersons became increasingly emotional upsets-required much support from team and social work to help stay calm. Family members in tears and upsets, very emotional. Family members (spoke persons) stated that they are not ready to give up trying and will discuss to the rest of the family-then inform us. family members visit throughout afternoon, status and poc updated frequently.\n\na/p: POD #10 - comatose. Neuro consult x2. eeg x1. ?septic with WBC ^52. levo gtt. afib. recieving CRRT keep goal positive/even. Wound impaired. No TF absorbant.\n\nCon't care as ordered. need cx of old iv tips, blood and sputum cx. TLC and support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-05 00:00:00.000", "description": "Report", "row_id": 1520030, "text": "7am-7pm update\nneuro: pt remains unresponsive. no cough and no gag. does not repsond to stimulation. left pupil slighly larger than the right (team aware). left pupil 4 mm and right 3 mm -> both pupils are non reactive. pt did move left arm once -> towards her body (team aware) no other movement noted.\n\nCV: pt remains in afib, HR 80-110's. SBP 80-120's. MAP 60-80's. levo gtt titrated to keep MAP > 70. levo gtt weaned to 0.20 mcg/kg/. bil feet and hands cool to touch. right foot with darker - almost back sole of foot and top of foot. pt with no pedal pulse and no popliteal pulses. pt with + femoral pulses by doppler. (team aware) + bil radial pulses by doppler\n\nresp: LS coarse throughout. suctioned for small amount of thick white sputum. pt with copious clear oral secreations. no vent changed made overnight. pt continues on 40% MMV. abg's good - see flowsheet. ETT rotated. pt noted to have irregualar breathing pattern - .\n\ngi/gu: pt with soft abd. + hypoative bs. TF reamin on hold d/t high gastric residual. pt on reglan q6h. aspirated 520 cc's brown residual from pedi tube -> team notified -> orders recieved to place OGT. OGT placed and put to LIS. OGT drained 700 cc's brown residual overnight. pt had 5 large loose stools overnight - stool sent for C DIFF. fecal bag placed. LFT remain slighlty elvated - se flowsheet\n\nCRRT: CRRT ran overight. CRRT ran even. pt ~ 450 cc's this am. lytes replaced per sliding scale. BUN 25 this am and creatinine 1.7 this am.\n\nID: pt afebrile overnight. wbc's 53.3 this am. pt given vanco last night (vanco level yesterday was 19.4 - vanco given per team). pt also remains on zoysn and flagyl. stool sent for CDIFF last night. new multi lumen and new quniton lines placed yesterday in the afternon. I removed old multi lumen and old quinton and sent the tips for culture\n\nskin: sternum with staples - clean and dry - new DSD placed. left elbow with muliple skin tears - covered with xeroform and DSD. multiple skin tears on left leg covered with tegaderms. coccyx with duoderm intact.\n\nsocial: 3 family members into visit last night\n\nplan: monitor neuro status, monitor rhythm -> ??? anticougulation for afib, wean levo gtt as tolerated, keep MAP > 70, monitor pulses, skin care, pulm toleit, emotional support, continue CRRT - run even, continue antibiotics, montior wbc's/LFT's/BUN and creatinine, montiro lytes, monitor cultures\n" }, { "category": "Nursing/other", "chartdate": "2155-03-05 00:00:00.000", "description": "Report", "row_id": 1520031, "text": "update 7p-7am\nendo: pt started on insulin gtt last night for BS of 214. insulin gtt titrated per protocol. insulin gtt turned off for BS of 74. last glucose was 88. see flowsheet. plan: continues to monitor BS and treated per protocol\n" }, { "category": "Nursing/other", "chartdate": "2155-03-05 00:00:00.000", "description": "Report", "row_id": 1520032, "text": "Respiratory Care: pt remains orally intubated and vented. No vent changes made today. Lung sounds coarse. Suctioned for thick yellow secretions.ABGs within normal values. MDIs given per order.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-05 00:00:00.000", "description": "Report", "row_id": 1520033, "text": "Neuro: unchanged. Pupil 3mm R and 4mm L. NR. NO corneal reflex/gag/cough. non respond to verbal/stimulus (rub & nail bed pressure). Left arm minimumly move toward body x3 today-inconsistent and nonpurposeful/purposeful (when stimulate left axillary/shoulder).\nteam awared.\n\nid: wbc elevated. hypothermic, bair hugger with affect. cultures pnd. con't iv vanco/zosyn & flagyl. po vancomycin added today. need vanco trough tonight.\n\ncv: afib 80s-120s. frequent pvcs-bigeminal, couplets to rare. replete lytes multiple times. when HR >115--sbp dipped to 70s (20pts)-unable to wean levo gtt. Cardioversion attempt x2 at 360J, amiodarone bolus x1->pt convereted to aflutter 2/3:1 for few hours with sbp improved, but now afib. con't po amiodarone. no anticoagulant start per am team round. hct stable. peripheral 2+, skin cool, absent PD/PT/Popliteal. dopplerabe r femoral. (left femoral with dialysis line). R foot toes/sole and of foot dusky/mottle-examine by team. started on heparin sc for DVT prophylactic.\n\nresp: remain in MMV. breathing irregular, uneven, apnea 5-15sec, RR 10. LS coarses xall fields.sxn sm-mod amt. gas metabolic acidosis w lactaid level rise->informed Np -to con't monitor, keep CRRT even. sat>96%. see careview. VAP protocol\n\ngi: OGT clamped. residual. restart tf nutren renal fs with benoprotein via dophoff. belly soft\nendo: treat bs with riss\ngu: CRRT -keep even per team round. fecal incon bag intact. amt stools.\nwound: see careview. sternal/left arm/coccyx dsd/duoderm cdi. vesta cream. miconazole powder to bilat groins/perinum.\nsocial: frequent family members visit -emotional. update on status throughout shift and support given. con't provision of TLC and support to pt and family\n\na/p: pt remain unresponsive. neuro unchanged. con't CRRT to keep even.Wean levo gtt as tolerated. advance tf to goal if tolerated. f/u cultures. support\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-06 00:00:00.000", "description": "Report", "row_id": 1520034, "text": "RESP CARE: Pt remains intubated/on vent on MMV with low MV set for 5.0 liters. PS 5/PEEP 5/.40. ABGs reveal slight resp acidosis this am. Breathing pattern resembles Biot's respirations. Lungs coarse with rhonchi, sxd thick yellow sputum. MDIs per with good effect noted. Exempt from weaning protocol per POE order.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-10 00:00:00.000", "description": "Report", "row_id": 1520054, "text": "ALTERED NEURO/CARDIOVASCULAR STATUS\nO: NEURO: PUPILS FIXED 4MM. NO GAG OR COUGH. MOVEMENT OF LEFT ARM NOT TO COMMAND, SLIGHT HEAD MOVEMENT. NEURO UNCHANGED. NO OTHER EXTREMITY MOVEMENT. NO PURPOSEFUL MOVEMENT.\n CARDIAC: SR WITH 2 EPISODES OF ^ PVC'S. K 3.5-3.3 RECIEVED 20 MEQ KCL X1 IN ADDITION TO 10 MEQ/100 WITH REPEAT K 3.5. K TO BE REPEATED AT 2200. LEVO WEANED TO .01 MCQ TRANSIENTLY HAD TO ^ TO .O2 MCQ DUE TO SBP 70'S. MAP 60-90. ISOLATED PAC'S NOTED X2. EXTREMITIES COOL TO TOUCH. DOPP DP,ABSENT PT. LEFT FOOT WITH BLACK AREAS NOTED UNCHANGED FROM PREVIOUS NOTE. CVP 7-TEENS. HCT 30 POST 1UPC. CALCIUM GTT AS PER ORDERS.\n RESP: ABG AND VENT SETTINGS UNCHANGED. ABG GOOD. BREATH SOUNDS COURSE UPPER ,DIMINISHED BIBASILAR. SUCTIONED FOR A SMALL AMOUNT OF THICK WHITE SPUTUM. 02 SAT >94%. WILL OVERBREATH .\n GI: ^ ORAL CLEAR SECRETIONS. TF AT GOAL 1 RESIDUAL OF >200 ML , OGT AND FT + PLACEMENT. 50 ML OF LIQUID BLACK GREEN STOOL. ABD SOFT. + BOWEL SOUNDS. SMALL AMOUNT OF OOZING AROUND FLEXISEAL.\n GU: CONTINUES, GOAL TO REMAIN EVEN UNTIL OFF LEVO. UO AMBER WITH SEDIMENT 0-27ML/HR. CREAT 1.6.\n ENDO: SSI X1.\n ID: VANCO LEVEL 26. DOSE HELD. PO VANCO GIVEN. TEMP 95.2AX HUGGER APPLIED.\n SKIN: ELBOW DSG D+I. COCCYX CLEANSED AND ALOEVESTA AND DOUBLE GUARD APPLIED X2. AREAS DRAINING SEROUS DRAINAGE- AREAS RED . LEG DSG WITH SEROSANG SMALL AMOUNT STAINING.\n SOCIAL: FAMILY BEGAN VISITING AT 1700, LEFT AT , NO ISSUES, FAMILY TALKING TO PT REQUESTING HER TO WAKE UP.\nA: REQUIRING LEVO TO KEEP MAP>60,PVC'S, REQUIRING TITRATION OF K+CA, NEURO UNCHANGED, SOUNDS MORE COURSE THAN ABLE TO SUCTION, COOCYX LOOKS MEAN, I+O EVEN WITHOUT THE UPC+ALBUMIN,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN LEVO TO OFF AS TOLERATED,PP, CSM,CVP, NEURO STATUS, RESP STATUS,I+O-KEEP EVEN UNTIL LEVO OFF-MONITOR RESIDUALS,LABS PENDING - MONITOR K+CA, AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-11 00:00:00.000", "description": "Report", "row_id": 1520055, "text": "Neuro) No change in neuro status from AFS documentation. pt. minimal movement of LUE only.\nCV) Remains on Levophed at .01mcq/kg.hr. Unable to wean to any lesser dose due to low BP's of 99-103 syst. CVP 12-16. Heart rhythm stable and regular with no ectopy.\nPulm) ABG's unchanged; WNL. Secretions yellow and thick. breath sounds very coarse. spont MV 4.8-5.2 l/. MMV mode.\nGI) high TF residuals. 300cc at 0400. Tube feedings held for now. Reglan 5mg iv q6 hrs. Flexiseal system intact. no additional stool this shift.\nGU) negligable amount urine output. in progress and I/O kept even.\nSKin) See AFS for dsg changes. Lower extr. kept elevated on pillows to minimize heel pressure on bed.\nLabs) HCT stable at 34. lytes repleted prn.\nPlan) comfort, vasopressors as needed; wean pressor if possible. ,\nMonitor GI status and resume TF if residuals are less than 200cc.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-03 00:00:00.000", "description": "Report", "row_id": 1520023, "text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and nonreactive. Does not open eyes or withdraw to noxious stimuli. Does not follow commands. No movement with any extremities. No corneals, No gag, No cough.\n\nCARDIAC: Tmax 100.0 p.o. HR 80-150's NSR/afib. Levophed gtt to maintain MAP > 70. Cardioverted x3 at 360 joules for HR 140-150's MAP's 40-50's. No effect. Given 150 mg Amiodarone, 2gms Mag and 20meq KCL and cardioverted again x 1. Did not convert. HR 120's afib, MAP's >70.\n\nRESP: LS coarse. Deep sxn for scant to moderate amts of thick tan secretions. Sputum cx sent. Mouth sxn for copious amts of clear thick secretions. Sat 95-100%. Tol vent settings.\n\nGI: Abd soft Hypoactive BS. Large amts of liquid dark brown stool. Guiac (-). Mushroom cath placed. TF residuals 50cc. Will be checked again in afternoon.\n\nGU: Incontinent of large amts of clear yellow urine. Straight cathed after incontinent for no urine.\n\nINTEG: Numerous skin issues see Carevue. Skin very dry, lotion placed throughout shift.\n\nPSYCH/SOCIAL: Numerous family members to see her throughout the shift. Daughter is adamant about everything to be done medically for mother. Does not want to withdraw care.\n\nCVVHDF: PFR to remain at 100 per renal. Changed filter x 2 d/t clots.\n\nOTHER: PAO2 off ABG's 350-370. Redraw is in the 160's. NP. ? of faulty lab??.\n\nPLAN: Family meeting with family tomorrow, Monitor hemodynamics, Provide extra comfort to patient and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-03 00:00:00.000", "description": "Report", "row_id": 1520024, "text": "resp care - Pt remains intubated and on MMV. No changes made this shift. BLBS included rhonchi and scattered wheezes. Pt was suctioned for moderate amounts of thick, yellow secretions and given meds as ordered. ABG was WNL with hyperoxygination. Continued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-23 00:00:00.000", "description": "Report", "row_id": 1519989, "text": "Neuro: pt on Propofol 20mcg, Pupils left slightly larger than right both non reactive. pt open eye lids several time last night when touching head but also when her name was called. NO other movement seen.\nResp: PO2's decreasing down to 65 Peep increased to 10 and Fio2 increased to 70% with repeat po2 of 86 air way pressues in the mid 20's rate decreased to 12 but pt is overbreathing at a rate of 15-18. pt has a resportory alkolosis with a metabolic compensation.\nC/V: heart rate junctional tach with a rate in the 80's -90's. Amiodarone continued per ho at 0.5mg/min. Svo2 dipped to 58% with CI of 2.1 MIlrinione restarted. neo on at 1.5-1.75 to maintain a bp around 120 Epi increased to 0.03mcg per Dr last night to help improve Blood pressure. Can switch to Levo if unable to maintain Bp around 120 with present neo dose. Temp up to 101.5 pt pan cultured except for sputum\nGI: OGT draining bilious fluid, no bowel sounds heard, no stool.\nEndo: Insulin gtt on and off through night per protocol.\nRenal: Urine outputs improved after milrinione restarted and/or bp increased to greater than 110. Urines as high as 60 on Lasix 10mg and Natrecor 0.2mcg. Plan for possible CVVH to be started today for fluid removal.\nSkin: pt has a large area around left anticub area where a blister had been. Area pink mosit covered with Aquacel dsg and wrapped.\nPlan: Maintain SBP >120, Urines >30 Plan for CCVH\n" }, { "category": "Nursing/other", "chartdate": "2155-02-23 00:00:00.000", "description": "Report", "row_id": 1519990, "text": "Respiratory Care:Pt remains orally intubated and vented. Several changes made on vent today, ABG showed mixed metabolic/respiratory alkalosis, Vt first decresed to 430 ~8cc per Kg, follow up gas showed worsening mixed resp/metab alkalosis. As per Dr pt was tried on SIMV but did not tolerate, RR 56-60, Pt then placed back on AC and Vt decresed to 300, pt still did not tolerate and RR remained in high 40s to low 50s, Vt then increased to 400 where pt settle down, 100cc dead space added to circuit. Follow up gas showed non-compensated metabolic alkalosis. Lung sounds clear/diminished at bases. Suctioned for none. MDIs given Q4. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-23 00:00:00.000", "description": "Report", "row_id": 1519991, "text": "update\nD: Pt POD #2 from Cabg/mv/pfo repair with a emergent re-op- Propofol to off this am, pt in a junctional rhythm- amiodarone to off-pt with svo2 74%-excellent co/ci-milrinone to off- neo weaned to off with sbp >140/--pt u/o slowly up to 80-100/hr. pt remained alkalotic with ph 7.52-7.62-base excess - attempts made to correct with vent- pt did not tol simv or cpap mode- resp rate >50. eventually pt placed on cmv with tv down to 430cc- abg did not improve--added diamox with did result in sl in ph--pt cont on lasix drip and natracor. renal in to eval pt- teams wants cvvh--to hopefully improve the alkalosis--eventually dialysis cath placed in right fem. renal re-consulted and decision made to intialte cvvh--using replacement fluid only.\ndecision made to re-sedate to hopefully improve vent control--enabling the ability to use simv mode.\nplan: start cvvh-sedate-? change to levo from neo to ? cause less vasoconstriction to renals.\nneuro: off propofol, pt not responding to stimuli-, pt does move tongue- non- purposeful. pupils diff to assess-2-3mm- ? reaction.\nno purposeful movements noted.\ncardiac: pt in junctional rhythm 90's- at one point up to 100-a wire trace noted a waves in the middle of the qrs. sbp up to 140's/-weaned neo to off easily. as day progressed- sbp back down (with temp coming down)-neo restarted, epi titrated back up to .02 mcq- svo2 remain 70-74%.\nextremities esp right foot cool, trunk warm. pedal pulses difficult to obtain-wooshy--\nresp: bs dim on left side- clear on right side, abg's- improved oxygenation-weaned fio2 to 50% with adeq pao2, pt remained alkalotic with ph 7.54-7.62-base excess . please refer to previos imfor in regards to vent changes.\ngi: abd soft, bs absent. ppi cont. no BM post op. ogt draining bilious material.\ngu: foley-draining 25-80cc/hr- pt cont on lasix/natracor-plan to start cvvh-\nskin: pt with multiple skin tears with serous drainage. back looks great.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-24 00:00:00.000", "description": "Report", "row_id": 1519992, "text": "Respiratory Care:\nPatient remains unresponsive, sedated on fentanyl and versed. She is on levo, neo and amio. S/P cardioversion for afib earlier tonight. She is on CVVHD. BS with improving aeration, abgs with improving oxygenation and acid/base status. See Carevue flowsheet for specifics. Plan to continue supportive care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-09 00:00:00.000", "description": "Report", "row_id": 1520046, "text": " 7p-7a\nneuro: unresponsive to verbal/painful stimuli, mild flexion of wrists with bath this am, occasional small movements of head spontaneously, not following commands, pupils equal and nonreactive to light or accomodation\n\ncv: sr 66-79 no ectopy while on , able to wean levo gtt to off post d/c, ~2 hours post and kcl/ca++ gtts d/ced pt started having frequent pacs (atrial bigeminy) and occasional pvcs lopressor iv given, perfusion with pacs intermittent->levo gtt restarted, iv amio gtt turned off once bag run out md order, but po amio dose given, 2gm magnesium sulfate given but no decrease in pacs/pvcs noted until ~0415->sr no ectopy, levo titrated to keep maps>60/sbp>90 max dose 0.1; midodrine ng q 8hrs, cvp 8-14, cool hands and feet, hands normal in colour, feet mottled in appearance; able to doppler dp pulses, but not pt, max temp 38.2 bair hugger removed, increased bloody oral secretions-md aware\n\nresp: lungs coarse uppers, diminished to bases; irregular breathing with small tidal volumes <150, dependent on vent for breathing; abg wnl; 02 sats 100% when able to obtain\n\ngi: bowel sounds present, soft non-distended belly; tolerating tube feeds:vivonex at 30ml/hr, goal 65ml/hr, no insulin coverage overnight; flexiseal in place draining green liquid stool\n\ngu: foley to gravity draining small amounts (0-15ml/hr) cloudy yellow urine; stopped at 2315 per team order once filter outdated\n\nskin: coccyx abraded and draining small amounts bloody drainage-cleansed per med order and left open to air, left arm abraded in multiple areas but no drainage-cleansed per med order and dressed accordingly, left leg old incision sites draining small amounts serosanguineous drainage-cleansed per med order and dressed accordingly\n\nlabs: repleted K+, PTT still elevated after redraw-md aware\n\nplan: restart at 1100 if needed, d/c sternal incision staples? replete lytes prn, change dsgs tomorrow unless soiled, continue to advance tube feeds as tolerated, titrate levopehd gtt to maintain sbp>90\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-09 00:00:00.000", "description": "Report", "row_id": 1520047, "text": "Resp Care\nRemains intubated and ventilated on MMV back up rate set at 500 x 10. Spontaneous breaths are irregular, barely triggering any tidal volume. Breath sounds coarse, given combivent and flovent inhalers. O2 sat 98-100% with normal abgs, good oxygenation. Plan is to continue with mechanical ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-09 00:00:00.000", "description": "Report", "row_id": 1520048, "text": "Resp Care\nPt remains intubated on MMV 500x10 no vent changes made this shift. Pt continues to take inconsistantly small spontaneous Vts <100cc. BLBS course, suctioned for mod amt of very thick white-pale yellow secretions. MDIs given per order. ABGs WNL. Plan to continue vent support with current settings.\n" }, { "category": "Nursing/other", "chartdate": "2155-02-28 00:00:00.000", "description": "Report", "row_id": 1520011, "text": "Respiratory Care\nPt remains intubated (#7.5 ETT 21@lip) and on vent support. No vent changes were made during shift. Lung sounds remain course and dim in the bases. Suctioned for scant amounts of think white secretions. MDI's were given with no adverse effects. Last ABG remains unchanged from yesterday's resp alk with good oxygenation. Care plan is to continue current therapy. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-04 00:00:00.000", "description": "Report", "row_id": 1520025, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms set and functioning per respiratory department protocol. No vent changes made overnight. Continues on cpap 5, ps 5 and 40% fio2, with MMV 4.0L as patient has periods of apnea. Breathsonds are coarse combivent/flovent given per . RSBI done (read with caution as patients volumes range from 60cc to over a liter). Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Bronchodilators per .\n" }, { "category": "Nursing/other", "chartdate": "2155-03-09 00:00:00.000", "description": "Report", "row_id": 1520049, "text": "shift update:\n\nneuro: neuro status unchanged. pupils non reactive. eyes open. no corneal reflex. left arm flexion noted w/care. head movement noted w/mouth care.\n\ncv/skin: nsr w/rare pvc noted. lopressor d/c'd->cont on levo, able to wean after albumin & restarted. sternal, mediastinal & left arm dsg's d&i. left leg dsg changed, x2 open areas w/mod amt serous drainage. coccyx w/multiple open areas skin care done as ordered. + dopp pp except left pt. dialysis cath changed over a wire->suture sites bleeding dr aware & into eval several times. pressure dsg applied w/o change, surgiseal applied w/good effect. sq heparin d/c'd d/t ptt>150, ptt at 1730 53 team aware.\n\nresp: lungs coarse & dim in bases. cont on mmv 40%, no vent changes. abg's good. suctioned for thick yellow secreations. et tube rotated.\n\ngi/gu: og clamped. doboff w/tf infusing. residuals doboff but lg residual in og. team aware. tf to remain at 30cc/hr & no free water bolus. minimal uop when off. inc lg amt of liquid stool around flexiseal, adjusted. guiac + stool.\n\nendo: fs wnl. see flowsheet.\n\nid: tmax 100.4. cont on iv zosyn, flagyl & po vanco.\n\nrenal: , k+ & ca gtt restarted. goal to keep even.\n\nsocial: many familymembers into visit, weeping & praying at bedside. update given.\n\nplan: cont current plan of care. wean levo as tolerates. skin care. to run even.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-10 00:00:00.000", "description": "Report", "row_id": 1520050, "text": "Resp Care\nRemains ventilated on MMV with consistently small spontaneous breaths.O2 sats 100%/abgs normal. Plan is for continued mechanical ventilation,possible trach/peg later this week.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-10 00:00:00.000", "description": "Report", "row_id": 1520051, "text": "7am-7pm update\nneuro: pt remains unresponsive. pupils 4 mm and non reactive. no cough and no gag. pt noted to move head and flex left arm. no other movement noted.\n\nCv: pt remains NSR, occasional pvc's noted. HR 70-80's. SBP 80-120's. MAP 50-70's. levo gtt titrated to keep SBP > 90 and MAP > 60. levo gtt weaned to 0.045 mcg/kg/. pt given albumin x1. hct stable. plt 95 this am. upper and lower ext cool to touch. right foot black in color on sole of foot and top of foot. pt with + dp's. pt's absent.\n\nresp: LS coarse. pt suctioned for small amount of thick white sputum. pt remains on 40% MMV with 5 peep and 5 ps. abg's good - see flowsheet.\n\ngi/gu: pt with + bs. pt contines on vivonex tube feeds via dobhoff. vivonex TF advanced to 50 cc/hr (goal 65 cc/hr) residals remain high -> 150-200 cc/hr's (order to hold if residual > 200). pt continues on reglan q6h. felixseal intact and draining liquid green stool. stool guiac + - team aware - hct stable. foley draining scant amount of yellow urine with sediment\n\n: creatinine down to 1.6 this am. run even overnight. lytes replaced per sliding scale\n\nendo: elvated bs treated with ss reg insulin\n\nID: WBC's 31.6 (down from yesterday). pt afebrile overnight. vanco level 35.2 last night -> vanco IV held last night per Dr . pt continues on zoysn, vanco PO and flagyl\n\nskin: left arm/elbow area with multiple skin tears/breakdown - wound bed red/a few black areas. dressing down skin RN recommendations. coccyx with multiple areas of abbrasions -> covered with double guard and vesta and left open to air - skin rn recommendations. right leg with 3 skin tears - weaping sserousanginous fluid -> covered with aquacel, covered with gauze, then abd pad and then kerlix\n\nsocial: son into visit last night\n\nplan: continue , monitor neuro status, wean levo gtt as tolartered, skin care, continue antiobiotics, monitor cultures, monitor hct/lytes/abg's/wbc's\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-10 00:00:00.000", "description": "Report", "row_id": 1520052, "text": "7-11am: no changes from previous shift excpt was able to slightly wean levo, goal for cvvh to keep even, did get one unit prbcs for hct of 28, did get albumin per team for ? intravascular dry, did wean up potassium gtt, and wean down calcium gtt. Plan: cont even on cvvh, wean off levo as tolerates, continue monitor for neuro changes.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-10 00:00:00.000", "description": "Report", "row_id": 1520053, "text": "BS coarse crackles; no change with MDI's. Continues on CVVH. Remains on MMV due to small spontaneous breaths (generally <100 cc's.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-01 00:00:00.000", "description": "Report", "row_id": 1520015, "text": "Neuro: not responding to any stimuli including pain, not moving extremities, pupils equal but nonreactive to light, no pain meds or sedation medications given this shift.\n\nCardiac: junctional high 40's to 50 range for short periods of time, nsr 60-80 range for most of the shift then for short perids of times in afib in the 100-115 range, continues neo gtt for bp support up and down on gtt rate, cvp 0-8 range, hard to doppler pulses on feet team aware does have popliteal pulses in bilat legs and does have left dorsel pulse, skin warm dry and intact, afebrile, +3 edema in extremities.\n\nResp: no changes on vent, lungs coarses in top of lungs, and dim in bases, sxned for small to moderate tan thick tan sectretions, abg with metabolic acidosis-and rep compensation with low co2's.\n\nSkin: chest with dsd that is cdi, left leg with steri strips and has scant serous drainage dsd placed over site, left leg with blister site with moderate serosang drainage and dsd changed over site, groin area with yeast and nystatin ordered, coccyx is intact, fib intact.\n\nGi/Gu: tf's at goal with residuals, abd is soft round with good bowel sounds-is on reglan, no bm yet tody, urinary cath and had 170 out, sent urine culture, continues cvvh running patient around even has been difficult to make patient negative due to dropping bp with increased pfr.\n\nID: d/c'd levoflox and added flagyl for c-diff profilax, continues vanco.\n\nSocial: family in to visit and up dated- is new spokes person but ok brief updates to rest of family, and cookie called, son in to visit with other sons, team called today and updated her.\n\nPlan: needs x 2 c-diff sents, continue cvvh, continue neo, monitor for any change in neuro signs.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-01 00:00:00.000", "description": "Report", "row_id": 1520016, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV 5/5 B/S ess clear sx'd once for large thick yellow. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-02 00:00:00.000", "description": "Report", "row_id": 1520017, "text": "respiratory care\nPt remains intubated , vent settings per carevue. BS clear bilaterally. SUctioned for copius amounts of tan thick secretions and bloody thin oral secretions. ETT position changed. MDI's given as ordered. RSBI= 10. Will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1520077, "text": "7P-7A\nNUERO: UNAROUSABLE/UNRESPONSIVE. PUPILS 4MM & FIXED. NO GAG, NO COUGH, NO CORNEAL REFLEXES. NO PUROSEFUL MOVEMENTS NOTED. TMAX 99.6\n\nCV: NSR OCCASIONAL PACS NOTED. LYTES PRN. LEVOPHED GTT RESTARTED @ 0.030MCG/KG/ FOR MAP <60. EXTREMITIES COOL TO TOUCH. DOPPLERABLE PULSES.\n\nRESP: TRACHED. MMV VENTILATOR SETTING. RATE INTIALLY SET 8 INCREASED TO 10 AFTER ABG REVEALS PCO2 56. REPEAT ABG WNL. SEE CAREVUE. SUCTIONED FOR COPIOUS AMOUNTS THICK YELLOW SPUTUM. MDI PER RT.\n\nGU/GI: MINIMAL UO. RISING BUN/CR 31/2.5 TOLERATING VIVONEX TF @ GOAL 60CC/HR VIA GTUBE. NO RESIDUAL. FLEXISEAL RECTAL TUBE TO GRAVITY WITH NO OUTPUT OVERNIGHT. IRRIGATED WITH NO EFFECT. (+)BS ABD SOFT.\n\nENDO: GLUCOSE COVERAGE PER PROTOCOL.\n\nSEE CAREVUE FOR SKIN ASSESSMENT.\n\nPLAN: TRANSFER TO REHAB MONDAY AFTER HEMODIALYSIS AND PICC LINE PLACEMENT. CONTINUE SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1520078, "text": "BS coarse crackles; occ rhonchi; no change with MDI's. Suctioned for mod amount yellow secretions. Remains on MMV 500x10; no ABG's. ? discharge to Rehab tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1520079, "text": "See and Carevue for detailed documentation\n\nNeuro: Pupils fixed , no cough/ gag, purposeful movement. Spinal reflex/ posturing noted in UE with movement of UE, head.\n\nResp: Stable on vent. Suctioned for minimal secretions. BS remain coarse thru out. Resp irregular at times but tolerating vent.\n\nCV: Rec'd patient in afib. Continued thru shift, rate in 80's BP tolerated with MAP>60, off levo. Now in NSR with PAC's. Low grade temp.\n\nGI: Tol tube feeds, minimal residual. Flexicath in place with small amounts liquid brown stool. Continue on vanco, erythro, flagyl. eaking around cath with turns. Skin care as noted on carevue.\n\nGU: Foley to gravity with small amounts amber urine.\n\nSocial: Family into visit. Toured rehab. Request transfer to .\nCase manager to eval in am.\n\nPlan: Continue cardiopulmonary monitoring. HD and PICC placement in am.\nTransfer to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-17 00:00:00.000", "description": "Report", "row_id": 1520080, "text": "Nursing Progress Note\nNeuro: unresponsive, pupils 4 fixed, no gag, no cough, corneals intact. Unable to close her eyes, taped shut for the night. No purposeful movement, posturing entension only.\n\nCVS: afebrile, MAP greater than 60 no drips, hr 70's to 80's sr with frequent pvcs at times. Pulses upper by doppler, unable to auscultate pulses by doppler in feet. Gorss generalized edema, third spacing and weeping brown plasma like fluid at any open site. A line transduced, IV patent. Dialysis cath permanent, not utilizd at this time.\n\nResp: ls coarse suction for thick yellow. Trach care done, remains sutured in. See rt notes for ventilatior and mdi details.\n\nGI: and soft, round, distended. Flexi seal rectal containment system in place, not working well due to hemmprhoids excessive leakage around system form anus. Gtube in abd. vivonex at 60 cc/hour (goal) tolerating without incident.\n\nGU: Foley catheter with concentrated cloudy urine. Due for HD tomorrow.\n\nPain: no apparent.\n\nEndo: fs bs may be covered wtih sliding scale regular insulin if needed.\n\nLytes: awaiting lab results for lyte repletion needs.\n\nPlan: awaiting bed at rehab per family.\n\nSee carevue flowhseet and at further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-01 00:00:00.000", "description": "Report", "row_id": 1520013, "text": "Respiratory Therapy\npt remains orally intubated on PSV and CVVHD. ETT moved to Lt corner of mouth, No vent changes made. BS vesicular scant secretions. ABG reveals a fully compensated metabolic acidosis. Plan; continue ventilatory support. please see carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-01 00:00:00.000", "description": "Report", "row_id": 1520014, "text": " 7p-7a\nneuro: neuro status unchanged overnight, unresponsive to verbal/painful stimuli, pupils 3mm nonreactive to light, no spontaneous movements, does not follow commands\n\ncv: sb/sr 52-72 increasing incidence of pacs this am, maps 65-95 neo gtt titrated to maintain map>70, occasional increase in sbp to 170s with stimulation, sometimes increases to 170 without stimulation, sbp will usually settle to wnl within 10-15 minutes, afeb\n\nresp: coarse upper lobes, diminished to bases, difficult to obtain 02 sat no matter where oxisensor placed, 02 sat okay by abg, increased irregularity of respirations this am (irregular in rhythm and tidal volumes), occasional 15-18 second pauses\n\ngi: bowel sounds present, tf advanced to goal 35ml/hr, minimal residuals, fingersticks ssri, abdomen soft nondistended, copious thin clear oral secretions, fib\n\ngu: possible incontinent episode vs fib leak, crrt continues, filter changed at 0300 for clotting, goal of -100ml/hr difficult to achieve with pt's bp labile\n\nlabs: hct dropped from 28->25, wbc increased to 18 from 11,team aware, abg improving after 1 amp bicarb\n\nsocial: pt visited by daughter and son and daughter-in-law early pm, spokesperson now daughter-in-law or son , rules for visiting ex. times/number of visitors/calling explained to family by \n\nassess: stable\n\nplan: continue current treatment, put pt on rate if needed, goal -100ml/hr crrt, neo gtt to maintain maps>70, Dr to call daughter-in-law to update family re pt's condition today\n" }, { "category": "Nursing/other", "chartdate": "2155-03-15 00:00:00.000", "description": "Report", "row_id": 1520072, "text": "Neuro: status unchanged, pupils equal and non reactine, does with mouth care posture head to side and posture left hand but not to command, no gag reflex, no corneal reflex.\n\nCardiac: nsr with occ pvc's, sbp's running in the 90's team aware and map's are all >60, dopplerable pedial pulses, running low grade temps around 100.0-tylenol given, skin warm and dry, bilat feet cool and cyanotic.\n\nResp: lungs are coarse, no vent changes made, sxned for small amounts of thick white secretions, abgs wnl's..\n\nSkin: skin care rn following patient, coccyx with 1 to + 2 multiple small areas of pressure breakdown-double guard cream applied and aqua seal dsd over sites, chest with dsd that is cdi except for proximal and distal areas with small dehis site that drains scat serous drainage, peg site is cdi, old medialstinal ct's sites are approximated and dsd intact, left arm a-line dsd changed for moderate serous drainage, left arm dsd changed for small amount of serous drainage, left leg x 2 small sites that drain moderate serous drainage was changed, on heparin sc, being turned and rolled frequently.\n\nGi/Gu: tolerating tf's at goal with no residuals, blood sugars wnl's this shift were running high yesterday day shift, abd soft and round with good bowel sounds, flexiseal intact draining liquid green stools, is small amount of liqid stool that drains around flexi seal, makes scant amounts of u/o.\n\nSocial: family in to visit and updated/family aware of plan of possible rehab early next week.\n\nPlan: start paper work this weekend for discharge, monitor for any neuro changes, change dressings as needed, turn and roll frequently, monitor temps.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-15 00:00:00.000", "description": "Report", "row_id": 1520073, "text": "Resp Care: pt continues on mechanical ventilation: MMV 500x8 40%+5. No changes made overnight. ABG: 7.43/48/162/33. Sxn'd for small-moderate amounts of thick white secretions. RSBI not done MD order: poor neuro status/unable to protect airway. Tx's per . PLAN: maintain mechanical ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-15 00:00:00.000", "description": "Report", "row_id": 1520074, "text": "Shift update\nNeuro: Pt unresponsive, pupils NR 4mm, no gag, no cough, no corneal reflexes. Left arm flexed inward w/ hands on care. See carevue.\n\nCV: HR 80-90s SR w/ rare to occasional pacs. K of 3.7 repleted w/ 20meq iv. SBP 90-110s. MAP>60, see carevue. Dopplerable DP pulses. See carevue for further details.\n\nResp: LS coarse. Trach #8, on MMV mode w/ sats 94-100%. see carevue for details. Trach care done.\n\nGI/GU: Abd soft, +BS. Flexiseal intact draining liquid green stool. Tolerating Vivonex FS at goal of 60cc/hr. Foley draining scant amt of amber yellow urine.\n\nEndo: Per RISS.\n\nSkin: See carevue.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Plan for rehab next week. PICC placement for Monday. Next HD scheduled for Monday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-15 00:00:00.000", "description": "Report", "row_id": 1520075, "text": "BS coarse crackles; no change with MDI's. Suctioned for small amount white secretions. Continue screening for long-term vent facility.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1520076, "text": "Resp Care: Pt continues on MMV-> rate increased to 10 after am ABG. LS coarse bilaterally. Instilled and suctioned large amounts of thick yellow secretions. Tx's given per . RSBI not done-> MD order pt exempt from weaning protocol secondary to inability to protect airway/neuro status. PLAN: discharge to rehab on Monday.\n" }, { "category": "Echo", "chartdate": "2155-02-21 00:00:00.000", "description": "Report", "row_id": 96839, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Congestive heart failure. Coronary artery disease. Mitral valve disease. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 09:39\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of\nthe LA. No spontaneous echo contrast or thrombus in the body of the LAA.\nNo mass/thrombus in the LAA. No spontaneous echo contrast is seen in the\nLAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV. PFO is present. Left-to-right shunt\nacross the interatrial septum at rest.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Moderately dilated LV cavity. No LV\naneurysm. Moderate regional LV systolic dysfunction. Moderately depressed\nLVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nFocal calcifications in ascending aorta. Mildly dilated aortic arch. Complex\n(>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No AS. Trace AR.\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Myxomatous\nmitral valve leaflets. Mitral leaflets fail to fully coapt. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. No MS. Moderate\nto severe (3+) 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. No TEE related\ncomplications. The patient received antibiotic prophylaxis. The TEE probe was\npassed with assistance from the anesthesioology staff using a laryngoscope.\nThe patient was under general anesthesia throughout the procedure.\n\nConclusions:\nPRE-CPB: 1. The left atrium is mildly dilated. No spontaneous echo contrast is\nseen in the body of the left atrium. No spontaneous echo contrast or thrombus\nis seen in the body of the left atrium or left atrial appendage. No\nmass/thrombus is seen in the left atrium or left atrial appendage. No\nspontaneous echo contrast is seen in the left atrial appendage. No thrombus is\nseen in the left atrial appendage.\n2. A patent foramen ovale is present. A left-to-right shunt across the\ninteratrial septum is seen at rest.\n3. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis moderately dilated. No left ventricular aneurysm is seen. There is moderate\nregional left ventricular systolic dysfunction with moderate anteroseptal and\ninferior hypokinesia.. Overall left ventricular systolic function is\nmoderately depressed.LVEF = 35%.\n4. Right ventricular chamber size and free wall motion are normal.\n5. There are simple atheroma in the ascending aorta. The aortic arch is mildly\ndilated. There are complex (>4mm) atheroma in the aortic arch. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta.\n6. There are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen.\n7. The mitral valve leaflets are severely thickened/deformed. The mitral valve\nleaflets are myxomatous. The mitral valve leaflets do not fully coapt. No mass\nor vegetation is seen on the mitral valve. Moderate to severe (3+) mitral\nregurgitation is seen.\n\nPOST-CPB: On infusions of epinephrine, phenyloephrine. Well-seated\nannuloplasty ring in the mitral position. MR is now trace. 3 mmHg peak\ngradient aqcross mitral valve. Improved LV systolic function on inotropiuc\nsupport. LVEF now 40-45%.\n\n\n" }, { "category": "Echo", "chartdate": "2155-02-17 00:00:00.000", "description": "Report", "row_id": 96840, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Murmur.\nHeight: (in) 62\nWeight (lb): 122\nBSA (m2): 1.55 m2\nBP (mm Hg): 130/80\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 10:41\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.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nModerate regional LV systolic dysfunction. [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.]\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid\ninferior - akinetic; basal inferolateral - akinetic; mid inferolateral -\nakinetic; septal apex - hypo; inferior apex - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated. There is moderate\nregional left ventricular systolic dysfunction with near akinesis of the basal\nhalf of the inferior and inferolateral walls. The more distal inferior and\ninferolateral, and distal septum are hypokinetic. The remaining walls contract\nwell. . [Intrinsic left ventricular systolic function is likely more depressed\ngiven the severity of valvular regurgitation.] Right ventricular chamber size\nis normal with mild global free wall hypokinesis. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate (2+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Left ventricular cavity enlargment with regional systolic\ndysfunction c/w CAD. Moderate mitral regurgitation most likely due to\npapillary muscle dysfunction. Pulmonary artery systolic hypertension. Right\nventricular free wall hypokinesis.\n\nCLINICAL IMPLICATIONS:\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": "ECG", "chartdate": "2155-02-17 00:00:00.000", "description": "Report", "row_id": 262950, "text": "Sinus rhythm. Low limb lead voltage. Consider left atrial abnormality. Mild\nQ-T interval prolongation. Since the previous tracing of earlier in the\nday no significant change.\n\n" }, { "category": "ECG", "chartdate": "2155-03-12 00:00:00.000", "description": "Report", "row_id": 262947, "text": "Baseline artifact\nRhythm uncertain and baseline artifact makes assessment difficult - may be\nsinus rhythm with atrial premature complex\nConsider prior inferior myocardial infarction\nNonspecific ST-T abnormalities\nSince previous tracing of , inferior Q waves more prominent and further\nT waves changes present\n\n" }, { "category": "ECG", "chartdate": "2155-02-21 00:00:00.000", "description": "Report", "row_id": 262948, "text": "Sinus rhythm. Low limb lead voltage. Diffuse non-specific ST-T wave\nflattening, new compared to the previous tracing of . The precordial\nvooltage has diminished as well. Question pericardial effusion. Followup and\nclinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2155-02-20 00:00:00.000", "description": "Report", "row_id": 262949, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2155-02-17 00:00:00.000", "description": "Report", "row_id": 263177, "text": "Sinus rhythm. Left atrial abnormality. Prolonged QTc interval. Clinical\ncorrelation is suggested. Since the previous tracing of no significant\nchange.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2192-05-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 570059, "text": "Chief Complaint: motorcycle accident, multiple trauma\n HPI:\n 58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Post operative day:\n HD2\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: Herpes\n PSH: L knee surgery x2\n : Valtrex 500'\n ALL: None\n Flowsheet Data as of 03:06 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: 71 (68 - 73) bpm\n BP: 127/74(84) {127/67(82) - 133/74(89)} mmHg\n RR: 12 (11 - 13) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 242 mL\n PO:\n TF:\n IVF:\n 242 mL\n Blood products:\n Total out:\n 0 mL\n 560 mL\n Urine:\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -318 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, abrasions on face/forehead\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, multiple abrasion\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 284 K/uL\n 11.5 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 107 mEq/L\n 140 mEq/L\n 32.9 %\n 15.1 K/uL\n [image002.jpg]\n 02:05 AM\n WBC\n 15.1\n Hct\n 32.9\n Plt\n 284\n Cr\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:13.7/24.0/1.2, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n Assessment And Plan: 58M s/p motorcycle accident suffering multiple\n injuries including Left frontoparietal and parietotemporal IPH, right\n maxillary sinus (lat wall), right temporal bone (w/ ext to external ear\n canal) and right parietal bone fx; Small right hemopneumothorax; b/l\n pulm consolidation (?contusion vs asp); Multiple R rib fractures (),\n R scapular fx (comminuted) and R clavicular fracture (displaced); No\n free air/fluid in abd/pelvis.\n Neurologic: IPH: neurosurg following- repeat head CT in AM;\n maxillofacial fx - Plastics following- max-fac CT in AM; sinus\n precautions; R temoral bone fx w/ external ear canal extension- ENT to\n consult in AM\n Neuro checks Q: 2hrs\n Pain: Morphine PCA\n Cardiovascular: stable\n Pulmonary: R rib fxs, ?b/l pulm contusions vs aspiration; small\n hemopneumothorax - oxygenation stable on nasal canula. Able to cough\n and take deep breaths\n Gastrointestinal: NPO, colace\n Renal: Cr normal, follow UOP\n Hematology: initial HCT 37\n Infectious Disease: valtrex (home med); no abx currently\n Endocrine: RISS\n Fluids: LR 100\n Electrolytes:\n Nutrition:\n General: R scapula/clav fx- ortho following, tx w/ sling for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:36 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2192-05-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 570104, "text": "Chief Complaint: motorcycle accident, multiple trauma\n HPI:\n 58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Post operative day:\n HD2\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: Herpes\n PSH: L knee surgery x2\n : Valtrex 500'\n ALL: None\n Flowsheet Data as of 03:06 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: 71 (68 - 73) bpm\n BP: 127/74(84) {127/67(82) - 133/74(89)} mmHg\n RR: 12 (11 - 13) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 242 mL\n PO:\n TF:\n IVF:\n 242 mL\n Blood products:\n Total out:\n 0 mL\n 560 mL\n Urine:\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -318 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, abrasions on face/forehead\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, multiple abrasion\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 284 K/uL\n 11.5 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 107 mEq/L\n 140 mEq/L\n 32.9 %\n 15.1 K/uL\n [image002.jpg]\n 02:05 AM\n WBC\n 15.1\n Hct\n 32.9\n Plt\n 284\n Cr\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:13.7/24.0/1.2, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n Assessment And Plan: 58M s/p motorcycle accident suffering multiple\n injuries including Left frontoparietal and parietotemporal IPH, right\n maxillary sinus (lat wall), right temporal bone (w/ ext to external ear\n canal) and right parietal bone fx; Small right hemopneumothorax; b/l\n pulm consolidation (?contusion vs asp); Multiple R rib fractures (),\n R scapular fx (comminuted) and R clavicular fracture (displaced); No\n free air/fluid in abd/pelvis.\n Neurologic: IPH: neurosurg following- repeat head CT in AM;\n maxillofacial fx - Plastics following- max-fac CT in AM; sinus\n precautions; R temoral bone fx w/ external ear canal extension- ENT to\n consult in AM\n Neuro checks Q: 2hrs\n Pain: Morphine PCA currently, would be good candidate for epidural\n Cardiovascular: stable, monitor hr and bp\n Pulmonary: R rib fxs, ?b/l pulm contusions vs aspiration; small\n hemopneumothorax - oxygenation stable on nasal canula. Able to cough\n and take deep breaths when pain controlled\n Gastrointestinal: NPO, colace\n Renal: Cr normal, follow UOP\n Hematology: initial HCT 37 to 33, repeat HCT later today\n Infectious Disease: valtrex (home med); no abx currently\n Endocrine: RISS\n Fluids: LR 100\n Electrolytes:\n Nutrition: npo\n General: R scapula/clav fx- ortho following, tx w/ sling for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:36 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2192-05-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 570119, "text": "Trauma, s/p\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": "2192-05-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 570120, "text": "58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Trauma, s/p\n Assessment:\n Alert and oriented and able to converse and follow commands without\n difficutly. Pupils are equal and round and briskly reactive to light.\n He moves all extremities with equal strength with the exception of his\n right arm which is immobilized by sling. Abdomen is soft with bowel\n sounds present. Abrasions to right elbow, shoulder and side of head are\n unchanged. A small amount of old blood is noted draining from right ear\n when hob elevated. He is hemodynamically stable with am hct result\n 32.9, Currently NPO except meds.\n Action:\n HOB> 30 degrees and sinus precautions maintained, neuro assessment q\n 2hrs. Repeat Hct sent to lab.\n Response:\n No change noted in assessment, Hct 33.4\n Plan:\n To be seen by ENT service today and have follow up Head and sinus CT.\n Continue npo status until after testing. Pt to transfer out of ICU.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain in right shoulder and ribs voiced with any movement. PCA\n morphine in use and pain level improved to at rest.\n Action:\n Epidural catheter placed for bupivicaine infusion by Acute Pain\n Service.\n Response:\n Rib pain now with activity. Right shoulder pain continues as\n moderate to severe with activity.\n Plan:\n Follow sensory level and rib pain levels and notify APS of increasing\n or unrelieved pain. Review use of PCA morphine with patient and\n encourage it\ns use before activities. Notify ICU team of escalating or\n uncontrolled pain. Keep right shoulder sling in place.\n" }, { "category": "Nursing", "chartdate": "2192-05-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 570121, "text": "58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Trauma, s/p\n Assessment:\n Alert and oriented and able to converse and follow commands without\n difficutly. Pupils are equal and round and briskly reactive to light.\n He moves all extremities with equal strength with the exception of his\n right arm which is immobilized by sling. Abdomen is soft with bowel\n sounds present. Abrasions to right elbow, shoulder and side of head are\n unchanged. A small amount of old blood is noted draining from right ear\n when hob elevated. He is hemodynamically stable with am hct result\n 32.9, Currently NPO except meds.\n Action:\n HOB> 30 degrees and sinus precautions maintained, neuro assessment q\n 2hrs. Repeat Hct sent to lab.\n Response:\n No change noted in assessment, Hct 33.4\n Plan:\n To be seen by ENT service today and have follow up Head and sinus CT.\n Continue npo status until after testing. Pt to transfer out of ICU.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pain in right shoulder and ribs voiced with any movement. PCA\n morphine in use and pain level improved to at rest.\n Action:\n Epidural catheter placed for bupivicaine infusion by Acute Pain\n Service.\n Response:\n Rib pain now with activity. Right shoulder pain continues as\n moderate to severe with activity.\n Plan:\n Follow sensory level and rib pain levels and notify APS of increasing\n or unrelieved pain. Review use of PCA morphine with patient and\n encourage it\ns use before activities. Notify ICU team of escalating or\n uncontrolled pain. Keep right shoulder sling in place.\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n ICH,RIB FX\n Code status:\n Full code\n Height:\n Admission weight:\n 88 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: benign PMH\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:75\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,428 mL\n 24h total out:\n 1,310 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:05 AM\n Potassium:\n 4.1 mEq/L\n 02:05 AM\n Chloride:\n 107 mEq/L\n 02:05 AM\n CO2:\n 24 mEq/L\n 02:05 AM\n BUN:\n 12 mg/dL\n 02:05 AM\n Creatinine:\n 0.8 mg/dL\n 02:05 AM\n Glucose:\n 181 mg/dL\n 02:05 AM\n Hematocrit:\n 33.4 %\n 11:19 AM\n Finger Stick Glucose:\n 196\n 07:00 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: Wrist watch\n Transferred from: \n Transferred to: CC602\n Date & time of Transfer: 1430\n" }, { "category": "Nursing", "chartdate": "2192-05-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 570089, "text": "58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Pt arrived to TSICU () from the ED via stretcher. Pt alert,\n oriented X 3. pt moving all extremities with limited movement to RUE\n secondary to pain. Pt speech clear, pupils are equal and reactive to\n light, cervical collar intact at present. Pt with superficial abrasion\n to right side of head, right shoulder and right elbow. LS clear but\n diminished at right base, Pox 96-98% on RA. Abdomen is soft with\n positive bowel sounds.\n Trauma, s/p\n Assessment:\n -CT showing : right temporal bone fracture, rib fractures , small\n right pneumothorax, right scapula fracture, right clavicular\n fracture, left intraparenchymal hemorrhage ( no shift noted)\n -Pt is alert and oriented X 3, MAE but RUE movement is limited by pain,\n PERRL, Cervical collar intact\n -LS clear but diminished at right base, pox 96-98% on RA. RR even and\n non labored\n Action:\n -Neuro exams Q 2 hours\n -right arm sling applied as per ortho recommendation for right arm\n support\n -Encourage couch and deep breath Q 1-2 hours as tolerated. CXR done\n with AM labs\n Response:\n -Neuro exams have remained stable\n -Respiratory status wnl\n Plan:\n -await CXR results, continue to follow neuro exams. Pt planned for\n repeat CT of head/maxillofacial/chest today ? discontinue cervical\n collar pending further CT results\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain on right shoulder/flank area. Rates pain as when\n patient is at rest but also reports pain level as with\n turning/movement\n Action:\n Morphine PCA initiated for pain control\n Response:\n Pt now rating pain as when pt still and resting however he\n continues to report pain level with activity\n Plan:\n Educate pt on pain control and encourage PCA usage prior to any turning\n or repositioning\n" }, { "category": "Physician ", "chartdate": "2192-05-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 570097, "text": "Chief Complaint: motorcycle accident, multiple trauma\n HPI:\n 58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Post operative day:\n HD2\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PMH: Herpes\n PSH: L knee surgery x2\n : Valtrex 500'\n ALL: None\n Flowsheet Data as of 03:06 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: 71 (68 - 73) bpm\n BP: 127/74(84) {127/67(82) - 133/74(89)} mmHg\n RR: 12 (11 - 13) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 242 mL\n PO:\n TF:\n IVF:\n 242 mL\n Blood products:\n Total out:\n 0 mL\n 560 mL\n Urine:\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -318 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, abrasions on face/forehead\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, multiple abrasion\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 284 K/uL\n 11.5 g/dL\n 181 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 107 mEq/L\n 140 mEq/L\n 32.9 %\n 15.1 K/uL\n [image002.jpg]\n 02:05 AM\n WBC\n 15.1\n Hct\n 32.9\n Plt\n 284\n Cr\n 0.8\n Glucose\n 181\n Other labs: PT / PTT / INR:13.7/24.0/1.2, Ca++:8.0 mg/dL, Mg++:1.8\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n Assessment And Plan: 58M s/p motorcycle accident suffering multiple\n injuries including Left frontoparietal and parietotemporal IPH, right\n maxillary sinus (lat wall), right temporal bone (w/ ext to external ear\n canal) and right parietal bone fx; Small right hemopneumothorax; b/l\n pulm consolidation (?contusion vs asp); Multiple R rib fractures (),\n R scapular fx (comminuted) and R clavicular fracture (displaced); No\n free air/fluid in abd/pelvis.\n Neurologic: IPH: neurosurg following- repeat head CT in AM;\n maxillofacial fx - Plastics following- max-fac CT in AM; sinus\n precautions; R temoral bone fx w/ external ear canal extension- ENT to\n consult in AM\n Neuro checks Q: 2hrs\n Pain: Morphine PCA currently, would be good candidate for epidural\n Cardiovascular: stable, monitor hr and bp\n Pulmonary: R rib fxs, ?b/l pulm contusions vs aspiration; small\n hemopneumothorax - oxygenation stable on nasal canula. Able to cough\n and take deep breaths when pain controlled\n Gastrointestinal: NPO, colace\n Renal: Cr normal, follow UOP\n Hematology: initial HCT 37 to 33, repeat HCT later today\n Infectious Disease: valtrex (home med); no abx currently\n Endocrine: RISS\n Fluids: LR 100\n Electrolytes:\n Nutrition: npo\n General: R scapula/clav fx- ortho following, tx w/ sling for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:36 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2192-05-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 570076, "text": "58M s/p motorcycle accident at 45mph, unhelmeted, +LOC, MCC,\n unhelmeted, +LOC, slid 45ft from bike. Multiple injuries including:\n Left frontoparietal and parietotemporal IPH, right maxillary sinus (lat\n wall), right temporal bone (w/ ext to external ear canal) and right\n parietal bone fx; Small right hemopneumothorax; b/l pulm consolidation\n (?contusion vs asp); Multiple R rib fractures (), R scapular fx\n (comminuted) and R clavicular fracture (displaced); No free air/fluid\n in abd/pelvis.\n Pt arrived to TSICU () from the ED via stretcher. Pt alert,\n oriented X 3. pt moving all extremities with limited movement to RUE\n secondary to pain. Pt speech clear, pupils are equal and reactive to\n light, cervical collar intact at present. Pt with superficial abrasion\n to right side of head, right shoulder and right elbow. LS clear but\n diminished at right base, Pox 96-98% on RA. Abdomen is soft with\n positive bowel sounds.\n Trauma, s/p\n Assessment:\n -CT showing : right temporal bone fracture, rib fractures , small\n right pneumothorax, right scapula fracture, right clavicular\n fracture, left intraparenchymal hemorrhage ( no shift noted)\n -Pt is alert and oriented X 3, MAE but RUE movement is limited by pain,\n PERRL, Cervical collar intact\n -LS clear but diminished at right base, pox 96-98% on RA. RR even and\n non labored\n Action:\n -Neuro exams Q 2 hours\n -right arm sling applied as per ortho recommendation for right arm\n support\n -Encourage couch and deep breath Q 1-2 hours as tolerated. CXR done\n with AM labs\n Response:\n -Neuro exams have remained stable\n -Respiratory status wnl\n Plan:\n -await CXR results, continue to follow neuro exams. Pt planned for\n repeat CT of head/maxillofacial/chest today ? discontinue cervical\n collar pending further CT results\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain on right shoulder/flank area. Rates pain as when\n patient is at rest but also reports pain level as with\n turning/movement\n Action:\n Morphine PCA initiated for pain control\n Response:\n Pt now rating pain as when pt still and resting however he\n continues to report pain level with activity\n Plan:\n Educate pt on pain control and encourage PCA usage prior to any turning\n or repositioning\n" }, { "category": "Radiology", "chartdate": "2192-05-05 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 1075212, "text": " 9:23 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT; HUMERUS (AP & LAT) RIGHTClip # \n ELBOW (AP, LAT & OBLIQUE) RIGHT; FOREARM (AP & LAT) RIGHT\n Reason: r/o\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC, unhelmeted, +LOC, landed on R side; OSH films showing\n R clav/scapula fx's\n REASON FOR THIS EXAMINATION:\n r/o\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Three radiographs right shoulder, two radiographs right humerus, two\n radiographs right elbow, one radiograph right forearm. Eight radiographs\n total.\n\n INDICATION: Pain, trauma.\n\n COMPARISON: CT torso, same date.\n\n FINDINGS: No evidence of acute fracture is detected involving the humerus.\n The glenohumeral and acromioclavicular joints are intact. Grossly comminuted\n and displaced fractures of the mid right clavicle and scapula demonstrated.\n Acute posterior fractures of the right posterior fourth through seventh ribs\n demonstrated. Apical opacity within the right lung with pleural base density\n most consistent with pleural fluid.\n\n The elbow appears intact without acute fracture or dislocation. Enthesopathic\n changes involving the triceps insertion detected. Single view of the right\n forearm is unremarkable. Of note, no dedicated wrist imaging demonstrated\n\n IMPRESSION:\n\n Grossly comminuted fracture involving the scapula, clavicle and posterior\n right ribs as detailed above.\n\n" }, { "category": "Radiology", "chartdate": "2192-05-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1075328, "text": ", E. CC6A 12:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: R temporal bone fx ext to external ear canalL frontoparietal\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n R temporal bone fx ext to external ear canalL frontoparietal hemorrhage,\n unchanged, no midline shift or hydro\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No significant change.\n\n" }, { "category": "Radiology", "chartdate": "2192-05-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1075243, "text": " 8:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ICH\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with intracranial hemorrhage, evaluate for\n interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Multiple foci of left parietotemporal intraparenchymal hemorrhage\n are unchanged. The largest in the measuring 1.0 x 1.5 cm, stable since the\n prior study. There is mild perihemorrhagic edema without significant mass\n effect or shift of normally midline structures.\n\n The and white matter differentiation in the remainder of the brain is\n well preserved. There are no acute major vascular territorial infarcts. There\n is no evidence of intraventricular hemorrhage.\n\n Right maxillary and parietotemporal bone fractures are unchanged. There is\n high attenuation maxillary and sphenoid sinus opacification, likely due sinus\n bleeding. There are multiple areas of right frontal soft tissue high densities\n which could reflect calcifications, unchanged.\n\n IMPRESSION: Unchanged multifocal parenchymal temporoparietal hemorrhage with\n mild vasogenic edema and right maxillary and parietotemporal fractures.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-05-06 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1075244, "text": " 8:51 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please obtain maxillofacial CT with 3 planar reformatting to\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58M s/p MCC, unhelmeted, +LOC, now with R max sinus lat wall fx\n REASON FOR THIS EXAMINATION:\n please obtain maxillofacial CT with 3 planar reformatting to assess max fx's\n and other facial fx's\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male status post MVC, unhelmeted, now LOC and right\n maxillary sinus lateral wall fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT acquisitions through the sinuses with multiplanar\n reformations without IV contrast.\n\n FINDINGS: As previously described hyperdense material is noted in the\n sphenoid sinuses and right maxillary sinus. Frontal and ethmoid air cells and\n the left maxillary sinus are relatively clear. Indentation with a small\n nondisplaced fracture is noted in the lateral wall of the right maxillary\n sinus. There is another nondisplaced longitudinal fracture through the\n anterior mastoid portion of the right temporal bone in close proximity to the\n middle ear cavity with opacification of the middle ear cavity. The anterior\n wall of the sphenoid air cells is indistinct and a small nondisplaced fracture\n in the anterior wall of the sphenoid sinus cannot be excluded. The previously\n described right superior parietal fracture is not included in the field of\n view of this study.\n\n The nasal septum demonstrates an S-shaped deviation. The lamina papyracea and\n the cribriform plate are intact. The left ostiomeatal unit is patent. The\n right appears to be blocked with complete opacification of the right maxillary\n sinus. Incidental note is made of right bullosa. The eye-globe is\n intact and the intraconal fat is normal.\n\n IMPRESSION:\n 1. Nondisplaced fracture of the lateral wall of the right maxillary sinus. and\n mastoid portion of the right temporal bone extension as described above. The\n superior parietal fracture is not included in the field of view.\n\n 2. Hyperdense opacification of the sphenoid and right maxillary sinus which\n could represent intrasinus hemorrhage given sinus wall fracture.\n\n\n (Over)\n\n 8:51 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please obtain maxillofacial CT with 3 planar reformatting to\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2192-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1075228, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change; please take at 5AM ICU rounds\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC with small hemothorax/PTX, bilat pulm contusion vs asp\n PNA\n REASON FOR THIS EXAMINATION:\n assess interval change; please take at 5AM ICU rounds\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Patient with motor vehicle collision and with multiple right-sided\n rib fractures.\n\n FINDINGS: Comparison is made to the prior chest CT from .\n\n Multiple right-sided rib fractures are seen. There is a small right apical\n pneumothorax. There is some atelectasis at the lung bases. No large pleural\n effusions or areas of consolidation are seen. There is a comminuted right\n scapular fracture as well as a right clavicular fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-05-05 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1075208, "text": " 8:49 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: ?abd CT chest second disc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 yo s/p motorcycle accident no helmet\n REASON FOR THIS EXAMINATION:\n ?abd CT chest second disc\n ______________________________________________________________________________\n WET READ: SBNa SAT 9:18 PM\n right temporal bone fx. multiple right sided rib fxs. small right ptx. no c\n spine fx.\n ______________________________________________________________________________\n FINAL REPORT\n CT C-SPINE WITHOUT CONTRAST.\n\n COMPARISON: None.\n\n HISTORY: Motorcycle accident.\n\n TECHNIQUE: MDCT axially acquired images through the cervical spine were\n obtained at outside hospital and was submitted for second opinion upon patient\n transfer.\n\n FINDINGS: The vertebral body heights and alignment are preserved. There is\n no prevertebral soft tissue swelling identified. There is no evidence of\n acute cervical spine fracture. Degenerative changes at C3-C4 are identified\n including disc space narrowing and marginal osteophyte formation. Partially\n imaged is a right skull base fracture (3, 33) and multiple right-sided rib\n fractures. There is a small right-sided pneumothorax with a small right\n hemorrhagic effusion.\n\n IMPRESSION: No evidence of cervical spine fracture. Multiple right-sided rib\n fractures and small right hemopneumothorax, partially imaged. Right skull\n base fracture partially imaged.\n\n Findings were posted to the ED dashboard and discussed with Dr. .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-05-05 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1075209, "text": " 8:50 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess pulm injuries, hemo/PTX, aortic dissection, abd injur\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC, unhelmeted, +LOC; OSH CTs showing multiple injuries\n REASON FOR THIS EXAMINATION:\n assess pulm injuries, hemo/PTX, aortic dissection, abd injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SAT 9:48 PM\n small right hemopneumothorax. multiple right sided rib fx . right clavicle\n and right scapula fx. tiny foci of air in mediastinum. no aortic injury. b/l\n contusions vs. aspiration. right liver lesion, likely hemangioma, splenic\n hypodensity too small to characterize. no free fluid or free air.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n COMPARISON: CT chest.\n\n HISTORY: Motorcycle accident.\n\n TECHNIQUE: MDCT axially acquired images of the chest, abdomen and pelvis were\n obtained. IV contrast was administered. Coronal and sagittal reformats were\n performed.\n\n FINDINGS:\n\n CT CHEST: The heart and great vessels are unremarkable. There is no evidence\n of aortic injury. There is no mediastinal hematoma. Tiny foci of air in the\n epicardial fat (2, 40) is identified and may represent a small\n pneumomediastinum. There is a small right pneumothorax with a tiny\n hemorrhagic effusion on the right. Bibasilar consolidations likely represent\n contusions versus aspiration. There is no axillary or mediastinal\n lymphadenopathy. The airways are patent to the subsegmental level. A\n prominent right hilar lymph node is identified, not meeting CT criteria for\n pathologic enlargement.\n\n CT OF THE ABDOMEN: Within the right lobe of the liver (2, 47), there is a\n lobulated enhancing lesion measuring 2.4 x 1.8 cm. This is incompletely\n characterized, but likely represents hemangioma. A subcentimeter hypodensity\n in left lobe (2, 49) is too small to characterize. There is no evidence of\n solid organ injury. The spleen demonstrates a subcentimeter hypodensity (2,\n 64) which is too small to characterize. An adjacent hypodensity (2, 60)\n which appears slightly more linear, is too small to characterize and may\n represent a tiny intrasplenic laceration. There is no surrounding perisplenic\n fluid. The pancreas, adrenal glands, kidneys, and gallbladder are\n unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy. Small\n bowel loops are normal in caliber and without focal wall thickening. There is\n no free fluid or free air.\n (Over)\n\n 8:50 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess pulm injuries, hemo/PTX, aortic dissection, abd injur\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS: The appendix is normal. The rectum, bladder, sigmoid\n colon are unremarkable. The prostate is enlarged. Foley catheter is within\n the bladder. There is no pelvic or inguinal lymphadenopathy. There is no free\n fluid.\n\n BONE WINDOWS: There is a displaced right clavicular fracture (2 13). A\n markedly comminuted right scapular fracture is also identified (2, 22). Rib\n fractures involving the right second through seventh ribs are identified with\n marked displacement of fracture fragments arising from the right fifth rib. No\n other fractures are identified.\n\n IMPRESSION:\n 1. Small right hemopneumothorax. Tiny foci of air within the epicardial fat\n pad. No evidence of aortic injury.\n 2. Bilateral consolidations which may represent aspiration versus contusions.\n 3. Multiple right-sided rib fractures, right scapular and right clavicular\n fractures as described above.\n 4. Enhancing liver lesion likely representing a hemangioma.\n 5. Splenic hypodensity, too small to characterize, although small\n intrasplenic laceration cannot be excluded. No perisplenic fluid identified.\n\n Findings were discussed with Dr. and posted to the ED dashboard.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-05-08 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1075561, "text": " 8:58 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: Assess pneumothorax and compare to previous chest xrays; r/o\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC w/ multiple injuries including bilat pulmonary\n contusions & right pneumothorax.\n REASON FOR THIS EXAMINATION:\n Assess pneumothorax and compare to previous chest xrays; r/o other pulmonary\n processes.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 11:45 AM\n Small right pleural effusion increased. Denser right chest wall and increased\n density along the axillary line could be due to increasing local chest wall\n hematoma. Bibasilar atelectasis increased.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n REASON FOR EXAM: 58-year-old man status post MCC with multiple injuries\n including bilateral pulmonary contusions, right pneumothorax. Assess\n pneumothorax and compared to previous chest x-ray. Rule out other pulmonary\n process.\n\n Since , lung volumes are lower. Small right pleural effusion\n increased, could be hemothorax given the clinical context. Multiple rib\n fractures on the right are unchanged. Increased density of the right chest\n wall and increased thickening along the right axillary line could be due to\n enlarging chest wall hematoma. Pneumothorax, if any, would be minimal.\n Bibasilar and mid lung opacities increased, more marked on the right, could be\n atelectasis.\n\n Results were discussed on the phone with at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2192-05-08 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1075562, "text": ", E. CC6A 8:58 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: Assess pneumothorax and compare to previous chest xrays; r/o\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC w/ multiple injuries including bilat pulmonary\n contusions & right pneumothorax.\n REASON FOR THIS EXAMINATION:\n Assess pneumothorax and compare to previous chest xrays; r/o other pulmonary\n processes.\n ______________________________________________________________________________\n PFI REPORT\n Small right pleural effusion increased. Denser right chest wall and increased\n density along the axillary line could be due to increasing local chest wall\n hematoma. Bibasilar atelectasis increased.\n\n" }, { "category": "Nursing", "chartdate": "2192-05-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 570073, "text": "Trauma, s/p\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": "Radiology", "chartdate": "2192-05-05 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1075206, "text": " 8:25 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: s/p MVC report of hemothorax on R. rib fx on R from OSH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 yo s/p motorcycle accident no helmet\n REASON FOR THIS EXAMINATION:\n s/p MVC report of hemothorax on R. rib fx on R from OSH\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old status post motorcycle accident without a helmet with\n report of rib fractures from the outside hospital.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed. There\n is no relevant prior imaging for comparison.\n\n FINDINGS:\n There is a fracture through the right mid clavicle. There is also a fracture\n through the right fifth rib posteriorly. There is a right apical cap/pleural\n effusion present. There is no pneumothorax. The cardiomediastinal silhouette\n is not enlarged. There is no focal pulmonary consolidation.\n\n CONCLUSION:\n 1. Right apical pleural cap/pleural effusion can be associated with vascular\n injury in the setting of acute trauma. Further imaging of the chest with CT\n is recommended.\n 2. Fracture of the right fifth rib posteriorly and fracture through the mid\n shaft of the clavicle without evidence of a pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2192-05-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1075207, "text": " 8:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess interval change, head bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58M s/p MCC, unhelmeted, +LOC, txr from OSH showing R head hematoma, skull fx,\n L intraparenchymal bleed\n REASON FOR THIS EXAMINATION:\n assess interval change, head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SAT 9:23 PM\n left intrapaarenchymal hemmorhage . no shift no hydro. right temporal bone fx.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: Outside study performed at 6:00 p.m. same day.\n\n HISTORY: Motorcycle accident.\n\n TECHNIQUE: MDCT axially acquired images of the brain were obtained. No IV\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: Multiple areas of intraparenchymal hemorrhage in the left frontal,\n parietal and left temporal lobe are identified (2, 12). There is no shift of\n normally midline structures. The ventricles and sulci are unremarkable. There\n is no evidence of hydrocephalus. Large right scalp hematoma with foci of air\n is also identified (2, 17). There is normal -white matter\n differentiation. The basilar cisterns are patent.\n\n There is a right lateral wall maxillary sinus fracture and a right temporal\n bone fracture which extends into the auditory canal (2, 8) and more superiorly\n into the right parietal bone (2, 13). There is blood identified within the\n sphenoid and right maxillary sinus.\n\n IMPRESSION:\n 1. Left frontoparietal and parietotemporal intraparenchymal hemorrhages\n without shift of midline structures or hydrocephalus.\n\n 2. Large right scalp hematoma.\n\n 3. Fractures of the right maxillary sinus, right temporal bone and right\n parietal bone. Blood identified within the right maxillary and sphenoid\n sinus.\n\n Findings were posted to the ED dashboard and discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2192-05-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1075327, "text": " 12:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: R temporal bone fx ext to external ear canalL frontoparietal\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n R temporal bone fx ext to external ear canalL frontoparietal hemorrhage,\n unchanged, no midline shift or hydro\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 2:06 AM\n PFI: No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n COMPARISON: .\n\n HISTORY: Hemorrhage.\n\n TECHNIQUE: MDCT axially acquired images of the brain were obtained.\n\n FINDINGS: Multiple foci of left temporal intraparenchymal hemorrhage are\n unchanged. There is mild surrounding edema identified without significant\n shift of normally midline structures or mass effect. There is normal -\n white matter differentiation in the remainder of the brain. There is no\n intraventricular hemorrhage identified.\n\n The right maxillary and right parietotemporal bone fractures are unchanged.\n High-attenuation material in the maxillary and sphenoid sinus is stable.\n\n IMPRESSION: No significant change in multifocal left parenchymal\n temporoparietal hemorrhage with mild surrounding edema and right maxillary and\n right parietotemporal fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-05-06 00:00:00.000", "description": "CT ORBIT, SELLA & IAC W/O CONTRAST", "row_id": 1075280, "text": " 1:54 PM\n CT ORBIT, SELLA & IAC W/O CONTRAST Clip # \n Reason: Please do thin slices of temporal bone and auditory canal to\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ? R temoral bone fracture. Please do thin slices of\n temporal bone and auditory canal to define fracture\n REASON FOR THIS EXAMINATION:\n Please do thin slices of temporal bone and auditory canal to define fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb SUN 4:35 PM\n longitudinal fracture of the anterior portion of the right temporal bone with\n extension upto the middle ear cavity. Equivocal medial displacement of\n malleus, attention on follow up is recommended. Remainder of middle and inner\n ear structures appear intact\n Mastoid and middle ear opacification likely from hemorrhagic components.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with question right temporal bone fracture.\n\n COMPARISON: CT sinus and mandible from earlier today and CT\n head from and .\n\n TECHNIQUE: Non-contrast helical CT acquisitions through the temporal bone\n with thin slices and multiplanar reformations.\n\n FINDINGS: There is a nondisplaced longitudinally oriented anterior fracture\n of the mastoid portion of the right temporal bone, which extends close to the\n middle ear cavity. There is opacification of the mastoid air cells as well as\n soft tissue density within the middle ear cavity in the external auditory\n canal. The Prussak space is also opacified. These suggest possible presence\n of hemorrhagic components given recent trauma and fracture. The ossicles\n appear grossly intact, however, there is a suggestion of medial displacement\n of the malleolus and a mild medial dislocation cannot be excluded, attention\n on followup is recommended. The cochlea, semicircular canal is normal. The\n carotid canal is also unremarkable and not involved in the fracture.\n\n There is persistent opacification of the sphenoid sinus and the right\n maxillary sinus with indentation and a small nondisplaced fracture of the\n posterolateral right maxillary sinus wall, better described on concurrently\n obtained CT sinus study. The remainder of the osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: Non-displaced longitudinal anterior fracture of the mastoid\n portion of right temporal bone as described above with hemorrhagic\n opacification of the middle ear and external ear cavity and equivocal medial\n dislocation of the malleus, attention on followup is recommended. Remainder of\n the middle and inner ear structures appear intact.\n\n (Over)\n\n 1:54 PM\n CT ORBIT, SELLA & IAC W/O CONTRAST Clip # \n Reason: Please do thin slices of temporal bone and auditory canal to\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2192-05-08 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1075672, "text": " 3:58 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for expanded hematoma vs effusion vs PNA\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58M s/p MCC w/worsened CXR after Bilat pulm contusion vs asp PNASmall R\n hemothorax, Small anterior R PTX, R clavicular fx, displaced, R scapula fx,\n comminuted, R # rib fx's\n REASON FOR THIS EXAMINATION:\n Please evaluate for expanded hematoma vs effusion vs PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 7:14 PM\n PFI: Right pleural effusion slightly increased, but still small. Bibasilar\n opacities are overall unchanged. There is no chest wall hematoma. Right\n upper lobe dependent opacities are changed in configuration, could be\n contusion or aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST\n\n REASON FOR EXAM: 58-year-old man status post MCC with worsened chest x-ray\n after bilateral pulmonary contusion versus aspiration pneumonia. Small right\n hemothorax, small anterior right pneumothorax, right clavicular fracture.\n Multiple fractures.\n\n TECHNIQUE: Chest MDCT was performed without contrast using 5-mm and 1.25-mm\n axial slice thickness. Coronal and sagittal reformations were also obtained.\n\n FINDINGS: Since , right pleural effusion slightly increased,\n but remains small. The effusion is mainly of fluid density but some areas are\n a little bit denser, could be blood. Posterior segment of the right upper\n lobe pulmonary opacity changed in configuration, could be aspiration or\n contusion. Bibasilar pulmonary opacities slightly decreased. Tiny subfissural\n nodule is on the left. Subpleural nodules are also present, all less than 4\n mm. Right pneumothorax and air bubble in the mediastinum cleared. Subcutaneous\n gas collections improved.\n\n Right clavicular fracture, comminuted right scapular fracture and right second\n to seventh rib fractures are unchanged. A calcified granuloma is at the left\n base in the atelectasis. Pericardial effusion is still minimal.\n\n This study was not tailored for subdiaphragmatic evaluation except to note a\n liver hypodensity, better depicted on the prior study.\n\n IMPRESSION:\n\n 1. Slightly increased small right pleural effusion, mostly of fluid density\n but with some regions of increased density, could be blood. Note that the\n change is minimal. Minimal increase in still tiny pericardial effusion.\n\n 2. No residual pneumothorax or air in the mediastinum.\n (Over)\n\n 3:58 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for expanded hematoma vs effusion vs PNA\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Slightly improved bibasilar opacities, could be resolving contusion or\n resolving aspiration. Change in configuration of right upper lobe opacity,\n could be aspiration or contusion.\n\n 4. Right clavicular fracture, severely comminuted right scapular fracture and\n right second through seventh rib fractures.\n\n 5. Hypodense liver lesions, better depicted on the prior study. Hypodense\n splenic lesion, too small to characterize.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2192-05-08 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1075673, "text": ", E. CC6A 3:58 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for expanded hematoma vs effusion vs PNA\n Admitting Diagnosis: ICH,RIB FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58M s/p MCC w/worsened CXR after Bilat pulm contusion vs asp PNASmall R\n hemothorax, Small anterior R PTX, R clavicular fx, displaced, R scapula fx,\n comminuted, R # rib fx's\n REASON FOR THIS EXAMINATION:\n Please evaluate for expanded hematoma vs effusion vs PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Right pleural effusion slightly increased, but still small. Bibasilar\n opacities are overall unchanged. There is no chest wall hematoma. Right\n upper lobe dependent opacities are changed in configuration, could be\n contusion or aspiration.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2137-02-09 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1222810, "text": " 1:23 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: SOB,HYPOXIA,EVAL FOR DVT\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with achondroplasia, hypoxia\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with achondroplasia and hypoxia. Question DVT.\n\n COMPARISON: .\n\n FINDINGS: Current examination is limited by body habitus. Allowing for such,\n there is normal color flow and augmentation in the common femoral, superficial\n femoral, popliteal, posterior tibial, and peroneal veins. Compression of the\n right distal superficial femoral vein was not obtained. However, entire\n extent of the superficial femoral vein demonstrates normal flow.\n\n IMPRESSION: Somewhat limited exam with no evidence to suggest DVT.\n\n" }, { "category": "Radiology", "chartdate": "2137-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222901, "text": " 11:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval Change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with respiratory distress, R sided consolidation\n REASON FOR THIS EXAMINATION:\n Interval Change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory distress.\n\n Portable AP radiograph of the chest was reviewed in comparison to \n and .\n\n The study is limited due to patient habitus. There is again redemonstrated\n substantial opacification of the right lung as well as consolidation at the\n left lung base. Heart size and mediastinum are unchanged. Bilateral pleural\n effusion is present. Overall, no substantial change in the short interim is\n demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1223163, "text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change of effusion\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with PNA, hx CHF\n REASON FOR THIS EXAMINATION:\n evaluate for interval change of effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:37 A.M. \n\n HISTORY: Pneumonia and CHF. Check effusion.\n\n IMPRESSION: Large right and moderate left pleural effusion, loculated, have\n not improved since . Large cardiac silhouette is longstanding.\n Given the technical limitations in imaging a patient of this size with bedside\n equipment, subtle pulmonary abnormalities are not likely to be detected.\n There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222983, "text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for volume overload\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with dyspnea\n REASON FOR THIS EXAMINATION:\n evaluate for volume overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of respiratory distress for\n interval change.\n\n COMPARISON: Multiple prior chest radiographs including the most recent from\n .\n\n FINDINGS: Portable semierect AP radiograph was obtained. The study is\n limited due to patient body habitus. There has been little interval change in\n comparison to prior study from the day before with substantial opacification\n of the right lung due to a pleural effusion as well as opacification of tbe\n left lung base along with a small left pleural effusion. Heart size and\n mediastinal contour remain unchanged.\n\n IMPRESSION: Overall little change in comparison to prior study from the day\n before with redemonstration of substantial opacification of the right lung as\n well as consolidation at the left lung base.\n\n" }, { "category": "Echo", "chartdate": "2137-02-08 00:00:00.000", "description": "Report", "row_id": 87866, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Resp distress\nHeight: (in) 59\nWeight (lb): 285\nBSA (m2): 2.15 m2\nBP (mm Hg): 138/65\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 15:21\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\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (>2.1cm) with <50%\ndecrease with sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV hypertrophy. Moderately dilated RV cavity. Mild global RV\nfree wall hypokinesis.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Severe PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic 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 - body habitus.\n\nConclusions:\nThe estimated right atrial pressure is at least 15 mmHg. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). The right\nventricular free wall is hypertrophied. The right ventricular cavity is\nmoderately dilated with mild global free wall hypokinesis. The aortic valve is\nnot well seen. Trivial mitral regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Severe pulmonary hypertension. Hypertrophied, dilated and mildly\nhypokinetic right ventricle. Small, underfilled left ventricle with preserved\nglobal systolic function. Limited study.\n\nCompared with the prior study (images reviewed) of , comparable\nfindings are similar (prior study is especially limited).\n\n\n" }, { "category": "Radiology", "chartdate": "2137-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222599, "text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval Change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with increased SOB\n REASON FOR THIS EXAMINATION:\n Interval Change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing shortness of breath.\n\n COMPARISONS: Chest radiograph . Chest radiograph . Chest CT .\n\n FINDINGS: Stable uniform opacification of the complete right hemithorax is\n consistent with a moderate to large pleural effusion. This is unchanged from\n prior exams. Moderate pleural effusion on the left, also stable. The left\n upper lobe is well aerated. Evaluation for pulmonary edema or consolidations\n is somewhat limited due to the amount of pleural fluid, but no definite edema\n or opacity is identified. Severe cardiomegaly is unchanged. The mediastinum\n is enlarged by fat deposition. There is no pneumothorax.\n\n IMPRESSION:\n 1. Stable bilateral pleural effusions, larger on the right than left.\n 2. Stable severe cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2137-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222574, "text": " 9:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? P NA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with dyspnea, hx of COPD\n REASON FOR THIS EXAMINATION:\n ? P NA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Dyspnea.\n\n COMPARISONS: .\n\n TECHNIQUE: Chest, supine AP portable.\n\n FINDINGS: The lower lungs was partly excluded. The heart appears enlarged\n but is incompletely assessed. Allowing for differences in technique, the\n mediastinal contours are probably unchanged. This view shows perihilar\n fullness and indistinct prominent pulmonary vascularity suggesting\n mild-to-moderate pulmonary edema.\n\n IMPRESSION: Limited view suggesting pulmonary edema.\n\n If a more complete evaluation for the possibility of pneumonia is needed, then\n additional radiographs could be performed, preferably with standard PA and\n lateral technique if possible clinically.\n\n\n" }, { "category": "ECG", "chartdate": "2137-02-08 00:00:00.000", "description": "Report", "row_id": 222059, "text": "Sinus rhythm. Right axis deviation. Non-specific ST-T wave changes. Compared to\nthe previous tracing of low voltage is no longer present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2137-02-07 00:00:00.000", "description": "Report", "row_id": 222060, "text": "Sinus tachycardia. Right axis deviation. Non-specific ST-T wave changes. Low\nvoltage in the precordial leads. Compared to the previous tracing of \nlow voltage is new.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2116-07-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1147375, "text": " 3:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? placement of Dobhoff tube\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NASH cirrhosis, complicated hospital course, with high\n residuals with NG tube feeding\n REASON FOR THIS EXAMINATION:\n ? placement of Dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placement.\n\n TECHNIQUE: Portable chest radiograph was obtained.\n\n COMPARISONS: Comparison is made to prior radiograph from .\n\n FINDINGS: The Dobbhoff tube is located in the stomach. The pleural effusion\n has increased with increased left lower lobe atelectasis. Line tip is at the\n mid SVC. Otherwise the cardiomediastinal silhouette, hilar silhouette, and\n pleural surfaces remain unchanged. No pneumothorax.\n\n IMPRESSION: Dobbhoff tube tip in the stomach. Increase in left pleural\n effusions and left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1145902, "text": " 6:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 52 yo F with fever p/w blood suctioned from ETT\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with h/o cirrhosis, mental retardation p/w fever, VRE\n bacteremia\n REASON FOR THIS EXAMINATION:\n 52 yo F with fever p/w blood suctioned from ETT\n ______________________________________________________________________________\n WET READ: MLHh SUN 12:43 AM\n Ltd portable study. Low lung vols, mod-large L and small R effusions,\n atelectasis, vague scattered pulm opacities better described on recent CT.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Fever, bacteremia, blood in ET tube.\n\n FINDINGS: The ET tube tip is about 3 cm above the carina. Left subclavian\n line tip is in the SVC. NG tube tip is off the film, at least in the stomach.\n This film is slightly limited by motion artifact. There is haziness to the\n lung parenchyma bilaterally, left greater than right that could represent\n pulmonary edema or infectious infiltrate. Given motion on the film, it is\n difficult to judge for interval change compared to the prior exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1147121, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NGT likely aspirated\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Nasogastric tube, likely aspiration.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The patient has been extubated, but the left central venous access\n line and the nasogastric tube are in unchanged position. Unchanged low lung\n volumes, unchanged relatively substantial left pleural effusion and\n retrocardiac atelectasis. A gas bubble in unexpected retrocardiac position\n may suggest the presence of a large hiatal hernia.\n\n Unremarkable right lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-07 00:00:00.000", "description": "P ART DUP EXT UP UNI OR LMTD PORT", "row_id": 1146259, "text": " 9:03 AM\n ART DUP EXT UP UNI OR LMTD PORT Clip # \n Reason: ? ARTERIAL CLOT, RT AXILLARY A LINE W/ NEW COLD AND PALE RT HAND\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with R-sided axillary art line and new cold pale hand.\n REASON FOR THIS EXAMINATION:\n r/o arterial clot\n ______________________________________________________________________________\n FINAL REPORT\n ARTERIAL DUPLEX STUDY\n\n HISTORY: Right-sided axillary arterial line and right-sided cold, pale hand.\n\n FINDINGS: Duplex and color Doppler of the right upper extremity was\n performed. The patient's arterial line within the axillary and brachial\n artery is visualized. There is normal arterial flow identified around this\n arterial line. No intraluminal echogenic material or vessel expansion is\n identified. There are normal triphasic waveforms involving the right\n subclavian, axillary, and brachial arteries.\n\n IMPRESSION: No abnormality appreciated involving the right upper extremity\n arterial system through to the level of the brachial artery. Waveforms\n suggest normal arterial inflow as well as normal arterial outflow beyond this\n point. Note, however, that small emboli to the digital level would not be\n identified on this study, either directly or indirectly.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-06 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1146128, "text": " 2:55 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o bowel obstruction\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NASH and ascites, increasing abdominal distension and\n increased residuals.\n REASON FOR THIS EXAMINATION:\n r/o bowel obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with non-alcoholic steatohepatitis and\n ascites, increasing abdominal distension and increased residuals. Rule out\n bowel obstruction.\n\n COMPARISON: Portable abdominal radiograph from .\n\n FINDINGS: Two abdominal radiographs, one supine and one left lateral\n decubitus, were submitted for review. There is a paucity of gas within both\n the small and large bowel. A small number of air-fluid levels are seen in the\n left lateral decubitus film. An NG tube is seen with its tip overlying the\n stomach. Degenerative changes are seen in the lumbar spine. The remainder of\n the imaged osseous structures are unremarkable. Surgical clips are seen in\n the right upper quadrant.\n\n IMPRESSION: Paucity of air in both the large and small bowel is a\n non-specific finding. If there is persistent concern for obstruction, a CT is\n recommended. No evidence of free air in the abdomen.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141675, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hx intubated\n REASON FOR THIS EXAMINATION:\n eval interval\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 52-year-old woman with shortness of breath and is intubated.\n\n FINDINGS: There is an endotracheal tube whose tip is 4.4 cm above the carina.\n The side port of nasogastric tube is at the GE junction and could be advanced\n several centimeters for more optimal placement. There is a left-sided central\n venous catheter with the distal lead tip within the mid SVC. The cardiac\n silhouette is within normal limits. There remains a left retrocardiac opacity\n and likely bilateral small pleural effusions, which are all unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1138951, "text": " 8:14 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please confirm PICC placement. Thanks,\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with transferred from OSH. Confirm PICC placement.\n REASON FOR THIS EXAMINATION:\n Please confirm PICC placement. Thanks,\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:37 \n\n HISTORY: Check PICC placement.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Left PICC line ends in the upper SVC. Generalized diffuse infiltrative\n pulmonary abnormality, chronicity indeterminate, could be infection, edema,\n drug reaction. Heart is borderline enlarged, exaggerated by low lung volumes.\n Consolidation opacify in the left lower lung could be pneumonia.\n\n Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1139826, "text": " 1:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Concern of ongoing aspiration. Please evaluate for interval\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with wheezing, concern of ongoing aspiration. Also with\n low-grade temperature to 100.5.\n REASON FOR THIS EXAMINATION:\n Concern of ongoing aspiration. Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Low-grade fever.\n\n FINDINGS: Left PICC continues to terminate in the mid superior vena cava.\n Heart size remains normal. Persistent left lower lobe opacity with air\n bronchograms, which may reflect infectious consolidation and/or atelectasis,\n accompanied by small left pleural effusion. Large hiatal hernia is also noted\n and is seen to better detail on prior CT scan.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140494, "text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman s/p NG to the left lung now removed.\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Study of one day earlier.\n\n FINDINGS: Removal of nasogastric tube. Cardiomediastinal contours are\n unchanged. Known large hiatal hernia, better seen on older CTs. Bilateral\n upper lobe predominant airspace opacities are similar, allowing for technical\n differences, but there is increasing opacity in the lower left hemithorax,\n possibly due to layering of the left pleural effusion, but additional area of\n consolidation is also possible in this patient with presumed multifocal\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-09 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 1142108, "text": " 7:29 PM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval liver for blood flow and ascites.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with autoimmune hepatitis, ? hepatorenal syndrome.\n REASON FOR THIS EXAMINATION:\n eval liver for blood flow and ascites.\n ______________________________________________________________________________\n WET READ: ENYa TUE 10:53 PM\n 1. Major intrahepatic vasculature patent and normal in flow direction.\n 2. Coarsened and echogenic liver compatible with known autoimmune hepatitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old woman, with autoimmune hepatitis. Question about\n hepatorenal syndrome.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER: The liver is diffusely\n coarsened and echogenic. There is no focal lesion. No intrahepatic or\n extrahepatic biliary ductal dilatation is noted. The CBD measures 5 mm in\n diameter. The patient is status post cholecystectomy. There is no\n perihepatic fluid. The enlarged spleen measures 15 cm. There are bilateral\n pleural effusions.\n\n Assessment of the hepatic vasculature is slightly limited by patient's\n intubation status and respiratory variation due to ventilation. Allowing for\n these limitations, major intrahepatic vasculature is patent with expected\n direction of flow assessed by Doppler.\n\n IMPRESSION:\n\n 1. Major intrahepatic vasculature patent with normal direction of flow.\n\n 2. Slightly coarsened and echogenic liver compatible with the history of\n autoimmune hepatitis. No intrahepatic or extrahepatic biliary ductal\n dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-22 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1139044, "text": " 11:55 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Please evaluate for aspiration risk.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with MR, high cholesterol, elevated LFTs, difficulty\n swallowing.\n REASON FOR THIS EXAMINATION:\n Please evaluate for aspiration risk.\n ______________________________________________________________________________\n FINAL REPORT\n VIDEO FLUOROSCOPIC SWALLOW\n\n COMPARISON: None.\n\n HISTORY: Constant dysphagia.\n\n FINDINGS: An oral and pharyngeal swallowing video fluoroscopic was performed\n today in collaboration with speech pathology. Thin liquid, nectar thick\n liquid, and puree consistency barium and one ground cookie coated with barium\n were administered. There was mild oral and pharyngeal dysphagia with\n prolonged chewing and mild swallow delay. However, there is no evidence of\n aspiration or penetration.\n\n Please refer to the speech pathology note under CareWeb for further details.\n\n IMPRESSION: No evidence of aspiration or penetration.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140359, "text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for NG tube placement, and change in lung parenchyma\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with F with cirrhosis, mr, gastric volvulus, respiratory\n distress, intubated now extubated\n REASON FOR THIS EXAMINATION:\n eval for NG tube placement, and change in lung parenchyma\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n FINDINGS: Removal of endotracheal tube. Nasogastric tube has apparently been\n withdrawn slightly in the interval, but terminates in the stomach. Assessment\n of the lungs is limited by respiratory motion. Allowing for this factor,\n there has been no substantial change in the appearance of the lungs or pleura.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-25 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1139397, "text": " 8:19 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: Evaluate liver parenchyma and evaluate for evidence of splen\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with mental retardation and hepatitis of unknown etiology.\n REASON FOR THIS EXAMINATION:\n Evaluate liver parenchyma and evaluate for evidence of splenomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with hepatitis of unknown etiology.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The liver shows no focal or textural abnormality. No biliary\n dilatation is seen and the common duct measures 0.4 cm. The portal vein is\n patent with hepatopetal flow. The gallbladder has been surgically removed.\n The pancreas and midline structures are obscured from view by overlying bowel.\n The spleen is enlarged measuring 14.7 cm. There is no hydronephrosis. The\n right kidney measures 11.0 cm and the left kidney measures 11.7 cm. There is\n minimal ascites within the abdomen and a small left pleural effusion.\n\n IMPRESSION:\n 1. No focal liver lesion is identified.\n 2. Splenomegaly.\n 3. Small left pleural effusion and minimal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-22 00:00:00.000", "description": "ESOPHAGUS", "row_id": 1139041, "text": " 11:27 AM\n ESOPHAGUS Clip # \n Reason: DYSMOTILITY\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dysmotility.\n\n COMPARISON: Chest radiograph from .\n\n BARIUM ESOPHAGRAM: Scattered images demonstrate diffuse patchy opacities\n throughout both lungs, which may reflect chronic aspiration,\n infection/inflammation, or edema. A left PICC line is seen terminating at the\n level of the superior cavoatrial junction.\n\n The patient ingested thin barium, without evidence of leak or aspiration.\n Severe esophageal dysmotility was seen, with tertiary contractions and reflux\n of contrast to the level of the pharynx. A moderate paraesophageal hiatal\n hernia is noted.\n\n IMPRESSION:\n 1. Severe esophageal dysmotility and reflux.\n 2. Moderate hiatal hernia.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141968, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female, intubated.\n\n STUDY: Semi-upright portable AP chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: Right-sided subclavian central line tip ends probably in the upper\n atrium. The endotracheal tube tip is just above the clavicular heads that is\n 4 cm above the carina. An endogastric tube courses inferiorly with the side\n port well below the GE junction. The heart and mediastinal contours are\n obscured by a diffuse opacification that affects both of the lower lungs,\n obscuring the hemidiaphragms as well. This likely represents bilateral\n pleural effusions with associated atelectasis. There is no pneumothorax. The\n osseous structures are grossly intact.\n\n IMPRESSION: Widespread pulmonary opacities affecting mainly the lower\n portions of the lungs most consistent with pleural effusions with associated\n atlectasis.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1142614, "text": " 11:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with acute lung injury, pulmonary edema, ? ARDS\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST ON \n\n HISTORY: Acute lung injury, question pulmonary edema or ARDS.\n\n IMPRESSION: AP chest compared to through :\n\n Progressive bilateral pulmonary consolidation has improved slightly since at 5:56 a.m. This could be volume dependent pulmonary edema. Heart size is\n normal. Pleural effusions are presumed but not substantial. No pneumothorax.\n ET tube at the upper margin of the clavicles is no less than 6 cm from the\n carina, 2 cm above optimal placement. Nasogastric tube ends in the stomach.\n Right jugular introducer or dual-channel catheter ends in the upper SVC, right\n subclavian line in the lower SVC. Heart size normal.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1139088, "text": " 4:39 PM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for infection or other pathology.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with elevated transferred from OSH.\n REASON FOR THIS EXAMINATION:\n Please assess for infection or other pathology.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Elevated LFTs.\n\n CHEST, PA AND LATERAL: There has been no significant change since the prior\n chest x-ray. The position of the PICC line remains unchanged. Opacification\n in the left lower lobe is again noted, which is probably due to pneumonia\n rather than effusion.\n\n IMPRESSION: No change, probable left lower lobe pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140132, "text": " 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for worsening change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with cirrhosis, gastric volvulus presents with ? aspiration\n pna s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for worsening change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, gastric volvulus.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: Endotracheal tube ends at least 3.2 cm above the carina.\n A left PICC line tip is in the lower SVC. Nasogastric tube extends beneath\n the diaphragm with the tip in the stomach.\n\n Cardiac size is top normal, unchanged. The mediastinal contour is normal.\n Bilateral perihilar and left lower base opacifications have increased and\n could be due to aspiration, pneumonia and/or atelectasis. A left retrocardiac\n opacity is stable, likely represents atelectasis and fluid filled\n intrathoracic stomach. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Increasing probabl multifocal aspiration pneumonia, alternatively edema.\n\n 2. Probable small left pleural effusion is new.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144658, "text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA, interval change; perform for morning MICU ro\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with recurrent aspiration PNA, here w/ respiratory distress\n REASON FOR THIS EXAMINATION:\n assess for PNA, interval change; perform for morning MICU rounds\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recurrent aspiration.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Continued low lung volumes may account for some of the prominence of the\n transverse diameter of the heart. There is evidence of mild elevation of\n pulmonary venous pressure. Retrocardiac opacification at the left base\n persists. In view of the clinical history, this could well represent an area\n of pneumonia associated with a small effusion, though extensive atelectasis\n could present a similar appearance.\n\n Tip of the Dobbhoff tube remains in the mid portion of the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-22 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1144089, "text": " 1:12 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: evaluate for aspiration, swallow eval\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 y/o F s/p hiatal hernia repair\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration, swallow eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post hiatal hernia repair.\n\n SWALLOW VIDEOFLUOROSCOPY:\n\n Video oropharyngeal swallow was performed in conjunction with the speech and\n swallow division. The patient demonstrates significant lethargy and refusing\n p.o. There was no evidence of penetration or gross aspiration.\n\n For further details, please refer to full swallow and speech division notes in\n OMR.\n\n IMPRESSION:\n\n No aspiration or penetration.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1142218, "text": " 11:38 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: position of RIJ HD catheter\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with autoimmune hepatitis and symptomatic hiatal hernia, tx\n to ICU for resp distress w/ aspiration PNA who is s/p laprascopic reduction of\n hiatal hernia, PCT liver biopsy.\n REASON FOR THIS EXAMINATION:\n position of RIJ HD catheter\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n COMPARISON: Study of earlier the same date.\n\n FINDINGS: New right internal jugular vascular catheter terminates within the\n lower superior vena cava, with no visible pneumothorax. Exam otherwise\n appears similar to the recent study except for slight improvement in bilateral\n alveolar opacities, likely due to pulmonary edema. Associated apparent\n improvement in right pleural effusion, but no change in left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141501, "text": " 3:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 F s/p hiatal hernia repair\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post hernia repair\n\n Comparison is made with prior study .\n\n NG tube tip is in the stomach. ET tube tip is in standard position 3.2 cm\n above the carina. Left PICC is in the lower SVC. There is no evident\n pneumothorax. There is no pleural effusion. Diffuse lung opacities have\n improved. Cardiac size is top normal. There are low lung volumes. There are\n bibasilar atelectasis larger on the left. Bilateral subcutaneous emphysema is\n new.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140026, "text": " 1:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please eval for OGT placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with cirrhosis, s/p OGT placement\n REASON FOR THIS EXAMINATION:\n Please eval for OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old woman with cirrhosis status post OGT placement.\n\n TECHNIQUE: Portable AP semi-upright chest radiograph.\n\n COMPARISON: Compared to chest radiograph .\n\n FINDINGS: Low lung volumes. There is interval worsening in pulmonary edema.\n Patient is intubated, with the tip of the NG tube 1.7 cm above carina. There\n is a left subclavian catheter, with tip at the mid SVC. There is stable mild\n retrocardiac atelectasis. There is stable herniation of gastric contents into\n the thorax. There is an NG tube in place with the tip below GE junction,\n likely in the stomach. There is opacity at the right lung apex which could be\n subsegmental atelectasis; however cannot exclude early pneumonia.\n\n IMPRESSION:\n\n 1. Interval worsening mild pulmonary edema.\n 2. RUL focal opacity could be atalectasis; however cannot exclude early\n pneumonia.\n 3. Interval placement of a feeding tube with tip below GE junction, likely\n projecting at the stomach.\n 4. Low positioning of the endotracheal tube with tip projecting 1.7 cm above\n carina.\n 5. Large stable herniation of gastric contents into thorax.\n 6. Stable retrocardiac opacity likely atelectasis.\n\n D/w Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141014, "text": " 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for acute pulmonary process.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with aspiration risk, fevers.\n REASON FOR THIS EXAMINATION:\n Evaluate for acute pulmonary process.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh WED 11:42 AM\n PFI: Left pleural effusion with similar-appearing multifocal consolidations\n consistent with pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female with aspiration risk and fevers.\n\n STUDY: Portable AP chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The left-sided PICC terminates in the SVC. When patient is rotated\n towards the right heart and mediastinal contours appear unchanged. Left\n pleural effusion persists. The lung volumes are low. The multiple regions of\n opacity may represent multifocal pneumonia. There is no pneumothorax.\n\n IMPRESSION:\n Left pleural effusion with similar-appearing multifocal consolidations\n consistent with pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141015, "text": ", V. MED FA10 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for acute pulmonary process.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with aspiration risk, fevers.\n REASON FOR THIS EXAMINATION:\n Evaluate for acute pulmonary process.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left pleural effusion with similar-appearing multifocal consolidations\n consistent with pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1144992, "text": " 4:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 52 yo F with h/o MR, hepatitis p/w fever, AMS\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with fever, AMS\n REASON FOR THIS EXAMINATION:\n 52 yo F with h/o MR, hepatitis p/w fever, AMS\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SUN 5:31 PM\n No acute intracranial abnormality. Punctate basal ganglial mineralization,\n within normal limits.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old woman, with fever and change of mental status. Assess\n for acute intracranial process.\n\n COMPARISON: CT head on .\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\n infarction. Punctate bilateral basal ganglial mineralization are again noted.\n The ventricles and sulci are normal in size and symmetric in configuration.\n There is no shift of normally midline structures. The -white matter\n differentiation is well preserved. The visualized paranasal sinuses and\n mastoid air cells are clear. The patient is status post right mastoidectomy.\n Soft tissue in the right external auditory canal likely represents cerumen.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Status post right mastoidectomy, with soft tissue density in the external\n auditory canal, recommend direct visualization to confirm cerumen.\n\n If clinical suspicion remains high for acute ischemic process, MRI is more\n sensitive.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-28 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1144993, "text": " 4:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 52 yo F with h/o hepatitis p/w fever, respiratory distress,\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 yo F with h/o hepatitis, MR, p/w fever, worsening AMS\n REASON FOR THIS EXAMINATION:\n 52 yo F with h/o hepatitis p/w fever, respiratory distress, evaluating for\n infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DSsd SUN 6:19 PM\n PFI:\n 1. No evidence of intra-abdominal abscess. Unchanged ascites.\n 2. Delayed dense nephrograms, worrisome for acute tubular necrosis.\n 3. No definite evidence of bowel wall thickening.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST .\n\n INDICATION: Hepatitis C, MR, with fevers and worsening altered mental status.\n ? infectious source. Worsening respiratory distress. Fevers.\n\n COMPARISON: CT of the chest from , CT of the abdomen and pelvis\n .\n\n TECHNIQUE: Volumetric CT of the abdomen and pelvis was performed following\n administration of oral contrast only. Multiplanar reformatted images were\n obtained and reviewed.\n\n CT ABDOMEN: Bilateral pleural effusions, and bibasilar and lingular\n atelectasis, left greater than right have of minimally increased since CTA of\n the chest .\n\n Within the abdomen, moderate ascites is not significantly changed in volume\n when compared to prior abdominal CT of . However, overall density\n of the fluid (previously , now 15-25 ), has modestly increased which\n could indicate interval hemorrhage within the fluid. Absence of intravenous\n contrast limits evaluation of the abdominal parenchymal organs and\n vasculature. Nasogastric tube remains coiled within the stomach, which is now\n mostly collapsed. Postoperative changes are noted from prior hernia repair,\n stable. Liver has unremarkable non-contrast appearance. Gallbladder is\n surgically absent. Pancreas, spleen, and adrenal glands are grossly\n unremarkable. Intra-abdominal loops of bowel opacify normally. There are no\n dilated bowel loops. No definite bowel wall thickening is appreciated. There\n is a small U-shaped density in the anterior bowel mesentery measuring 3.5 x\n 2.9 cm (2, 38), likely representing a small hematoma, unchanged. There is a\n tiny fluid-containing ventral hernia.\n\n Delayed dense nephrogram in both kidneys, with minimal excreted contrast in\n the collecting systems is noted, most recent contrast administration was for\n the CT of the chest o'clock. There are no focal renal lesions.\n (Over)\n\n 4:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 52 yo F with h/o hepatitis p/w fever, respiratory distress,\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is no free intraperitoneal air. There is no intra-abdominal\n lymphadenopathy. Generalized body wall edema is unchanged.\n\n CT PELVIS: Pelvic ascites is unchanged. Previously noted questionable cecal\n wall thickening is little changed, and remains difficult to evaluate due to\n surrounding fluid. No other definite area of wall thickening is identified.\n Bladder is decompressed with Foley catheter balloon in place. There is no\n abnormal pelvic or inguinal lymph node.\n\n There is no osseous lesion suspicious for malignancy.\n\n IMPRESSION:\n\n 1. No evidence of intra-abdominal abscess. Unchanged volume of ascites,\n which has slightly increased in density, a finding which could indicate\n interval development of some degree of hemoperitoneum. Clinical correlation\n is recommended.\n\n 2. Equivocal cecal wall thickening, difficult to evaluate due to noncontrast\n technique and surrounding fluid, but unchanged from prior CT. Colitis cannot\n be excluded.\n\n 3. Slight increase in bilateral pleural effusions, and associated bibasilar\n atelectasis, left greater than right.\n\n 4. Delayed dense nephrograms in both kidneys, with minimal excretion into\n nondilated collecting systems, likely representing acute tubular necrosis.\n\n 5. Unchanged small hematoma in the anterior small bowel mesentery.\n\n Findings discussed with Dr. at 18:44 on .\n\n" }, { "category": "Radiology", "chartdate": "2116-06-28 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1144994, "text": ", MED MICU 4:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 52 yo F with h/o hepatitis p/w fever, respiratory distress,\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 yo F with h/o hepatitis, MR, p/w fever, worsening AMS\n REASON FOR THIS EXAMINATION:\n 52 yo F with h/o hepatitis p/w fever, respiratory distress, evaluating for\n infectious source\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No evidence of intra-abdominal abscess. Unchanged ascites.\n 2. Delayed dense nephrograms, worrisome for acute tubular necrosis.\n 3. No definite evidence of bowel wall thickening.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144884, "text": " 3:03 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: placement of ET tube, NG tube\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n placement of ET tube, NG tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female in respiratory distress, evaluate placement of\n ET tube.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Endotracheal tube and nasogastric tube are in\n unchanged position as is a right internal jugular central venous catheter. As\n before the endotracheal tube lies somewhat low and should be repositioned.\n There is no pneumothorax. The cardiomediastinal silhouette is stable.\n Accounting for differences in technique, mild pulmonary edema has mildly\n improved especially on the left. There is small left-sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1142362, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with autoimmune hepatitis and symptomatic hiatal hernia, tx\n to ICU for resp distress w/ aspiration PNA who is s/p laprascopic reduction of\n hiatal hernia, PCT liver biopsy.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. The more central parts of the pre-existing\n bilateral parenchymal opacities show minimal regression. Otherwise, the\n severity and distribution of the opacities is unchanged. Unchanged size of\n the cardiac silhouette, unchanged retrocardiac atelectasis. No newly appeared\n focal parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1139992, "text": " 10:48 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Respiratory distress.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman now in respiratory distress.\n REASON FOR THIS EXAMINATION:\n Respiratory distress.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: Respiratory distress.\n\n COMPARISON: , 9:33.\n\n FINDINGS: As compared to the previous examination, the patient has been\n intubated. The tip of the endotracheal tube projects 2.5 cm above the carina.\n Unchanged course and position of the left subclavian line.\n\n Minimally increasing retrocardiac atelectasis. Unchanged huge herniation of\n gastric content into the thorax. Otherwise, no changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144854, "text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with respiratory distress.\n\n COMPARISON: and .\n\n FRONTAL CHEST RADIOGRAPH: Lines and tubes are in unchanged position. The ETT\n tube lies somewhat near the carina and could be repositioned. Again seen is\n left retrocardiac opacity as well as air space opacity greater on the left,\n which has increased compared to but is stable compared to the\n most recent chest radiograph. There is a small left sided pleural effusions.\n Findings are most likely secondary to pulmonary edema and less likely\n infection.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1144866, "text": " 11:51 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE, assess for pna\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with repiratory distress\n REASON FOR THIS EXAMINATION:\n r/o PE, assess for pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DSsd SAT 3:06 PM\n PFI:\n 1. No central or segmental pulmonary embolism. Distal branch evaluation is\n limited by contrast bolus timing.\n 2. Suboptimally positioned endotracheal tube, approaches and may enter the\n proximal right main stem bronchus. Recommend tube withdrawal several\n centimeters for more optimal positioning.\n 3. Small pleural effusions and bibasilar atelectasis, left greater than\n right.\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST, \n\n INDICATION: Respiratory distress.\n\n COMPARISON: Radiographs from same day and abdominal CT from .\n\n TECHNIQUE: Volumetric CT of the chest was performed before and after IV\n contrast administration per departmental CTPA protocol. Multiplanar\n reformatted images were obtained and reviewed.\n\n CTA CHEST: There is no central or segmental pulmonary embolism. Evaluation\n of subsegmental and more distal branches is limited by contrast bolus timing.\n There is no dissection. The thoracic aorta is normal in caliber and contour\n throughout.\n\n A right internal jugular central venous catheter tip terminates in the lower\n SVC. Endotracheal tube is in place, and is positioned with the tip relatively\n low lying, angled towards, and probably entering the proximal right main stem\n bronchus. Nasogastric tube is in place, coiled in the stomach. There is\n fluid filling the somewhat distended esophagus at least to the level of the\n thoracic inlet.\n\n Heart is normal. There is no pericardial effusion. Central airways appear\n patent to the subsegmental level, though there is slight narrowing of the left\n main stem bronchus just distal to its origin, which may be related to slight\n expiratory phase of scan acquisition. There is no pathologically enlarged\n mediastinal or hilar lymph node. There are scattered small bilateral axillary\n lymph nodes, not meeting CT criteria for pathologic enlargement.\n\n There are small bilateral pleural effusions, left greater than right. There\n (Over)\n\n 11:51 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE, assess for pna\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is dependent bibasilar atelectasis, left greater than right. Lungs are\n otherwise grossly clear, though evaluation is slightly limited by low lung\n volumes.\n\n This study is not specifically tailored for subdiaphragmatic evaluation.\n Limited views of the upper abdomen are unremarkable, except to note unchanged\n ascites. There is minimally prominent peritoneal enhancement, unchanged from\n prior. Small liver lesions in segments II and III remain incompletely\n characterized.\n\n There are no focal bony lesions. Degenerative changes in the upper thoracic\n spine, with disc space narrowing and endplate sclerosis at T3/4, are little\n changed from prior study of .\n\n IMPRESSION:\n\n 1. No central or segmental pulmonary embolism. Distal branch evaluation is\n limited by contrast bolus timing.\n\n 2. Suboptimally positioned endotracheal tube, approaches and may enter the\n proximal right main stem bronchus. Recommend tube withdrawal several\n centimeters for more optimal positioning.\n\n 3. Small pleural effusions and bibasilar atelectasis, left greater than\n right.\n\n 4. Distended fluid filled esophagus at least to the level of the thoracic\n inlet, which predisposes patient to aspiration. Distal esophageal obstruction\n or other abnormality cannot be excluded\n\n 5. Ascites, with borderline peritoneal enhancement, unchanged from prior\n studies.\n\n 6. Incompletely characterized liver lesions in segments II and III which have\n reduced in extent over time suggesting resolving injury or ischemic change.\n\n Findings discussed via telephone with Dr. at 3pm on .\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1144867, "text": ", MED MICU 11:51 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE, assess for pna\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with repiratory distress\n REASON FOR THIS EXAMINATION:\n r/o PE, assess for pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No central or segmental pulmonary embolism. Distal branch evaluation is\n limited by contrast bolus timing.\n 2. Suboptimally positioned endotracheal tube, approaches and may enter the\n proximal right main stem bronchus. Recommend tube withdrawal several\n centimeters for more optimal positioning.\n 3. Small pleural effusions and bibasilar atelectasis, left greater than\n right.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1144868, "text": " 11:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for cause of respiratory disress.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with repiratory distress\n REASON FOR THIS EXAMINATION:\n Evaluate for cause of respiratory disress.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf SAT 12:43 PM\n Study severely limited by motion artifact despite repeat attempts. Within\n these limitations, no acute large vascular territory infarct, hemorrhage is\n noted. The ventricles and sulci are normal in size and configuration.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Woman with respiratory distress.\n\n COMPARISON: Reference head CT from .\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n Motion degraded images were repeated twice, but no satisfactory images were\n obtained of the skull base.\n\n FINDINGS:\n\n This study is limited due to severe head motion, no acute large vascular\n territory infarct, shift of midline structures, mass effect, or acute\n hemorrhage is noted. The ventricles and sulci are normal in size and\n configuration. The visible paranasal sinuses and mastoid air cells are well\n aerated.\n\n IMPRESSION:\n\n Limited study shows no acute intracranial abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1139965, "text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with new wheezing.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Wheezing.\n\n Comparison is made with prior study performed a day earlier.\n\n There is respiratory motion that limits the evaluation of this study, allowing\n this limitation, left lower lobe opacities consistent with atelectasis or\n pneumonia are stable. There are no new lung abnormalities. Cardiac size is\n tip normal. Left PICC remains in place. There is no pneumothorax. A large\n hiatal hernia is again noted. Small left pleural effusion is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2116-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140451, "text": " 11:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for ng tube placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman s/p ng tube placement.\n REASON FOR THIS EXAMINATION:\n eval for ng tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Study of earlier the same date.\n\n FINDINGS: Nasogastric tube has been withdrawn several centimeters, with side\n port now projecting within a large hiatal hernia. Bilateral upper lobe\n airspace opacities have worsened compared to previous studies, and are\n concerning for a multifocal pneumonia, possibly an aspiration pneumonia in the\n setting of a large hiatal hernia. Unchanged left retrocardiac opacity and\n small left effusion. Focal, somewhat rounded lucency in right upper lobe\n between first and second anterior ribs is probably an area of spared lung\n parenchyma.\n\n IMPRESSION:\n 1. Nasogastric tube side port terminates within large hiatal hernia.\n 2. Worsening bilateral upper lobe predominant airspace opacities suggestive\n of evolving pneumonia, possibly aspiration pneumonia. Lucency in right upper\n lobe is probably spared lung parenchyma but attention to this area on followup\n radiographs is recommended to exclude a necrotizing pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141787, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman POD 3 s/p hiatal hernia repair\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hiatal hernia repair, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is little relevant\n change. Borderline size of the cardiac silhouette. Unchanged position of the\n multiple monitoring and support devices. Unchanged retrocardiac atelectasis\n with suspicion of a small left pleural effusion. No interval appearance of\n new focal parenchymal opacities. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-16 00:00:00.000", "description": "RP UNILAT LOWER EXT VEINS RIGHT PORT", "row_id": 1143272, "text": " 6:39 PM\n UNILAT LOWER EXT VEINS RIGHT PORT Clip # \n Reason: FEVER REDNESS R/O DVT\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p lap hiatal hernia repair, c/b hepatorenal syndrome,\n ARDS, now continued fevers w/o source\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: YGd TUE 7:34 PM\n No RLE DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with fever without clear source. Question\n DVT.\n\n COMPARISON: None available.\n\n FINDINGS: Grayscale and color Doppler son were performed of the right\n common femoral, superficial femoral, and popliteal veins demonstrating normal\n compression, color flow, and augmentation. Normal color is demonstrated in\n the right peroneal and posterior tibial veins.\n\n IMPRESSION: No evidence of DVT within the right lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-04 00:00:00.000", "description": "MRI ABDOMEN W/O CONTRAST", "row_id": 1141214, "text": " 8:49 AM\n MRI ABDOMEN W/O CONTRAST Clip # \n Reason: Please assess for evidence of obstruction in biliary tree.\n Admitting Diagnosis: HEPATITIS\n Contrast: MAGNEVIST Amt: 2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NASH cirrhosis, now question of biliary obstruction.\n REASON FOR THIS EXAMINATION:\n Please assess for evidence of obstruction in biliary tree.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:31 PM\n No biliary dilatation. Sm amount peri-hepatic ascites.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female with NASH cirrhosis, now question biliary\n obstruction.\n\n Elevated alkaline phosphatase.\n\n COMPARISON: Abdominal ultrasound and reference abdominal MR\n .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging was performed on a 1.5\n Tesla magnet, including attempted intravenous administration of 0.1 mmol/kg of\n gadolinium intravenous contrast, but the patient could not tolerate the study\n and only 2 cc of Magnevist contrast was given. 6 ounces of pineapple juice\n and 1 cc of Magnevist gadolinium contrast were orally administered.\n\n MR ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The study suffers technical\n limitations due to patient motion and inability to perform breath-hold\n maneuvers. However, the common bile duct is well visualized measuring 7.5 mm\n (6:19). There is no intrahepatic biliary ductal dilatation. There is a small\n amount of perihepatic ascites (6:17). The liver, spleen, pancreas, adrenal\n glands, and visualized bowel appear unremarkable except for a large hiatal\n hernia, and left lung base atelectasis also seen on prior CT chest\n examination.\n\n Dependent body wall edema is seen diffusely, and bilaterally, best appreciated\n on the axial T2 HASTE (9:20).\n\n IMPRESSION:\n\n 1. No evidence of biliary obstruction.\n 2. Small amount of perihepatic ascites.\n 3. Significant dependent body wall edema indicative of \"third-spacing\"\".\n\n" }, { "category": "Radiology", "chartdate": "2116-06-04 00:00:00.000", "description": "MRI ABDOMEN W/O CONTRAST", "row_id": 1141215, "text": ", V. MED FA10 8:49 AM\n MRI ABDOMEN W/O CONTRAST Clip # \n Reason: Please assess for evidence of obstruction in biliary tree.\n Admitting Diagnosis: HEPATITIS\n Contrast: MAGNEVIST Amt: 2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NASH cirrhosis, now question of biliary obstruction.\n REASON FOR THIS EXAMINATION:\n Please assess for evidence of obstruction in biliary tree.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No biliary dilatation. Sm amount peri-hepatic ascites.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1142162, "text": " 4:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman POD 4 s/p lap hiatal hernia repair\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient four days after repair of\n hiatal hernia.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 4 cm above the carina. The ET tube tip passes below the\n diaphragm terminating in the stomach. The right subclavian line tip is at the\n cavoatrial junction.\n\n There is significant interval worsening of the chest radiograph seen as\n bilateral perihilar opacities consistent with interval development of alveolar\n pulmonary edema. Bilateral pleural effusions cannot be excluded. Bibasilar\n atelectasis is unchanged.\n\n Findings discussed with Dr. over the phone by Dr. at the\n time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141544, "text": " 3:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with cirrhosis s/p laprascopic reduction hiatus hernia and\n liver biopsy.now with increasing qxygen requiremnt and worsening liver\n functions\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n 52-year-old woman with cirrhosis, status post laparoscopic reduction of hiatus\n hernia and liver biopsy, now with increasing oxygen requirement and worsening\n liver function. Interval change.\n\n chest,1 vw\n Comparison is made a previous chest radiograph dated .\n\n FINDINGS:\n\n The ET tube lies 4.5 cm above the carina. The tip of the left-sided PICC line\n lies in mid-SVC as before. An NG tube extends beneath the diaphragm, off the\n film.\n\n The cardiac silhouette is grossly unchanged. Again see is increased\n retrocardiac density and a small left effusion. Subcutaneous emphysema is\n again seen along the left upper abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1142100, "text": " 6:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for infiltrate, pna\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with respiratory failure, now with fever.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pna\n ______________________________________________________________________________\n WET READ: PXDb TUE 8:03 PM\n Interval improvement of lung aeration with persistant bilateral patchy opacity\n more confluent in retrocardiac region, could reflect residual edema with\n atelectasis, however superimposed infection is not excluded. ( )\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with respiratory failure and\n fever.\n\n Portable AP chest radiograph was compared to most recent radiograph from , .\n\n There is interval improvement of lung aeration most likely due to interval\n resolution of pulmonary edema. There are still present bilateral opacities in\n the bibasal retrocardiac areas as well as in the perihilar areas with a\n residue of pulmonary edema and underlying known extensive consolidation.\n Bilateral pleural effusions are unchanged. The position of supporting devices\n is unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-06 00:00:00.000", "description": "RENAL U.S.", "row_id": 1141578, "text": " 9:46 AM\n RENAL U.S. Clip # \n Reason: eval hydro, source of renal failure\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hx s/p POD 1 lap hiatal hernia, PTC liver bx now with\n inc creatinine, low UOP.\n REASON FOR THIS EXAMINATION:\n eval hydro, source of renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SAT 11:31 AM\n Essentially normal renal ultrasound. No evidence of hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Decreased urine output, status post laparoscopic hiatal\n hernia repair and liver biopsy. Clinical concern for hydronephrosis.\n\n COMPARISON: Abdominal MRI from .\n\n TECHNIQUE: Ultrasound images of the kidneys and urinary bladder were\n obtained.\n\n FINDINGS: Both kidneys are in normal anatomic location and demonstrate normal\n echogenicity and contour. There is no evidence of hydronephrosis, stone, or\n masses. The left kidney measures 11.2 cm in length. The right kidney\n measures 11.3 cm in length. Urinary bladder contains a Foley catheter and is\n collapsed.\n\n IMPRESSION: Essentially normal renal ultrasound. No evidence of\n hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-06 00:00:00.000", "description": "RENAL U.S.", "row_id": 1141579, "text": ", S. TSURG TSICU 9:46 AM\n RENAL U.S. Clip # \n Reason: eval hydro, source of renal failure\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hx s/p POD 1 lap hiatal hernia, PTC liver bx now with\n inc creatinine, low UOP.\n REASON FOR THIS EXAMINATION:\n eval hydro, source of renal failure\n ______________________________________________________________________________\n PFI REPORT\n Essentially normal renal ultrasound. No evidence of hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-11 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1142323, "text": " 12:04 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? SEPSIS\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52F a/w autoimmune hepatitis and symptomatic hiatal hernia, tx to ICU for resp\n distress w/ aspiration PNA who is s/p laprascopic reduction of hiatal hernia,\n PCT liver biopsy.\n REASON FOR THIS EXAMINATION:\n assess for any effusions, collections\n CONTRAINDICATIONS for IV CONTRAST:\n crt 3.1;crt 3.1;crt 3.1\n ______________________________________________________________________________\n WET READ: 3:18 AM\n 1. Bilateral severe peribronchial mixed ground-glass and consolidative\n opacities, concerning for ARDS.\n 2. Bibasilar patchy consolidative opacities, compatible with multifocal PNA\n +/- atelectasis.\n 3. No bowel obstruction. Liquid-stool filled colon. Colonic wall not\n adequately assessed without IV contrast.\n 4. Small perihepatic fluid. Diffuse small ascites. No free air.\n 5. Severe anasarca.\n 6. No definite evidence of intra-abdominal fluid collection to suggest\n abscess, in the limits of non-IV contrast study.\n 7. Borderline splenomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female with autoimmune hepatitis and symptomatic hiatal\n hernia status post laparoscopic reduction now with respiratory distress and\n aspiration pneumonia. The patient is also status post liver biopsy. Assess\n for any effusions or intra-abdominal collections.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous helical acquisition through the chest, abdomen and\n pelvis was performed without intravenous contrast. Oral contrast was\n administered. Coronal and sagittally reformatted images were created.\n\n FINDINGS:\n\n CT CHEST: The heart is normal in size. There is no pericardial effusion.\n Multiple prominent mediastinal lymph nodes are identified measuring up to 7 mm\n in short axis which do not meet criteria for pathologic enlargement. No hilar\n lymphadenopathy is identified on this non-contrast study. Two Central venous\n catheters are noted terminating at the cavoatrial junction. An endotracheal\n tube terminates approximately 4 cm above the carina. There has been interval\n development of diffuse ground-glass opacities which are located centrally,\n sparing the periphery of the lungs. There are superimposed areas of focal\n consolidation scattered throughout both lungs most prominently within the\n lower lobes and right middle lobe. There is mild interlobular septal\n thickening most prominent at the apices. The previously noted large hiatal\n (Over)\n\n 12:04 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? SEPSIS\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hernia is not present on the current study status post endoscopic hernia\n repair. Bilateral pleural effusions are identified moderate on the right and\n small on the left with adjacent compressive atelectasis. No pneumothorax is\n identified. A nasointestinal tube is identified terminating within the\n stomach.\n\n CT ABDOMEN: There is a geographic region of hypodensity noted within segments\n II and III of the liver which is new. No additional liver abnormalities are\n identified on this non-contrast study. There is no intrahepatic biliary\n dilatation. The patient is status post cholecystectomy. The spleen is\n borderline enlarged measuring 13 cm in craniocaudad dimension. The adrenal\n glands, kidneys, and pancreas are grossly unremarkable in appearance. Multiple\n retroperitoneal lymph nodes are identified which do not meet criteria for\n pathologic enlargement. There is a small-to-moderate amount of intra-\n abdominal ascites.\n\n CT PELVIS: No definite pelvic masses or lymphadenopathy is identified on this\n non-contrast study. A small amount of free fluid is noted in the pelvis. A\n Foley is noted within the bladder. The visualized loops of small bowel are\n unremarkable.\n\n CT BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified.\n Multilevel degenerative changes noted throughout the spine. There is diffuse\n anasarca.\n\n IMPRESSION:\n\n 1. Diffuse ground-glass opacities with focal areas of sparing and additional\n patchy reas of superimposed consolidation. These findings may be consistent\n with pneumonia and or aspiration with possible superimposed edema. Bilateral\n pleural effusions moderate on the right and small on the left.\n\n 2. Diffuse body wall edema and mild-to-moderate amount of intra-abdominal\n ascites without focal or organized fluid collections identified.\n\n 3. Geographic areas of hypoattenuation involving the medial aspects of\n segments II and III of the liver which are new compared to the prior study.\n These findings may related to edema or infarct.\n\n\n (Over)\n\n 12:04 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? SEPSIS\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2116-06-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1141706, "text": " 12:17 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate for pneumothorax\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman POD 2 s/p hiatal hernia repair, now s/p R subclavian line\n placement\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 52-year-old woman with two days status post hernia repair.\n\n FINDINGS: There has been placement of a right-sided subclavian catheter with\n the distal lead tip in the right atrium. This can be pulled back\n approximately 2 cm for more optimal placement. Left-sided central venous\n catheter, nasogastric tube, and endotracheal tube are in unchanged position.\n There remain bilateral pleural effusions, and left retrocardiac opacity, which\n are stable. No pneumothoraces are seen.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1145030, "text": " 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with esld here w/ respiratory distress\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory distress in a patient with end-stage\n liver disease.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach.\n Cardiomediastinal silhouette is unchanged. There is progression of the left\n retrocardiac opacity, most likely consistent with worsening of atelectasis,\n although infectious process would be another possibility. The rest of the\n findings are unchanged, including small pleural effusion and right basal\n atelectasis, minimal .\n\n The right internal jugular line tip is at the cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1143315, "text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p hiatal hernia repair w/insult to liver and kidney\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post hiatal hernia repair with insult to liver and\n kidneys.\n\n Comparison is made with prior study .\n\n Cardiac size is top normal. Left subclavian catheter tip is at the confluence\n of the brachiocephalic vein, unchanged. NG tube tip is way below the\n diaphragm.\n\n Small bilateral pleural effusions associated with bibasilar atelectasis left\n greater than right are unchanged. Perihilar opacities left greater than right\n are unchanged from improved from . There are likely pulmonary\n edema. There is no evidence pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1144786, "text": " 8:55 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Placement of CVL RIJ\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with ascites, resp failure\n REASON FOR THIS EXAMINATION:\n Placement of CVL RIJ\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with placement of right IJ line.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: There has been interval placement of a right\n internal jugular line with tip in the proximal SVC. Left internal jugular\n line is in unchanged position as is an endotracheal tube. Dobbhoff tube has\n been replaced by a nasogastric tube which is well coiled within the stomach.\n No pneumothorax is appreciated. Otherwise, the lungs are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1147221, "text": " 7:19 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval PICC placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with MR and h/o respiratory failure now extubated s/p PICC\n placement.\n REASON FOR THIS EXAMINATION:\n eval PICC placement\n ______________________________________________________________________________\n WET READ: OXZa TUE 12:46 AM\n Right PICC with tip likely in azygous vein. Should be repositioned. discussed\n with at 8pm .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Assessment of line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the right-sided PICC line\n is better visible. Curving of the catheter tip, however, still suggests\n entrapment in the azygos vein. Therefore, repositioning should be attempted.\n The nasogastric tube and the left-sided access line are unchanged. Unchanged\n retrocardiac atelectasis. No complications, no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-16 00:00:00.000", "description": "P DUPLEX DOPP ABD/PEL PORT", "row_id": 1143149, "text": " 8:36 AM\n DUPLEX DOPP ABD/PEL PORT; LIVER OR GALLBLADDER US (SINGLE ORGAN) PORTClip # \n Reason: eval for portal flow\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NASH cirrhosis, ascites, s/p paracentesis\n REASON FOR THIS EXAMINATION:\n eval for portal flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 52-year-old female with cirrhosis, ascites, evaluate for portal\n flow.\n\n COMPARISON: Doppler ultrasound, .\n\n FINDINGS: Note is made that this is a somewhat technically limited study. No\n focal liver lesion is identified. No biliary dilatation is seen. Minimal\n amount of ascites is seen in the lower quadrants.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main portal vein, right portal vein and left portal vein are\n patent with hepatopetal flow. Appropriate flow is seen in the main hepatic\n artery. Appropriate flow is also seen in the hepatic veins.\n\n IMPRESSION:\n 1. Patent hepatic vasculature:\n 2. No focal liver lesion and no biliary dilatation seen.\n 3. Minimal ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1145328, "text": " 6:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman intubated s/p LIJ placement\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: LLTc TUE 11:36 PM\n New left IJ terminates at the upper SVC with the tip oriented transversely,\n and may possibly be located within the right brachiocephalic vein. Coiled NGT\n within the stomach is unchanged since the prior examination. Left basilar\n atalectasis is unchanged in appearance.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation, assessment after line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a new left internal jugular\n vein catheter shows a normal course and the tip projecting over the upper SVC.\n The tip of the catheter, however, abuts the wall of the SVC in right angle and\n does not, as expected, points downwards.\n\n There is no evidence of complications, notably no pneumothorax.\n\n Unchanged coiled nasogastric tube in the stomach. Unchanged endotracheal\n tube.\n\n Unchanged appearance of the moderately enlarged cardiac silhouette and the\n opacity in the left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1143921, "text": " 10:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm Dobhoff in stomach\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with cirrhosis NASH.\n REASON FOR THIS EXAMINATION:\n confirm Dobhoff in stomach\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, \n\n CLINICAL INFORMATION: Dobbhoff tube placement.\n\n FINDINGS:\n\n Dobbhoff tube has been placed, and the tip terminates in the stomach.\n Followup recommended. Study is not tailored to evaluate the bowel gas\n pattern.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-26 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1144717, "text": " 1:16 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? e/o perforation\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with lactate elevation, non-verbal\n REASON FOR THIS EXAMINATION:\n ? e/o perforation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with elevated serum lactate level, rule out\n perforation.\n\n COMPARISON: Abdominal plain films from .\n\n FINDINGS: There is no evidence of free air on this supine film; however, this\n technique is suboptimal for visualization of small amounts of intraperitoneal\n air. Air and stool is noted in the colon. The remainder of the bowel gas\n pattern is normal. A Dobbhoff tube is seen with its tip in the stomach.\n Surgical clips are seen in the right upper quadrant. The imaged osseous\n structures are unremarkable.\n\n IMPRESSION: There is no evidence of free air on this supine film; however,\n the supine technique is suboptimal for visualization of intraperitoneal air.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-14 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1142954, "text": " 7:18 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Assess for DVT.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with cirrhosis NASH c/b hepatorenal syndrome and ARF.\n Continues to have fevers.\n REASON FOR THIS EXAMINATION:\n Assess for DVT.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh SUN 9:43 PM\n PFI: No evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old female with cirrhosis secondary to NASH complicated by\n hepatorenal syndrome and acute renal failure, now presenting with fevers.\n\n STUDY: Bilateral lower extremity venous ultrasound.\n\n FINDINGS: Grayscale and color Doppler images were obtained of the bilateral\n common femoral, bilateral superficial femoral, bilateral popliteal, bilateral\n posterior tibial, and bilateral peroneal veins. Normal compressibility, flow,\n and augmentation is demonstrated.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-14 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1142955, "text": ", S. TSURG TSICU 7:18 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Assess for DVT.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with cirrhosis NASH c/b hepatorenal syndrome and ARF.\n Continues to have fevers.\n REASON FOR THIS EXAMINATION:\n Assess for DVT.\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1147214, "text": " 5:12 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Please check picc tip position. #5f, power picc 42.5 cm's. p\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hepatitis\n REASON FOR THIS EXAMINATION:\n Please check picc tip position. #5f, power picc 42.5 cm's. please page beeper #\n with wet read asap. thanks.\n ______________________________________________________________________________\n WET READ: OXZa MON 7:25 PM\n New right PICC line with tip likely in azygous. Should be repositioned.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hepatitis, check PICC line position.\n\n COMPARISON: , 7:49 a.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n right-sided PICC line. The tip of the line shows an atypically curvature\n directed medially, suggesting entrapment of the catheter tip in the azygos\n vein. Unchanged small right pleural effusion and subsequent retrocardiac\n atelectasis. No other relevant changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1145332, "text": " 7:58 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? line placement, pulled back 1.5cm\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with line pulled back\n REASON FOR THIS EXAMINATION:\n ? line placement, pulled back 1.5cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n COMPARISON: , 7:00 p.m.\n\n FINDINGS: As compared to the previous radiograph, the lines, including the\n newly placed left internal jugular vein, are unchanged in course and position.\n\n No other changes have occurred.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1145381, "text": " 9:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess location of NGT\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman intubated with NGT placed\n REASON FOR THIS EXAMINATION:\n please assess location of NGT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post nasogastric tube placement.\n\n COMPARISON: , 11:41 p.m.\n\n FINDINGS: As compared to the previous radiograph, the nasogastric tube has\n been replaced. Currently, the tube is not coiled and the tip projects over\n the central parts of the stomach. No complications. The other monitoring and\n support devices are in unchanged position. No other radiographic changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1142897, "text": " 11:08 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placeemnt of L SC TLC\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with hiatial hernia repair.\n REASON FOR THIS EXAMINATION:\n line placeemnt of L SC TLC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a subclavian catheter that extends to about the junction of the\n brachiocephalic vein and the superior vena cava. Otherwise, little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1147225, "text": " 8:03 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval picc placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with MR with new picc placement, tip in azygous.\n REASON FOR THIS EXAMINATION:\n eval picc placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC line placement.\n\n COMPARISON: , 7:43 p.m.\n\n FINDINGS: As compared to the previous radiograph, there has been\n repositioning of the right-sided PICC line. The tip of the line projects over\n the mid SVC and is now in correct position. There is no evidence of\n complications, the nasogastric tube and the left-sided line are unchanged.\n Unchanged retrocardiac atelectasis and small pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1147575, "text": " 8:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pneumonia/pleural effusion\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with tachypnea after transfer from MICU\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia/pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: transfer from MICU.\n\n Portable AP chest radiograph was compared to .\n\n The Dobbhoff tube passes below the diaphragm with the tip not included in the\n field of view. The right PICC line tip is most likely at the level of mid\n SVC. Cardiomediastinal silhouette overall is unchanged. Left retrocardiac\n opacity consistent with atelectasis is unchanged. There is mild pulmonary\n edema, but no overt volume overload. Lung volumes continue to be low.\n Overall, there is no significant change compared to several most recent\n radiographs.\n\n Contrast in the bowel is demonstrated most likely due to administration of the\n contrast to verify position of the Dobbhoff tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1142856, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52F a/w NASH cirrhosis and symptomatic hiatal hernia, tx to ICU for resp\n distress w/ aspiration PNA who is s/p laprascopic reduction of hiatal hernia,\n PCT liver biopsy. Now w/ ARDS, ? hepatorenal syndrome, ATN, ? shock liver.\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and hiatal hernia, with respiratory distress and\n aspiration.\n\n FINDINGS: In comparison with study of , there is continued bilateral\n pulmonary opacifications. Cardiac silhouette remains within normal limits and\n lung volumes are again low. No large pleural effusion or pneumothorax.\n\n Monitoring and support devices remain in place, with the right IJ catheter\n appearing to be in the lower portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1142746, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with vs ARDS, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman with ARDS.\n\n COMPARISON: Several prior studies, most recent dated .\n\n FRONTAL CHEST RADIOGRAPH:\n\n The endotracheal tube ends at the level of the thoracic inlet. The\n nasogastric tube ends in the stomach. Right subclavian line ends at the\n superior cavoatrial junction.\n\n The cardiomediastinal contours are stable. The lung volumes are low on\n today's study. Bilateral alveolar opacities have slightly increased in\n extent, particularly at the right lung base. There is no pneumothorax or\n large pleural effusion.\n\n IMPRESSION:\n\n More extensive bilateral alveolar opacities, compared with 1 day earlier.\n ? worsening pulmonary edema, infection, or ARDS.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144590, "text": " 3:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumonia\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with dyspnea\n REASON FOR THIS EXAMINATION:\n ? pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Dyspnea.\n\n Portable AP chest radiograph was compared to .\n\n There is no change in the appearance of the Dobbhoff tube and left central\n venous line. The patient continues to be in interstitial pulmonary edema with\n left retrocardiac opacity, consistent with atelectasis/infection. There is\n small amount of left pleural effusion which is unchanged since the prior\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-30 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1145302, "text": " 3:44 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? ileus\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with bowel distention, liver disease, renal failure, sepsis\n REASON FOR THIS EXAMINATION:\n ? ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with bowel distention, liver disease, renal\n failure, sepsis, question ileus.\n\n COMPARISON: Abdominal radiographs from .\n\n FINDINGS: One portable abdominal plain film was acquired which shows a small\n amount of air in the small bowel and colon. The observed bowel gas pattern is\n nonspecific. The imaged osseous structures are unremarkable. There has been\n interval removal of a Dobbhoff feeding tube.\n\n IMPRESSION:\n 1. No evidence of ileus or obstruction.\n 2. Interval removal of Dobbhoff tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144735, "text": " 1:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? ETT placmeent\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n ? ETT placmeent\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of an endotracheal tube with its tip approximately 2.2 cm above the\n carina. Otherwise, there is little overall change. Patchy opacification in\n the retrocardiac region and elsewhere in left hemithorax is worrisome for\n consolidation. An alternative could be asymmetric pulmonary edema that is\n more prominent on the left, though this is the opposite of the usual pattern.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144169, "text": " 6:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung parenchymal condition\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman s/p Nissen's\n REASON FOR THIS EXAMINATION:\n lung parenchymal condition\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent Nissen fundoplication. Evaluate lungs.\n\n FINDINGS: Comparison is made to radiograph dated . There is marked\n interval improvement in the appearance of pulmonary venous distenSion since\n the previous radiograph. There is left lower lobe atelectasis which is\n stable. The heart size and mediastinal contours are normal. The nasogastric\n tube is in satisfactory position and its distal tip is projected over the body\n of the stomach where surgical clips are present.\n IMPRESSION: Interval improvement in the degree of pulmonary venous distension.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1144909, "text": " 7:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate ET tube\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with ET tube pulled out a few CM\n REASON FOR THIS EXAMINATION:\n evaluate ET tube\n ______________________________________________________________________________\n WET READ: YGd SAT 9:18 PM\n ETT 3.8 cm above carina. Feeding tube unchanged. Otherwise unchanged. x\n pg \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube re-positioning.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The endotracheal tube has been withdrawn and now\n lies 3.8 cm above the carina. The right internal jugular central venous line\n and feeding tube are in unchanged position. Examination is otherwise\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1142936, "text": ", S. TSURG TSICU 4:13 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52F a/w NASH cirrhosis and symptomatic hiatal hernia, tx to ICU for resp\n distress w/ aspiration PNA who is s/p laprascopic reduction of hiatal hernia,\n PCT liver biopsy c/b Now ARDS vs. acute lung injury, hepatorenal syndrome vs.\n shock liver and ATN, on CVVH - am, now UO somewhat improved, still\n minimal. Continues to be febrile despite fungal and broad antibiotic coverage.\n REASON FOR THIS EXAMINATION:\n assess interval change\n CONTRAINDICATIONS for IV CONTRAST:\n ATN;ATN;ATN\n ______________________________________________________________________________\n PFI REPORT\n 1. Improved aeration of the lung parenchyma, with decreased but persistent\n bibasilar consolidations, which could be due to some combination of pneumonia,\n aspiration, and volume loss. Persistent but improved more central and\n perihilar ground-glass opacities, which can be seen in the setting of\n infection, edema and ARDS.\n 2. Anasarca, bilateral small pleural effusions, small abdominal and pelvic\n ascites.\n 3. Geographic region of liver hypoattenuation, which may be due to edema or\n infarct, as previously noted.\n 4. No drainable fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1142935, "text": " 4:13 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52F a/w NASH cirrhosis and symptomatic hiatal hernia, tx to ICU for resp\n distress w/ aspiration PNA who is s/p laprascopic reduction of hiatal hernia,\n PCT liver biopsy c/b Now ARDS vs. acute lung injury, hepatorenal syndrome vs.\n shock liver and ATN, on CVVH - am, now UO somewhat improved, still\n minimal. Continues to be febrile despite fungal and broad antibiotic coverage.\n REASON FOR THIS EXAMINATION:\n assess interval change\n CONTRAINDICATIONS for IV CONTRAST:\n ATN;ATN;ATN\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 8:41 PM\n 1. Improved aeration of the lung parenchyma, with decreased but persistent\n bibasilar consolidations, which could be due to some combination of pneumonia,\n aspiration, and volume loss. Persistent but improved more central and\n perihilar ground-glass opacities, which can be seen in the setting of\n infection, edema and ARDS.\n 2. Anasarca, bilateral small pleural effusions, small abdominal and pelvic\n ascites.\n 3. Geographic region of liver hypoattenuation, which may be due to edema or\n infarct, as previously noted.\n 4. No drainable fluid collection.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 52-year-old female with cirrhosis and hiatal hernia, transferred\n to the intensive care unit for respiratory distress, treated for aspiration\n pneumonia, who is status post laparoscopic reduction of hiatal hernia,\n post-liver biopsy, with lung findings concerning for ARDS versus acute lung\n injury, multiorgan failure.\n\n COMPARISON: CT torso dated .\n\n TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained\n without administration of intravenous contrast. Oral contrast was\n administered.\n\n CT CHEST WITHOUT INTRAVENOUS CONTRAST: The patient is intubated, with the\n endotracheal tube ending 3.5 cm above the carina. Left PICC ends in the left\n brachiocephalic vein. Right internal jugular line ends in the superior vena\n cava. The nasogastric tube coursing through the esophagus, ending in the\n stomach.\n\n There is no pneumothorax. The aeration of the lung parenchyma is improving,\n with decreased density and extent of the opacities, which still persist\n bilaterally, with more consolidative appearance at the base on the right.\n (Over)\n\n 4:13 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is increased volume loss in the left lower lobe with a mildly swirled\n appearance of the atelectatic portion of the left lower lobe somewhat like\n round atelectasis. The overall appearance is probably due to combination of\n atelectasis and pneumonia.\n\n Pleural effusions are non-hemorrhagic and small; the right, slightly decreased\n compared to the prior study. Non-contrast appearance of the heart and great\n vessels is unremarkable. The airways are patent to the segmental levels\n bilaterally.\n\n CT ABDOMEN WITH NO INTRAVENOUS CONTRAST: Small amount of perihepatic fluid\n persists. Radiographic region of hypoattenuation within segments II and III\n of the liver persists. The patient is post-cholecystectomy, there is no\n intrahepatic biliary ductal dilatation. The spleen is not enlarged. The\n non-contrast appearance of the kidneys is unremarkable. The colon continues\n to be fluid filled. The wall is not adequately assessed. There is no\n evidence of small bowel obstruction. The spleen is mildly enlarged, measuring\n 15 cm.\n\n The adrenal glands and pancreas are unremarkable, given lack of IV contrast.\n Small retroperitoneal and mesenteric nodes as well as stranding persists along\n with small amount of abdominal ascites, which could be all secondary to third\n spacing. There is no drainable fluid collection. There is no free\n intraperitoneal air.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: There is small amount of free fluid in\n the pelvis, which is nonhemorrhagic. The urinary bladder is decompressed\n around Foley catheter. The uterus and rectum are unremarkable, the sigmoid\n colon is decompressed, likely accounting for the appearance of the wall\n thickening. There is no inguinal or pelvic lymphadenopathy.\n\n BONE WINDOWS: There is no lytic or sclerotic lesions concerning for\n malignancy and no fracture. Again seen is diffuse total body wall edema.\n\n IMPRESSION:\n\n 1. Improved aeration of lung parenchyma, with persistent predominantly basal\n consolidations and perihilar ground-glass opacities.\n\n 2. Small bilateral pleural effusions.\n\n 3. Diffuse body wall edema with mild abdominal and pelvic ascites without\n focal fluid collection.\n\n 4. Persistent geographic area of hypoattenuation involving the medial aspect\n (Over)\n\n 4:13 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess interval change\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of segment II and III of the liver of uncertain etiology. Edema or infarcts\n could be considered. When clinically appropriate, if the patient can have a\n contrast-enhanced CT or MR examination, depending patient factors, this\n appearance could be investigated further. Alternatively, a short-term\n follow-up with ultrasound might be able to provide some information and could\n provide a baseline for follow-up of the abnormality, if it is later\n visualized. Doppler features could also be reassessed in light of persistence\n of this abnormality.\n\n 5. Left PICC ends in the left brachiocephalic vein.\n\n 6. Thickening of the distal colon, involving the sigmoid and through the\n upper rectum, even allowing for underdistension. Differential considerations\n include colitis in the appropriate setting or sequelae of portal congestion.\n Since the upstream colon is mildly prominent, the fact that the distal is mild\n to moderately narrowed may be causing slight obstruction, although contrast\n passes entirely through the area. The whole segment was collapsed on the last\n examination, limiting assessment and comparison. Correlation with clinical\n factors is recommended.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1143000, "text": " 9:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for dobhoff placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with new dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval for dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff placement.\n\n FINDINGS: In comparison with study of , there has been placement of a\n Dobbhoff tube that extends to the body of the stomach. Retrocardiac\n opacification persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-16 00:00:00.000", "description": "CT LIMITED 1-2 SCANS", "row_id": 1147713, "text": " 6:02 PM\n CT LIMITED SCANS Clip # \n Reason: Evaluate for Pulmonary Embolism\n Admitting Diagnosis: HEPATITIS\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, NASH cirrhosis, mental retardation, now with tachycardia\n and tachypnea, evaluate for pulmonary embolism.\n\n Please note this is a limited study with only scout images available. The\n study was incompletely terminated given patient's worsening clinical status\n and dropping oxygen saturation and inability to lie flat on the CT table.\n This was discussed with patient's referring physician and further assessment\n was performed by radiology nurse, Ms. , and the patient was\n transferred back to the floor by the physician given change in clinical\n status.\n\n Provided frontal and lateral scout demonstrate a retrocardiac density\n evaluation is limited by multiple overlying wires from EKG leads. There is\n post-pyloric tube, remainder of the partially imaged lungs are grossly\n unremarkable. Please note this is not a diagnostic evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1145344, "text": " 11:17 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? line in place\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with new L subclavian\n REASON FOR THIS EXAMINATION:\n ? line in place\n ______________________________________________________________________________\n WET READ: LLTc TUE 11:53 PM\n Interval removal of right IJ. Placement of new left subclavian central line\n terminating at the lower SVC. No pneumothorax is seen. ET tube and OG tube\n unchanged in position.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New left subclavian line in place.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the previous left internal\n jugular vein has been removed and replaced by a new left subclavian line.\n This line now shows expected course and expected position of the tip in the\n mid-to-lower SVC.\n\n There is no evidence of pneumothorax.\n\n Endotracheal tube and nasogastric tube are in unchanged position.\n\n Unchanged appearance of the heart and the opacities in the left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-28 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1145003, "text": " 7:54 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for brain edema, meningeal enhancement, brainstem i\n Admitting Diagnosis: HEPATITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with tachypnea, continued fevers for months, unknown etiology\n of tachypnea and fevers; hx of mental retardation\n REASON FOR THIS EXAMINATION:\n evaluate for brain edema, meningeal enhancement, brainstem involvement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Female with tachypnea, continued fever for months of unknown\n etiology and history of mental retardation, to assess for an intracranial\n lesion.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including post-contrast imaging required post-administration of\n 16 mL of Magnevist.\n\n Multiplanar 2D and 3D reformations were performed.\n\n Comparison is made with prior CT of .\n\n FINDINGS:\n\n There is a non-specific focus of high signal intensity in the left parietal\n subcortical white matter which demonstrates high signal intensity on FLAIR and\n T2 weighted images without enhancement on post contrast images. There is no\n evidence of an intracranial mass, mass effect, edema or shift of normal\n midline structures. The ventricles and sulci are unremarkable. There is no\n evidence of restricted diffusion. The visualized paranasal sinuses appear\n unremarkable.\n\n IMPRESSION: Non-specific, nonenhancing focus of high signal on FLAIR and T2\n weighted images in the left parietal lobe. The differential considerations are\n demyleination, vasculitis or sequlae of small vessel disease.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-25 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1144574, "text": " 1:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for abd abscess. pt with low grade temps;(plz do it wit\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman s/p hiatal hernia repair, ascites,\n REASON FOR THIS EXAMINATION:\n eval for abd abscess. pt with low grade temps;(plz do it with PO contrast down\n NJ)\n CONTRAINDICATIONS for IV CONTRAST:\n recent renal failure;recent renal failure\n ______________________________________________________________________________\n WET READ: 5:36 PM\n 1. No evidence of abscess. Cecal wall thickening is noted which was not\n present on the prior study. While this could be due to underdistension, a\n focal colitis cannot be excluded. Previously noted sigmoid and descending\n colonic wall thickening is not present on today's study and may have been due\n to underdistension.\n\n 2. Areas of hypoenhancement in segment II/III of the liver, smaller in size\n than the area of hypoenhancement seen on the prior noncontrast CTs. This\n likely reflects involving infarct and subsequent scarring.\n\n 3. Moderate ascites, increased since .\n\n 4. Trace right pleural effusion. Small left pleural effusion with adjacent\n compressive atelectasis. Overall atelectasis and ground glass and patchy\n opacities at the lung bases improved.\n\n 5. Anasarca.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman status post hiatal hernia repair. Evaluate for\n abdominal abscess. Patient with low-grade temperature.\n\n COMPARISON: CT torso of , and .\n\n TECHNIQUE: Axially acquired images were obtained from lung bases through the\n pubic symphysis after administration of 130 mL of Optiray intravenous contrast\n and oral contrast. Coronal and sagittal reformatted images were also\n displayed.\n\n FINDINGS:\n CT OF THE ABDOMEN WITH IV AND ORAL CONTRAST: There are small bilateral\n pleural effusions, left greater than the right. However, since ,\n these are much smaller in size. There is adjacent compressive bibasilar\n atelectasis, also improved since the previous study. The areas of patchy\n opacities at the lung bases likely represent improving aeration of\n atelectasis/pneumonia. An NG tube ends within the stomach. The patient is\n status post hiatal hernia repair. Fluid is noted within the visualized distal\n esophagus.\n (Over)\n\n 1:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for abd abscess. pt with low grade temps;(plz do it wit\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The spleen, adrenal glands, pancreas, kidneys, and liver are within normal\n limits. The patient is status post cholecystectomy. There is a moderate\n amount of ascites, which has increased in amount since the previous study. No\n free air is present. There is no abscess.\n\n There is questionable bowel wall thickening of the cecum which was not present\n on the prior study. However, the bowel is collapsed in this area and the wall\n thickening could be artifactual. Oral contrast is seen to the level of the\n descending colon. There is no evidence of obstruction.\n\n Areas of hypoenhancement within segment II and III of the liver are noted,\n corresponding with the general area of hypodensity noted on the prior\n noncontrast CTs, with an overall slight decrease in size of these segments.\n\n CT OF THE PELVIS WITH IV AND ORAL CONTRAST: There is a large amount of stool\n within the rectum. The uterus is within normal limits. A small focus of air\n within the bladder is likely due to recent instrumentation. The bladder is\n otherwise normal in appearance. There is a large amount of free fluid within\n the pelvis, which has increased since the previous study. No pelvic or\n inguinal lymphadenopathy is present.\n\n There is diffuse anasarca as before.\n\n BONE WINDOWS: No concerning osseous lesions are identified.\n\n IMPRESSION:\n 1. No evidence of abscess. Moderate amount of ascites, which has increased\n since the previous study.\n\n 2. Small bilateral pleural effusions, which have decreased in size since the\n previous study. Adjacent bibasilar atelectasis in addition to diffuse\n ground-glass and patchy opacities at the bases have improved.\n\n 3. Small areas of hypoenhancement within segment II and III of the liver with\n slight decrease in size of these segments likely reflects evolving infarct and\n subsequent scarring corresponding with the area of hypodensity noted on the\n previous noncontrast CT studies.\n\n 4. Possible bowel wall thickening of the cecum, new since the previous study.\n While this may be due to underdistended bowel, focal colitis cannot be\n excluded. Previously described thickening of the distal colon is not seen on\n today's study and may have been due to underdistension on the previous study.\n\n (Over)\n\n 1:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for abd abscess. pt with low grade temps;(plz do it wit\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2116-07-02 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1145563, "text": " 11:07 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: give PO contrast, assess for acute infectious process\n Admitting Diagnosis: HEPATITIS\n Field of view: 45 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with respiratory failure and VRE bacteremia on daptomycin,\n recent hiatal hernia reduction in , suddenly worse this morning with temp\n 103, worry for bowel perf\n REASON FOR THIS EXAMINATION:\n give PO contrast, assess for acute infectious process\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 3:35 PM\n 1. Bilateral pleural effusions worse since with associated\n either bibasilar compressive atelectases or infectious process such as pna in\n the correct clinical setting. Patchy ground glass opacities in bilateral\n lungs are unchanged since .\n 2. Anasarca, ascites.\n 3. Increase enteric contrast within the esophagus may reflect refluxing back\n of contrast from the stomach (presumably administered via NG tube).\n 4. NG and ETT in std placement.\n\n d/w Dr. at 15:30pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman with respiratory failure and VRE bacteremia, on\n daptomycin, who had recent hiatal hernia reduction in . Patient presents\n with fever this morning.\n\n COMPARISON: CT abdomen and pelvis, .\n\n CT OF THE CHEST: Patient is intubated with ET tube in standard position. The\n esophagus is not very well evaluated on this study with small hiatal hernia\n noted. There is enteric contrast within the esophagus, which may represent NG\n tube-administered contrast refluxing back into the esophagus from the stomach.\n Bilateral pleural effusions, left greater than right have increased since , with adjacent consolidation or compressive atelectasis. Minimal\n ground-glass opacification within the upper lungs is relatively unchanged\n since . Mediastinal, axillary and hilar lymph nodes do not meet\n CT size criteria for pathologic enlargement. In the setting of respiratory\n failure, it is also noted that the mainstem bronchi are nearly collapsed on\n this examination, as well as on the prior chest CT, although not on .\n This may be due to the respiratory cycle but bronchomalacia could be\n considered clinically.\n\n CT OF THE ABDOMEN: There is evidence of ascites and generalized anasarca.\n The liver, spleen and bilateral adrenal glands are unremarkable. Pancreas is\n within normal limits. The patient is status post cholecystectomy. There is\n no free air within the abdomen. Intra-abdominal loops of large and small\n (Over)\n\n 11:07 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: give PO contrast, assess for acute infectious process\n Admitting Diagnosis: HEPATITIS\n Field of view: 45 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bowel are unremarkable. Retroperitoneal and mesenteric lymph nodes do not\n seem to meet CT size criteria for pathologic enlargement.\n\n CT OF THE PELVIS: The bladder is not well distended. A Foley catheter is\n noted. The uterus, rectum and descending colon appear unremarkable. There is\n extensive pelvic free fluid. Pelvic lymph nodes are not well appreciated.\n\n OSSEOUS STRUCTURES: No focal lytic lesion suspicious for malignancy\n identified. Patchy sclerotic lesions in the visualized thoracolumbosacral\n spine are stable since prior.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions worse since with associated\n either bibasilar compressive atelectases or infectious process such as\n pnuemonia in the correct clinical setting.\n\n Patchy opacities in bilateral lungs, predominantly at the apices, are\n unchanged since , although improved since earlier on . These are partly coalesced into peripheral mixed consolidations and\n ground glass opacities, which are not striking however, so organizing\n pneumonia in addition to pulmonary infection could be considered.\n\n In the setting of respiratory failure, it is also noted that the mainstem\n bronchi are nearly collapsed on this examination, as well as on the prior\n chest CT, although not on . This may be due to the respiratory cycle\n but bronchomalacia could be considered clinically.\n\n 2. Anasarca, ascites, probably increased somewhat.\n\n 3. Increase enteric contrast within the esophagus may reflect refluxing back\n of contrast from the stomach (presumably administered via NG tube).\n\n 4. NG and ETT in standard placement.\n\n Discussed Dr. at 15:30pm on .\n\n" }, { "category": "Radiology", "chartdate": "2116-07-02 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1145564, "text": " 11:08 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: rule out deeper neck injury - spreading rash on neck since y\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with respiratory failure and VRE bacteremia on daptomycin,\n recent hiatal hernia reduction in , suddenly worse this morning with temp\n 103, worry for bowel perf\n REASON FOR THIS EXAMINATION:\n rule out deeper neck injury - spreading rash on neck since yesterday\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 3:26 PM\n No inflammation/ abscess in the within the limitaitons of the study.\n Dense secretions/ mucosal thickening the nasopharynx and nasal cavity- ?\n related to intubation.\n Heterogeneous rt. lobe of thyroid nodule- consider ultrasound.\n See report on CT Torso for lung changes.\n D/w Dr. . Flora by Dr.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, bacteremia, rash on the left side of the\n neck, to evaluate for infection/abscess in the neck, including the parotid\n glands.\n\n COMPARISON: None.\n\n TECHNIQUE: CT of the neck with IV contrast, with sagittal and coronal\n reformations.\n\n FINDINGS:\n\n There are dense secretions noted in the nasal cavity along with mucosal\n thickening extending into the nasopharynx, along with ETT and NGT in place.\n Can be correlated with clinical examination.Assessment for any focal lesions\n in this location is limited. Similarly, evaluation at the level of the\n maxilla/mandible is limited due to dental artifacts.\n Within these limitations, there is no obvious evidence of increased\n attenuation of the subcutaneous fat or in the deeper soft tissues of the neck\n to suggest inflammation. There is no obvious rim-enhancing lesion to suggest\n an abscess.\n There is a heterogeneous area noted in the right lobe of the thyroid which\n needs further evaluation with ultrasound.\n\n There are small scattered lymph nodes noted in both sides of the neck,\n borderline in size and not significantly enlarged by CT size criteria. The\n visualized portions of the parotid glands are unremarkable.\n\n Multilevel degenerative changes are noted in the cervical spine, with\n (Over)\n\n 11:08 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: rule out deeper neck injury - spreading rash on neck since y\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mild-to-moderate canal stenosis and moderate-to-severe neural foraminal\n narrowing.\n\n The right common carotid and the cervical internal carotid arteries are\n markedly tortuous in course.\n Bilateral pleural effusions, with areas of consolidation/air space opacities\n are noted in the lung apices on both sides, better assessed on the concurrent\n CT torso study.\n\n The esophagus is dilated, with fluid level and mucosal thickening and\n inadequately assessed on the present study, better evaluated on the torso CT.\n\n IMPRESSION:\n 1. Within the limitations of the study, there are no obvious areas of\n inflammation/abscess in the neck.\n 2. Heterogeneous nodule in the right lobe of the thyroid measuring 1.5x1.6cm,\n needs further evaluation with ultrasound.\n 3. Multilevel degenerative changes in the cervical spine with mild canal\n stenosis and moderate-to-severe neural foraminal narrowing.\n 4. Changes in the lung apices, bilateral pleural effusions with\n consolidation/air space opacities. See the concurrent CT torso report.\n 5. Mucosal thickening, with secretions in the nasal cavity and in the\n nasopharynx, likely related to intubation. To correlate clinically (for\n infection/inflammation).\n\n Discussed with S. Flora by Dr. , on p.m.\n\n" }, { "category": "Echo", "chartdate": "2116-07-02 00:00:00.000", "description": "Report", "row_id": 90943, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 58\nWeight (lb): 168\nBSA (m2): 1.69 m2\nBP (mm Hg): 97/56\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 11:05\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: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality.\n\nMITRAL VALVE: No masses or vegetations on mitral valve, but cannot be fully\nexcluded due to suboptimal image quality. Normal mitral valve supporting\nstructures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No masses or\nvegetations are seen on the tricuspid valve, but cannot be fully excluded due\nto suboptimal image quality. Normal tricuspid valve supporting structures. No\nTS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No masses or vegetations on pulmonic valve, but cannot be\nfully excluded due to suboptimal image quality.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF 65%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. No masses or vegetations are\nseen on the aortic valve, but cannot be fully excluded due to suboptimal image\nquality. No masses or vegetations are seen on the mitral valve, but cannot be\nfully excluded due to suboptimal image quality. No masses or vegetations are\nseen on the tricuspid valve, but cannot be fully excluded due to suboptimal\nimage quality. The estimated pulmonary artery systolic pressure is normal. No\nmasses or vegetations are seen on the pulmonic valve, but cannot be fully\nexcluded due to suboptimal image quality. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , left ventricular systolic function now appears normal.\n\nIMPRESSION: Suboptimal image quality. No obvious vegetations seen.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Echo", "chartdate": "2116-06-01 00:00:00.000", "description": "Report", "row_id": 90944, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Renal failure.\nHeight: (in) 58\nWeight (lb): 189\nBSA (m2): 1.78 m2\nBP (mm Hg): 148/96\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 14:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<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. TDI E/e' < 8, suggesting normal\nPCWP (<12mmHg). No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate 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. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thicknesses and cavity size are normal. There is\nmild regional left ventricular systolic dysfunction with akinesis of the basal\nto mid inferior wall and mid inferolaterl hypokinesis. Overall left\nventricular systolic function is mildly depressed (LVEF= 45 %). Tissue Doppler\nimaging suggests a normal left ventricular filling pressure (PCWP<12mmHg).\nRight ventricular chamber size and free wall motion are normal. The diameters\nof aorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are mildly thickened. There is\nno mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction consistent\nwith coronary artery disease.\n\n\n" }, { "category": "ECG", "chartdate": "2116-06-25 00:00:00.000", "description": "Report", "row_id": 239104, "text": "Sinus rhythm. Low QRS voltage in the precordial leads. Compared to the\nprevious tracing of there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2116-06-05 00:00:00.000", "description": "Report", "row_id": 239105, "text": "Sinus rhythm. Delayed R wave progression and T wave inversion in\nlead V2 are non-specific and may be positional. Low precordial QRS voltage.\nProlonged QTc interval. Findings are non-specific. Clinical correlation is\nsuggested. Since the previous tracing of absent lead V1 and unstable\nbaseline in lead V2 on previous tracing makes comparison difficult.\n\n" }, { "category": "ECG", "chartdate": "2116-05-29 00:00:00.000", "description": "Report", "row_id": 239106, "text": "Sinus rhythm. Baseline artifact. Lead V1 is not recorded. There is low\nprecordial lead voltage. Compared to the previous tracing of no\napparent diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2116-05-28 00:00:00.000", "description": "Report", "row_id": 239107, "text": "Normal sinus rhythm, rate 86. Q-T interval prolongation. Generalized\nnon-specific repolarization abnormalities. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2116-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1145983, "text": " 11:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for f/u\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with fever and intubated, need cxr for f/u.\n REASON FOR THIS EXAMINATION:\n please eval for f/u\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Fever, intubated.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is an increase in the left-sided effusion that is layering\n posteriorly. There continues to be left lower lobe consolidation and patchy\n infiltrates bilaterally. The ET tube is 2.5 cm above the carina. The left\n subclavian line is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-07-15 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1147533, "text": " 3:17 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post pyloric DH feeding tube\n Admitting Diagnosis: HEPATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with NASH s/p resp failure and prolonged ICU course\n REASON FOR THIS EXAMINATION:\n please place post pyloric DH feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with NASH, status post respiratory failure and\n prolonged ICU course. Please place post-pyloric feeding tube.\n\n COMPARISON: CT torso from .\n\n FINDINGS: A Dobbhoff tube was seen with its tip overlying the stomach. An\n attempt was made to advance the Dobbhoff tube into a post-pyloric position;\n however, multiple attempts were unsuccessful. The Dobbhoff tube was therefore\n removed and a new feeding tube was inserted. Under fluoroscopic guidance, the\n new 8-Fr - feeding tube was advanced into the fourth portion of\n the duodenum. Contrast was then injected through the tube, which showed\n filling of a loop of small bowel.\n\n The imaged osseous structures appear grossly unremarkable. Surgical clips are\n seen in the right upper quadrant of the abdomen.\n\n IMPRESSION: Removal of Dobbhoff tube. Placement of a post-pyloric\n - feeding tube with its tip in the distal duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2116-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1147723, "text": " 7:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for PNA\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with complicated history w/ frequent intubations for\n aspiration PNA, sepsis, NASH cirrhosis w/ hypoxia, wheezing\n REASON FOR THIS EXAMINATION:\n Eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: History of frequent intubations for aspiration\n pneumonia.\n\n Portable AP chest radiograph was compared to .\n\n The feeding tube tip is most likely in the duodenum. The right PICC line tip\n is at the level of mid SVC. The bilateral pleural effusions and left\n retrocardiac opacity has not been changed significantly in the interim. The\n right upper lobe opacity has progressed and might be concerning for\n progression of pneumonia especially given the overall improvement of perihilar\n opacities consistent with improvement of pulmonary edema.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2183-11-06 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 805168, "text": " 9:22 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate heart and lungs\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress\n born by repeat C-section\n REASON FOR THIS EXAMINATION:\n evaluate heart and lungs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with respiratory distress born by repeat C-section. Evaluate\n heart and lungs.\n\n FINDINGS: The lung volumes are increased. There are streaky lung opacities\n seen diffusely which may represent transient tachypnea of the newborn.\n Clinical correlation is required. A patchy opacity is seen in the left upper\n lobe and may represent atelectasis superimposed on the thymic shadow. The\n heart and mediastinal contours appear grossly normal. A pleural effusion is\n not definitely seen.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-06 00:00:00.000", "description": "Report", "row_id": 1974629, "text": "Neonatology Attending\n\nFT infant with respiratory distress admitted from L&D.\n\nInfant born to 35 yo G2P1 B+, GBS-, HBsAg-, RPR-NR woman. Reported benign antepartum. Scheduled C/S. AROM at delivery. Apgars 9, 9.\n\nGFR noted and persisted in DR. to NICU.\n\nExam remarkable for generally pink term infant in mild respiratory distress with vital signs as noted, soft AF, nl facies, intact palate, mild-moderate retractions, clear breath sounds with good air entry, 1-2/6 systolic murmur, present femoral pulses, flat soft n-t abdomen without hsm, nl phallus, testes in scrotum, nl perfusion, fair tone/activity.\n\nSaO2 89-94% in RA\nBlood glucose 76\n\nTerm infant with respiratory symptoms and borderline normal oxygen saturation. Given schedule C/S, most likely diagnosis is TTN. Will monitor cardio-respiratory status closely and support oxygen needs as indicated.\n\nNo known sepsis risk. Will obtain cbc, blood culture. No further evaluation or treatment unless has abnormal cbc, positive blood culture, or persistence of symptoms.\n\nWill keep NPO for now. Following blood glucose.\n\nPrimary pediatrician is Dr. - .\n\nFamily is aware of current condition and immediate plan of care.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1974652, "text": "NPN\n\n\n#2 Resp- In and out of NC 13-25cc 100%.See flowsheet. BS\nclear. Mild retractions.RR= 30=70.\n#3 F/N-Abd soft,+bs, no loops.Br feeds for Mom well ad lib\ndemand waking q 3-4hrs.Voiding+ stooling in adeq amts. Wt\ndown 95gms.\n#4 Mom here to BR feed q 3-4 hrs.Indep with cares.\n#6 Bili- Jaundice.Remains under single phototx w/eye shields\non.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1974650, "text": "Fellow note\nFamily meeting with parents today. Updated them on progress and possible discharge home later this week. Pleased with his progress and eager to get him home. Pt's pediatrician, Dr. , also updated by phone today.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1974653, "text": "Neonatology Attending\n\nDay 5\n\nRemains in RA after weaning off nasal cannula at 2300 last night. RR 40-50s. Clear breath sounds. Mild retractions. Sats >95%. No murmur. HR 120-160s. Pink. Weight 3420 gms (-95). Breast feeding. Waking every 2 to 3 hours. Bilirubin 13. Started on phototherapy.\n\nAdequate breathing control. Adequate saturations in RA. Improved feeding. Circumcision today. Needs hepatitis B vaccine, hearing screen. Anticipate discharge tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1974654, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in RA. Skin with decreased jaundice, pink. AFOF. MMM. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Extremities warm and well-perfused. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1974655, "text": "2. remains in RA, color pink-jaundice, BBS clear and\nequal, RR40-60, sats 93-98. continue to monitor.\n3. breast feeding q2-3h well, abd soft, no spits, voiding\nand passing gr stool.\n4. Mom up to breast feed q2-3h as baby demands, signed\nconsent for circ,circ care reviewed as well as routine baby\ncare, called pedi, Dr , for appt for this thurs\nor fri, preparing for possible dc to home tomorrow.\n5. waking q2-3h to breast feed, very alert and active, temps\nstable in crib, needs hearing screen and hep b vaccine prior\nto dc.\n6. phototherapy dc'd ~1500, for rebound bili in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-12 00:00:00.000", "description": "Report", "row_id": 1974656, "text": "NPNOte\n\n\n#2.Placed on nasal cannula at 3.15am for having desat to\n85-88%, with shallow resp pattern. prior placing on nasal\ncannula blow by x2 for having desat to mid 80's as advised\nby .BBS clear equal, no retrations, no spells thus far\nthis shift. A;required supplemental 02 to mainatin sats. P;\ncont to wean 02 as tolerated.\n\n#3. Todays weight=3.370, down 50gms, Mom breast feeds on\ndemand, po fed x1 60cc BM, po fed well, tolerated, BS+, no\nloops, voided, stoled. A; Feds tolerated. P; cont current\nfeeding plan.\n\n#4. Mom independent with cares and breast feeding.asking app\nquestions, mom was updated by and Dr. OB, inview\nof oozing circ site, pedi will be Dr . A; mom\nP; cont update and teaching.\n\n#5. Alert,a ctive with acre, temp stable in a open crib,\nswaddled with blanket, MAE, Circ site oozing noted,\npressure applied, diaper changed,vaseline applied, surgicele\napplied by Dr. for cont.trickling of blood. surgicele\nin place with clot. MOm present. A; aga P; cont to monitor.\n\n#6. Mildly jaundiced, alert, active with care,bili sent A;\nMildly jaundiced.P; pending results.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-12 00:00:00.000", "description": "Report", "row_id": 1974657, "text": "Neonatology Attending\n\nDay 6\n\nRemains on nasal cannula after brief period in RA. Sats drifting into mid-high 80s up until oxygen supplementation reinstituted. Now at 13 cc/min flow. RR 30-80s. Minimal retractions. HR 120-160s. No murmur. Pink. Rebound bilirubin 11.2 this morning. Weight 3370 gms (-50). Breast feeding. Benign abdomen. Took one bottle for 60 cc. Surgicel used for post-circumcision bleeding. Stable temperature in open crib.\n\nMild residual respiratory insufficiency. Will continue to monitor closely and wean oxygen as allowed. Feeding well. Bilirubin in acceptable range.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-12 00:00:00.000", "description": "Report", "row_id": 1974658, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in NCO2. Skin pink, decreased jaundice. AFOF. MMM. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. Soft 1/6 systolic murmur at LLSB. Normal femoral pulses. Abd soft, ND, +BS. Nomal male. S/p circ. Now healing well, no bleeding. Extremities warm and well-perfused. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1974651, "text": "NPN 0700-1900\n\n#2 Alt. in Resp. Function\nO: Received infant in NC 100% 50-75cc. Weaned 02 over course of day with sats remaining >93. Placed in RA at 1800 and sats presently 94-98. RR 40's-60's with + SC retractions. Breath sounds are clear and =. No apnea, bradycardia or desats noted today.\nA: Newborn with resolving TTN\nP: Continue close observation and monitoring of sats in RA.\n\n#3 Alt. in Nutrition\nO: On ad lib demand breastfeeding only. Abd. is round, soft with + BS, no loops. No spits. Voiding QS Q diaper change and passing green stool. Waking Q 2.5-4 hrs and breastfeeding well > 10 min. each time. Mom states that her milk is in and has brought up some expressed milk from pumping in between breastfeeds. Infant started on polyvisol and did take 5cc BM with vitamins.\nA: Term infant feeding well, all breastfeeding\nP: Continue with present feeding plan. Follow daily wts.\n\n#4 Alt. in Parenting\nO: Mom up for all feeds. Dad in X 2. Updated. Family meeting held. Questions answered. Mom D/C'd today but is staying tonight in parent room. She is independent in feeding and caring for .\nA: Involved, loving parents\nP: Keep informed and support.\n\n#5 Alt. in Development\nO: Maintaining temp in open crib, nested with boundaries in place. Waking on own and feeding well. Alert and responsive to interaction. Sleeps well between feeds. Likes pacifier.\nA: Appropriate for GA\nP: Continue to support developmental needs.\n\n#6 Hyperbilirubinemia\nO: Infant's color jaundiced. Bili at 1215 13.1/0.2. Single phototherapy started at 1400 with eye patches in place. Infant is feeding and voiding well. Passing green stool.\nA: Increased bili\nP: Continue phototherapy and recheck bili tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-12 00:00:00.000", "description": "Report", "row_id": 1974659, "text": "NPN 0700-1900\n\n#2 Alt. in Resp. Function\nO: Received infant in NC 02 100% 50cc. From 0700-0900 02 weaned with sats >94. Placed in RA at 0900. Sats have been 94-100 since, with an occasional drift to 91-92, QSR. RR 30's-50's with mild SC retractions. Breath sounds are clear and =. No apnea, bradycardia or desats noted.\nA: Doing well in RA, resolving TTN\nO: Continue close observation and monitoring of sats and resp effort. Document any spells.\n\n#3 Alt. in Nutrition\nO: On ad lib demand feedings. Abd. is round, soft, with + BS, no loops. Voiding and stooling QS. Waking Q 2-4 hrs. Breastfed well all feeds. PO fed 90cc E20 after mom went home.\nA: Feeding well\nP: Continue with present feeding plan and follow daily wts.\n\n#4 Alt. in Parenting\nO: Mom in Q feeding from 0800-1400. Dad in X 2. Both parents updated. Mom went home today and hopes to return this evening to feed infant.\nA: Involved, parents\nP: Keep informed and support.\n\n#5 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for feeds. Alert and active with cares. Breast and bottle feeding well. No spells. Off 02 since 0900.\nA: Appropriate behaviors for GA\nP: Continue to support developmental needs.\n\n#6 Hyperbili\nO: Phototherapy D/C'd yesterday at 1600. Rebound bili this AM 11.2/0.2. Down from Mon. bili 13.1/0.2. Infant remaind mild/mod. jaundiced but id feeding well and voiding and stooling QS.\nA: Decreased bili\nP: D/C problem but continue to monitor and assess for increase or decrease in jaundice.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-13 00:00:00.000", "description": "Report", "row_id": 1974660, "text": "NPNOte;\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal\nretractions present, no spells thus far this shift.\nOCCassional sat drifts to 90-91 noted with shallow resp\npattern. A;stable in Rair. P; cont to monitor.\n\n#3.On BM20/ E20, po fed,adlib, tolerated, BS+, no loops,\nvoided, stooled. A; Feeds tolerated. P; cont current feeding\nplan.\n\n#4.Parents visited inbetween care, held the baby. A; \nP; cont dev support.\n\n#5. alert,active with acre, temp stable in a open crib,\nswaddled with blanket, MAE, Circ healing.A; AGA p; cont dev\nsupport.\n\n#6. MIldly jaundiced,alert,a ctive. P; cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1974639, "text": "Neonatology-NNP PRogress Note\n\nPE: on an open warmer, in nasal cannula O2 , tachypnic with mild retractions, bbs cl=, rrr s1s 2no murmur, pulses 2+=, abd soft, nontender, V&S, afso, active with care, peripheral iv, pink, slightly jaundiced\n\nSee attending note for plan\nMet with Mom to review clinical issues and criteria for discharge. SHe plans to be discharged on Monday. Will continue to keep informed\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1974640, "text": "#1 O: Infant completed 48h r/o for sepsis. Bl cx neg and\nantibx d/c'd. A: No obvious s/s of sepsis. P: Problem\nresolved.\n\n#2 O: Received infant in high flow NC 02 in 200cc's of flow\nwith o2 at 100%. Infant weaned to low flow NC 100% o2 with\nflow of 100-200cc's. RR mainly 30's-60's when at rest but as\nhigh as 90's when disturbed. O2 sats 94-99%. LS clear and =.\nNo spells. A: Tachypneaic at times requiring o2. P: Cont to\nmonitor.\n\n#3 O: TF increased to 80cc/kg/d. Infant breastfeeding with\ncares; very sleepy with this but doing more at last feed\nwith latching on and some sucking. Receiving IV fluids of\nD10 with additives via new PIV placed at 1600 today.\nGeneralized edema noted. Abdomen benign; voiding and\nstooling mec stools with diaper changes. DS 72. Mom would\nlike to just BF but understands infant will need to learn\nthe suck swallow reflex and coordination of bottling as\nwell. Didn't push infant to bottle today due to mom in\nattempting to BF every time and infant still with increased\nRR. A: Learning to BF. P: Cont to monitor and encourage po\nfeeds when ready.\n\n#4 O: Mom in for 1200 and 1600 cares times. Independent with\ntemp and diapering. Mom signed consent for PKU and hep B\nthis eve. Mom with NNP at bedside; given parent\npacket. Will be d/c'd Monday. Would like circ done but told\nby NNP this could be done once infant was off o2. Mom asking\nappropriate questions. A: Involved, loving. P: Cont to\nsupport and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1974641, "text": "#5 O: Received infant on radiant warmer set in servo mode. Infant dressed in t-shirt, swaddled in blanket and hat on at 1200 cares; warmer turned off at this time. Infant's temp remains stable. AFSF. Awake and alert with cares; sleepy while attempting to BF. Sleeps well between cares. Sucks on pacifier when offered. A: AGA. P: Cont to support development.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1974644, "text": "Day 3\nCGA 39 1\n\nNC 125-150cc, 100%. RR50-70s. +Rtxns. BS bilaterally. CBG last night 7.31/45. No murmur. HR 110-140s. BP 73/34, 43.\n\nJaundiced. Bili 8.5/0.3.\n\nWt 3530, up 55 gms. TF 80 cc/k/day D10w w 2 Na, 1K. +BF q 4 hours. Abd soft. +BS. Nl voiding (2.5).\nd/s 95\nPassing meconium stools.\n\ns/p 48 hours of abx for sepsis evaluation.\n\nIn open crib.\n\nA/P:\n - Monitor O2 need, wean as tol\n - Encourage po intakes and wean IVF accordingly\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1974645, "text": "NNP On-Call\nPhysical Exam\nGeneral: infant in open crib, on nasal cannula O2; baseline retractions and head bobbing\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures open/opposed; symmetric facial features\nCHest: sternal and intercostal retractions\nCV: RRR: no murmur appreciated; normal S1 S2; femoral pulses +2\nABd: cord on/drying; soft; no masses; + bowel sounds\nGU: normal male; testes descended\nExt: moving all\nNeuro: appropriate tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1974646, "text": "2. remains on nasal cannula 100% 75-150cc flow,\ndecreasing throughout the day, RR50-70, sc retractions, BBS\nclear and equal, no spells A: resolving TTN P: continue to\nmonitor.\n3. TF 80cc/k/d D10 with Na and K infusing now at 40cc/k,\nbreast feeding well q3-4h, abd soft, active bowel sounds,\nvoiding and passing stool, DS 76 P: continue to wean ivf as\ntolerated, may breastfeed ad lib.\n4. Mom here q3-4h for cares and feeding, Dad in throughout\nday with 2y old sister A: very loving, concerned family P:\ncontinue to update and offer support.\n5. temps stable swaddled in open crib, waking q3-4h for\nfeedings, very active and alert. continue to support growth\nand development.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1974647, "text": "NPN 1900-0700\n\n\n1. : 48 hour rule out complete. Will D/C problem.\n\n2. RESP: PT remains in low flow nasal cannula, requiring\n50-75cc flow. RR 30-60's. Lung sounds are clear.\nOccasional mild S/C retractions noted. No spells/desats\nnoted.\n\n3. F&N: Pt received on IVF of D10 with sodium infusing at\n40cc/k/d. IVF weaned to 30cc/k/d at 2100 adn was found out\nat 0100. NNP Buck made aware and IV was left out. Pt is\nbreastfeeding ad lib amounts Q horus and D/S 73-79. Abd\nbenign. BS+. No spits noted. Voiding and passing stool.\nWeight loss 15 grams.\n\n4. PAR: Mom in to do cares and breastfeed X3. SHe is\nindep with cares.\n\n5. DEV: is active and alert during his cares. Temp\nstable swaddled inopen crib. Fontanels are soft and flat.\nPt remaisn slightly jaundiced.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1974648, "text": "Neonatology Attending\n\nDay 4\n\nRemains on nasal cannula at 25 cc/min flow. RR 30-70s. Mild retractions. Clear breath sounds. No murmur. HR 110-140s. Pink. Bilirubin 8.5 two days ago. Weight 3515 gms (-15). Ad lib demand feeds. Blood glucose 70s. Waking every 3-4 hours to breast feed. Stable temperature in open crib. Mother to be discharged tonight.\n\nDoing well overall. Weaning oxygen as allowed. Monitoring closely. Rechecking bilirubin. Family meeting today.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1974649, "text": "Fellow note; physical exam\nAlert and active. In NCO2, mild retractions. Skin jaundiced. AFOF. MMM. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Extremities warm and well-perfused. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1974642, "text": "NPN:\n\nRESP: NC-100%, 200cc flow to maintain sats 94-97%. RR=60-80 with SC retraction. BBS =/clear. No A&Bs thus far tonight.\n\nCV: No murmur. HR=120-150. BP=73/34 (43). Color pink w/slight jaundice. Mild generalized edema. Perfusion good.\n\nFEN: Wt=3530g (+ 55g). TF=80cc/kg/d. Breast fdg mod to well q 4 h; no supplement given after breast. IV of D-10-W w/NaCl 2mEq, KCl 1mEq/100cc at 80cc/kg/d. Dx=95. Abd soft, flat, active bs, no loops. U/O=2.5cc/kg/h over past 8 h. Transitional stools.\n\nG&D: Term infant. Temp stable in crib. Active and alert w/good tone. Swaddled and nested. Rested well.\n\nSOCIAL: Parents in at . Mother in to breast feed x 2. Independent w/baby care.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1974643, "text": "NPN:\n\nLABS: CBG: 7.31/ 45/ 46/ 24/ -3. Bili: 8.5/ 0.3/ 8.2. PKU done.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1974632, "text": "Neonatology Attending\n\nDay 1\n\nRemains on nasal cannula at 175-200 cc/min flow. RR 50-80s. Clear breath sounds with mild retractions. No bradycardia. Murmur present. BP mean 37. HR 120-160s. Weight 3650 gms (-15). NPO. IV dextrose at 60 cc/kg/d. Urine output < 1 cc/kg/hr. No stool passed. On ampicillin and gentamicin.\n\nCourse remains consistent with TTN. be transitioning into element of surfactant deficiency. Will continue to monitor closely. Will allow to put to breast but otherwise keeping NPO. Reuling out on antibiotics.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1974633, "text": "NPN 7A-7P\n\n\n#1 Infant remains on amp and gent. Admission CBC w/diff\nunremarkable, blood cultures neg to date. Does remain on\nnasal cannula flow of 300cc's. Will con't to monitor\nclosely.\n\n#2 On 100% FiO2, increased to 300cc's this afternoon for\nsa02's bordering 90-92%. LS = and clear, RR 50-80's. Is\npink, murmur audible but precordium less active. (U/O has\nincreased this shift also.) Will wean as tolerated but\nobserve for increased respiratory distress.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1974634, "text": "Fellow note; physical exam\nAlert and active. In NCO2. Tachypneic with mild to moderate retractions. Skin pink. AFOF. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. 2/6 systolic murmur at LSB c/w PDA. Normal femoral pulses. Abd soft, ND, +BS, no HSM. Extremities warm and well-perfused. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1974635, "text": "NPN (con't)\n\n\n#2 Infant now weaned to 150cc's of 100% Fi02, retractions\nand tachypnea continue, sao2's maintained at low-mid 90's.\nInfant's voiding has increased, murmur not audible at this\ntime. Will con't to wean as tolerated.\n\n#3 TF remain at 60cc/k/d, is NPO. PIV fluid changed to D10\nw/s meqNaCL + 1 meq KCl/100cc's. U/O: 2cc/k/hr this shift.\nD/S:91. Urine output has increased this shift, will con't to\nmonitor closely.\n\n#4 Parents in multiple times to visit this shift, also\nbrought in grandparents and infant's sibling. Parents\nupdated at bedside by RN and fellow. Understand that inant\nhas improved a bit and that we will con't to watchf\nrespiratory status closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1974636, "text": "NPN\n\n\n1.Sepsis: Infant remains on antibiotics, bld cx's pending,\ntemps 99.2 on open warmer.\nA/P: Cont. amp/gent, monitor for signs of sepsis.\n\n2.Resp: Remains in nasal cannula mostly in 200cc in 100% 02,\nincreasing to 300cc during cares. RR=49-90, mild SC/IC\nretractions, sats>95.\n\n\n\n\n\n\n\n\n\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": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1974637, "text": "NPN Cont'd\n\n\nResp: Comfortable in prone position, sucking on pacifier.\nA/P: Cont. to wean 02 as tolerated, monitor exam.\n\n3.FEN: Wt=3.475kg, down 175gr. NPO wtih TF 60cc/kg/d. PIV in\nleft hand of D10W w/NACL and KCL. Abd soft, UOP 2.3cc/kg/hr\nlast 12hrs. Stooling mec q diaper.\nA/P: Consider feeds with stable resp exam, mom wants to BF.\nCheck Dstix.\n\n4.Parenting: Mom in this am briefly updated at bedside.\nAnxious for him to start weaning off his oxygen. Cont. to\nupdate and support PRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1974638, "text": "Neonatology Attending\n\nNow day of life 2 for this 38 week gestation infant with retained fetal lung fluid/r/o sepsis.\nIn 200cc of O2 100%.\nRR 50-90s.\nCVS - HR 110-140s BP 78/47 52\n\nWt. 3475gm down 175gm on 60cc/kg/d of IV fluids\nNPO\nUO - 2.3cc/kg/hr and passing meconium\n\nLytes 137 4.2 103 26\nDS 72\n\nID - on amp and gent - cultures no growth so far\n\nAssessment/plan:\nTerm infant with probable retained fetal lung fluid.\nWill initiate breastfeeding today.\nFluids to be increased to 80cc/kg/d.\nWill dc antibiotics if cultures negative this afternoon.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-06 00:00:00.000", "description": "Report", "row_id": 1974630, "text": "NURSING ADMISSION NOTE\n\n Baby boy was admitted to the NICU form L&D w/ resp distress. Please see attending note for maternal history. He was born at 1150 via repeat, elective C/S. Apgars were . He arrived at 1345, grunting , flaring and retracting.\n\nRESP: Breath sounds were clear on arrival, but slightly diminished. +Grunting, Nasal flaring, + mild intercostal/subcostal retractions. Initial o2 sat-89%- BBO2 placed and sat up to 97%. He has occasionally required BBo2 throughout the afternoon for drifts to low 90's but has usually maintained sats at 96-99%.\n By 1700, grunting has become less severe and is now intermittent. RR 30-70's.\nA/P: Will continue to follow closely and assess need for constant supplemental o2.\n\nCV: Soft murmur is audible. Hr 130-150's. Color is pink and well-perfused. Initial BP 's w/ borderline MAP's 37-39. Monitored clsoely and self-resolved- with MAP's currently 42-48. Color is pink and well-perfused. Pulses are wnl.\n\nF&N: BW-3.665gms. Infant is NPO. Intial d/s and repeat at 3hrs both- 76. IV placed at 1830 due to persistent grunting. IVF ( D10w) infusing now at 60cc/kg/d. Infant has voided once since delivery. No stool passed yet. Mom wishes to nurse.\n\nDEV: Temp is stable on an open warmer- warmer weaned x 2. He is nested, with boundaries. He is alert and active w/ cares. Baby cares were given as ordered.\n Skin is intact- no bruising noted.\n\nPARENTS: Dad and relatives have been in to visit. Dad was updated at the bedside. Mom plans to visit this evening.\n\nID: CBC benign- no shift. Given grunting at 7hrs of age, AMp + Gent started.\n\nA/P: Term newborn- probale TTN\n Slowly improving.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1974631, "text": "NPN 7pm-7am\n\n\n#1: Infant has had persistant resp distress requiring NC\n100% with 100-200cc's flow. CBC was begnin and bld cx is\npending. Infant was started on Amp and Gent. Temp is stable.\nNo other s/s of infection noted. A: On antibiotics. P: Will\ncont to follow bld cx and infants s/s of infection.\n\n#2: Received infant in RA at 1900, at infant was\ndesating to low 80's requiring BBO2. Notified RT and infant\nwas placed in NC 100% with flow of 200cc's. Infants RR\n30-80's with sats >94%. Infants LS are clear and equal with\nmod IC/SC rets. CxR was done at 9pm, it was hazy and\nconsistant with TTN per Dr. . Weaning O2 as tol to\nkeep sats >95%. Infant has had no brady's at this time in\nthe shift. Will occ desat when crying, self resolves. A:\nTTN. P: Cont with NC and wean O2 as tol. repeat CxR.\nWill cont to monitor resp status.\n\n#3: Infant's BW was 3665gm and current weight 3650gms down\n15gms. Infant on TF 60cc/kg/d D10W running through PIV in\nleft hand, patent and infusing well. Infant in NPO due to\nresp status. D/S 99. Abd soft, girth stable, +bs, no loops\nnoted. Voiding and no stool at this time in shift. Infant\nwas gagging and I suctioned stomach for lg amounts of clear\nfluid. Infant tol well. A: On IV fluids for Resp distress.\nP: Will cont to monitor weight and exam and follow D/S.\n\n#4: Parents were in at to visit. I updated them on plan\nof care for infant. Explained the NC, need for IV fluids and\nantibiotics. Parents spoke with Dr. . They stated\nthere understanding. Mom was able to change diaper. Mom came\nback up for visit at 0300. A: Very loving parents. P: Will\ncont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-13 00:00:00.000", "description": "Report", "row_id": 1974661, "text": "Case Management Note\nFor d'c planning, you can use VNA as this is preferred VNA for Pilgrim. Need for home services has been approved by RN at HP . I will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-13 00:00:00.000", "description": "Report", "row_id": 1974662, "text": "Neonatology Attending\n\nDay 7\n\nRemains in RA. Clear breath sounds. RR 40-50s. No retractions. Mild saturation drifts to low 90s. No bradycardia. No murmur. HR 110-160s. Weight 3355 gms (-15). On ad lib demand feeds. Breast feeding daily. Bilirubin 11.2. On vitamins. Alert, active. Circ site healing well.\n\nContinues to demonstrate mild breathing control immaturity. Will continue to monitor cardio-respiratory status. Hopefully this will resolve in next day. Still not gaining weight. Will follow.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-13 00:00:00.000", "description": "Report", "row_id": 1974663, "text": "Nursing NICU NOte.\n\n\n2. Resp. O/Pt remains in RA. Occasional brief desaturations\nnoted this am as low as 89%. Team is aware. A/Occasional\ndrifts noted, otherwise resp status appears stable in RA.\nP/Cont. to monitor.\n\n3. F/N. O/ADlib demand feeding. Mother in to breastfeed this\nam. Pt nursed 2 times thus far. Eager to feed. Latches on\nwell and demonstrates strong suck bursts. Please refer to\nflowsheet for examinations of pt from this shift. A/Appears\nto be tolerating present feeding regimen. P/Cont. to monitor\nfor s/s of feeding intolerance.\n\n4. Parents. O/Mother in this am. Mother is updated and is\naware of plan of care. Mother independently took pt's temp,\ndid cord care and nursed pt. A/Parents are known to be\nactively involved in pt's care. P/Cont. to support and\neducate parents.\n\n5. G/D. O/Pt's temp stable thus far in an open air crib.\nWoke on own to feed. Awake and alert this am. Please see\nflowsheet for the remainder of the shift. A/Age appropriate.\nP./Cont. to support pt's growth and dev needs.\n\n6. hyperbili. O/Skin sltly jaundiced. P/Cont. to monitor for\nevidence of increasing juandiced/bilirubin.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-13 00:00:00.000", "description": "Report", "row_id": 1974664, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in RA. SKin pink. AFOF. MMM. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. Soft 2/6 systolic murmur at LSB. Normal femoral pulses. ABd soft, ND, +BS. Normal male s/p circ. Circ healing well. Extremities warm and well-perfused. Good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-14 00:00:00.000", "description": "Report", "row_id": 1974665, "text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 93-100%. RR 20-50's. LS\nclear and equal. Infrequent drifts to 88-90%,\nself-resolving.\n\nFEN: bw=3665g. wt=3360g (up 5g). PO ad lib BM/E20. Yest\nTFI=91cc/kg plus nursing. Bottling 105-110cc q4-4.5hrs.\nBelly soft, +BS, no loops, no spits, voiding and stooling.\nOn polyvisol.\n\nParents: Mom called X1, updated over the phone. Plans to\ncall later this shift.\n\nG&D: Temps stable, swaddled in open crib. Wakes for feeds.\nAlert and active with cares. Sleeps well between. Hands to\nface. Circ care done qdiaper, site healing.\n\nHyperbili: Infant appears slightly jaundiced. Remains off\nphototherapy.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-14 00:00:00.000", "description": "Report", "row_id": 1974666, "text": "Neonatology Attending\n\nDay 8\n\nRemains in RA. RR 20-50s. Clear breath sounds. Sats 93-100%. Occasional brief, mild drifts. BP mean 47. Weight 3360 gms (+5). Demand feeds. Took 91 cc/kg and breast fed several times. Circ site clear. Benign abdomen.\n\nDoing well. Improved respiratory status. Ready for discharge. Follow up with Dr. . Discharge summary pending.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-14 00:00:00.000", "description": "Report", "row_id": 1974667, "text": "Nursing Progress Note\n\n2 Term Respiratory Distress\n3 ALt FLUID & NUTRITION\n4 ALt PARENTING\n5 Alt in growth and development\n6 Hyperbili\n\n#2 O: remains in room air w/sats 95-100% at rest. Lungs\nclear/equal, color sl. jaundiced/pink. RR 40's-60's, no\nretractions. A: Stable in room air P: resolve problem.\n#3 O: on ad lib demand feeds, waking q3-5h, taking 110cc\nbottle, nursing well for mom 15mins/side. vdg and stooling.\nabd benign. circ clean, healing well, vaseline applied. A:\nfeeding well p: resolve problem.\n#4 O: parents here, reviewed d/c instructions, car seat.\nIndependent w/cares. P: home. f/u w/pedi on monday. vna\nfaxed. resolve problem.\n#5 O: alert, vigorous, feeds well. P: f/u at home w/pedi\nresolve problem.\n#6 O: color still sl. jaundiced, sclera sl. icteric P: pedi\nto follow.\n\nREVISIONS TO PATHWAY:\n\n 2 Term Respiratory Distress; resolved\n 3 ALt FLUID & NUTRITION; resolved\n 4 ALt PARENTING; resolved\n 5 Alt in growth and development; resolved\n 6 Hyperbili; d/c'd\n\n" } ]

[ { "category": "ECG", "chartdate": "2145-02-19 00:00:00.000", "description": "Report", "row_id": 311887, "text": "Sinus rhythm. No significant change from the previous tracing of .\n\n" }, { "category": "Nursing/other", "chartdate": "2145-02-20 00:00:00.000", "description": "Report", "row_id": 1470437, "text": "PATIENT IMPROVING AS NIGHT PROGRESSED. CV-SR IN THE 90'S TO LOW 100'S W/O ECTOPY. WEANED OFF LEVOPHED BY 5AM, WITH SBP 120'S, CI >2.0 WEANED TO IABP 1:3, PLAN TO CHECK CI. RESP- NILSECRETIONS WITH SUNCTIONING, GOOD ABG ON 40%, PLAN TO WEAN TO EXTUBATE AFTER IABP DCD. GI- ORAL NGT DRAINING BROWNISH SECREIONS,OBESES ABDOMEN. GU- U/O SLOWING DRIFTING OFF THIS AM 25TO 30CC/HR. ENDO- INSULIN DRIP AT 2U/HR LASI 4HRS. ALL OTHER LABS WNL, PTT PENDING THIS AM. PAIN- SEDATED WITH TORADOL 15MG/Q6HRS, ALONG WITH 4MG MSO Q3-4/HRS.\n" }, { "category": "Nursing/other", "chartdate": "2145-02-20 00:00:00.000", "description": "Report", "row_id": 1470438, "text": "Pt weaned off IABP, IABP dc'd. Fem art line dc'd. Pt weaned from vent and extubated. VSS and WNL. Stable day.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-02-21 00:00:00.000", "description": "Report", "row_id": 1470439, "text": "PATIENT BACK TO BED BY , DID WELL WITH 2MAN ASSIST. BS WELL CONTROLLED WITH INSULIN DRIP AT 3U/HR. PATIENT GIVEN 25MG BENADRYLIV FOR SLEEP THEN MSO4 4MG FOR STERNAL DISCOMFORT, SLEEPING IN SHORT NAPS.\n" }, { "category": "Nursing/other", "chartdate": "2145-02-21 00:00:00.000", "description": "Report", "row_id": 1470440, "text": "NEURO: INTACT.\n\nCV: A-FEBRILE, VSS AND WNL. NO ECTOPY, PACER WIRES CAPPED AS PT HAS NOT REQUIRED PACING AND TOLERATES BETA-BLOCKERS. CORDIS/SWAN DC'D. PIV X 2 FLUSHED (L HAND AND R ANTECUBE) BOTH SITES CLEAR, AND BOTH IV'S FLUSH EASILY.\n\nRESP: SATS WELL ON O2 VIA NC. BREATH SOUNDS CLEAR APEXES AND DIMINISHED BASES. CT'S DC'D.\n\nGI: PT SMALL HEART HEALTHY BREAKFAST. NO STOOL YET.\n\nGU: ADEQUATE URINE VIA FOLEY.\n\nSKIN: SURGICAL INCISION COVERED WITH DRESSING - CLEAN, DRY, AND INTACT. PT HAS A PILONATED CYST DRAINING ON UPPER BUTTOCKS. MD'S AWARE.\n\nPAIN: PT REPORTS ADEQUATE PAIN RELIEF. PERCOSET GIVEN.\n\nSOC: WIFE UPDATED VIA PHONE.\n\nACTIVETY: PT UP TO CHAIR WITH ASSIST OF TWO.\n\nPLAN: PT READY FOR TRANSFER TO .\n" }, { "category": "Nursing/other", "chartdate": "2145-02-19 00:00:00.000", "description": "Report", "row_id": 1470432, "text": "IABP @ 1:1 W MINIMAL AUMENTATION & ASSIST. STABLE HEMODYNAMICS,MVO2 ALLOWING WEANING OF VASOPRESSIN AFTER VOLUME ADMINISTRATION.CONTINUES ON MILRINONE & LEVO. IABP & FEMORAL A LINES FREQ. DAMPENING DUE TO OBSRUCTION FROM LG. ABDOMEN.FEET WARM BILAT. W PALPABLE DP'S. PLAN DC IABP IN A.M.BS DISTANT W MARGINAL PO2 ON ARRIVAL. TV'S INCREASED & ALBUTEROL MDI'S STARTED FOR ? OBSTRUCTIVE VENTILATORY PATTERN. PO2 IMPROVING W WARMING. MIN. CT DNG.\n" }, { "category": "Nursing/other", "chartdate": "2145-02-19 00:00:00.000", "description": "Report", "row_id": 1470433, "text": "BP FALLING W LOW SVR,ACCEPTABLE CI,FALLING FILLING PRESSURES.LOW AMBER URINE. MILRINONE DECREASED & VOLUME GIVEN W EFFECT. IABP TRACE REMAINS DAMPENED W POOR ASSIST & AUGMENTATION. CXR & KUB REPEATED AS DEVICE COULD NOT BE VISUALIZED PN PREVIOS XRAY. NO CHANGE IN VASCULAR STATUS. , X 4 TO COMMAND BUT WILL DEFER VENT WEANING UNTIL LACTATE FALLS PER DR. .\n" }, { "category": "Nursing/other", "chartdate": "2145-02-19 00:00:00.000", "description": "Report", "row_id": 1470434, "text": "IABP ADVANCED BY P.A. WITH NO REAL CHANGE IN WAVEFORM. PLACED ON 1:2 FOR STABLE HEMODYNAMICS WITH NO ASSIST OR UNLOADING & CONTINUED LOW SVR W LEVOPHED REQUIREMENTS. PLAN DC IN A.M. C/O BACK PAIN DESPITE REPOSITIONING. TORADOL & MSO4 GIVEN W SEDATIVE EFFECT.\n" }, { "category": "Nursing/other", "chartdate": "2145-02-20 00:00:00.000", "description": "Report", "row_id": 1470435, "text": "UPDATE TO DR. AT MN, PATIENT DOING WELL, MILIRONE SHUT OFF, 4HRS LATER CI 2.1-2.3, WILL FOLLOW CLOSELY, NEED MORE VOLUME U/O SLOWING DOWN 40CC/HR/CVP 8, OR NEED MILRONE BACK ON WILL FOLLOW. IABP AT 1:2, WITH NIL AUGMENTATION, PLAN TO D/C IN AM, WILL CHECK COAGS/PLTS IN AM. PRESENTLY CI GREATER THAN 2.O WITH SVO2 66%. WEANINF OFF LEVOPHED SLOWLY, PRESENTLY AT .05. ABG GOOD, WITH NILSECRETIONS, ALLDSG D/I PATIENT COMFORTABLE WITH MSO4Q3-4HRS, WITH TORADOL REGIME, ALSO ON PROPOFOL DRIP AT 25. PLAN TO D/C IABP IN AM THEN WEAN TO EXTUBATE. PATIENT WITH HX OF SLEEP APNEA, WEARS BIPAP MASK AT HOME. TO NOTE NOT A DIABETIC, BUT ON INSULIN DRIP WILL FOLLOW.\n" }, { "category": "Nursing/other", "chartdate": "2145-02-20 00:00:00.000", "description": "Report", "row_id": 1470436, "text": "Resp Care,\nPt. remains intubated cureently on SIMV 1000/10/.4/5peep. ABG 7.47/34/83/25. Fio2 weaned down to 40%. No further changes, may wean today. See vent flowsheet.\n" } ]

[ { "category": "ECG", "chartdate": "2105-02-23 00:00:00.000", "description": "Report", "row_id": 244045, "text": "Supraventricular tachycardia and left bundle-branch block. In the context\nof prior recording of the rhythm is likely atrial flutter. Followup and\nclinical correlation are suggested.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 713692, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n Endoscopy done on which showed erosions and gastritis. GI felt\n that she might have lesions further down in small bowel.\n .\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Endoscopy done showed erosions and gastritis. GI felt that it\n was possible she might have lesions further down in small bowel. \n HCT=29.5 after being transfused with 3 units PRBC. . Denies n/v.\n tolerating clear liqs.\n Action:\n Gi by to evaluate pt and no intervention ordered. pt ordered for\n repeat hct at 1700. diet advanced to clear liq diet. Pt started on\n pantoprazole 40 mg iv as ordered. pt ambulated in icu with steady\n gait.\n Response:\n Stable hemodynamically. Hct stable. Repeat hct at 1700=34.8\n Plan:\n Follow hemodynamics and hcts as ordered. transfuse as needed. With any\n signs of occult bleeding notify medical team. Transfer to medical floor\n bed when available\n" }, { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 713693, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n Endoscopy done on which showed no clear source of bleeding. GI\n felt that she might have lesions further down in small bowel. Pt\n received total of 4 units PRBC in M/SICU and HCT stabilized.\n .\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n AAOx3, denies pain/discomfort, no nausea.\n Ambulates to bedside commode with supervision, steady gait. Pts mother\n at bedside.\n Vitals stable, on room air.\n No s/s bleeding.\n HCT stable 33.8 -> 34.8 w/ PM labs.\n Action:\n Receiving IV protonix as ordered.\n Diet advanced to regular.\n Response:\n Pt ate some toast and tolerated well.\n Pts vitals remain stable.\n No s/s bleeding.\n Plan:\n Cont to monitor pt for s/s bleeding.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HAMATEMESIS;UPPER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n 25 Inch\n Admission weight:\n 73.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history: NSAID's induced gastritis\n Surgery / Procedure and date: endoscopy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:76\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 100 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98 %\n O2 flow:\n FiO2 set:\n 24h total in:\n 610 mL\n 24h total out:\n 1,175 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:34 AM\n Potassium:\n 3.8 mEq/L\n 02:34 AM\n Chloride:\n 108 mEq/L\n 02:34 AM\n CO2:\n 23 mEq/L\n 02:34 AM\n BUN:\n 19 mg/dL\n 02:34 AM\n Creatinine:\n 0.6 mg/dL\n 02:34 AM\n Glucose:\n 89 mg/dL\n 02:34 AM\n Hematocrit:\n 34.8 %\n 05:04 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 M/\n Transferred to: 11 \n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2132-11-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 713694, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n Endoscopy done on which showed no clear source of bleeding. GI\n felt that she might have lesions further down in small bowel. Pt\n received total of 4 units PRBC in M/SICU and HCT stabilized.\n .\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n AAOx3, denies pain/discomfort, no nausea.\n Ambulates to bedside commode with supervision, steady gait. Pts mother\n at bedside.\n Vitals stable, on room air.\n No s/s bleeding.\n HCT stable 33.8 -> 34.8 w/ PM labs.\n Action:\n Receiving IV protonix as ordered.\n Diet advanced to regular.\n Response:\n Pt ate some toast and tolerated well.\n Pts vitals remain stable.\n No s/s bleeding.\n Plan:\n Cont to monitor pt for s/s bleeding.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HAMATEMESIS;UPPER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n 25 Inch\n Admission weight:\n 73.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history: NSAID's induced gastritis\n Surgery / Procedure and date: endoscopy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:116\n D:76\n Temperature:\n 98.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 100 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98 %\n O2 flow:\n FiO2 set:\n 24h total in:\n 610 mL\n 24h total out:\n 1,175 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:34 AM\n Potassium:\n 3.8 mEq/L\n 02:34 AM\n Chloride:\n 108 mEq/L\n 02:34 AM\n CO2:\n 23 mEq/L\n 02:34 AM\n BUN:\n 19 mg/dL\n 02:34 AM\n Creatinine:\n 0.6 mg/dL\n 02:34 AM\n Glucose:\n 89 mg/dL\n 02:34 AM\n Hematocrit:\n 34.8 %\n 05:04 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 M/\n Transferred to: 11 1174\n Date & time of Transfer: 00:20\n" }, { "category": "Physician ", "chartdate": "2132-11-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 713447, "text": "Chief Complaint:\n HPI:\n 20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n .\n In the ED her initial vital signs were T 97.4 HR 124 BP 131/80 RR 20 O2\n 100%. She was guaiac positive. A NG lavage was performed with induced\n emesis which was grossly bloodly. She cleared after 250ccs. She was\n tachycardic, but hemodynamically stable. She received a total of 2 L\n of NS and 1 unit of PRBCs, and was type and crossed. GI was consulted\n over the phone and recommended MICU admission. Her labs were\n significant for a Hct of 23.1, down from 24.9 earlier today, 34.5 on\n discharge on . The patient was given 40mg pantoprazole. Her\n vital signs on transfer were HR 119 BP 115/80 O2 100% on RA.\n Allergies: NKDA\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Prilosec OTC 2 tabs \n Seroquel PRN insomnia\n Past medical history:\n Family history:\n Social History:\n NSAID Gastritis\n NC\n Student at . The patient has a history of using marijunana and\n oxycontin recreationally, sober for 3 years. Denies alcohol usage, quit\n smoking 4 months ago, prior to which she smoked for 2 years.\n Review of systems:\n (+)ve: lightheadedness, nausea, melena\n (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest\n pain, palpitations, rhinorrhea, nasal congestion, cough, sputum\n production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal\n dyspnea, vomiting, diarrhea, constipation, hematochezia, dysuria,\n urinary frequency, urinary urgency, focal numbness, focal weakness,\n myalgias, arthralgias\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n GENERAL: Pleasant, well appearing female in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Tachycardic, but regular. Normal S1, S2. No murmurs, rubs or\n . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A\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 Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n 20 yo female with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n .\n .\n #. Hematemesis: EGD proven NSAID gastritis on recent admission, not\n being treated adequately with over the counter dosing of prilosec. At\n this point peptic ulcer disease should be considered. H pylori was\n checked on recent admission and was negative. GI was consulted in the\n ED and will continue to follow on the floor.\n - Appreciate GI recs, may require repeat EGD in AM\n - IV PPI \n - maintain 2 large bore IVs\n - Q8H Hct\n - Active type and cross, transfuse for Hct < 30\n - IV fluids PRN\n - Avoid NSAIDS\n - Zofran PRN\n - NPO for now\n .\n #. Tachycardia: Most likely secondary to volume loss. Will continue\n volume resuscitation as above. Monitor on telemetry.\n .\n #. Insomnia: Continue home seroquel PRN\n .\n #. History of Narcotic Abuse: At the patient's request will avoid all\n narcotic medications.\n .\n FEN: NPO until hematemesis resolves, replete lytes PRN\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen not needed\n -Pain management with no pain meds\n .\n ACCESS: 2 PIV's\n .\n CODE STATUS: Full Code\n .\n EMERGENCY CONTACT: Mother and sister\n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: pneumoboots while in bed\n Stress ulcer: PPI \n VAP:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU for now\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM:\n I have seen and examined the patient and concur with Dr \n evaluation above. Ms presents to the EW after having\n complaints of intermittent dark stool over the past few days. She had\n an admission earlier this month for NSAID induced gastritis ( on EGD)\n and was placed on protonix upon discharge. She reports using OTC\n prilosec and Tylenol for symptom control. She has a history of severe\n migraines and denies other drug or ETOH consumption. She was noted to\n have a tachycardia ( 120\ns) on arrival with a Hct of 24 and had emesis\n of frank blood in the EW. She has been transfused 2 units pRBC\ns and NS\n in addition with slow improvement in her HR. She has 2 peripheral IV\n for rescucitation. Repeat Hct is pending.\n GI staff are aware and will perform repeat EGD today given concerns for\n ongoing UGI bleed ( possibly related to an ulcer) or perisistent\n gastritis from pills. She will be kept NPO until procedures have been\n completed.\n CC time: 35 mins\n ,M.D\n Pulmonary and Critical Care Medicine,\n . , , MA\n ------ Protected Section Addendum Entered By: , MD\n on: 06:00 AM ------\n" }, { "category": "Nursing", "chartdate": "2132-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713452, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup. Received protonix iv,2 lit N/S\n fluid bolus ( for tachycardia) ,started with 1^st unit PRBC and\n transffered to for endoscopy in the am and further\n management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with h/o dark stool ,dropped crit 10 points from previous\n admission,denies any pain. No GI bleed or hemetemesis since admission.\n Pt with her menstrual period. Tachycardia,no PVC\ns noted .c/o nausea.\n Action:\n Started with 1^st unit blood from ER and 2^nd unit transfused in ICU\n given over 2 hrs for tachycardia. VSS. NPO for endoscopy today am.\n Zofran 4mg iv for nausea\n Response:\n Post transfusion crit and other am labs sent after 5.45 am. VSS, HR\n down to 100\n Plan:\n f/u with am labs , transfuse as needed. Maintain NPO for endoscopy\n today.\n" }, { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713643, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n .\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Endoscopy done showed erosions in fundus and some gastritis\n better from prior, antrum is healing. Gi felt that it was possible she\n might have lesions further down in small bowel. hct=29.5 after\n being transfused with 3 u prbc\ns but this am down to 24.5. post\n transfusion this am repeat hc=33.8. pt passed lg amts of liq black\n stool. Denies n/v. tolerating clear liqs.\n Action:\n Gi by to evaluate pt and no intervention ordered. pt ordered for\n repeat hct at 1700. diet advanced to clear liq diet. Pt started on\n pantoprazole 40 mg iv as ordered. pt ambulated in icu with steady\n gait.\n Response:\n Stable hemodynamically. Hct stable\n Plan:\n Follow hemodynamics and hcts as ordered. transfuse as needed. With any\n signs of occult bleeding notify medical team. Transfer to medical floor\n bed when available\n" }, { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713554, "text": "FULL CODE\n ALL: nkda\n 20 yo female with h/o bipolar disorder, migraine headaches, past\n narcotic abuse with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable at 29.5 x2 after 3units PRBC yesterday. Tachycardic high\n 90\ns to 100\ns at rest up to 127 with activity. Endoscopy performed at\n bedside during day shift noted some erosion but no sign of active\n bleed. Tolerating clears early in shift but became nauseous after some\n vanilla ice cream. Pt menstruating. No BM this shift.\n Action:\n Zofran IV x1 with no effect, reglan 10mg IV x1 with good effect, am\n labs drawn\n Response:\n AM Hct= 24.5. Transfusing 1unit PRBC over 2hrs\n Plan:\n Cont to monitor for s/s bleed , re-check HCT 2hrs post transfusion and\n again in AM\n NPO since midnight ? GI rec\ns after Hct drop this am.\n Plan had been for pt to be d/c\nd and have Hct checks as an outpatient\n ROS:\n Neuro: A&O x3, oob to commode, gait steady.\n Pulm: LSCTA b/l with sats >95% on RA\n GU: Voiding in commode >150cc per void w/o complaint.\n Skin: CDI\n Lines: PIV x2\n Psychosocial: Pt\ns mother has been at bedside overnight. As per\n mother, pt was using marijuana and narcotics 3-4 years ago and was\n subsequently dx\nd with BPD. Pt has been very pleasant and cooperative\n with staff but became very agitated and crying uncontrollably toward\n mother at ~2300. Calmed easily and again became appropriate when\n assessed by this RN; has remained calm and cooperative.\n" }, { "category": "Nursing", "chartdate": "2132-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713430, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup. Received protonix iv,2 lit N/S\n fluid bolus ( for tachycardia) ,started with 1^st unit PRBC and\n transffered to for endoscopy in the am and further\n management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with h/o dark stool ,dropped crit 10 points from previous\n admission,denies any pain. No GI bleed or hemetemesis since admission.\n Pt with her menstrual period. Tachycardia,no PVC\ns noted\n Action:\n Started with 1^st unit blood from ER and 2^nd unit transfused in ICU\n given over 2 hrs for tachycardia. VSS. NPO for endoscopy today am.\n Response:\n Post transfusion crit and other am labs sent after 5.45 am. VSS, HR\n down to 100\n Plan:\n f/u with am labs , transfuse as needed. Maintain NPO for endoscopy\n today.\n" }, { "category": "Nursing", "chartdate": "2132-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713536, "text": "FULL CODE\n ALL: nkda\n" }, { "category": "Nursing", "chartdate": "2132-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713537, "text": "FULL CODE\n ALL: nkda\n 20 yo female with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n" }, { "category": "Nursing", "chartdate": "2132-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713429, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup. Received protonix iv,2 lit N/S\n fluid bolus ( for tachycardia) ,started with 1^st unit PRBC and\n transffered to for endoscopy in the am and further management.\n .\n" }, { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713597, "text": "FULL CODE\n ALL: nkda\n 20 yo female with h/o bipolar disorder, migraine headaches, past\n narcotic abuse with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable at 29.5 x2 after 3units PRBC yesterday. Tachycardic high\n 90\ns to 100\ns at rest up to 127 with activity. Endoscopy performed at\n bedside during day shift noted some erosion but no sign of active\n bleed. Tolerating clears early in shift but became nauseous after some\n vanilla ice cream. Pt menstruating. No BM this shift.\n Action:\n Zofran IV x1 with no effect, reglan 10mg IV x1 with good effect, am\n labs drawn\n Response:\n AM Hct= 24.5. Transfusing 1unit PRBC over 2hrs, done at 06:50\n Plan:\n Cont to monitor for s/s bleed , re-check HCT 2hrs post transfusion\n (08:50) by venipuncture (easy draw)\n NPO since midnight ? GI rec\ns after Hct drop this am.\n Plan had been for pt to be d/c\nd and have Hct checks as an outpatient\n ROS:\n Neuro: A&O x3, oob to commode, gait steady.\n Pulm: LSCTA b/l with sats >95% on RA\n GU: Voiding in commode >150cc per void w/o complaint.\n Skin: CDI\n Lines: PIV x2\n Psychosocial: Pt\ns mother has been at bedside overnight. As per\n mother, pt was using marijuana and narcotics 3-4 years ago and was\n subsequently dx\nd with BPD. Pt has been very pleasant and cooperative\n with staff but became very agitated and crying uncontrollably toward\n mother at ~2300. Calmed easily and again became appropriate when\n assessed by this RN; has remained calm and cooperative.\n" }, { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713613, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n .\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2132-11-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 713629, "text": "Chief Complaint: GIB\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Likely spurious hct of 26 overnight led to 1 UPRBC\n 24 Hour Events:\n ENDOSCOPY - At 11:30 AM\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 Fentanyl - 11:55 AM\n Midazolam (Versed) - 12:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:02 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 89 (79 - 113) bpm\n BP: 122/67(79) {92/40(53) - 125/83(92)} mmHg\n RR: 23 (17 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 25 Inch\n Total In:\n 3,640 mL\n 350 mL\n PO:\n 60 mL\n TF:\n IVF:\n 661 mL\n Blood products:\n 919 mL\n 350 mL\n Total out:\n 3,470 mL\n 350 mL\n Urine:\n 2,520 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 170 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, 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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 212 K/uL\n 89 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 108 mEq/L\n 140 mEq/L\n 33.8 %\n 8.1 K/uL\n [image002.jpg]\n 06:01 AM\n 10:34 AM\n 04:14 PM\n 02:34 AM\n 09:11 AM\n WBC\n 8.1\n 8.1\n Hct\n 24.0\n 29.7\n 29.5\n 26.4\n 33.8\n Plt\n 211\n 212\n Cr\n 0.5\n 0.6\n Glucose\n 89\n 89\n Other labs: PT / PTT / INR:12.4/22.6/1.0, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n Hct now stable w/o evidence of further bleeding. Remains very\n puzzling. Hard to believe she has two different lesions that de \n have caused bleeding and her EGD shows healing but NG lavage in ED was\n pos. Would be inclined to wait for awhile, monitor hct regularly, and\n then decide if there is any reason to investigate further.\n ICU Care\n Nutrition:\n Comments: clear advancing to full\n Glycemic Control:\n Lines:\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2132-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 713632, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 11:30 AM: Showed erosions in fundus and\n some gastritis, better from prior, antrum is healing. GI felt that it\n was possible that she might have lesions further down in the GIT\n especially in the SB to account for the melena. pt. should have close\n f/u post discharge with her PCP for blood draws to make sure she does\n not go undetected in case she were to drop crit again. Her lesions are\n expected to take up to a month or more to heal.\n -updated health service \n -gave pm seroquel dose.\n -nausea in pm not resolved with zofran, gave reglan and tylenol for\n HA.\n -Hct 29.7 -> 29.5 -> 26.4 this AM, received another unit of blood ->\n 33.8\n This morning, pt reports: Feeling fine. Nausea from overnight has\n resolved. No dizziness, lightheadedness, abdominal pain. Had one\n black stool this AM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:55 AM\n Midazolam (Versed) - 12:00 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 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 108 (88 - 111) bpm\n BP: 111/63(74) {92/40(53) - 129/92(100)} mmHg\n RR: 20 (18 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 25 Inch\n Total In:\n 3,640 mL\n PO:\n 60 mL\n TF:\n IVF:\n 661 mL\n Blood products:\n 919 mL\n Total out:\n 3,470 mL\n 150 mL\n Urine:\n 2,520 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 170 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Gen: awake and alert, lying comfortably in bed, pale appearing\n HEENT: NCAT, PERRL, OP clear, MMM, neck supple\n CV: RRR, nl S1, S2, no m/r/g\n Pulm: CTAB\n Abd: +BS, soft, NT, ND\n Extrem: no c/c/e, 2+ DP pulses, wwp\n Labs / Radiology\n 212 K/uL\n 9.3 g/dL\n 89 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.4 %\n 8.1 K/uL\n [image002.jpg]\n 06:01 AM\n 10:34 AM\n 04:14 PM\n 02:34 AM\n WBC\n 8.1\n 8.1\n Hct\n 24.0\n 29.7\n 29.5\n 26.4\n Plt\n 211\n 212\n Cr\n 0.5\n 0.6\n Glucose\n 89\n 89\n Other labs: PT / PTT / INR:12.4/22.6/1.0, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:3.8 mg/dL\n Imaging:\n EGD: Focal area of erythema and granular mucosa of about 4 cm was\n noted in the fundus of the stomach consistent with gastritis. But no\n active bleeding or signs of recent bleed was noted.\n Duodenum: Normal duodenum.\n Impression: Abnormal mucosa in the stomach\n Otherwise normal EGD to second part of the duodenum\n No new imaging.\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n 20 yo female with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n .\n .\n #. Hematemesis: History of NSAID gastritis on recent admission, EGD\n performed this admission showed healing gastric mucosa but no clear\n source of bleeding. GI thinks that patient may have a small bowel\n source of bleeding, although crohns is low likelihood.\n - Will touch base with GI about need for further imaging now that\n post-transfusion hct suggests bleeding has stopped\n - PPI \n - maintain 2 large bore IVs\n - Q8H Hct ; next hct due 5pm\n - Active type and cross, transfuse for Hct < 30\n - IV fluids PRN\n - Avoid NSAIDS\n - Zofran PRN\n - will advance diet to clears\n .\n #. Tachycardia: Improved at rest, but continues to have tachycardia\n with exertion. Most likely secondary to volume loss and anemia. Will\n continue volume resuscitation as above. Monitor on telemetry.\n .\n #. Insomnia: Continue home seroquel PRN\n .\n #. History of Narcotic Abuse: At the patient's request will avoid all\n narcotic medications.\n ICU Care\n Nutrition: NPO for now, will advance to clears this AM\n Glycemic Control:\n Lines:\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: pneumatic boots\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments: patient, mother and sister\n status: Full code\n Disposition: Callout to medicine floor\n" }, { "category": "Physician ", "chartdate": "2132-11-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 713424, "text": "Chief Complaint:\n HPI:\n 20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n .\n In the ED her initial vital signs were T 97.4 HR 124 BP 131/80 RR 20 O2\n 100%. She was guaiac positive. A NG lavage was performed with induced\n emesis which was grossly bloodly. She cleared after 250ccs. She was\n tachycardic, but hemodynamically stable. She received a total of 2 L\n of NS and 1 unit of PRBCs, and was type and crossed. GI was consulted\n over the phone and recommended MICU admission. Her labs were\n significant for a Hct of 23.1, down from 24.9 earlier today, 34.5 on\n discharge on . The patient was given 40mg pantoprazole. Her\n vital signs on transfer were HR 119 BP 115/80 O2 100% on RA.\n Allergies: NKDA\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Prilosec OTC 2 tabs \n Seroquel PRN insomnia\n Past medical history:\n Family history:\n Social History:\n NSAID Gastritis\n NC\n Student at . The patient has a history of using marijunana and\n oxycontin recreationally, sober for 3 years. Denies alcohol usage, quit\n smoking 4 months ago, prior to which she smoked for 2 years.\n Review of systems:\n (+)ve: lightheadedness, nausea, melena\n (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest\n pain, palpitations, rhinorrhea, nasal congestion, cough, sputum\n production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal\n dyspnea, vomiting, diarrhea, constipation, hematochezia, dysuria,\n urinary frequency, urinary urgency, focal numbness, focal weakness,\n myalgias, arthralgias\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n GENERAL: Pleasant, well appearing female in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Tachycardic, but regular. Normal S1, S2. No murmurs, rubs or\n . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A\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 Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n 20 yo female with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n .\n .\n #. Hematemesis: EGD proven NSAID gastritis on recent admission, not\n being treated adequately with over the counter dosing of prilosec. At\n this point peptic ulcer disease should be considered. H pylori was\n checked on recent admission and was negative. GI was consulted in the\n ED and will continue to follow on the floor.\n - Appreciate GI recs, may require repeat EGD in AM\n - IV PPI \n - maintain 2 large bore IVs\n - Q8H Hct\n - Active type and cross, transfuse for Hct < 30\n - IV fluids PRN\n - Avoid NSAIDS\n - Zofran PRN\n - NPO for now\n .\n #. Tachycardia: Most likely secondary to volume loss. Will continue\n volume resuscitation as above. Monitor on telemetry.\n .\n #. Insomnia: Continue home seroquel PRN\n .\n #. History of Narcotic Abuse: At the patient's request will avoid all\n narcotic medications.\n .\n FEN: NPO until hematemesis resolves, replete lytes PRN\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen not needed\n -Pain management with no pain meds\n .\n ACCESS: 2 PIV's\n .\n CODE STATUS: Full Code\n .\n EMERGENCY CONTACT: Mother and sister\n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: pneumoboots while in bed\n Stress ulcer: PPI \n VAP:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2132-11-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 713425, "text": "Chief Complaint:\n HPI:\n 20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n .\n In the ED her initial vital signs were T 97.4 HR 124 BP 131/80 RR 20 O2\n 100%. She was guaiac positive. A NG lavage was performed with induced\n emesis which was grossly bloodly. She cleared after 250ccs. She was\n tachycardic, but hemodynamically stable. She received a total of 2 L\n of NS and 1 unit of PRBCs, and was type and crossed. GI was consulted\n over the phone and recommended MICU admission. Her labs were\n significant for a Hct of 23.1, down from 24.9 earlier today, 34.5 on\n discharge on . The patient was given 40mg pantoprazole. Her\n vital signs on transfer were HR 119 BP 115/80 O2 100% on RA.\n Allergies: NKDA\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Prilosec OTC 2 tabs \n Seroquel PRN insomnia\n Past medical history:\n Family history:\n Social History:\n NSAID Gastritis\n NC\n Student at . The patient has a history of using marijunana and\n oxycontin recreationally, sober for 3 years. Denies alcohol usage, quit\n smoking 4 months ago, prior to which she smoked for 2 years.\n Review of systems:\n (+)ve: lightheadedness, nausea, melena\n (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest\n pain, palpitations, rhinorrhea, nasal congestion, cough, sputum\n production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal\n dyspnea, vomiting, diarrhea, constipation, hematochezia, dysuria,\n urinary frequency, urinary urgency, focal numbness, focal weakness,\n myalgias, arthralgias\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n GENERAL: Pleasant, well appearing female in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Tachycardic, but regular. Normal S1, S2. No murmurs, rubs or\n . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A\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 Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n 20 yo female with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n .\n .\n #. Hematemesis: EGD proven NSAID gastritis on recent admission, not\n being treated adequately with over the counter dosing of prilosec. At\n this point peptic ulcer disease should be considered. H pylori was\n checked on recent admission and was negative. GI was consulted in the\n ED and will continue to follow on the floor.\n - Appreciate GI recs, may require repeat EGD in AM\n - IV PPI \n - maintain 2 large bore IVs\n - Q8H Hct\n - Active type and cross, transfuse for Hct < 30\n - IV fluids PRN\n - Avoid NSAIDS\n - Zofran PRN\n - NPO for now\n .\n #. Tachycardia: Most likely secondary to volume loss. Will continue\n volume resuscitation as above. Monitor on telemetry.\n .\n #. Insomnia: Continue home seroquel PRN\n .\n #. History of Narcotic Abuse: At the patient's request will avoid all\n narcotic medications.\n .\n FEN: NPO until hematemesis resolves, replete lytes PRN\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen not needed\n -Pain management with no pain meds\n .\n ACCESS: 2 PIV's\n .\n CODE STATUS: Full Code\n .\n EMERGENCY CONTACT: Mother and sister\n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: pneumoboots while in bed\n Stress ulcer: PPI \n VAP:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2132-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 713591, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 11:30 AM: showed erosions in fundus and\n some gastritis, better from prior, antrum is healing. GI felt that it\n was possible that she might have lesions further down in the GIT\n especially in the SB to account for the melena. pt. should have close\n f/u post discharge with her PCP for blood draws to make sure she does\n not go undetected in case she were to drop crit again. Her lesions are\n expected to take upto a month or more to heal.\n -updated health service \n -gave pm seroquel dose.\n -nausea in pm not resolved with zofran, gave reglan and tylenol for\n HA.\n -Hct 29.7 -> 29.5 -> 26.4 this AM, receiving another unit of blood,\n made NPO in case GI wants further w/u in am\n This morning, pt reports:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:55 AM\n Midazolam (Versed) - 12:00 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 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 108 (88 - 111) bpm\n BP: 111/63(74) {92/40(53) - 129/92(100)} mmHg\n RR: 20 (18 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 25 Inch\n Total In:\n 3,640 mL\n PO:\n 60 mL\n TF:\n IVF:\n 661 mL\n Blood products:\n 919 mL\n Total out:\n 3,470 mL\n 150 mL\n Urine:\n 2,520 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 170 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Labs / Radiology\n 212 K/uL\n 9.3 g/dL\n 89 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.4 %\n 8.1 K/uL\n [image002.jpg]\n 06:01 AM\n 10:34 AM\n 04:14 PM\n 02:34 AM\n WBC\n 8.1\n 8.1\n Hct\n 24.0\n 29.7\n 29.5\n 26.4\n Plt\n 211\n 212\n Cr\n 0.5\n 0.6\n Glucose\n 89\n 89\n Other labs: PT / PTT / INR:12.4/22.6/1.0, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:3.8 mg/dL\n Imaging:\n EGD: Focal area of erythema and granular mucosa of about 4 cm was\n noted in the fundus of the stomach consistent with gastritis. But no\n active bleeding or signs of recent bleed was noted.\n Duodenum: Normal duodenum.\n Impression: Abnormal mucosa in the stomach\n Otherwise normal EGD to second part of the duodenum\n No CXR this am\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:37 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": "2132-11-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 713593, "text": "Chief Complaint:\n 24 Hour Events:\n ENDOSCOPY - At 11:30 AM: showed erosions in fundus and\n some gastritis, better from prior, antrum is healing. GI felt that it\n was possible that she might have lesions further down in the GIT\n especially in the SB to account for the melena. pt. should have close\n f/u post discharge with her PCP for blood draws to make sure she does\n not go undetected in case she were to drop crit again. Her lesions are\n expected to take upto a month or more to heal.\n -updated health service \n -gave pm seroquel dose.\n -nausea in pm not resolved with zofran, gave reglan and tylenol for\n HA.\n -Hct 29.7 -> 29.5 -> 26.4 this AM, receiving another unit of blood,\n made NPO in case GI wants further w/u in am\n This morning, pt reports:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:55 AM\n Midazolam (Versed) - 12:00 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 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 108 (88 - 111) bpm\n BP: 111/63(74) {92/40(53) - 129/92(100)} mmHg\n RR: 20 (18 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 25 Inch\n Total In:\n 3,640 mL\n PO:\n 60 mL\n TF:\n IVF:\n 661 mL\n Blood products:\n 919 mL\n Total out:\n 3,470 mL\n 150 mL\n Urine:\n 2,520 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 170 mL\n -150 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Gen: awake and alert, lying comfortably in bed, pale appearing\n HEENT: NCAT, PERRL, OP clear, MMM, neck supple\n CV: RRR, nl S1, S2, no m/r/g\n Pulm: CTAB\n Abd: +BS, soft, NT, ND\n Extrem: no c/c/e, 2+ DP pulses, wwp\n Labs / Radiology\n 212 K/uL\n 9.3 g/dL\n 89 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 108 mEq/L\n 140 mEq/L\n 26.4 %\n 8.1 K/uL\n [image002.jpg]\n 06:01 AM\n 10:34 AM\n 04:14 PM\n 02:34 AM\n WBC\n 8.1\n 8.1\n Hct\n 24.0\n 29.7\n 29.5\n 26.4\n Plt\n 211\n 212\n Cr\n 0.5\n 0.6\n Glucose\n 89\n 89\n Other labs: PT / PTT / INR:12.4/22.6/1.0, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:3.8 mg/dL\n Imaging:\n EGD: Focal area of erythema and granular mucosa of about 4 cm was\n noted in the fundus of the stomach consistent with gastritis. But no\n active bleeding or signs of recent bleed was noted.\n Duodenum: Normal duodenum.\n Impression: Abnormal mucosa in the stomach\n Otherwise normal EGD to second part of the duodenum\n No CXR this am\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n 20 yo female with recent admission for NSAID gastritis admitted for\n repeat upper GI bleed.\n .\n .\n #. Hematemesis: History of NSAID gastritis on recent admission, EGD\n performed this admission showed healing gastric mucosa but no clear\n source of bleeding. Patient may have small bowel source and is\n continuing to bleed this am.\n - Will contact GI about possibility of initiating capsule study prior\n to discharge\n - PPI \n - maintain 2 large bore IVs\n - Q8H Hct ; next hct due 2 hours after transfusion finishes\n - Active type and cross, transfuse for Hct < 30\n - IV fluids PRN\n - Avoid NSAIDS\n - Zofran PRN\n - NPO for now\n .\n #. Tachycardia: Improved at rest, but continues to have tachycardia\n with exertion. Most likely secondary to volume loss and anemia. Will\n continue volume resuscitation as above. Monitor on telemetry.\n .\n #. Insomnia: Continue home seroquel PRN\n .\n #. History of Narcotic Abuse: At the patient's request will avoid all\n narcotic medications.\n ICU Care\n Nutrition: NPO for now, will advance if no procedure planned by GI\n Glycemic Control:\n Lines:\n 18 Gauge - 01:37 AM\n Prophylaxis:\n DVT: pneumatic boots\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments: patient, mother and sister\n status: Full code\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2132-11-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713512, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup. Received protonix iv,2 lit N/S\n fluid bolus ( for tachycardia) ,started with 1^st unit PRBC and\n transffered to for endoscopy in the am and further\n management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with h/o dark stool ,dropped crit 10 points from previous\n admission,denies any pain. No GI bleed or hemetemesis since admission.\n Pt with her menstrual period. Tachycardia,\n Action:\n Received 3 untis PRBC since admission , bedside endoscopy performed\n Response:\n No s/s active bleed on scope, some erosion noted, maintaining HCT @\n 29.5\n Plan:\n Cont to monitor for s/s bleed , check HCT in AM then Pt will have HCt\n monitored q 2 weeks as out pt, tolerating clears advance diet as\n tolerated\n" }, { "category": "Nursing", "chartdate": "2132-11-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 713667, "text": "20 yo female with a history of narcotic abuse, was recently diagnosed\n with NSAID gastritis following admission for GI bleed, presents\n with anemia. The patient was recently discharged following brief ICU\n admission for upper GI bleed. EGD at that time showed likely NSAID\n gastritis. The patient had reported significant NSAID use for chronic\n migraines. Since that time, the patient had been unable to fill her\n protonix prescription, but had been taking prilosec OTC. She followed\n up in , and was found to have a 10 point Hct drop, (24). She\n reports intermittent dark stools since discharge two weeks ago. She\n also reports intermittent nausea, but denies vomiting. She was\n referred to the ED for further workup.\n .\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Endoscopy done showed erosions in fundus and some gastritis\n better from prior, antrum is healing. Gi felt that it was possible she\n might have lesions further down in small bowel. hct=29.5 after\n being transfused with 3 u prbc\ns but this am down to 24.5. post\n transfusion this am repeat hc=33.8. pt passed lg amts of liq black\n stool. Denies n/v. tolerating clear liqs.\n Action:\n Gi by to evaluate pt and no intervention ordered. pt ordered for\n repeat hct at 1700. diet advanced to clear liq diet. Pt started on\n pantoprazole 40 mg iv as ordered. pt ambulated in icu with steady\n gait.\n Response:\n Stable hemodynamically. Hct stable. Repeat hct at 1700=34.8\n Plan:\n Follow hemodynamics and hcts as ordered. transfuse as needed. With any\n signs of occult bleeding notify medical team. Transfer to medical floor\n bed when available\n" }, { "category": "ECG", "chartdate": "2132-11-11 00:00:00.000", "description": "Report", "row_id": 224453, "text": "Sinus tachycardia. Otherwise, normal tracing. Compared to the previous tracing\nof the rate is increased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2132-11-14 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1112779, "text": " 12:22 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for source of upper gi bleed\n Admitting Diagnosis: HAMATEMESIS;UPPER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with recurrent upper GI bleed despite cessation of NSAIDs,\n concern for small bowel lymphoma. Please give IV and PO contrast. Please wait\n for morning on Friday to allow patient to sleep.\n REASON FOR THIS EXAMINATION:\n eval for source of upper gi bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa FRI 3:20 PM\n Normal CT examination.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent upper GI bleed.\n\n TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was\n obtained after the administration of oral contrast and 130 cc IV Optiray\n contrast. Axial, coronal, and sagittal reformats were constructed.\n\n FINDINGS:\n\n CT ABDOMEN WITH ORAL AND IV CONTRAST:\n\n FINDINGS: The lung bases demonstrate no pleural effusions or concerning\n nodules or lesions. The visualized portions of the heart and great vessels\n are unremarkable.\n\n The liver, spleen, bilateral kidneys, bilateral adrenal glands, gallbladder,\n and pancreas are unremarkable. The small and large bowel of normal size and\n caliber. The stomach appears normal. No abdominal free air, free fluid, or\n lymphadenopathy is seen.\n\n CT PELVIS WITH ORAL AND IV CONTRAST: The large bowel, rectum, and bladder\n appear normal. The uterus is normal in size and shape with normal follicular\n activity for a patient of this age. No pelvic free air, free fluid, or\n lymphadenopathy is seen.\n\n BONE WINDOWS: The osseous structures are unremarkable.\n\n IMPRESSION: Normal CT examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-11-14 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1112780, "text": ", R. MED 11R 12:22 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for source of upper gi bleed\n Admitting Diagnosis: HAMATEMESIS;UPPER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with recurrent upper GI bleed despite cessation of NSAIDs,\n concern for small bowel lymphoma. Please give IV and PO contrast. Please wait\n for morning on Friday to allow patient to sleep.\n REASON FOR THIS EXAMINATION:\n eval for source of upper gi bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Normal CT examination.\n\n\n" } ]